LADY JUSTICE THIRLWALL: Good morning, Mr De La Poer.
MR DE LA POER: My Lady, can I ask Dr John Gibbs to come forward, please.
LADY JUSTICE THIRLWALL: Dr Gibbs, would you like to come forward?
DR JOHN GIBBS (sworn)
LADY JUSTICE THIRLWALL: Do sit down.
MR DE LA POER: Can we begin, please, with your full name?
GIBBS: I am John Gibbs.
DE LA POER: So far as your contribution in writing to this Inquiry is concerned, can I confirm,
please, with you that you have given a witness statement dated 1 July 2024?
GIBBS: Yes.
DE LA POER: And a witness statement dated 6 September 2024?
GIBBS: Yes.
DE LA POER: Are the contents of both of those statements true to the best of your knowledge and
belief?
GIBBS: Yes, they are.
DE LA POER: Dr Gibbs, we are going to begin by introducing you briefly. Is it right that in 1983,
you graduated MBBS?
GIBBS: Yes.
DE LA POER: Meaning that you completed the academic part of the training to be a doctor?
GIBBS: Yes, it was the basic medical degrees.
DE LA POER: Did you become a Fellow of the Royal College of Paediatrics and Child Health in
1996?
GIBBS: Yes.
DE LA POER: Insofar as your career is concerned, did you begin in Cornwall?
GIBBS: Yes.
DE LA POER: You subsequently worked at Guys, Great Ormond Street and Alder Hey?
GIBBS: Yes.
DE LA POER: That for a period of time you conducted research at University College London?
GIBBS: Yes, I did.
DE LA POER: And that you took up the role of Consultant paediatrician at the Countess of Chester
Hospital in 1994?
GIBBS: Yes.
DE LA POER: And that so far as paediatrics is concerned, do you have a special interest in epilepsy
and childhood
disability?
GIBBS: Yes, I did. But all of us paediatricians in Chester were general paediatricians who covered
paediatrics in general at a district general hospital level and neonates. Could I just add at the
beginning, please, that I do deeply regret and I am ashamed that I failed to protect the babies from
harm by Letby, but I do understand that the parents concerned probably now would prefer explanations
rather than belated apologies.
DE LA POER: Returning to your career. Did you become the Paediatric Lead Clinician between the
period 2000 and 2004?
GIBBS: Yes.
DE LA POER: Then Paediatric Clinical Director between 2004 and 2009?
GIBBS: Yes, that is right.
DE LA POER: Did you retire from medicine in 2019?
GIBBS: Yes, five years ago.
DE LA POER: Albeit that you worked, including supporting the response to the pandemic in 2020?
GIBBS: Yes.
DE LA POER: Thank you, Dr Gibbs. We are going to move to the next topic, which is your awareness of
deliberate harm cases.
Firstly, in 2015, were you aware of the case of Beverley Allitt?
GIBBS: Of who?
DE LA POER: Beverley Allitt?
GIBBS: Yes, I was, yes.
DE LA POER: Was that something that just formed part of your general awareness or had you received
any particular training or warning about it that you can recall?
GIBBS: I can't recall any particular training. I was just aware, as most paediatricians at that time
and before that time would have been aware, because of such media interest and such importance to
paediatrics. But time, memories fade over time. So Beverley Allitt was not at the front of my mind
most of the time I was practising.
DE LA POER: To take a case closer in time to the summer of 2015, were you aware of the situation of
two nurses at the Stepping Hill Hospital?
GIBBS: Yes, I wasn't quite sure how many nurses were involved but I was aware of the insulin problem
at that hospital.
DE LA POER: Insulin problem. When I said two, and you mentioned this in your statement, one nurse
falsely accused?
GIBBS: Yes.
DE LA POER: One nurse convicted?
GIBBS: Yes.
DE LA POER: And we know that in the late spring of 2015, the nurse who was convicted was sentenced
in the Crown Court. Was that sentence something that you were aware of, do you think, back in the
summer of 2015?
GIBBS: I can't remember whether I was but I was aware of the situation over those years that had
happened at Stepping Hill Hospital.
DE LA POER: So were you aware in the summer of 2015 that insulin had in the past been used as a
weapon?
GIBBS: Yes.
DE LA POER: To move to my third topic, which is just for you as our first witness of fact working
at the Countess of Chester Hospital, to introduce the neonatal unit. Can I just say this to you, Dr
Gibbs and for the benefit of everybody else: paragraphs 5-35 of your witness statement will be
published on the Inquiry website where you deal in some detail with setting the scene. You and I are
just going to go through some of those matters. We don't need to go through all of them. So we begin
with this: the neonatal unit formed part of the paediatric department; is that correct?
GIBBS: Yes, it did and that's a typical set-up in
a district general hospital.
DE LA POER: And the paediatric department at that time sat in the Urgent Care Division of the
hospital?
GIBBS: Yes.
DE LA POER: Obstetrics sat in the Planned Care part of the hospital?
GIBBS: Yes, it did.
DE LA POER: Just pausing there for a moment. In your view, bearing in mind the very close
relationship between those two specialties, did the fact that they sat in separate divisions within
the hospital cause any difficulties relevant to the matters that we are considering?
GIBBS: To some extent but I don't think to a significant extent. The reason being that aware of how
closely we needed to work with our obstetric colleagues particularly from the neonatal side of our
department, governance -- clinical governance structures were maintained between paediatrics and
obstetrics even though we were in separate divisions. The problem with us, we had been downgraded
really from -- there used to be three divisions, one was women and children's and then there was
medicine and surgery. Because we had been split, the women and children's, to the two divisions that
were then created, that meant we
didn't have a direct line to the senior managers. When I was Lead Clinician back in -- and Clinical
Director up to 2009, I sat on the Management Board and liaised more closely with the senior
Executives. My colleague, Dr Jayaram, who was Lead Clinician in 2015/16, didn't have that position.
He had to liaise through the Urgent Care Clinical Director. So from that point of view, being
slightly more separated from the managers was a bit of a problem. But we knew, and Dr Jayaram knew,
how to contact the managers which is why I think it wasn't such a big problem. Interestingly, the
women and children's departments had been joined back together again now at the Countess of Chester
Hospital.
DE LA POER: Just to reflect back what you have just said to make sure I have understood it. When
you were Clinical Director, you had regular meetings with the senior management and built up
relationships at those meetings; is that right?
GIBBS: Yes, yes.
DE LA POER: But by contrast, in the ordinary run of things, Dr Jayaram would be expected to contact
a layer of management below the senior management for his concerns?
GIBBS: Yes.
DE LA POER: Meaning that he didn't have the same sort of relationships that you would have had
because he simply wasn't sitting round the table as frequently?
GIBBS: That's correct.
DE LA POER: Now, as far as the Consultant body was concerned, you have mentioned Dr Jayaram who was
the Clinical Lead for paediatrics which was the equivalent relevant, albeit in a different
structure, to the one that you had held?
GIBBS: (Nods)
DE LA POER: Dr Stephen Brearey was the neonatal lead; is that right?
GIBBS: Yes.
DE LA POER: And that was an additional clinical role for him, not a management role?
GIBBS: That's correct.
DE LA POER: There were then three other consultants who were present throughout the entire period
we will be looking at: Dr ZA, Dr V and Dr Saladi; is that right?
GIBBS: Yes.
DE LA POER: At the start of the period we will be looking at Dr Liz Newby was part of the
Consultant body; is that right?
GIBBS: Yes, she was.
DE LA POER: And she left around March 2016, I believe?
GIBBS: Right, yes.
DE LA POER: And was she replaced by Dr Suzy Holt?
GIBBS: Yes, she was.
DE LA POER: Who was then part of the Consultant body up until past May 2017?
GIBBS: Yes.
DE LA POER: Now, at the start of the period that we are going to be looking at in detail, and I
will just date-stamp it for you, June 2015, what was your view about whether there were enough
Consultants?
GIBBS: Sorry, could you repeat?
DE LA POER: What was your view about whether there were enough Consultants in the paediatric
department?
GIBBS: We knew, we -- we felt we needed more Consultants and we were planning to have two extra
Consultants so that we could provide enough regular cover for both sides of our department, that's
the paediatric ward and the neonatal unit.
DE LA POER: So enough Consultants for the whole paediatric department of which the neonatal unit
was part?
GIBBS: Yes.
DE LA POER: And was a business case created for two more Consultants?
GIBBS: Yes. I can't remember exactly when it was created, it was created around 2016 onwards.
DE LA POER: Yes, well --
GIBBS: And well before June 2016.
DE LA POER: You will take it from me that records indicate that at some point in 2016 it was agreed
that those two extra Consultants would be appointed and those appointments were made in 2017; does
that sound about right?
GIBBS: Yes, yes.
DE LA POER: So that's the Consultant body. Let's just turn to deal with the senior nurses. Sister
Ann Murphy was the lead nurse for children's services; is that right?
GIBBS: That's correct.
DE LA POER: And there were two ward managers, the paediatric ward was run by nurse Anne Martyn, as
she was then?
GIBBS: Yes.
DE LA POER: Now McGlade. The neonatal unit was run by Nurse Eirian Powell?
GIBBS: Yes.
DE LA POER: Now, in your witness statement, Dr Gibbs, you run through a number of different types
of meetings which took place and it is not necessary, given that's going to be published, for us to
go through all of them. But let's just mark some of them. There were monthly
neonatal unit risk management meetings; is that right?
GIBBS: Yes.
DE LA POER: There would be -- my word -- ad hoc, meaning arising as required, mortality review
meetings; is that right?
GIBBS: For neonates.
DE LA POER: For neonates.
GIBBS: Yes.
DE LA POER: There would also be a monthly meeting which Consultants could attend; is that
right?
GIBBS: Yes, just going back to the mortality meetings~--
DE LA POER: Yes.
GIBBS: There was an ad hoc one for neonates which I think in 2015/16 probably took place two or
three times. But there was also a two monthly meeting where we met with our obstetric colleagues and
neonatal deaths or other problems were discussed at that meeting as well. I don't know if you are
going to come on to that.
DE LA POER: I was. It was this -- what you say in your statement is every one to two months there
is a maternal and neonatal mortality and morbidity meeting?
GIBBS: Yes.
DE LA POER: Sometimes I think referred to as the perinatal meeting?
GIBBS: Yes.
DE LA POER: There was also a Monday meeting between paediatricians and nurse managers?
GIBBS: Yes. Each week.
DE LA POER: With one formal one a month?
GIBBS: Yes, once a month it was -- we had more people attending from finance, IT to look at the
general activity of our department, yes.
DE LA POER: It was at those monthly ones that minutes would be kept?
GIBBS: Yes.
DE LA POER: Less formally, as a group of Consultants, were there also informal discussions between
you in twos and more in each of your offices?
GIBBS: Yes, which were generally unminuted.
DE LA POER: And was it at some of those meetings, as we will come to in a while, that Letby was
first discussed?
GIBBS: Yes.
DE LA POER: So far as the staffing levels on the NNU were concerned, and you deal with this at
paragraph 38 if you want to turn it up, we have already heard from Sir Robert Francis Kings Counsel
about the BAPM guidelines as to minimum safe staffing?
GIBBS: Yes.
DE LA POER: In your view, were there adequate nursing staff on the NNU during the period
2015/16?
GIBBS: There is two answers to that. Yes, I felt so and there was similar nursing staffing to that
that we had in prevent years, it hadn't suddenly changed in 2015/16. But no in that it was below the
BAPM guidelines. But it was my understanding at the time that many hospitals -- many -- failed to
meet the BAPM standards for nurse staffing on the neonatal unit.
DE LA POER: So three points then, yes? Firstly, lower than the guidelines suggest?
GIBBS: Yes.
DE LA POER: Secondly, that that had been a longstanding problem?
GIBBS: Yes.
DE LA POER: Thirdly, in your understanding, that was comparable to many other hospitals?
GIBBS: Yes, and if I could just add a figure there that might come up later. When we had the College
review -- I am not going to talk much about that yet -- in September 2016, the reviewers pointed out
that the nursing staffing levels on our neonatal unit were 21% below the BAPM recommendation. But
that compared to within the region all the other units, the average was 27% below the BAPM
recommendations, which just hopefully confirms what
I said: most other hospitals did not meet the guidelines and we are actually slightly better off
staffing wise than other neonatal units in the Cheshire and Merseyside region.
DE LA POER: Is what you have said about nurses also true of the doctors in terms of the adequacy
and number?
GIBBS: In theory we had enough doctors. But because of the busy paediatric ward as well, we
Consultants weren't spending enough time on the neonatal unit, although we had the numbers, but we
needed more to satisfy enough time on the neonatal unit and although we had adequate numbers of
registrars, there were often gaps in the rota. People had dropped out of training for different
reasons, maternity leave, doing research, going abroad and those gaps in the rota did cause a
problem for us and all the other hospitals I was aware of in our region.
LADY JUSTICE THIRLWALL: Can I just ask you, so although you had enough registrars, in theory --
GIBBS: Yes.
LADY JUSTICE THIRLWALL: -- I think gaps in the rota, does that mean they just weren't there?
GIBBS: Yes, we should have had seven registrars and often we only had six and that was the case
during 2015/16.
LADY JUSTICE THIRLWALL: Thank you.
MR DE LA POER: Dr Gibbs, I am now going to move on to a subtopic of relationships. We will start
here. In summary what is your view about the relationship between the Consultant body during the
period 2015-2017?
GIBBS: Relationship between Consultants?
DE LA POER: Consultant paediatricians, yes?
GIBBS: Oh, it was good. It became strained only from the fact that we felt under considerable stress
as events unfolded during that two-year period.
DE LA POER: As between all of the doctors, how was the relationship?
GIBBS: With ourselves and our junior doctors?
DE LA POER: Indeed.
GIBBS: I understood it to be very good. Of course the view of the Consultant, how you feel you
relate to your junior doctors may be different from a junior doctor perspective, but I am sure you
will be hearing from some of the doctors who were in training at the time later on.
DE LA POER: How about between the doctors and the nurses?
GIBBS: I felt it was very good. Until we started -- Consultants started developing concerns about
what was happening on the neonatal unit and that caused a strain between ourselves and the senior
nurses on the neonatal
unit.
DE LA POER: Well, speaking of senior --
GIBBS: Sorry, that was a consequence of what was happening on the unit, it wasn't the cause of what
was happening on the unit; it came afterwards.
DE LA POER: Speaking of senior nurses, I just want to invite you to consider an opinion, so you
have an opportunity to comment upon it, from Eirian Powell. She suggests that Consultants thought
all staff members worked cohesively because staff did exactly what they were told to do by the
Consultants without challenging them. Does that accord with your experience of that period?
GIBBS: No, it doesn't. But sometimes what I might feel is the case a relationship with -- with
nurses may be slightly different from their point of view. I am disappointed and surprised to hear
that Eirian Powell has said that. If she had said it towards the mid to end of -- well, any time
from the end of 2015 beginning of 2016 onwards, tensions were building up at that time between us
Consultants and senior nurses, so I can understand it. I would be very surprised and disappointed if
that was the case earlier on in 2015 and in preceding years.
DE LA POER: Another observation for your comment, please, from Eirian Powell, she suggests that
Consultant communication with nurse managers and midwives was sometimes poor and they didn't listen
to the views of others?
GIBBS: Sorry, I didn't hear that last word didn't listen to?
DE LA POER: The views of others.
GIBBS: Again I am disappointed and rather surprised to hear that. I do understand and it came out
when the nurses spoke to the Royal College reviewers in September 2016, that they felt at times --
and I thought this wasn't frequently, but at times when nurses felt that we ought to escalate and
that doesn't just mean the Consultants, it means the Registrars as well, escalate problems, that's
Registrar up to Consultant and Consultant to the regional neonatal centres, sometimes the nurses
felt that should have happened quicker than it did and they -- it appears that they felt they were
not empowered to say anything. I always thought the nurses could say whatever they liked at any time
to me and I hoped I listened. But I do think there came a strong and unpleasant difference of
opinion about what was happening on the neonatal unit that maybe has coloured all those comments
that you just read out from Eirian Powell.
DE LA POER: In terms of the relationship between the Consultants and managers outside of the
paediatric department but below the Executives, so here I am thinking about people in the role such
as Head of Risk, did you or your colleagues have relationships with that tier of management?
GIBBS: Yes. We had an associate or assistant business manager to assist us in the paediatric
department and we had good relationships with her. But she had to answer to the business manager in
the urgent care, so we are several -- you know, one layer below that and we didn't have a good
relationship with the urgent care management, not because there was anything wrong with them but we
were removed from them. We had a good relationship with our assistant business manager. As far as
clinical risk is concerned, it's a complicated network of different committees and groups that were
supposed to look at risk and I must confess I was confused by that even though I worked at that
hospital, even though I had been a Clinical Director in the past, and I think at times it was
difficult to know how risk was being managed.
DE LA POER: Finally on the topic of relationship, and we are going to come back to risk in a little
bit more detail, the relationship at the start of the period, so
June 2015, between the Consultants and the Executive Directors?
GIBBS: I wasn't aware of any problems. As has been discussed previously the way our management
structure was set up within the hospital, we were quite removed from them. We knew who they were, we
saw them occasionally, and we didn't have a close relationship with them. You might say just that
because I had been Clinical Director in the past and I said I sat on the management board like all
the clinical directors do and I knew the Chief Executive Medical Director, Nursing Director, met
them at different meetings, that I might have known them a bit better but all those personnel had
changed over by 2015/16.
DE LA POER: So your pre-existing relationships were no longer relevant?
GIBBS: Yes, those people had retired or left or moved to other jobs.
DE LA POER: Dealing with what is quite a big topic but in summary form for now, during the period
2015 through to June 2016, so here we are talking about the period before the deaths of [Child O]
and [Child P] towards the end of June 2016, did you have any hesitation or reason to think that you
wouldn't be listened to by those
Executive Directors if you went to them with a problem?
GIBBS: No.
DE LA POER: So although you didn't know them well, you didn't regard them as hostile to your
position or unwilling to listen?
GIBBS: No, I didn't, no.
DE LA POER: So I said I would come back to the topic of risk and here I would just like to look at
Datix reporting?
GIBBS: Yes.
DE LA POER: It may be that was what you were referring to a moment ago. Let's see.
GIBBS: That's part of the risk management, yes.
DE LA POER: So firstly, because you are here to help us by way of introduction to some matters,
just tell us in a nutshell what is a Datix form?
GIBBS: Well, a Datix form is just an electronic form for recording clinical incidents and clinical
incidents are just events that may cause concern, either did cause concern or potentially might
cause concern. That's when there's been problems with care of patients. And you are supposed to fill
in a Datix form when you are aware of such an event and that will then go through the clinical risk
system within the Trust.
DE LA POER: Now, I just want to focus on your answer there. You gave the first half of the answer
which was when there is an incident which may be of concern or was of concern?
GIBBS: Yes.
DE LA POER: And then you added "to do with the care", or words to that effect. Would it only be
when there were concerns about arising from care that you would fill out the Datix or could you just
fill out a Datix if you were generally concerned without really being able to put your finger on
what it was you were concerned about?
GIBBS: I am not sure and I never filled a Datix form in to do with a general concern, it was always
a specific concern about a particular patient and a particular event with a particular patient.
DE LA POER: So if we just test that with an example. If a baby suddenly and unexpectedly collapsed
and recovered, and you didn't understand at the time the reason for that sudden and unexpected
collapse, is that the sort of thing that you would fill out a Datix for or would you not fill it out
because you didn't identify any issue with care?
GIBBS: Generally would not fill it out, no, because you had to identify what was the problem, a
medication error, a lack of equipment, a staffing problem that led to that episode.
DE LA POER: So as far as you were concerned, a Datix form presupposed that you were able to
identify something that had gone wrong?
GIBBS: That's correct. I might have been wrong in that understanding, but that was my understanding.
DE LA POER: But if you simply couldn't figure out why a particularly serious event was happening
that wouldn't necessarily lead to a Datix?
GIBBS: No and I ought to add that, myself included, I think in general clinicians are not good at
filling in Datix forms when they should and I believe -- but I only have experienced of the Countess
of Chester as a Consultant, I believe that's a widespread problem and it is said that a department
in a hospital is very risk aware and good from that sense by filling in lots of Datix forms but also
you get criticised by having so many events in your hospital there is a disincentive to fill them
in.
DE LA POER: Just doing your best to get to the bottom of why you think that phenomenon is, ie
doctors not as good as some of their colleagues at filling out Datix forms, what do you think the
reason for that is?
GIBBS: That not being aware one should have been filled in, not having the time to fill them in
sometimes, and in my experience, nurses are much better
at filling in Datix forms than doctors.
DE LA POER: Well, you have mentioned nurses there. Often with a clinical event there will be a
number of members of staff present?
GIBBS: Yes.
DE LA POER: If there are, if there is more than one person there, whose responsibility is it to
fill out a Datix form?
GIBBS: Anyone's.
DE LA POER: And how is the situation avoided where if there are six people present, all six of them
put in a Datix form? Is there to be any communication between people about who will do it?
GIBBS: That would be a slightly embarrassing situation. I think the risk managers would tell you
they would much rather receive six forms than no form on the same incident and I think probably more
often they receive no form.
DE LA POER: But was there, for example, a line of communication with perhaps one of your nursing
colleagues where you could say as a Consultant: this needs a Datix form, would you mind filling it
in? Is that the sort of dialogue that you had or would that not be an appropriate request?
GIBBS: Yes, you could have that dialogue. I think by
and large the nurses just took it upon themselves correctly to form a fill in when it needed to be
done, the doctors didn't and in part mitigation for that is that doctors tend to be responsible for
a large number of patients, say a paediatrician if you are on-call, all the babies on the neonatal
unit, all the children on the paediatric ward. The nurses look after, and it depends the medical
needs of the patient, maybe just one patient or maybe just a small group of patients. So although we
all have responsibility for Datix forms, the nurse who is with the patient most the time for the
whole of her or his shift is more likely to fill the Datix form in than a doctor that's hurrying
from one patient to another.
DE LA POER: Do you think there was any possibility that doctors were, or you were -- speaking for
yourself -- assuming that the nurse would do it if one was required?
GIBBS: Sometimes. But I admit that is not a good excuse for not filling one in.
DE LA POER: In the event that such an assumption is made, can you see that there may be a risk
around that and I will explain what I mean by that, that it may be that the doctor in that
particular situation has a better understanding of what has gone wrong and the nurse may not have
identified it and that therefore if the nurse is to be relied upon unless the doctor speaks to the
nurse about filling in the Datix, something the doctor thinks is significant may not be
recorded?
GIBBS: That is true. I think generally, though, the more significant a doctor or I might have felt
an event was that needed a Datix form, that is more likely to encourage me or another doctor to fill
the Datix form in but it doesn't guarantee it would happen.
DE LA POER: I want to deal briefly with safeguarding. Have you as part of your preparation for your
evidence had an opportunity to have a look at Working Together 2015?
GIBBS: Yes.
DE LA POER: Had you received any training about Working Together and there was a previous iteration
in 2013 and one before that in 2010, had you received any training about that document by June of
2015?
GIBBS: Yes, I had received general training to do with safeguarding that at times related to parts
of Working Together. I never received training where you sat down or discussed or went to a
presentation on Working Together. Parts of Working Together came into general safeguarding training.
I would add, though, that I cannot recall -- it doesn't mean it didn't happen, I can't recall ever
being given any training on the 2015 guidelines that had come into force whether there were any
changes compared to the previous guidelines.
DE LA POER: Had your safeguarding training included as any part of it how you might go about
reporting a concern related to a colleague?
GIBBS: I am hesitating because I can't remember if that ever came under safeguard training although
generally it is under that area. I was aware and I did know the -- I thought I knew the rough steps
you should take if you were concerned about a colleague, yes. I can't remember if that was covered
in safeguarding training, but we did have specific safeguarding training each year.
DE LA POER: Well, what in 2015/16 was your understanding about the steps you should take if you had
a concern about a risk from a colleague?
GIBBS: It depended on the colleague. For a junior doctor or so-called doctor in training, and these
are qualified doctors but they are still counted as in training until they get to Consultant level,
that each doctor in training had an educational supervisor who was a Consultant. If you had concerns
about a training doctor's performance, you would discuss that with the educational supervisor and
that would then be fed back
and discussed with the doctor. If there were serious concerns, it could be fed back to the training
school which in each region of the country there is a training school for doctors in every specialty
and for us in Chester it would have been the Mersey Deanery for training doctors. If you had a
concern about a doctor and if there were serious concerns, that doctor would be supervised or even
removed from the training rota. That's a junior doctor.
DE LA POER: How about nurses?
GIBBS: Can I come on to --
DE LA POER: Of course, no, I don't want to interrupt.
GIBBS: Because that's the most difficult part of the answer.
DE LA POER: Yes.
GIBBS: If you had a concern about a Consultant colleague, that's more difficult because you are at
the same sort of level, the same level of seniority, but you would discuss it with the Lead
Clinician or Clinical Director. But it would be a difficult if the concern was with the Lead
Clinician and Clinical Director. So you would go one higher and if necessary you would go to the
Medical Director to discuss concerns about a Consultant colleague's performance.
DE LA POER: And for nurses?
GIBBS: More difficult because they are sort of a separate structure. And so I felt I knew well how
to handle concerns about another doctor, either a training doctor or a Consultant. When it came to
concerns about nurses you would mention those to the ward manager usually, unless it was the ward
manager his or herself that you were concerned about, and you would go to a higher nurse then, and
then leave them to deal with it. I felt, but I don't know for sure, that the nurses had a similar
way of dealing with problems that we doctors would have; that for a nurse in training it's her
training supervisors that would look at her, the concern about that. For a nurse who's qualified, a
more senior nurse would look at the problem and if necessary escalate it up, up to the divisional
nurse manager and if necessary to the nursing director and of course we all know we knew that
ultimately concerns about a doctor can be fed back to the General Medical Council but you wouldn't
do that without usually involving senior doctors like the Medical Director. Similarly on the nursing
side they could report a nurse to the Nursing Midwifery Council, but we would not go to those bodies
straight away; we would try to deal with it within the hospital structure initially.
DE LA POER: Obviously there are concerns and there are concerns. The vast majority no doubt are of
a clinical nature: somebody isn't safe in what they are doing, making mistakes. What did you
understand to be the correct way of dealing with a situation where you had a nurse and the concern
included the possibility of deliberate harm or criminal activity?
GIBBS: I don't recall that ever being discussed in my training as a junior doctor or in the
mandatory training we did each year as a Consultant. But I assumed, and I think it is a reasonable
way to assume, that you would deal with them initially in the way you dealt with a performance
problem. If it was the nurse, you would discuss it with the nurse manager and if the nurse manager
was concerned it would go to the next level up, ultimately to the Director of Nursing in the
hospital.
DE LA POER: Why wouldn't you in those circumstances go to the safeguarding department?
GIBBS: Because I regarded the safeguarding department, particularly in paediatrics, as being there
to help manage a concern about a particular child or family, not a concern about other members of
staff.
DE LA POER: Do you think it's wrong to characterise situations where there is concern about a nurse
potentially causing deliberate harm as a safeguarding issue?
GIBBS: It is a safeguarding issue but it wasn't one that I would have envisaged going to the
safeguarding team who we involved regularly with concerns about individual patients or the patient's
family.
LADY JUSTICE THIRLWALL: So that would be in relation to parents?
GIBBS: Parents or other caregivers.
LADY JUSTICE THIRLWALL: Or other caregivers.
GIBBS: Yes.
LADY JUSTICE THIRLWALL: Sorry, Mr De La Poer.
MR DE LA POER: Not at all. So you tell me if I have got this wrong but is what you are saying that
it just wasn't in the way you thought about how to solve this problem that the safeguarding unit may
be part of the solution.
GIBBS: That's correct. Yes. If a member of staff was suspected of harming patients, for example, I
would go to their -- their line managers and if you were worried, as you would do with something
like that, you would want to escalate it quite quickly to the most senior line managers in the
hospital. I wouldn't have thought of involving the safeguarding team who were there generally to
sort of -- and in paediatrics my
whole experience had been are there to help manage an individual child or family.
DE LA POER: Just exploring the idea of going to their line manager. Is a potential challenge of
going to their line manager with such a potentially serious allegation or even if it does not amount
to an allegation, a concern that human relationships may get in the way of dealing with it as
quickly as it needs to be dealt with?
GIBBS: Yes, that is true. But in that situation you would look to escalate it to higher managers who
were slightly further removed from the person in question. We all develop good working relationships
within our own teams at ward level and it probably ought to be easier -- but not easy -- for someone
outside the ward level to deal with a concern like that than a fellow colleague at ward level.
DE LA POER: We will come back to the local safeguarding policy in just a moment. But if we move to
the topic of the external reporting of child death. You have had a chance to look at Working
Together 2015. Did you note the part which deals with Sudden Unexpected Death in Infancy and
Childhood?
GIBBS: Have I noted it now?
DE LA POER: Yes, now?
GIBBS: Yes.
DE LA POER: Now, as part of your preparation?
GIBBS: Yes, I don't remember my attention being drawn to that back in 2015 but it is my
responsibility to try and keep up to date with the enormous number of guidelines in all different
aspects of our specialty.
DE LA POER: Having had a chance to read that now --
GIBBS: Yes.
DE LA POER: -- do you agree or doing with the proposition that those guidelines, the SUDiC
guidelines, applied to babies who died in hospital?
GIBBS: I am still actually not certain now and I was -- I just did not realise it did. That's now.
Back in 2015/16 I did not realise it applied to babies in hospital. I had very sadly intermittently
throughout my career had to deal with SUDiC cases and usually SUDI, the infant rather than the
child, and I felt I knew how to deal with those in a multi-agency manner, including the police. That
was -- the scenario was always a cot death type situation of a baby at home and then dealing with
the police. Why in that situation? Because the police look at the home circumstances, the behaviour
of the caregivers, parents or others, whether they have drug or alcohol problems, whether there
could have been child abuse or neglect and in most cases there won't be for a cot death. I didn't
have that same understanding -- I didn't have the understanding that same approach was supposed to
apply to children in hospital, but most specifically a neonate who had never been home from hospital
back in 2015/16. I think a lot of other clinicians -- but I can only talk for myself -- had that
same understanding. I did -- I have read Dr Garstang's expert view and as she admitted, her very
well-resourced child review programme in Birmingham probably would have handled it differently to
us, but she has an academic interest in it and I didn't realise that's the way she would have
managed it at that time.
DE LA POER: You were also invited to consider the Pan Cheshire guidelines, so these are the more
local guidelines?
GIBBS: Yes.
DE LA POER: Again, having read those now, do you agree or disagree that they, like Working
Together, indicate that the SUDiC process applies to hospital deaths as well?
GIBBS: Probably, probably it does. I didn't realise back in 2015 and the reason I say "probably", it
is not at all clear that it does. Is it possible to have a look at -- I don't mind either guideline,
they have got the same flowchart in them, if we have got the Pan
Cheshire guidelines for SUDiC?
DE LA POER: Yes, we can certainly bring that up.
GIBBS: It would be page 9 for that -- actually no, no, I think it is page 91 for the Pan Cheshire
guidelines.
DE LA POER: So the Pan Cheshire guidance is INQ0013225, I believe. My Lady, you have that in hard copy at tab 5 of your
Consultant core bundle, so that's the double bundle.
GIBBS: Thank you, and this is page 91, I think we are all looking at, and this is the flowchart.
DE LA POER: Yes.
GIBBS: Now, there is a lot of text as well but flowcharts are designed as a visual aid to help you
follow a process. If we look at the child death and so on, when it starts and expected death, we are
not talking about expected deaths, we are talking about the left-hand column which at the top is
headed "Sudden and Unexpected Death of an Infant or Child". If you work your way down that
flowchart, at the top is "Ambulance and Police immediate response". Then the next box it starts with
"Where appropriate, child and carer transferred to hospital". That's what this flowchart shows. That
was my understanding of how SUDiC is managed. This is the 2015
guideline. It just shows it must be a child in the community because you don't call an ambulance to
a child on the neonatal unit. This is a child in the community and the ambulance and police get
involved. The child comes to hospital. Sadly, the baby -- and it is often a baby, it is a cot death
type problem often, not always, the baby may not actually be alive at home but often the ambulance
-- or the parents first and then the ambulance staff start resuscitation, bring the child to
hospital and sadly we have to declare the child dead in hospital and then follow the process shown
here. I wouldn't have from this flowchart realised this applies to a neonate who has not come from
home.
DE LA POER: Could we just scroll to the top just to see -- the heading is "Child Death in
Hospital/Community"?
GIBBS: Yes.
DE LA POER: So obviously you have drawn attention to parts lower down but in the heading is
included "hospital".
GIBBS: Yes, because most children who are found collapsed at home, as this flowchart shows, are
brought to the A&E department where we continue resuscitation until we realise it is hopeless.
DE LA POER: So dying in hospital having been transferred there in a state of distress?
GIBBS: Yes, yes.
DE LA POER: I understand.
GIBBS: If you want to look at page 85 I think on this guideline --
DE LA POER: I think that's one that our technology is just letting us down with. I wonder if we
might come back to that?
GIBBS: Okay.
DE LA POER: That's not to -- yes, it has just been pointed out that that document has 67 pages so
the reference you have given --
GIBBS: The document we are just looking at?
DE LA POER: The Pan Cheshire.
GIBBS: I thought we were looking at page 91 there, weren't we? 9, the other one is 91. Sorry, okay,
well we can leave that for the moment.
DE LA POER: I am sure we can come back to it.
GIBBS: Well, I can just point out this is the Pan Cheshire guideline, the other was the Working
Together guideline, sorry. We don't have to look it, it's got the same flowchart in it and honestly
someone can check that it is the same flowchart. It starts with the top bit: ambulance and police
called, child brought to hospital. And the child may be declared dead at home because ambulance I
think and police can declare a child dead or a baby dead at home but often they will try to
resuscitate the baby, bring to hospital. Which is why the SUDiC could occur in the community or be
declared the death in the hospital. That's why I said when you said "But does that only apply in
that situation, could it apply in hospital?" I said possibly it could, but it's unclear.
DE LA POER: One more policy to have a look at which is the hospital safeguarding policy.
GIBBS: Yes.
DE LA POER: That's INQ0003250. This is a document you have had a chance to have a look before
coming here today. Can we just go to page 11 -- sorry, forgive me, page 33. This is the hospital's
own policy. Here it defines it as: "The sudden unexpected death, unexpected in 24 hours prior to
death of a child under the age of 24 months, irrespective of the place of death at home or in the
community, in the hospital emergency department or ward."
GIBBS: Yes.
DE LA POER: Again from your point of view, does that enlighten the position any further or does it
maintain the ambiguity?
GIBBS: It could be taken either way and my
understanding back in 2015, most of these SUDiCs are babies in the first year of life, cot death
type problems. A child -- an older child can die suddenly in hospital and that's why an older child
dying in hospital, the SUDiC procedures do apply. Why get the police, for example, involved in
those? Because the child had lived at home and all the home circumstances, the parents or
caregivers' behaviours and problems and possibilities of neglect exists. I didn't take that as
happening on the neonatal unit.
DE LA POER: Thank you very much indeed, can we take that down?
GIBBS: Could I also add, these are the documents to do with SUDiC?
DE LA POER: I beg your pardon?
GIBBS: Is this the end of the documents to do with SUDiC?
DE LA POER: Well, I was going to just acknowledge that you had, before I moved on to the next
topic, provided a document dated 2011 --
GIBBS: Yes.
DE LA POER: -- which you have drawn to the Inquiry's attention. I wasn't going to ask you any
questions about it but if there is any part of it you want to draw attention to?
GIBBS: Yes, that that document from the BAPM again, that same organisation, from 2011 that applied
in 2015/16, it wasn't updated until 2022 so it did apply at the time of the incidents we are going
to be considering, that relates to babies who die within the first week of life either at home or
still in the hospital. It only applied to term babies and admittedly it was -- it is designed to
address the investigation, the medical investigation of those babies. But because these are babies
who suddenly unexpectedly die in the first week of life, it does overlap with SUDiC and it says in
the introduction to that particular document that SUDiC guidelines tend to emphasise death in the
community. But they do mention police in that BAPM document and the only mention of the police is
that if the family of a child dying in the first week of life suddenly, if the family are already
known to Social Services or to the police, then information should be obtained from those agencies.
It doesn't give the impression those agencies are automatically involved in SUDiC but that was not a
SUDiC document. The other document just to mention, if you don't mind, please, is the SUDiC document
from the Royal College of Paediatrics and Child Health.
DE LA POER: Yes.
GIBBS: It is a joint document with our paediatric college and the College of Pathologists, and the
one that applied in 2015/16, Dr Garstang -- I mean, that's what our SUDiC policy is based on in
managing these babies. Dr Garstang admitted in her evidence on the transcript that that doesn't
mention death in hospital at all. She felt that was well out of date at that time because she would
have done it differently in Birmingham, but that document that our SUDiC policy is based on doesn't
mention death in hospital and Dr Garstang said that a revision of that at the end of 2016 which is
still in force now is wholly inadequate and needs updating.
DE LA POER: Thank you very much indeed, Dr Gibbs. We are going to move now to start our review of
the period beginning in June 2015 and you know, because I have already told you this, that to help
us we are going to just mark between us a number of events, some of which you weren't a direct party
to but we can just make sure that they are not disputed fact and everybody can therefore follow what
the context of it is. So if we begin with the death of [Child A], the date was 8 June 2015. Now,
that wasn't a child that you were involved in the care of, is that right?
GIBBS: That's correct, yes.
DE LA POER: We will come to [Child C] which I think begins at paragraph 104 in your statement but
just --
GIBBS: What paragraph was that again?
DE LA POER: Paragraph 104, page 30 if you want to turn to it.
GIBBS: Sorry, it might be my hearing but the echo I sometimes miss the number.
DE LA POER: Not at all.
LADY JUSTICE THIRLWALL: You are not alone.
MR DE LA POER: So the next date is the sudden and unexpected deterioration of [Child B], the date
for that for those deteriorations 9 and 10 June 2015. Again not a child who you provided any care
for?
GIBBS: That's correct. But I did hear about those children, there was concern in the department
about them.
DE LA POER: We are going to come and have a look at some of the documentation about that. So we
come to [Child C] which, as I say, is dealt with in your statement from paragraph 104 on page 30 and
[Child C] died on 14 June of 2015?
GIBBS: Yes.
DE LA POER: If we just run through some of your involvement, and I am not going to rehearse all the
medical detail that you provide, it is extremely helpful and we are very grateful, but we just need
to understand your involvement as you would have understood it at the time. Do we see from your
paragraphs 108 and 109 that you were at home and you received a call to attend?
GIBBS: Yes, it was at night, yes.
DE LA POER: The request was for your presence urgently and you arrived within just a few
minutes?
GIBBS: Yes, fairly quickly, yes.
DE LA POER: And when you arrived full resuscitation was in progress of [Child C]?
GIBBS: Yes.
DE LA POER: It was not successful and was stopped after 30 minutes?
GIBBS: Yes.
DE LA POER: Now, what you say at paragraph 118 is that you learned from Dr Davis in her police
statement that there was no response from [Child C] to the resuscitation which you comment is
unusual.
GIBBS: I note -- I think she said in her statement it is unusual.
DE LA POER: Yes?
GIBBS: But I would agree with that.
DE LA POER: You would agree with that?
GIBBS: It is unusual in a child who has suddenly deteriorated. Sadly, resuscitations after cardio
respiratory arrest, that's a combined failure of circulation and breathing, sometimes the patient of
any age, including neonates, does not respond, but particularly if they have been ill for some time
and steadily deteriorating, they have no reserve left. When a baby suddenly collapses you would hope
to get some response, even if it is not sustained you would -- and you would sometimes hope you
would get a good response and save the baby. So it is unusual from a sudden collapse in the baby
that was managing well beforehand not to get a response to resuscitation.
DE LA POER: I think what Dr Davis has said in her police statement wasn't something that you were
aware of at the time; is that right?
GIBBS: I wasn't aware of what at the time, sorry?
DE LA POER: That there had been no response to resuscitation or was that something that --
GIBBS: No, I was yes.
DE LA POER: You knew that at the time?
GIBBS: Well, yes, I attended 10 minutes into the resuscitation, yes, and there was no response from
that point onwards. I think I was told there was no response
beforehand. But I wasn't there at the very beginning, if that's what you mean, but I knew there was
no response to the resuscitation, yes.
DE LA POER: [Child C] was referred to the Coroner?
GIBBS: Yes.
DE LA POER: And was your reasoning for that that you weren't able to sign the death
certificate?
GIBBS: Yes, I didn't know why [Child C] had collapsed and died.
DE LA POER: And in terms of your concerns and suspicions at the time that something unnatural may
have happened or something very wildly out of the ordinary, you didn't have any such concerns at the
time; is that right?
GIBBS: Yes, not at all.
DE LA POER: We will come to the point at which your concerns come to the forefront of your mind but
we will move on from [Child C] to [Child D] and again, [Child D] died on 22 June 2015. But I don't
think that that was a child that you were closely involved in the care of?
GIBBS: That's correct, I was not involved.
DE LA POER: If I can just pause here. You have had an opportunity, and we can bring it on screen,
if you want to see an extract from Ruth Millward, the head of risk and safety's opinion, do you
recall reading that it was just an extract from her witness statement?
GIBBS: Yes. I think, along the lines that she wasn't aware of these problems, is that correct?
DE LA POER: Well, let's just go to page 56. Paragraph 260. What she says, and here she is talking
about the three deaths that had occurred in relatively quick succession: "I now recognise it would
have been appropriate for the hospital to have reported the overall increase in neonatal deaths that
occurred in June 2015 as a serious incident. This would have then triggered a comprehensive
investigation into the increased mortality rate at a much earlier stage. However, given the small
number of cases reviewed this may not have resulted in Letby's earlier suspension." So we don't need
to worry about the second part of it but the first part, identifying cluster of three deaths as a
serious incident, is that something that you agree with Ruth Millward about that or disagree or is
that not for you as a Consultant paediatrician to be getting involved in?
GIBBS: I will -- I am prepared to comment on that.
DE LA POER: Yes.
GIBBS: This partly relates to my confusion about how risk management works. I don't understand what
Mrs Millward means by "would have been appropriate for the hospital to have reported the increase in
deaths as a serious incident". I thought they were, I thought there was a Serious Incident Review of
the first three deaths, I thought it had happened. Now, whether it had been reported to the right
channel and gone to the right committee and been reported from the hospital to someone outside the
hospital, I don't understand that part of the working of clinical risk management. I thought these
deaths were reported as a serious incident and I thought they were reviewed including the Director
of Nursing being involved in that review.
DE LA POER: I think, although she will speak for herself, what she is saying is that whilst each of
them may have separately been identified as a serious incident, it is identifying a serious incident
in relation to all three. So the cluster is the incident, not the individual occasion of each death,
I think that's what she is saying, but she will tell us because she is coming to give evidence
later?
GIBBS: Yes.
DE LA POER: But if that's what she is saying, is that a process that you understand or can comment
upon?
GIBBS: The cluster was dealt with as a serious, unexpected or untoward incident, the cluster of the
first three deaths and the Director of Nursing was involved in that review, I understood. Now,
whether we have reported it as a hospital to the right authority or classified that serious incident
in the right way I don't know but it was -- I thought it was dealt with as a serious incident and
all three deaths were looked at together.
DE LA POER: Well, I am sure we can ask her about it when she comes. Thank you very much, Dr
Gibbs.
GIBBS: Well, also the people involved in that, because it would be Dr Brearey, one of the risk
managers and the Director of Nursing were involved in that Serious Incident Review. Maybe it didn't
get to Mrs Millward but other senior people were involved in it to my understanding.
DE LA POER: We can take that document down. We are going to --
GIBBS: It is possible that the right Datix form wasn't filled in for that but it was reviewed as a
serious incident.
DE LA POER: We are going to just move forward in time to the 23 June and here we have INQ0025743. Again, my Lady, the hard copy of that is in your core bundle which is two lever-arch folders, so I am not sure --
LADY JUSTICE THIRLWALL: That doesn't matter, I can look at it on the screen, thank you.
MR DE LA POER: Thank you. Can we please go to the final email. So let's just scroll to the bottom
of the thread. This is an email from you dated 23 June 2015, 10.04 to your Consultant colleagues. I
will just read the first part out and you can then speak to the generality of it. "Rachel Lambie
..." That's Dr Lambie?
GIBBS: (Nods)
DE LA POER: "... came to see me this morning, I think because I was the only person in the office
when she came, to say the Registrars are very concerned about the recent neonatal deaths and
collapses where [[Child B] is identified] all the infants showed a strange purpuric looking rash
that probably wasn't true purpura. However, I pointed out that [Child C] who also died did not have
this rash but it's true that [Child A] [Child B] and the recent death, [Child D], did show similar
strange colour on collapsing. Rachel also said that all the neonatal nurses are very worried. They
feel we ought to do something and also what else different the Registrars can do". So if we just
pause there. You had had a conversation with Dr Lambie?
GIBBS: Yes.
DE LA POER: And have you summarised in that email everything that we need to know about the content
of that conversation. Does that capture the nature of it?
GIBBS: As far as I can remember from eight years ago, yes, that's the essence of it. And the reason
I said that sort of slightly facetious remark probably because I was the only one in the office, I
had been involved with [Child C] but not [Child A], [Child B] and [Child D]. It is absolutely fine
for a Registrar to come and talk to any Consultant about a concern, but my colleagues had been
involved and I think one or two of them had been involved in three of those four. So I was passing
this message on because they had more experience, particularly I didn't feel [Child C] had the same
rash that I was told the other three babies had, but I had never seen that rash because I wasn't
involved with those three babies.
DE LA POER: The final paragraph you said: "Although I have mentioned we are looking into this I am
not exactly sure how this is being done." You then go on to speak directly to Dr Brearey and
Dr Jayaram and propose a meeting just to allow people to air concerns?
GIBBS: Yes.
DE LA POER: Do you know if that meeting ever took place?
GIBBS: I don't think so. I can't remember now whether it did or not. Unless the Inquiry Team have
the document from that meeting I can't remember if it ever took place. I think -- from the email
correspondence above, I think my colleagues were going to talk to different Registrars rather than
have a meeting of everyone together, I think that's what the emails say about --
DE LA POER: Let's just scroll up, please.
GIBBS: That was in lieu of the meeting, I think. Our worry at this stage was that we had some
medical problem on the unit like some -- and you do get superbugs or some nasty infection or, as has
happened on some units, contamination of the feeding fluid for babies, there was something that was
affecting all these babies. But they seemed to have different problems and Baby C [Child C] to me
seemed different to what I was told about the other children.
DE LA POER: If we can just scroll down a little, please. Are we able to scroll? It is buffering. I
think we have jumped to the bottom of the thread again.
GIBBS: But even at the top that we just saw, my colleague Dr Brearey is suggesting how to deal with
it and not a presentation -- well, they are going to be presented at the morbidity and mortality
meetings, exactly how we fed back to the Registrars at the time I can't remember.
DE LA POER: Well, let's see. I think if we put it in -- we can just see that Dr Newby in a reply
says: "I agree. I have just been grilled by Dave Harkness. This is causing a lot of concern and
upset." Dave Harkness being Dr Harkness who again was one of the Registrars I think on --
GIBBS: Yes, he was, a colleague of Dr Lambie, another Registrar, yes.
DE LA POER: The email threads goes on, we don't need to look at the detail of it, but in short, we
can see that Dr Brearey mentions the PMM tomorrow afternoon: "Please encourage all juniors and
nurses to attend and discuss in this forum rather than privately"?
GIBBS: Yes, that was one of the morbidity and mortality meetings. And also I might be wrong here, so
as I say I am sure you will look into this. I thought the three other babies yes, the -- yes, the
three babies [Child A], [Child C] and [Child D] were
looked at as a serious incident together as well. But that wasn't with the Registrars that was with
the Director of Nursing, Dr Brearey and one of the team from the risk management department.
DE LA POER: So we are going to move forward from 23 June to 29 June and here we will look at INQ0036166. This is a senior clinicians meeting that you attended on 29 June.
We don't need to look at all of the detail of it, I know you have had a chance to see this before.
We can go to the second page, please, the fourth paragraph. We can see where it. Says: "There was
also an issue raised round the fact that with the three recent neonatal deaths the Registrar had
been quite worried and feel that nothing is being done. Behind the scenes reviews are going on but
it was felt that formal debriefs should probably take place rather than any specific meeting to
discuss all three." So again at that time would you agree, Dr Gibbs, it seems that the Registrars
are making known their particular concerns to the Consultant body?
GIBBS: Yes. And I was only involved with [Child C] and there a debrief was held on [Child C], I
think a few days before 29 June, that involved the Registrar and some of the nurses who were
concerned with [Child C]'s sad death. It was actually Dr Davis that was mentioned before, another
one of the Registrars, it wasn't Dr Lambie or Dr Harkness. So at least for one of those babies a
debrief had taken place with the Registrar and nurses who had been involved in the resuscitation of
[Child C]. I am not sure what debriefs took place for Children A,B and D.
DE LA POER: Now you have mentioned second -- forgive me, you have mentioned a serious incident
meeting. We may be able to bring that up now, INQ0003530. This is 2 July and if you want a reference for yourself, Dr Gibbs,
I think if you look at paragraph 72 on page 22. I'm sorry to make you move around, you might want to
keep a finger in where you are but page 22, paragraph 72. INQ0003530. Now, this may have been what you were referring to earlier. SUI,
serious untoward review, 2 July of 2015. Now was this a meeting that you had attended or did --
GIBBS: No, I didn't attend that but I knew it had taken place and Ruth Millward was at that meeting
because she -- at the top line there "RM" I presume is her. There might have been someone else who
has those
initials. "SB" is my colleague Dr Brearey, "AK" I assume is Alison Kelly, the Director of Nursing.
DE LA POER: We will ask them about the detail of it. We can take it down, that's to mark that
moment. But you comment upon that meeting in your paragraph 72, just saying that: "There were
informal discussions between Consultants around July 2015, several had been involved with the death
on the NNU. It was recognised that Letby had been present on each occasion."
GIBBS: Yes.
DE LA POER: So Letby's name had come up as a common factor in July of 2015?
GIBBS: Yes. Yes, I can't remember how, obviously it had obtained greater significance as time went
on and that association persisted, but I can't remember if we looked closely or considered in our
informal discussions, and being informal unminuted discussions, there is nothing to go back to
check, which is a problem. I am not sure how closely we considered other members of staff as well
because some of them might have been involved in several of those and obviously Letby wasn't the
only nurse involved in all of those. I don't know if she was the only common factor but she was
noted
because she was involved in the resuscitation for all four babies.
DE LA POER: Just help us to understand the terms in which her name came up. At this time, you had
no suspicions of any deliberate harm being caused to babies?
GIBBS: No, and in fact, felt sympathy for Letby at that time because felt she had been unlucky to
have been involved in a number of incidents. It can happen to any of us, and it's happened to me
during my career, that you have a bad run where when you are on-call or on duty; in a short space of
time, a number of unfortunate incidents, cot deaths and other deaths may happen. But then that stops
happening if it is just an unfortunate coincidence.
DE LA POER: Now, if we can just complete the 2 July because that meeting, the serious untoward
incident meeting wasn't the only meeting that took place. Also taking place, and we will bring it up
INQ0000108 -- forgive me, I can see you are indicating, Dr Gibbs.
GIBBS: Sorry. But that's a Serious Incident Review meeting and I don't understand -- and it involved
those babies. I don't understand why Ms Millward said it wasn't reported as a serious incident and
those deaths together weren't reported. What were they having that meeting on all those deaths
together for with the
Director of Nursing and Ruth Millward herself if it wasn't reported? Does it only mean the right
form wasn't submitted through Datix? I don't understand.
DE LA POER: Well, you can rest assured she will be asked. We are going to go to page 178, please,
and here we can see within [Child C]'s notes that on 2 July there was a Sudden Unexpected Death in
Infancy Childhood additional strategy meeting and you are one of those identified as being
present?
GIBBS: Yes.
DE LA POER: We don't need to go into the detail of the discussion then. You have told us in clear
terms you weren't suspicious at that time of any deliberate harm being caused but just help us with
this. You didn't, as I have understood your evidence, think that SUDI applied to deaths in hospital,
but this meeting appears to be a SUDI meeting. So just help us to understand that?
GIBBS: Right. Maybe I should qualify what I meant about SUDI not applying in hospital. Of course
sudden unexpected deaths can occur in hospital and can occur on a neonatal unit, but if you are
talking about the guidelines on the procedures for managing a SUDI, which includes what is known as
the Joint Agency Response, the JAR, I didn't think that applied in hospitals to a baby that's never
been home. I thought that applies to cot deaths that occur in the home. So the actual: can a baby
die suddenly in hospital? Yes, and that's a sudden unexpected death. I didn't think the procedure
that involved the JAR applied to babies who had never been home.
DE LA POER: And so just in summary form, what was the purpose of an initial strategy meeting
then?
GIBBS: Because all child deaths have to be reported through the CDOP procedure, Child Death Overview
Panel, and most -- most of the babies on our neonatal unit came from the West Cheshire area. A few
come from the Wirral area and a few come from North Wales and they have different CDOP or CDOP
related processes in those areas. I was a little surprised to come to this meeting because I wasn't
normally expected to come to CDOP meetings for the majority of our babies who come from the West
Cheshire area and I thought (redacted).
DE LA POER: Thank you. We can take that document down and then finally --
GIBBS: Even on this document, you have not shown it, which might have been embarrassed me but I saw
this and I realised: on that document there, it does say "no police involved" and you might say why
did I think that should be there if we don't normally involve the police
for a baby who dies on a neonatal unit? This is a generic form and it is the same sort of form that
would happen with a review meeting for a typical cot death baby and that's why I thought there was a
little box there for saying are the police involved or not.
DE LA POER: I understand. The last event on 2 July was, as I am sure you will take from me but we
can look at the document, a debrief in relation to [Child C]. Does that accord with your
recollection?
GIBBS: On 2 July, wasn't it?
DE LA POER: Yes.
GIBBS: Right, fine, I was wrong then. That meeting on the 29th when we talked about having debriefs
was just before the debrief we had on [Child C]. Sorry, I thought it was the other way round in
time.
DE LA POER: That's fine. Unless you want to, there is no need to go to the document, but that's
date we have got?
GIBBS: Fine, fine.
MR DE LA POER: So I think that that concludes 2 July 2015 and, my Lady, I note the time. Would now be a convenient moment?
LADY JUSTICE THIRLWALL: Yes, indeed. So, Dr Gibbs, we are going to take a 15-minute break so would you be back, please, at 25 to 12. (11.18 am) (A short break) (11.35am)
LADY JUSTICE THIRLWALL: Yes, Mr De La Poer.
MR DE LA POER: Dr Gibbs, we will move forward to [Child E] which, if you want a reference so you
have your statement in front of you, is paragraph 140 at page 43. I will try and summarise just a
couple of points from what you say in your evidence. You examined [Child E] on 2 August. There was a
deterioration on 3 August which was unexpected and [Child E] died on 4 August, is that your
understanding?
GIBBS: Sadly that's my understanding, yes.
DE LA POER: What you say at paragraph 142 is that it was surprising that [Child E] rapidly
deteriorated and died?
GIBBS: Yes. That's after I had found him well the previous day. Others who were looking after him
the day he died will be able to report how well he seemed before he suddenly collapsed.
DE LA POER: What you tell us at paragraph 144 is you were not at that time suspicious?
GIBBS: No.
DE LA POER: We move forward to [Child F] and the 5 August and again we are just continuing in your
witness statement. I will try and give a summary. [Child F] had
persistently high glucose and was given insulin?
GIBBS: Yes, very early in life.
DE LA POER: Very early on. You had a discussion with Dr Harkness, you tell us in paragraph 147,
about the management of [Child F]?
GIBBS: Yes, and just to set it into context the fact he required -- [Child F] required insulin in
the first day or two of life for a short period, he had been off insulin for quite a few days before
the incident we are now going to talk about.
DE LA POER: Yes. You examined [Child F] at about 8.30 in the morning of 5 August; is that
right?
GIBBS: Yes, yes.
DE LA POER: But what you tell us in paragraph 156 is that although you can't say exactly when the
blood results were required, you were not -- you yourself didn't see the results of the blood
result?
GIBBS: That's correct. I had been on-call over that night and that's why 8.30 in the morning I had a
look at -- examined [Child F]. I knew he had a low blood sugar at that time I thought the most
common problem which is not unusual in neonates -- newborn babies -- is that he probably had an
infection and when babies have infections they can drop their blood sugars. During the rest of the
day when a colleague was looking after [Child F], he continued to have low blood sugars despite
needing quite a lot of extra sugar given in the intravenous fluids he is receiving and that's why in
that unusual context he had some special blood tests done.
DE LA POER: What you say at paragraph 157 is that -- and we will have a look at the insulin result
in a moment: "I believe it was a collective failure on the part of our paediatric team to not have
recognised the significance of the insulin and C-peptide result in [Child F] in mid-August 2015.
With hindsight this was a serious failure because we realised that [Child F] had been administered
insulin and this was not indicated and had not been prescribed for him and this should have raised
immediate and serious concerns either about possible deliberate harm on the NNU or that there were
seriously deficient procedures and practices on the NNU that led to insulin being given to a patient
accidentally."
GIBBS: That is correct. Those insulin results came back a week after they had been taken from Baby
F, [Child F]. So it was a week later and looking at [Child F]'s notes, certain junior doctors,
training doctors, and a Consultant did look at those results. It is recorded in the notes and it
seems to me they didn't
understand the significance of those results. I wasn't aware of those results at the time. Now it's
easy for me to say I wasn't aware of those results, I wasn't on the ward on that day therefore I
don't -- it has no effect on me. I did look after [Child F] when I was on-call on subsequent days a
few days later, so did some of my colleagues. We all had the opportunity to look back at those
results although we would normally do so if we were still concerned about the baby and [Child F]'s
blood sugars came back to normal quite a few days before those insulin results came back. But any of
us could have seen those results. So I don't think it is fair to say just those few doctors who saw
the results didn't respond appropriately to them. We all had a chance to look at those results.
DE LA POER: If we can bring up INQ0000861. We have got two documents just to bring up. Now, is this the form
that you would expect to see the results on your system?
GIBBS: No.
DE LA POER: No. So we can ask somebody else about that. We can then go to INQ --
GIBBS: I did -- I assume this is a lab not a ward based result, but I am not sure but as I say,
others can confirm that.
DE LA POER: INQ0000862. Is this a more familiar view or
not something that you would see when accessing the notes?
GIBBS: No, this isn't a view I would expect to see. No. And I wasn't aware of the comment on the
middle right-hand side.
DE LA POER: There is a query there about exogenous, meaning externally administered as opposed to
generated by the body?
GIBBS: That's correct, yes. Now, I have assumed -- and again others can confirm this -- this is a
screen that was used in the laboratory. If it was a screen that we should have seen at ward level I
didn't know how to access this particular screen, which is a problem, but I think it's a screen that
the lab used rather than we would see at the ward level when looking at patient results.
DE LA POER: That was exactly why I wanted you to have a look at it and give us your comments on it.
Thank you, that can be taken down. The phrase that I read out to you at 157, the second sentence,
you say: "With hindsight this was a serious failure ..." Can I just ask why you have applied the
words "with hindsight" to this?
GIBBS: Because I didn't know this result until about
two years or so later when I was preparing a statement for the police and then I came across this
result. I suppose for those that knew the insulin results on the day or the day after they came back
a week after the bloods had been taken, then maybe that's not -- they might not say with hindsight,
they will have to explain why they interpreted them in the way they did. But with hindsight I didn't
even know -- I didn't know these results until a few years later. Looking at those results -- and I
have to admit as well, I had to check what is a significance of a C-peptide as opposed to the
insulin level so you would need to look that up. I am not sure most paediatricians would have that
in their head immediately, it is an uncommon blood test to request that realising it meant this was
likely to be insulin that had been injected into the baby.
DE LA POER: We are going to continue to move forward in our timeline. We need to return to [Child
C]. You deal with this at paragraph 120 of your statement, page 36. This is your discussion with Dr
-- now you will help me with the pronunciation?
GIBBS: Kokai.
DE LA POER: Thank you, who is a pathologist?
GIBBS: Yes.
DE LA POER: About the postmortem results?
GIBBS: Yes.
DE LA POER: For [Child C]?
GIBBS: Yes.
DE LA POER: We don't need to go into the science of it or the medicine of it. But following your
conversation with Dr Kokai, were you satisfied at that time that [Child C]'s death had been
adequately explained or did you still have concerns?
GIBBS: I was satisfied that the death had been partly explained. When requesting a postmortem on a
child who's died, particularly when it was a sudden or unexpected death and when the cause is
unclear to myself at the ward level, you are hoping that the postmortem will find a cause so that
you can explain to the parents why their child died. It will not compensate for the tragedy of
losing the child but it is logical to help a bit to have an explanation for the child's death and
some causes of death will have an influence or possible consequences for future children or
pregnancies and so on. So in a way it was a relief to find a cause for death. But without going into
the detail again, because of the unusual nature of the resuscitation and then (redacted), I wasn't
sure whether the damage to the heart that was noticed on this postmortem would have all
happened at and after the resuscitation or whether it happened before. It was Dr Kokai's view that
the damage to the heart had happened before the resuscitation and therefore caused the collapse but
it didn't fully explain it because I then asked "but why did the damage occur to the heart?" So you
keep going back one more step. But with Baby C [Child C] being an at-risk baby, very small, growth
retarded, difficulties with perfusion from the placenta, the afterbirth, before the baby was born
possibly that might have explained why the heart was -- had suffered this insult. But it didn't
quite fit together.
DE LA POER: In terms of your state of mind in August 2015, does it follow that whilst you weren't
entirely satisfied with the explanation that you had been given, you didn't think that there was any
more investigation that was required --
GIBBS: Yes.
DE LA POER: -- by you?
GIBBS: Yes.
DE LA POER: At that time you were not suspicious of any deliberate harm being caused by anyone?
GIBBS: Yes, because sadly it had been my experience even after postmortem it is not always possible
to explain a death and that is occasional. When that
situation keeps arising, something very strange is happening.
DE LA POER: Just to bookmark 21 August 2015. We understand that you had a discussion with [Child
C]'s parents, I am not going to ask you about that but it may be you will be asked some questions
about it later, so we will move forward to September 2015 and [Child G] which you deal with at
paragraph 159 on page 48 and following. Again, as before hopefully, Dr Gibbs, I can be efficient
about this, just pick out from the following paragraphs that [Child G] was transferred to the
Countess of Chester at 11 weeks of age, they experienced a rapid collapse on 7 September 2015,
something that you weren't involved with, transferred back to Arrowe Park.
GIBBS: That was a severe collapse requiring ventilation.
DE LA POER: Yes. There was -- they then came back to the Countess and there was a collapse on 21
September 2015 which you tell us about at paragraph 163.
GIBBS: Yes.
DE LA POER: And you were involved in the care of [Child G] following that deterioration and you
describe at paragraph 172 that you were slightly surprised at the time of the deterioration but not
too surprised?
GIBBS: Yes. I have a problem with -- and I think
there is a problem with -- what we mean by a collapse in a baby and I do mention this in my
statement and maybe we don't want to go into it in too much detail now. We recognise when a death
has occurred and we can monitor those events. I am not sure that we know exactly what a collapse is
in a child. Different people will mean different things. I wouldn't have said that [Child G]
collapsed in the morning of 21 September, had a vomit, dropped the oxygen level but actually didn't
need any resuscitation. Later on that same day, [Child G] dropped her oxygen levels again and did
need some resuscitation so that second one was more of a collapse. But in the literature different
definitions are used for "collapse", why does that matter, if you want to monitor collapse, there is
a warning that collapses may be recurring too often in a unit and might indicate a problem on that
unit. You need to be able to define what a collapse is and I wouldn't say Baby G [Child G] had a
collapse in the morning of 21st but she did have a collapse later on. "Collapse" normally means in
everyday language a fall to the ground often with loss of consciousness. That obviously doesn't
apply to babies, but whether you mean the heart or the breathing is compromised what level of
support that requires is all dependent on how you define a collapse. That's not so relevant to Baby
G [Child G] just now, it is relevant if you want to monitor collapses as a warning sign on a unit
that there is too many collapses going on.
DE LA POER: And in terms of your overall reflection following your involvement with [Child G], your
position was that you had some concern about the vomiting that you had been told about, but you
weren't otherwise concerned or suspicious about the circumstances that you had been involved in?
GIBBS: Yes, and could I just add with [Child G], I feel I was misleading myself, I felt [Child G]
was a very vulnerable baby, extremely premature baby. She had a number of collapses. I now know that
some of those collapses were induced by Letby. I didn't realise that at the time. So I felt this is
a baby who is prone to collapses so I wasn't too surprised when that baby had a few difficult spells
on that day and I must say when we come to it, the same applies to [Child I].
DE LA POER: If we move forward, please, to [Child H], this is paragraph 181 on page 54. Again, just
summarising, I hope I am using the word "collapse", maybe I will use the word "deterioration". There
was deterioration in [Child H] due to oxygen desaturation; is that right?
GIBBS: Yes.
DE LA POER: You conducted an assessment of [Child H] and [Child H] subsequently responded well; is
that right?
GIBBS: Yes.
DE LA POER: That's your paragraph 188, I think.
GIBBS: Yes, before then other doctors -- the Registrar had intervened and given treatment and at
that time, the baby responded well to the treatment.
DE LA POER: There were further collapses on 26 and 27 September 2015?
GIBBS: Yes.
DE LA POER: As you say you told the police that the number of sudden deteriorations were unusual in
such a short period of time?
GIBBS: Yes, and most of them at night, yes.
DE LA POER: What you say at paragraph 193 is that both you and Dr Jayaram noticed that Letby had
been the nurse caring for [Child H]?
GIBBS: Yes.
DE LA POER: So just to help us to understand that, was that a conversation between the two of you
at around this time in September or was that a subsequent conversation where you referred back to
[Child H]?
GIBBS: I can't clearly remember now. I think it's -- it was a looking back at it when we were trying
to make sense of the number of collapses and deaths that were
happening and then realising that Letby was around for many of the ones. Not all of them.
DE LA POER: So not at the time?
GIBBS: No, I knew she had been involved at the time because I was there helping baby -- [Child H]
and Letby, amongst many other nurses, was around helping. But trying to work out was she always
there for each of those and had she been there for previous collapses or deaths, that was looking
back at them when I started to get more concerned and I can't remember exactly when. I would say
towards the end of 2015 but more so at the beginning of 2016.
DE LA POER: I am just going to look briefly at an email that you sent to Dr Mittal, or Dr Mittal,
if I have pronounced that. INQ0103110. This is on 28 September. I make clear this isn't a reference to an
indictment baby. Your email is at the bottom and over the page. What I just wanted to ask you about
is on page 1, please. At the bottom, firstly if we just scroll up a tiny bit we will see Dr Mittal's
sign-off. He is a Consultant paediatrician in the community and designated doctor for safeguarding;
is that right?
GIBBS: Yes.
DE LA POER: You said in this email "we have had another
neonatal death"?
GIBBS: Yes.
DE LA POER: My question really was to what degree insofar as you were aware had Dr Mittal been kept
informed of the neonatal deaths that had taken place in 2015?
GIBBS: As designated doctor for safeguarding, we sent the CDOP, Child Death Overview Panel, forms to
Dr Mittal for each the deaths.
DE LA POER: So you would have expected that Dr Mittal had received such a form in respect of every
death --
GIBBS: Yes.
DE LA POER: -- on the neonatal unit?
GIBBS: Yes, but depending on where the child lived. He would have received forms for every baby on
the neonatal unit whose parents lived in West Cheshire. There were a few from the Wirral,
(redacted).
DE LA POER: Can I just stop you there. We are not going to go into the other areas, you haven't
said anything wrong, but were there other areas that would not have been sent to Dr Mittal?
GIBBS: I am not sure. I thought they all went to Dr Mittal or his secretary and those babies whose
parents didn't live in West Cheshire, those forms would be sent to the other areas. But the babies
who lived in West Cheshire would stay with Dr Mittal. Whether he was aware of the babies whose forms
had gone off to the other areas or not I don't know.
DE LA POER: Well, you can rest assured he will be asked. We are going to move forward to [Child I]
who died on 23 October -- we can take that down, thank you very much indeed, on 23 October 2005. You
deal with [Child I] at paragraph 196, page 58. Again, I will just do as I did before, try to
summarise what you say. That [Child I] was born at the Liverpool Women's Hospital, transferred to
Chester, transferred back to Liverpool and then transferred back to Chester. That's your 196. Is
that right?
GIBBS: Yes.
DE LA POER: There were significant breathing problems over three nights, you deal with that at
198?
GIBBS: Yes.
DE LA POER: Transferred back to Arrowe Park with suspected necrotising enterocolitis, (NEC)?
GIBBS: Yes.
DE LA POER: Back to Chester two days later?
GIBBS: Yes.
DE LA POER: And then five days after return to Chester, the sudden drop in oxygen saturation which
resulted in you being called in?
GIBBS: Yes.
DE LA POER: Upon arrival you found that [Child I] had improved remarkably, that's your paragraph
201; is that right?
GIBBS: Yes.
DE LA POER: You were then called back in just an hour later following the same pattern of
deterioration as you say at paragraph 203?
GIBBS: That's correct.
DE LA POER: [Child I] did not recover from that second deterioration that you attended?
GIBBS: Yes, tragically not, yes.
DE LA POER: Was, so far as you were concerned, [Child I]'s death sudden and unexpected?
GIBBS: To an extent. And the reason I say that it was a sudden collapse and [Child I] did it twice
that same night. But as you already recounted a few weeks earlier over consecutive nights [Child I]
had had serious collapses and Consultants had been called in each time so a little like [Child G], I
had gained the impression that [Child I] was quite a vulnerable, very premature baby -- had been a
very premature baby and was prone to these collapses. I didn't realise then that the earlier
collapses have now been attributed to harm by Letby. So I thought this was a baby who was quite
precarious who
decompensated quickly.
DE LA POER: You tell us at paragraph 4 that you were unsettled by [Child I]'s death?
GIBBS: Yes.
DE LA POER: Now, you have mentioned that the collapses the period before, one of the matters the
Inquiry is investigating is whether Letby was moved off the care of [Child I] on one shift because
of concern with her association with those collapses, so that's a matter that we are investigating.
My question for you is: is that something that you were aware of?
GIBBS: No.
DE LA POER: If that had occurred, is that something that you would have expected to be told
about?
GIBBS: It -- no, depending on the reason for moving a nurse off a particular -- was it off
particular shifts or off care of that particular patient?
DE LA POER: Off care of that particular baby is our present understanding, we are
investigating.
GIBBS: Oh, right. If it was thought that nurse was harming the baby then we should have -- well,
probably we should have all known. When I say "we", Consultants and senior nurses, not everyone in
the department. If it was a concern that -- which I had understood later on was the reason for
moving Nurse Letby off
different shifts, if it was a concern a nurse had been unfortunate in experiencing a series of
stressful conditions and therefore like we felt early on it was unfair on her, then to move her out
of that situation is not an unreasonable thing to do. So it depends on the reason she was moved from
that patient.
DE LA POER: If it was that first reason, ie somebody was sufficiently concerned that she might be
causing harm to the babies, so not for her emotional welfare --
GIBBS: Yes.
DE LA POER: -- is that a situation that you would expect that if somebody is taking that step, that
they would also take other steps as well, such as notifying senior management?
GIBBS: Yes. But she should be removed from all patient care in that situation, as happened much
later on.
DE LA POER: Yes.
GIBBS: Rather belatedly in June or July 2016.
DE LA POER: I am just going to read you part of the transcript from Mother I and just ask for your
comment on it, please. She says: "Dr Gibbs said that our baby was basically a full term baby and
these collapses shouldn't have kept happening. He mentioned about our baby having a postmortem
examination. I said I didn't want her to have one as I wanted her leaving alone but he informed me
that I didn't have a say and that she needed to have one as her death had been unexpected and the
results would be needed to clear the hospital." Is that a conversation that you can recall and if
so, what were the terms of it?
GIBBS: I can't recall that exact conversation. I can't imagine why or how I would ever have used
that final phrase. The reason for doing a postmortem in a baby who's just died is to try -- if you
need a post-mortem because you don't know the cause of death, is to find the cause of death for
reasons I have already mentioned in associated with [Child C]. It had nothing to do with clearing
the hospital or anyone else and I can't imagine -- I don't think -- well, it is difficult, I am sure
Mother thinks I said that, so I am not going to argue with her in her -- at the time in her grief. I
would never have said something like that. Now, she also said I forced her into having a postmortem.
I can understand why she felt like that. In the circumstances where a death is unexplained and you
need to refer the death to the Coroner, you don't --
parental consent doesn't come into it as far as I understand and postmortem has to take place if the
Coroner agrees and that's what I was trying to tell the Mother. It's -- one of the worst things as a
paediatrician is those occasions when you have to deal with a parent who's just lost their baby or
child and they are in utter despair and it is very difficult to talk about the child or baby having
a postmortem in those circumstances. I think most parents or some parents would hate me for bringing
that subject up.
DE LA POER: I just want to bring up another document to ask you a very focused question about it.
INQ003288.
GIBBS: Can I just make one comment about Mother I. I thought it was really kind of her in her
statement and in the transcript that although she said she didn't like me, I think something like
that, and that I had forced her into the postmortem, she did make the comment I think and it is in
her statement, that maybe it was the mood I was in or something like that, at the time, and that her
mother thought that I was fine who was there. That's very kind of her to add that, she didn't need
to add that because I am glad that at least to the Grandmother of [Child I], I didn't appear quite
so horrible as Mum perceived me, but I can understand
asking a parent -- well, telling a parent their baby has to have a postmortem would be received very
badly by some parents.
DE LA POER: Thank you very much indeed. This is on 26 November 2015. It is a meeting that you
attended neonatal mortality meeting. You deal with this in your witness statement. It is indicated
at the top the period of assessment is August to October 2015, but [Child E], as you observe in your
statement, is not included in this review. Do you know why?
GIBBS: No.
DE LA POER: Bearing in mind that that was the period of assessment, do you think [Child E] should
have been included in this review?
GIBBS: Yes, if [Child E] hadn't been reviewed in another meeting and as we say, this is the neonatal
mortality meeting. There are also perinatal obstetric and paediatric morbidity mortality meetings
that run at other times and Baby E [Child E] might have been discussed then. Do I know that Baby E
[Child E] definitely was discussed? No. I don't have a record of that, but I am not trying to put
all the responsibility on Dr Brearey as our lead for neonatology, if anyone has a record of that
when Baby E [Child E] was discussed at a morbidity meeting, Dr Brearey will hopefully have a record
of that.
DE LA POER: Thank you. We will move forward to the back end of 2015. [Child J]. You deal with
[Child J] at paragraph 213, page 63. Again, in summary, there were a number of desaturations and
seizures and your position as you set out at 224 was there was an explanation for the seizures but
not the desaturations.
GIBBS: I think a possible explanation for the seizures.
DE LA POER: Yes, possible explanation, but not for the desaturations?
GIBBS: No.
DE LA POER: Now --
GIBBS: But Baby J [Child J] was a complicated baby with -- it is all there, so I won't go through
it, with a problem we didn't often deal with, seldom dealt with on the neonatal unit related to her
bowel and the surgery she had undergone and the need to manage her stomas. So that increased the
number of unusual conditions that might have caused the problem to Baby J [Child J].
DE LA POER: But we are now, according to your statement and the evidence you have given, in the
general vicinity of when your concerns were starting to come to --
GIBBS: Yes.
DE LA POER: -- coalesce, if you like?
GIBBS: Yes, and I have to admit and I don't know how poor Baby J [Child J]'s parents might take it,
Baby J [Child J] didn't feature in my concern.
DE LA POER: Are you able to identify, and I know you have given this a lot of thought, whether it
was a particular incident that caused that or was it simply a thought that crossed your mind that
you began to focus on and think about more deeply?
GIBBS: Thinking of Baby I [Child I]'s death and then thinking back to Baby C [Child C]'s death, the
two babies I have been involved with, by the -- and it is not that I don't want to give a date, I
can't remember exactly when I became concerned something unusual, not natural, might be happening on
the unit, maybe the end of 2015 or early 2016 and when we come to it, the thematic review helped to
sort of concentrate the concern.
DE LA POER: At that stage when the concern first came to your mind, was Letby among the thoughts
connected?
GIBBS: I don't think so, when it first came to mind. But it -- looking back at them, talking to
colleagues realising the only common factor that we could identify was Letby, that became a concern,
yes.
DE LA POER: Do you think that was before the thematic review in February 2016 or after?
GIBBS: I am not sure. Maybe a bit before. The thematic view helped to confirm it.
DE LA POER: Can you recall which of your colleagues you were speaking to?
GIBBS: No.
DE LA POER: Are we talking Consultant colleagues --
GIBBS: Yes, yes.
DE LA POER: -- though? When Letby was first identified as being connected in your mind to the
concerns you had about something being wrong on the unit, and you were speaking to others, were you
speaking in terms of the possibility that she was causing deliberate harm?
GIBBS: I am not sure, which isn't -- doesn't mean I am saying no, I am not sure when I first had
those concerns that we were talking about deliberate harm but that did come later. It is something
that came up from time to time. I was aware of what had happened at Stepping Hill Hospital and I was
aware not only that patients had been harmed and some killed with insulin, that the wrong nurse was
accused because she happened to be on duty every time and someone else had done it but managed to
conceal their activities and so on. So thinking about might Letby have done it, I was also aware
that Letby might be completely innocent and it was just a coincidence as it was at Stepping Hill for
the nurse falsely accused.
DE LA POER: Although in the Stepping Hill case, there was
still a perpetrator?
GIBBS: Yes.
DE LA POER: Just not the person who was first identified?
GIBBS: Yes.
DE LA POER: So we will move forward to the thematic review of neonatal mortality, that's 8 February
2016.
GIBBS: Sorry, can I -- you are absolutely right about Stepping Hill. I was just trying to think. But
I had been aware and I have mentioned it earlier and we were talking about the earlier deaths that I
had been in a situation where I have had two cot deaths in one week and they happened in the
community and then another child from an accident dying. So within a short space of time expecting
just one death every year or two, there were three. So you don't have to have a perpetrator to be
unfortunate and be on duty when sad events keep happening. I did know that Staff Nurse Letby tended
to be around on the neonatal unit a bit more than other nurses because she did extra shifts.
DE LA POER: As these thoughts start to come to your mind, and I think as best we can we have
date-stamped them end of 2015/beginning of 2016 and at least the possibility that somebody might be
causing harm to babies, came to your mind, did it occur to you that bearing in mind
Stepping Hill, bearing in mind Beverley Allitt and insulin, that one useful investigation that might
have been done as 2015/2016 came about was to look back at insulin results, was that something that
you thought about as something that you could do at that stage in conjunction with your Consultant
colleagues?
GIBBS: No, it didn't. At that stage there was one insulin result by that stage.
DE LA POER: Well, quite. Do you agree that had you thought in those terms there was a result to be
found that would have immediately raised a very large red flag?
GIBBS: Yes. But I had been involved with Baby F [Child F] early in the morning, about 8, 8.30 in the
morning on the neonatal unit when his blood sugars were low and at that time I thought it was
possibly due to infection. I can't remember whether I knew he went on to have insulin blood tests
after that.
DE LA POER: The thematic review of neonatal mortality was -- just so that everybody understands it
-- arranged to look back at the deaths that had occurred over the course of 2015 and a doctor from
the Network was invited to join?
GIBBS: Yes. From the Neonatal Network.
DE LA POER: Yes, again I hope I pronounce this quickly, Dr Subhedar?
GIBBS: Subhedar.
DE LA POER: Thank you very much for the correction. You didn't attend yourself the meeting which
took place on 8 February?
GIBBS: That's correct.
DE LA POER: Before the meeting, did you have any discussion with Dr Brearey or Dr V who also
attended about Letby or any particular concerns you wanted them to take into that meeting?
GIBBS: I can't remember. I was -- and as far as I knew from informal discussions, I think all my
Consultant paediatric colleagues, so the other six, were concerned about the number of deaths and I
think around this time, by 2016, definitely the realisation that Letby was being involved with most
of them there were some deaths and collapses that I knew she wasn't around at the time but that --
that association was causing concern, yes. That is -- not particularly to look at Letby to look at
the deaths and try and find out why we had more than usual was the reason to have that thematic
review.
DE LA POER: Now, I don't need to show you it because you have seen it already, but we know that
there was a chart or spreadsheet produced by Eirian Powell at which
Letby's name was highlighted in red. Was this a document that you saw at the time?
GIBBS: I don't remember her name being highlighted in red. I did see the document with all the
nurses who had been on duty for those deaths entered into it. I don't recall Letby being highlighted
in red. I have seen several different versions of that document that were circulated between some
time after the 8 February and up to about beginning of March. I am not saying I never did. I can't
remember seeing one that highlighted anyone's name.
DE LA POER: We don't need to --
GIBBS: And you would have to look closely at it. You can see Letby's name for each of those, amongst
many other nurses. The association wouldn't be immediately obvious if you didn't spend a lot of time
trying to work out who is the common person.
DE LA POER: But it would be, do you agree, immediately obvious to you looking at it because by the
time that chart was produced, you had Letby's name in your mind?
GIBBS: Yes.
DE LA POER: So from your point of view, an informed reader, you could look at that chart and note
the frequency of the occurrence of her name?
GIBBS: Yes. Just a slight concern, as I say in my
statement. For some of those babies there were very few nurses's names and I find it difficult to
believe that all the nurses who are around on the unit at that time was recorded on that chart for
all of the babies and that just means just in case there is someone else that's been missed off.
DE LA POER: We will look at the thematic review document briefly in a moment when we get to the
finalised version in March, but there was a CQC visit on 16 to 18 February and some of your
Consultant colleagues were spoken to. I was just wondering, were you among the Consultants that were
spoken to by the CQC?
GIBBS: I don't remember being one of them. If I was, it obviously didn't stick in my mind, I don't
remember though. I knew there was a CQC visit going on.
DE LA POER: Would that meeting have been an appropriate forum, or indeed privately afterwards, to
raise with the CQC concerns about the neonatal mortality that existed at that time?
GIBBS: Yes, but I wouldn't have thought it's appropriate to talk about a particular member of staff.
There are other ways to deal with that rather than asking the CQC who happen to be visiting the
hospital about that.
DE LA POER: So not specifics in terms of members of staff
but that is an appropriate forum, whether publicly or privately, immediately after the meeting for
any Consultant who is speaking to an inspector to say: are you aware of the increasing
mortality?
GIBBS: Yes, or to indicate in some -- that we are struggling on the neonatal unit, yes.
DE LA POER: At the same time as the CQC visit, [Child K] collapsed. Forgive me?
GIBBS: Sorry, just to go back to that CQC visit. It is a bit inappropriate though -- and I don't
remember meeting the CQC inspectors, it is a bit inappropriate to just tell the CQC inspectors when
they happen to be visiting if you haven't tried to sort that out within your own Trust management
structure. It's almost like telling OFSTED you have got a problem with a teacher and you have never
told anyone in the school, it would have to be an OFSTED inspection, you have never tried to deal
with that problem within the school.
DE LA POER: But wasn't the position in -- on 17 February 2016 that the internal investigation at
the ward level had been conducted with input from the Network and there still wasn't a clear
explanation for the increase in deaths?
GIBBS: Yes, that's correct. The thematic review did identify some sub optimal care issues, none of
them thought to be very significant as in none of them thought to have caused any of the deaths. But
that thematic review did highlight, as will be obvious if you look at the review point number 1,
that there had been several -- it doesn't mention how many -- unexpected, unexplained deaths. That's
the worry.
DE LA POER: Yes, I am just wondering, bearing in mind that that had been identified by the CQC
visit, whether it wasn't time to tell the CQC about that and what your thought is on that
subject?
GIBBS: I would have thought you deal with that within the hospital first and then go to the CQC if
it's not been dealt with.
DE LA POER: So far as [Child K] was concerned, you don't mention [Child K]'s collapse in your
statement. That's not a criticism. Is that not something that you were involved in at the time?
GIBBS: That's correct. I don't think I ever saw [Child K] who was only on the unit for a relatively
short time.
DE LA POER: We then come to the revised thematic review of neonatal mortality and we can go
straight to the review and just look at a couple of parts of it. INQ0003251. So this is the updated version although the date remains the same
there, but you can take it from me that
this is the updated version. Page 7, the point that you have just made, that the first theme that
was added to this as against the original draft was: "Some of the babies suddenly and unexpectedly
deteriorated and there was no clear cause for the deterioration and death identified at
postmortem."?
GIBBS: Yes.
DE LA POER: The other matter to draw your attention to on this page is that it's been identified
that six babies from 9 had arrested between midnight and 4 in the morning?
GIBBS: Yes.
DE LA POER: Was that something that you were aware of at the time, that that trend had been
identified?
GIBBS: Not precisely, but I had been called in for some of those collapses -- these are all death
babies. Some of the deaths and indeed collapses, babies who didn't die, like the earlier collapses
of [Child I], the week or two before [Child I] died, and they were all seen to be occurring in the
early hours of the morning but I hadn't been involved in most of those. So I wasn't aware that I
knew that some of them had occurred at that time. I didn't realise 6 out of 9 had occurred then.
DE LA POER: Thank you. We can take that document down.
GIBBS: But I was aware of that once I saw this thematic review document.
DE LA POER: Of course. So that's 2 March. Now, on 7 April, around that time Letby was moved on to
day shifts. We know that now. What I would like to know from you, Dr Gibbs, is whether that's
something that you knew at the time?
GIBBS: I don't think I did. Some time later or maybe -- not at the time, no. Some time later, like
weeks later, I think I was aware and this I think, and I can't remember, it's trying to think back
to eight years ago. I did not know at the time she was moved off nights, no, I think I knew some
weeks later.
DE LA POER: If we move forward to [Child L] on 9 April 2016. Just going into the care that you were
involved in for [Child L]. By this stage in April of 2016, your suspicions had begun to coalesce, is
that right, that something was wrong on the unit?
GIBBS: Yes, and one aspect that made it more difficult to be not even sure, to try to help confirm
those suspicions, was that there was a very strong argument being put forward from the senior nurse
on the unit that this suspicion was totally wrong and that we were maligning Nurse Letby and that
she was a very competent, safe nurse.
DE LA POER: So just to be clear about that. The conversation that you are aware of that involved
the ward manager Eirian Powell saying that, did that occur before 9 April, was that?
GIBBS: Oh, I am not sure and my colleague Dr Brearey would probably know that because he met every
month to do the clinical incident review with Eirian Powell, the ward manager, and someone from the
risk management department. I think some of those meetings or in between those meetings Dr Brearey
had had discussions and email correspondence with those people, but he will have to confirm when he
had those meetings or discussions and what was said at those. I knew from Dr Brearey that there was
a very firm push-back from the senior nursing level that this was utterly wrong and we were being
unfair on Nurse Letby and I worried that were we being unfair, knowing about the nurse who was
wrongly accused in Stockport.
DE LA POER: But you still had a suspicion?
GIBBS: Yes.
DE LA POER: And so if matters had reached that point where you had a suspicion about Letby, would
say it appropriate at that time for you to do something?
GIBBS: Yes. But I knew efforts were being made by Dr Brearey to address that, not just with the ward
manager, but with the Medical Director and Director of Nursing. Exactly what he said and how he
conveyed that concern to those Senior Executives, he would have to explain.
DE LA POER: But if your suspicion was right -- and it is only a suspicion as you have told us --
then Letby might pose a very serious danger, wasn't that the natural consequence of your
suspicion?
GIBBS: Yes.
DE LA POER: If that is your reasoning at the time, doesn't that risk require immediate action?
GIBBS: Yes, it should have done. But perhaps I was and maybe we were -- but my colleagues have to
answer from themselves, the other paediatricians -- influenced by the conviction that we were wrong
from the nursing side. And I regret that we or I didn't go to the police at this time after the
thematic review. Why didn't I go straight to the police? Why didn't we paediatricians go straight to
the police? And I know that the parents of the later babies will not thank us for this, the
suspicion was that there might be something that had affected a number of babies, children on the
unit, and it would be best managed through the Senior Executives in the Trust and this is a similar
problem for why -- what do we do later on as well, why
didn't we go straight to the police and not keep trying to involve the senior managers? When you
have a major problem in a hospital, for example, that a whole serious of tests have been done
wrongly and people have been wrongly reassured that they didn't have cancer at screening tests, it
is a major incident, many patients, not just those affected, every one who has ever used that
service in that year, or due to use the service over the next year, is going to be very concerned
and that's why the Trust has communication teams and set up helplines and that's how you deal a
problem like that. Was I wrong to have waited for that to happen? The way things turned out, yes.
DE LA POER: There was of course an alternative route and we have discussed it already, to going
straight to the police, and that would be to involve the safeguarding department but that is just
not within the way you thought about things at the time; is that right?
GIBBS: Yes. The safeguarding department, from the paediatric point of view, is the appropriate
department to go to when you have concerns about a particular child or baby and how -- and I know
it's difficult saying this now we know what Letby was doing, it is if you have concerns about the
way the carers are managing the child
or baby. We did do that for babies on the neonatal unit, it is occasional, whose parents either
behaved in quite an irresponsible manner or didn't turn up to visit their baby, we would contact the
safeguarding team and social services and look at what support was needed for that family.
DE LA POER: We will move forward --
GIBBS: But it seemed more appropriate if you are worried about a series of problems going on over a
period of time, and where there is a member of staff, to involve Senior Executives than going to the
safeguarding team that I would normally -- and I might have been wrong -- expect to involve when you
have concerns about management of a particular child.
DE LA POER: [Child L], we know from the results that were taken that there was an indication that
insulin had been externally administered.
GIBBS: Yes.
DE LA POER: Was that something that you saw at the time?
GIBBS: No. I had dealt with [Child L] when his blood sugars were low. The blood tests were done --
had been done the day before, actually, but the results weren't back for -- it wasn't quite a week,
a few days later, as far as I can tell looking at the notes now in retrospect. I didn't know those
results at the time.
DE LA POER: You have accepted at 268 of your statement that your view is that this is a collective
failure on the part of the pediatricians, the page reference is 77.
GIBBS: Yes, for the same reasons as [Child F].
DE LA POER: Again you have used that phrase for with the benefit of hindsight. Are you there
indicating that is because you didn't know about it at the time?
GIBBS: Yes, I found out the results two years later whilst doing a police statement and reviewing
the records.
DE LA POER: But that is something that you could have known at the time?
GIBBS: Possibly. Consultant colleagues who were looking after the baby when the results came back
are more likely to have known at the time, and indeed if looking at the medical notes for Baby L
[Child L], some of the junior doctors did record those results in the notes but I wasn't around on
the ward at that time, I wasn't on duty, I wasn't the Consultant of the week for that baby when the
results came back. But Baby L [Child L] and M were followed up in my baby clinic and I only saw them
briefly because a new Consultant who started then, one of the new nine Consultants took over that
clinic. But it just shows that these babies were being seen by other people afterwards and the
result was sitting in their notes. But when you are seeing a baby in clinic a year or two later,
monitoring their development, you don't always look back at all the results they had done whilst
they were on the neonatal unit. But I think we all collectively have responsibility for missing
that.
DE LA POER: [Child M], 9 April 2016. [Child M] is the twin of [Child L]. [Child M] collapsed. Were
you aware of that collapse at the time?
GIBBS: Not at the time. I knew the following day when I saw [Child M] on the ward and he was doing
very well then. He had made a good recovery, complete recovery.
DE LA POER: At the time did you put that collapse of [Child M] in the category of the sudden and
unexpected deteriorations that are spoken about in the thematic review or did you not regard that as
suspicious at the time?
GIBBS: That added to concern, not because I saw [Child M] looking very well in the neonatal unit the
following day, which is fantastic he made such a good recovery, it is because my colleague Dr
Jayaram, who had been there at the time of the collapse and came in to help resuscitate Baby M
[Child M], he was concerned that there had been a sudden collapse. So I gained the concern from
what he had said.
DE LA POER: So again just help us with this in your thought process at the time. Before [Child M]'s
collapse you had reached a point where you thought there is a possibility that deliberate harm may
be being caused. Then there is another incident of potential further deliberate harm. Again, just
help us to understand why when you have that conversation with Dr Jayaram you are not saying: we
need to do something straight away about this?
GIBBS: Because it still wasn't clear that harm was happening to the babies. And why, despite that
thematic review, most of the babies had an explanation for their deaths from the ones that had had
the postmortem. That doesn't include all the babies. One of the babies who didn't have a postmortem
the clinician, my colleague at the time, felt that the doctor knew what had caused that baby's
death, not realising, as we now know, it was Letby. So because we had explanations for all the
deaths we -- I wasn't sure that harm had happened to these babies. Just because it's -- it's I think
an important concept that's going to come back when we talk about how we related to the managers
later on, we now classify those many of those deaths as unexpected, unexplained
and unusual. They were relatively unexpected but some of the babies did have lots of risk factors.
They were not completely unexplained; some of them had postmortems that seemed to explain the death
but they didn't explain it adequately when we looked back at it. But some of them had unusual
features like strange rashes. But because of all that, it wasn't clear that these were unexplained
deaths, they were deaths that had explanations that were not entirely satisfactory, especially when
we looked back at them.
DE LA POER: If we use the language of safeguarding which we see in Working Together, and we can
look at the page if we need to, but I am sure you don't, is safeguarding principles are engaged if
you think someone may have harmed a child?
GIBBS: Yes.
DE LA POER: Does that reflect your state of mind at the time?
GIBBS: Yes. But there was uncertainty about whether harm had happened to these babies. But because
there was the possibility we should have involved the police earlier some time in 2016 and I feel I
was at fault, and my colleagues have to speak for themselves, in not involving the police earlier
and trying to do that through the managers and that to get the communication
system and the helpline set up for parents and the general public who might be concerned.
DE LA POER: There was a meeting on 11 May of 2016, which you didn't attend. It was Dr Brearey
meeting with Mr Harvey and Ms Kelly, also present Nurse Powell. Going into that meeting, presumably
firstly you knew that that meeting was happening?
GIBBS: Yes.
DE LA POER: Was it your expectation that Dr Brearey would say in terms that there was a concern of
the possibility of deliberate harm?
GIBBS: Yes, and more than that, to actually say the suspicion had fallen on Nurse Letby: exactly
what he said to those two Senior Executives he will be able to tell you.
DE LA POER: Absolutely.
GIBBS: Also how he had asked him to go to that meeting and what level of concern had been expressed
when requesting that meeting and when he requested that, I am sure he will be able to tell you.
DE LA POER: But your expectation in terms of here he is going into speak for the group of you,
certainly speak for you, about the collective concern was not just that there is a concern about the
nurse, but even more than that, that there is a concern that she may be deliberately harming
babies?
GIBBS: Yes.
DE LA POER: And did you speak to him after the meeting?
GIBBS: Yes. I can't remember exactly where and when. He fed back to us that no decision had been
made but the senior managers were considering the problem and hopefully we would come to a decision.
That could have been a trigger, should have been a trigger that we bypass managers and went to the
police. And we failed to do that.
DE LA POER: We will just have a look at an email that Dr Brearey sent following that meeting, INQ0005721. You deal with this at paragraphs 270 and following on page 78, but
it is the email of 16 May that he sent. The first paragraph is a short summary from Dr Brearley to
his Consultant colleagues about the meeting. He describes it as a helpful meeting, sometimes Dr
Gibbs there is a difference between what people put in writing and what they say privately. What was
your understanding from having spoken to Dr Brearey about whether it was a good meeting or not?
GIBBS: I understood it wasn't a helpful meeting. Who's been copied into this?
DE LA POER: Eirian Powell has been copied in as has Ann Murphy?
GIBBS: Not the two Executives. I wondered whether the phrasing was representing who had got the
email but not -- yes.
DE LA POER: From your understanding from him, that wasn't what he was saying privately about the
meeting?
GIBBS: In some sense it had been helpful because I understood that Dr Brearey felt the Senior
Executives were becoming were understanding the issues. The unhelpful bit is nothing had been done
about it so it was partly helpful but the outcome was disappointing.
DE LA POER: You have told us that that outcome should have been a trigger for further action from
the Consultant paediatricians or certainly from you?
GIBBS: Yes.
DE LA POER: The second part speaks about coming across a baby who deteriorates suddenly or
unexpectedly or needs resuscitation to notify both Dr Brearey and Ms Powell and you were aware --
thank you, we can take that down -- that [Child N] suddenly and unexpectedly deteriorated, 3 June
and 15 June?
GIBBS: (Nods) I am not sure I knew about 3 June. It might have been mentioned at handover, we have a
handover when we are on-call. But I knew the deterioration on 15 June, yes.
DE LA POER: Bearing in mind what Dr Brearey had said
there, was that a collapse that you were directly aware of in [Child N] on 15 June something that
you spoke to him and Nurse Powell about?
GIBBS: No, I didn't, because he was involved in the collapse. It depends which collapse. Baby N
[Child N] on that day, [Child N] on that day had a number of deteriorations and created a lot of
difficulties needing a specialist team from Alder Hey to come over and assist and Dr Brearey was
involved in that. I was the only involved later on in the evening but I knew Dr Brearey and I am
fairly sure, but I can't remember now, Mrs Powell knew about those collapses on that day.
DE LA POER: So although you had received that email, in your mind Dr Brearey already knew about it,
didn't need to be told twice?
GIBBS: Yes, he was involved in it.
DE LA POER: We then move forward to [Child O] on 23 June of 2016. You deal with [Child O]'s care at
page 84 starting at paragraph 295 of your statement, and what you tell us at 297 is that you were
uncomfortable arriving on the neonatal unit to find [Child O] undergoing a resuscitation; is that
right?
GIBBS: Yes, yes. Can I just mention for [Child N], to go back for a moment?
DE LA POER: Of course.
GIBBS: Again, [Child N]'s parents might not be happy to hear this, but I wasn't that concerned that
his collapses were unexplained. They were strange. Eventually -- they haven't been properly
explained. He was a complicated little boy that had a blood disorder, it was thought he suffered a
bleed into his lung on the day he had these problems, on that 15 June, and there was a great deal of
difficulty from four -- two Consultants, two Consultant paediatricians, Consultant anaesthetist and
some of the Registrars at viewing his windpipe, trying to put a tube into his lungs to help him
breathe, because of a swelling and that could have been related to his bleeding disorder. So just
Baby N [Child N], I didn't -- it wasn't apparent to me that he had been harmed in any way, it was
more his complicated medical problems. As things turned out later on, and once he had gone to Alder
Hey and the specialist doctors there for the blood disorder looked on things, they felt it was
probably unlikely his blood disorder accounted for his problems but at the time and including when
the sad events happened to Baby O [Child O] and P [Child P], I felt [Child N]'s problems could have
a medical explanation.
DE LA POER: As you come into the NNU to find [Child O] undergoing resuscitation, was one of the
thoughts that you had that this was a further example of the sort of events that had been troubling
you and giving rise to your suspicion?
GIBBS: Yes, but not directly that it's Letby again. It was because, as I said, knowing what
happened, looking back on it, it sounds foolish to think just wasn't sure harm really was happening
on the unit, but my main concern is this is just yet another collapse on our unit, we have had far
too many. I didn't immediately think therefore this baby has been harmed and did Letby do it? So I
was just concerned there had been another sudden collapse.
DE LA POER: Do you think that the mental approach you were taking to the index of certainty that
you needed was perhaps wrong; in other words that you didn't need to conclude that you were sure
that deliberate harm was being caused before doing something, in fact -- and that was the way you
were thinking about it at the time but that in fact your approach should have been to apply a
different threshold?
GIBBS: It should have been a lower threshold, yes. I -- I don't -- I wasn't at the time thinking I
have got to be convinced that harm is happening, that I wasn't sure was harm happening at all, but
there was that suspicion and I didn't expect to be convinced because
it's -- it was only after a further detailed assessment over a long period of time that the fact
that harm had happened became more clear.
DE LA POER: Following the death of [Child O], did you have any discussions with those who were
present about the suspicions that had previously been in your mind?
GIBBS: Immediately after [Child O]'s death, no, I don't think I did. Again, I don't think I did.
There is nothing recorded in the notes that I know of in O or Brother P and I had come on to the
unit to -- I was on-call that evening. The resuscitation of [Child O] was already in progress when I
arrived on the unit. I turned my attention to the two other triplets, siblings and to check -- and
particularly to check for medical problems in them because when you have multiple births if one baby
has got a problem like an infection all of the babies in that group could be developing the same
problem or about to. And really there wasn't time to talk to other colleagues about it because I had
to deal with the other two babies and the colleagues who had been involved in the resuscitation
their focus was on the grieving parents.
DE LA POER: [Child P] died the following day, 24 June. Between the two deaths, were you aware of
any steps that your Consultant colleagues were taking to raise their
concern outside of the neonatal unit?
GIBBS: I am not sure that day. I can answer I was aware by Monday the 27th and as I mention in my
statement I can't remember the discussions that might have taken place on the 25th, I think -- no,
24th.
DE LA POER: 23rd for [Child O].
GIBBS: Yes.
DE LA POER: 24th for [Child P].
GIBBS: Yes. But the discussion was on -- that was a Friday, the 24th. I was in clinic that day. I
think I had found out that [Child P] had died after the clinic, but I can't remember exactly what
the discussions were because I muddled them between discussions we had, might have had that evening
and the discussions we definitely had about our concerns on the following Monday.
DE LA POER: We will --
GIBBS: But to answer your question, I was -- I did -- I was aware of what my colleagues, how my
colleagues had tried to raise the issue with concern specifically about Nurse Letby but I think it
was by Monday the 27th I was aware of that.
DE LA POER: That's when you became aware?
GIBBS: Yes. But I might have known in the evening of the 24th, I can't remember now.
DE LA POER: [Child Q] deteriorated on 25 June 2016. Were
you aware of that at the time?
GIBBS: Yes and we come to what we mean by collapse and deterioration. It happened in several stages.
I was aware he had had a deterioration in the morning of that day, the 25th, and then I was aware
that he had slowly deteriorated and needing ventilation that evening. It looked like a more medical
problem, a baby that's slowly got worse whose breathing reduced and then had to go on a ventilator
and we were covering him for infection at the time and it seemed to be more consistent with that
sort of medical problem.
DE LA POER: So does it come to this: going into the meeting on 27 June 2016, in your mind [Child O]
and [Child P] had been weighed into the balance in terms of the concerns you had but [Child Q]
hadn't?
GIBBS: Absolutely, yes. I was enough concerned about [Child Q] in the morning just to -- I mean,
it's in my statement so maybe we don't need to go there too much, just to ask some of the nurses on
the unit who had been looking after [Child Q] at the time. And I don't -- when a child collapses
your attention is why did they collapse, what had been wrong, what were the observations beforehand,
what were the indicators they were about to collapse. I never asked who was looking after them. So
it was unusual to ask that question.
DE LA POER: So in terms of marking a moment in time --
GIBBS: Yes.
DE LA POER: -- was that the first time that you were making investigations outside of the
Consultant body to ask others --
GIBBS: Yes.
DE LA POER: -- to give you information --
GIBBS: Yes.
DE LA POER: -- pertinent to your concerns?
GIBBS: Yes, and it was perhaps my rather feeble attempt to try and offer some protection, if some
harm was going on, that it was known on the unit that I was on-call that day, I was watching who was
doing what on the unit.
DE LA POER: So were you expecting that it would get back to all the nursing staff that Dr Gibbs
wanted to know who had care of [Child Q]?
GIBBS: Yes. Because I never normally ask that. When -- when -- and I didn't think [Child Q]'s
deterioration that morning was that significant. He wasn't that unwell, but I just -- any
deterioration was worrying us after Baby O [Child O] and P [Child P].
DE LA POER: So we come to the senior paediatrician meeting on 27 June of 2016. You probably don't
need to look it
up because you will recall it. But what you say in your statement is that: "All Consultants
expressed serious concerns about the number of deaths and the persistent association with
Letby."
GIBBS: Yes.
DE LA POER: Persistent association is one thing. In that meeting with your Consultant colleagues,
was the fact that she may be causing deliberate harm to babies spoken out loud?
GIBBS: I would be surprised if it wasn't. I can't recall exactly. I don't think there is any
recorded notes from that meeting, it was an unminuted meeting, and I would be surprised if we didn't
discuss it then. What might have inhibited us, the senior nurses were there as well and
relationships were proving difficult, becoming a bit difficult whenever we broached the subject --
well, I knew from Dr Brearey when he broached the subject of Nurse Letby it created problems with
the nursing staff, senior nursing staff. I am not sure of the more junior, the below ward manager
staff, I don't know if they knew anything about this at all at that time.
DE LA POER: What you say in your statement is that following the meeting, your understanding was
that
Dr Brearey telephoned the Medical Director Mr Harvey?
GIBBS: Yes.
DE LA POER: Do you know what he said to Mr Harvey in that conversation?
GIBBS: No, but I assumed he conveyed those concerns, including Nurse Letby to Mr Harvey, but he will
be able to confirm. Mr Harvey hopefully will be able to confirm.
DE LA POER: There is something of a record of that meeting, INQ0003116. If we go to page 2 and scroll down. This is Dr Brearey's email,
which you are copied into as is Mr Harvey. If you just scroll down, please. It may be easiest just
to leave the whole document on the screen. It begins: "I thought it might be helpful to put down in
an email what was discussed at the senior paediatricians meeting yesterday." So this is the 28th,
referring back: "~... significant concerns about the increased mortality, the sudden deterioration
of apparently well babies, no cause identified and the presence of one member of nursing staff at
these episodes. There has been a watchful waiting approach since our last meeting with Ian and
Alison in March." That may or may not be an incorrect date, we will
investigate that. It may be a reference to May. "However ~..."
GIBBS: I would have thought so, yes.
DE LA POER: "~... since the episodes and deaths last week there was a consensus at the senior
paediatricians meeting that we felt on the basis of ensuring patient safety on the NNU this member
of staff should not have any further patient contact on the NNU."
GIBBS: Yes.
DE LA POER: It goes on to refer to the external peer review, which is clearly a reference to a
conversation he has had with Mr Harvey. But in terms of capturing what the position of the senior
paediatricians was at lunchtime on 27 June, does that accord with your recollection?
GIBBS: Yes, it is.
DE LA POER: And if we scroll up to the top, so back to page 1. Again you can leave it on the full
screen. We can see a response from Karen Townsend just to Dr Brearey. So you weren't on copy for
this but we are going to look at the email at the top because it speaks about you. Dr Brearey
replies to Karen Townsend's email saying: "Just to confirm then Ian and Alison are happy for LL to
work on NNU in the same capacity as last week despite the Paediatric Consultant Body expressing our
concerns this may not be safe and that we prefer her not to have any further patient contact."
Largely saying the same thing as below, but in very direct terms. Did that represent your view at
the time?
GIBBS: Yes. I mean --
DE LA POER: Thank you. We can take that down. Now, the Inquiry understands, and again this is a
matter we will be investigating, that Letby worked day shifts on the 28th, so the day that that
email was sent the day after the paediatric Consultant meeting, the 29th, so the Wednesday of that
week and the 30th. Now, were you aware that she continued to be on the ward after that Consultant
paediatric meeting?
GIBBS: I must have been, I suppose, is the only honest way I can answer it. I am trying to think of
the meetings we had and yes, I think the determined efforts from us paediatricians to ensure that
Nurse Letby wasn't on the ward I can remember that at the meeting on 13 July. So I must have been
aware she was still around on the unit before then. I thought she was going on annual leave at that
time. So I don't know quite when she went on annual leave and how many days she was on the ward
before she went on annual leave.
DE LA POER: 1 July is our understanding and it is important that you don't guess here. So is it
fair, being fair to you that if she did continue on the ward that will have been something you were
aware of at the time?
GIBBS: Probably, yes.
DE LA POER: Well, bearing in mind that you are uncertain I don't want to ask you an unfair question
about that I will just move on.
GIBBS: I mean, should she have? No.
DE LA POER: Should she have? No?
GIBBS: Yes.
DE LA POER: And obviously at that time, the managers, senior managers were being consulted about
the next steps. As a Consultant paediatrician in that very difficult situation, if something is
unsafe is happening in your view and that you have raised it with senior managers and they say we
are comfortable with this level of risk, what is it that you should do?
GIBBS: Well, disagree with them. Is that what you're saying?
DE LA POER: Well, that's words. Does it require any action or do you simply engage with them
verbally?
GIBBS: I thought at this time -- I am just getting
the dates muddled. I am fairly sure at this time steps were being taken early July to downgrade the
unit.
DE LA POER: We haven't got to July yet. We are talking about the period 28, 29 and 30 June so
whilst, we understand, Letby was still on the ward --
GIBBS: Yes.
DE LA POER: -- post the assertions that have been made on the 27th and in writing on the 28th, that
the Consultant paediatric body feel that that's unsafe. I am just trying to understand how, as a
Consultant paediatrician, you manage that situation where that is your view.
GIBBS: Yes.
DE LA POER: The senior managers are not acting immediately upon it. What is it that --
GIBBS: Well, I should have done and we should have done something more definitive. But as I am
struggling to remember, I am not sure if I was aware she was still on the ward for those -- I
thought she was going off on annual leave but as you say that wasn't until 1 July. But in answer to
your question if we knew she was still on the ward and thought she might be harming patients, we
should have got her off the word or got the police involved then. But I can't remember if I was
aware she was still working on the ward.
DE LA POER: We have time, I think just before lunch, to look at an email thread on 29 June which
you were involved in starting with an email from Dr Saladi. INQ0003112. If we go to page 3, which is the bottom of the thread, you I am
sure will be very familiar seeing this again with Dr Saladi's email. I would like if I can just to
summarise it for you. What it comes to is -- and if you need to remind yourself, I don't want to
rush you, but what it comes to is Dr Saladi saying we need to contact the police. Do you recollect
--
GIBBS: Yes.
DE LA POER: -- and agree that that's a summary. If we just go over the page, so to page 4, the
substance of Dr Saladi's reasoning is there. I just wanted to ask you about the first sentence at
the top of the page: "We have moved this particular staff member from night shifts to day shifts and
from ITU care to HDU/SCBU care." You have told us that there came a point when you realised that
Letby had been moved from night shifts. Do you think that when you received Dr Saladi's email that
was news to you, the first time you heard about it, or do you think you had heard about that
earlier?
GIBBS: I knew she had been moved off night shifts earlier than that, we discussed it a bit earlier,
and it was because she had been unlucky and had difficult experiences and to give her more support
during the daytime. But it was -- you say that happened in April and I have seen it said I think in
the documents it said it happened in April. It was some time after that I became aware. I think I
knew she had been moved off night shifts before this particular email. I didn't know about her being
moved off ITU care to lower-level care.
DE LA POER: That was exactly what I was going to ask you about.
GIBBS: I didn't know.
DE LA POER: We obviously can ask Dr Saladi about that --
GIBBS: Yes.
DE LA POER: -- but that must have been the first time that you learned of that then?
GIBBS: Yes, and I mean Dr Saladi must have got that from somewhere. I wasn't aware that was true
actually.
DE LA POER: Thank you. If we go up to page 3, so to the next page again. We can leave it on the
whole page view. We can see that Dr Jayaram responds thanking Dr Saladi saying: "Steve and I are
trying to meet with senior execs
ASAP to discuss exactly this issue. However they do not seem to see the same degree of urgency as we
do. Until we meet them I am reluctant to go to external non-medical agency ie the police off my own
back. I am going to speak to the MDU today to find out where I stand as lead for the service with
regards to these concerns and I will share their thoughts with you all." So that was what Dr Jayaram
was saying at the time. If we then go to page 2, please. In fact, Mr Harvey was on copy to those
previous emails and replies: "Ravi - this is absolutely being treated with the same degree of
urgency. It has already been discussed and action is being taken. All emails cease forthwith. "We
will share with you what action we are taking." I just wanted to ask you Dr Gibbs whether you have a
recollection of receiving that email on 29 June and what your reaction to it was. We are going to
see the email that you sent in a moment, but what was your reaction to that email?
GIBBS: Well, partly pleased that the Senior Executives were treating this urgently. Yes, it was a
bit uncomfortable that we were told to cease all emails forthwith and as you can see from my email
we weren't going to do that. If you have serious concerns
we would carry on discussing them.
DE LA POER: Page 1. We see that you do exactly that. Starting your email: "Despite Ian asking us to
cease emails on the issue we are entitled to discuss our concerns with one another." You say: "We
are all agreed that something has to be done fairly quickly to try and ensure our neonatal patients
are protected. It is exactly what should be done and what if any information should be released
concerning this action that is difficult to decide and which no doubt is exercising our Senior
Executives minds." Now, you, Dr Gibbs, have mentioned a number of times the helpline and using the
communication department of the hospital, which is clearly a very important part of reassuring the
public. But should deciding on such things which may be complicated in terms of exactly what you are
saying to the outside world hold up taking immediate action to ensure safety?
GIBBS: No, but I am -- no, it shouldn't. The reason I made this comment is -- I might be wrong and
they will answer for themselves -- it was my understanding that they, that those sort of concerns:
how do we communicate this generally to
parents concerned, to the public would be exercised, they would be thinking about that.
DE LA POER: So you were effectively trying to walk in their shoes saying: I think that these are
the relevant factors that they will be considering?
GIBBS: Yes.
DE LA POER: Rather than you endorsing them as in fact being the right way of thinking about
them?
GIBBS: That's right and that's why they are not going to give us an immediate answer, that's why Dr
Jayaram was frustrated that he thought they weren't treating it urgently. Mr Harvey assured him that
he was treating it urgently; that it's not just shall we go to the police. It's shall we go to the
police and then what communication strategy do we put out because calling the police into to look at
the whole unit, as we know in the end, has to be managed through what you tell all the parents.
DE LA POER: Absolutely. But has going straight to that calling the police perhaps skipped a stage,
which is that patient safety is addressed internally in the first instance and that doesn't require
a communication strategy and I am just seeking your comment on whether that is being perhaps
overlooked in all of this; that there is -- immediate action needs to be taken internally, then a
big decision like the police can follow?
GIBBS: Yes, of course that has to happen. But hopefully that was what the managers were thinking
about. I don't think the Medical Director can go marching onto the ward and pull a nurse off the
ward. There has to be discussions with her line manager and presumably with the senior nurses and so
on to remove a person from their duties.
DE LA POER: And is that the position even if the entire Consultant body are saying that nurse is
unsafe?
GIBBS: That has -- that ought -- that action I just described ought to be done fairly quickly and I
think, I know we have looked at what Dr Brearey wrote. From my point of view it was not "This nurse
is unsafe", "This nurse might be unsafe." But you should treat that "might be" and "is" unsafe with
a similar degree of urgency, yes.
DE LA POER: We will just conclude this email by indicating that Dr Jayaram said on 29 June, 10:24
at the top of the email thread: "The Trust are contacting the police soon once some information
gathering has taken place which is why Ian has asked for the chit-chat to stop for now." And then he
makes a reference to a matter which is
in your lower email where you raise the possibility of air in the skull, which we don't need to look
at now. So was it your understanding at that time that the police would be involved imminently.
GIBBS: Yes, from that email. Yes, and it had taken us a long time and we delayed too long but at
last it looked like the right action was being taken.
MR DE LA POER: My Lady, would that be a convenient moment?
LADY JUSTICE THIRLWALL: Yes, thank you very much indeed. So we will rise now until 5 past 2. If you could be back by then, please, Dr Gibbs. (1.04 pm) (The lunch break) (2.05 pm)
LADY JUSTICE THIRLWALL: Yes, Mr De La Poer.
MR DE LA POER: Dr Gibbs we have reached a stage in my questioning where we are going to start to
focus more on what you were understanding the senior managers were doing, and of course --
GIBBS: But would you mind, Mr De La Poer, if -- I was finding it a bit difficult to answer some of
your questions just before lunch when you were rightly pointing out that I and perhaps my colleagues
should have acted more decisively earlier and I would just like
to try and offer a few explanations, none of which are adequate, that I was extremely concerned of
putting parents -- bereaved parents through the agony of a murder investigation if we got it
completely wrong and no one had harmed patients. Also, contrary to what Eirian Powells seems to have
put in her statement, I did listen to nurses, I valued their contribution although I might not
always agree with it and therefore the strong assertion from the nursing side that we got it
completely wrong and Letby had done nothing influenced me but did not convince me. Finally, I
suppose, just wrongly looking for some stronger indication there had been harm because no one on the
unit throughout that time seemed to have seen anyone harm a patient and also the postmortems that
had been done didn't seem to reveal any harm having been caused to patients. So all of those
contributed to me and maybe my colleagues, but they will have to let you know -- contributed to me
dithering at that time which is why I said at the beginning I am ashamed for not having protected
babies from harm, particularly the babies later on in 2016.
DE LA POER: Thank you very much indeed for that clarification, Dr Gibbs.
Before I move on to the next phase, it has been drawn my attention that I just need to ask you a few
more questions about the moment of that crystallisation, that's my word, not yours, of when things
moved to the front of your mind and you were thinking: I have concerns possibly about Letby. I think
that your evidence this morning was that that was some time before the end of 2015; have I got that
right?
GIBBS: Yes, I think I said and if I didn't, I am saying it now, I can't remember when I first -- I
mean if you say certainly after Baby I [Child I] died I didn't feel then that harm was being done to
these babies but I was feeling very uneasy that it was strange that we had had -- I had been
involved with two babies with such unusual deaths that I felt, and then after that and maybe late
2015 or early 2016, begun to worry that harm may have been happening on the unit, yes.
DE LA POER: So you have described a two-stage process there and you very much focused upon your own
internal thoughts. What I just wanted to clarify with you is whether it was around the time of
[Child I] that you voiced those thoughts, as they were at that time, to any of your colleagues or
whether you heard your colleagues voice any such thoughts at around that time?
GIBBS: Yes, after [Child I] -- after I had been involved with [Child I]'s death, so not at the time
of [Child I], and yes, I was beginning to talk about concerns there might be harm but I think that
was more early 2016. Now, I can't remember the dates and I am not trying to conceal anything. I just
do not remember. Some of my colleagues were concerned about harm I think earlier and I didn't agree
at that time that we are talking about when -- just because Letby had been around when a few
unfortunate -- a few worrying incidents happened that didn't mean she had done anything and just
because you have worrying incidents by themselves doesn't mean that someone is harming patients. So
maybe some of my colleagues -- and one in particular and he will be here to answer, to give his
evidence later, I think maybe Dr Brearley might have got worried a bit earlier than I did and maybe
that's because he was involved so closely in reviewing all the incidents in the monthly clinical
incident meetings. That doesn't mean he kept it secret from himself; he did discuss it with us. But
perhaps he developed concerns earlier than I did.
DE LA POER: And raised those concerns with you in some form or other and at the time of first
hearing them your instinct was to think: well, I am not sure I agree that this is a problem?
GIBBS: Yes, yes.
DE LA POER: So that the point when things start to become of concern for you, you had already heard
at least Dr Brearey voicing concerns and presumably that fed into your own concern --
GIBBS: Yes.
DE LA POER: -- at that time?
GIBBS: Yes.
DE LA POER: Again I appreciate it is a long time ago but doing your best to give us as close a date
as you can, [Child I] died in October 2015?
GIBBS: Yes.
DE LA POER: I think you have indicated your concerns arose after that, although not immediately
after that?
GIBBS: Yes, but that was a concern about strange deaths, not fully explaining [Child C] and [Child
I].
DE LA POER: Absolutely. In terms of Dr Brearey firstly raising with you that he was concerned about
strange deaths, did he discuss that with you before [Child I]?
GIBBS: I can't remember.
DE LA POER: In terms of when --
GIBBS: People were talking about strange events. The rashes in Baby A [Baby A]&B [BabyB] were
very strange and worried my colleagues and some of the Registrars, as you have seen in that email.
But as far as I remember, no one at that
time was any suggestion that someone has deliberately harmed patients. So concern about strange
events had happened from June 2015.
DE LA POER: But for your part in terms of unexplained or strange deaths, that was following [Child
I]?
GIBBS: We have accepted Baby A [Child A] and B [Child B] had strange rashes and Baby A [Child A]'s
death didn't appear to be properly explained.
DE LA POER: And Baby C [Child C] you have told us you weren't entirely satisfied --
GIBBS: Yes.
DE LA POER: -- following the postmortem --
GIBBS: Yes.
DE LA POER: -- and before the postmortem you considered it even less explicable?
GIBBS: Yes.
DE LA POER: So let's just, rather than focusing upon the moment --
GIBBS: But with Baby C [Child C], I had accepted the postmortem gave a cause for his death. As I
said earlier it didn't quite explain why that heart damage had happened but I assumed it might have
been from the poor blood flow before he was born and so on. So I am not saying I had no explanation
at all for his death and I think -- I don't know Baby C [Child C]'s parents would know otherwise,
I think that uncertainty we had discussed it together, but I had no inclination at that time any
harm had been done to Baby C [Child C].
DE LA POER: Just focusing on the moment when somebody other than you voiced out loud their concern
that perhaps deliberate harm was being caused, we know because you have told us that was before you
reached that point yourself. Are you able to help us with whether that was before or after [Child
I]?
GIBBS: I can't remember. Sorry.
DE LA POER: And just to complete this piece, the moment when you thought for the first time perhaps
deliberate harm is being caused, was that within 2015?
GIBBS: I am not sure. It could have been towards the end of 15 or early 16. I think the big worry
was after the thematic review.
DE LA POER: That's in February?
GIBBS: Yes, February.
DE LA POER: 2016.
GIBBS: One of the surprises, and maybe it shouldn't have been a surprise to me as a Consultant
working on the unit, I didn't realise there had been quite so many deaths either. So just the full
enormity of it started to hit me when I saw that thematic review.
DE LA POER: Thank you. I apologise to you that we didn't deal with that as a piece at the time. So
let's return, please, to late June of 2016. There were according to records two meetings on 29 and
30 June with Senior Executives attended by Dr Brearey, Dr Saladi and Dr Jayaram?
GIBBS: (Nods)
DE LA POER: I will come back to what they were told as you understood it in a moment, but before we
get to that, if we could please bring up INQ01002065. If we go to page 2, please, a document exhibited by Dr Saladi,
but which I think you have seen. We can see that on 30 June at 8.25 in the morning at the bottom the
thread Dr Jayaram circulates an article which you then comment upon and I hope I capture the
medicine correctly but fundamentally it is about air embolus?
GIBBS: Sorry, I am just reading it. I don't remember seeing this before, sorry. Maybe --
DE LA POER: If you haven't that's a failing of our process and I apologise. So take your time
reading it.
GIBBS: Maybe I have seen this. I can't remember amongst all the documents. But ...
DE LA POER: At all events, having taken a moment just to refresh your memory and it being an e-mail
that you were on copy to --
GIBBS: It is fine, it makes sense. Thank you, yes.
DE LA POER: Yes. Is it right that on Thursday, 30 June and following that there was a discussion,
whether in writing or in person, about the possibility of air embolus --
GIBBS: Yes.
DE LA POER: -- as between you and so that we are clear about it, what was being discussed was the
possibility of murder or attempted murder being caused by air embolus; in other words, the
deliberate application of it?
GIBBS: Yes.
DE LA POER: That was the context of this discussion?
GIBBS: Yes.
DE LA POER: So although not reaching any conclusions, the Consultants at this time are saying
between themselves: I wonder if Letby has murdered or attempted to murder children using air
embolus?
GIBBS: Yes, and that starts to answer a question, this is just speculation, that why did the
postmortem show no evidence of harm? It is a devious and subtle way of trying to harm patients which
tends to leave nothing behind afterwards for a postmortem to find, tends to. Some people, as was
argued at the Letby trial, there are some subtle indications that you can sometimes see postmortem,
difficult to distinguish the
air embolus changes from natural gas changes in a body postmortem.
DE LA POER: So that's your state of mind. It has reached that?
GIBBS: Yes.
DE LA POER: I am not suggesting everybody was sure that was what was the case, but it had
crystallised to: might Letby have killed and attempted to kill babies?
GIBBS: Yes, this is one way it might have been done and that no one noticed and there was nothing to
find in the babies. All of these concerns, including the concerns without knowing about the air
embolus, were without knowing about the insulin results. We didn't have to have the insulin results
to eventually come to the conclusion harm might have been occurring on the unit.
DE LA POER: And was this an important or unimportant step forward in your thinking at that time? I
mean what significance did you ascribe to this article and formulating the possibility in that
way?
GIBBS: I don't feel it helped much. It was useful in just realising silent ways, hidden ways of
killing that leave nothing at postmortem could have happened. As I have mentioned in this email, I
wasn't involved in the babies that had the rash that might have been due to air
embolus. That rash only occurred in very few babies in the paper that Dr Jayaram is quoting here and
those babies had different problems related to the nature of their ventilation from back in the
1970s and 80s so I wasn't sure that that paper really explained what we had seen in our babies but
it was interesting that the possibility of air embolus in a more subtle way might have explained
some of the collapses.
DE LA POER: Was that something that you ever yourself raised in a meeting as a potential
explanation for what might have happened?
GIBBS: Well, I am sure you are not trying to catch me out here, I --
DE LA POER: I am not. Your recollection?
GIBBS: Well, I did not raise air embolus at this stage, it was Dr Jayaram who found this paper. I
thought I had raised the possibility of air embolus after seeing this paper but I now think one of
the emails on 29 June, I talk about air inside the skull of one of the babies on a skeletal survey
X-ray done at postmortem and I wondered was that significant and that would have been air embolus as
well. That was -- I thought it was after seeing this paper. From the timeline of these emails, I had
suggested that before. The reason that didn't seem to take us anywhere is when I quickly looked
into: can you get air inside the body after death naturally, the answer is yes, so I thought that
didn't help.
DE LA POER: So you are absolutely right you did raise air inside the skull. In fact we didn't focus
on it but those emails where Mr Harvey said "all email traffic should cease", you then sent a
message to Dr Brearey and Dr Jayaram?
GIBBS: Yes.
DE LA POER: In fact that's on 29th. Your recollection is exactly correct?
GIBBS: Yes.
DE LA POER: My question was more directed --
LADY JUSTICE THIRLWALL: Didn't we look at that earlier?
MR DE LA POER: We did, yes, that was the one just before lunch.
LADY JUSTICE THIRLWALL: Yes, thank you.
MR DE LA POER: Absolutely. So far as my question was really going to whether or not you raised with
outside of your paediatric group -- obviously the paediatric group is talking about, whether you
raised with any of the managers in any of the meetings or anything like that, saying: look we have
been discussing air embolus, we are wondering whether that's something
that should be investigated?
GIBBS: I don't remember that. But I have seen in the various documents one of these meetings with
the managers around the end of June/beginning of July Dr Jayaram -- I have seen it written in the
handwritten notes -- raised that possibility.
DE LA POER: Yes.
GIBBS: I don't remember that.
DE LA POER: No.
GIBBS: But -- but likely to have been one of the meetings after he saw this paper and sent this
email round.
DE LA POER: Yes.
GIBBS: So yes, it was raised and I think it was with managers. But I can't remember which meeting
that was.
DE LA POER: Well, we will be asking Dr Jayaram about it and you are right about your recollection,
it does appear in minutes I was asking specifically about you?
GIBBS: No.
DE LA POER: But we will deal with -- you didn't?
GIBBS: I don't remember raising that, no, it was only in that email about the air in the skull which
I now know is a day before. I don't know that precipitated Dr Jayaram to start looking at this but
he found this paper the day after I raised the issue about the air in
the skull.
DE LA POER: 1 July, the day after this, we can bring that down. You deal with this in your witness
statement although I am sure I can remind you without inviting you to turn it up but I can give you
the reference. This is a meeting which you attended together with Dr Brearey and Dr Jayaram and
Stephen Cross?
GIBBS: Yes.
DE LA POER: Was present at that meeting?
GIBBS: Yes. Well, I will just qualify that sorry. I thought it was on 1 July. It was some time
around end of June/beginning of July and do you know where that meeting took place, have you got
that down anywhere?
DE LA POER: I'm afraid I can't answer that question confidently --
GIBBS: I thought Mr Cross had come to speak to us in what we call the conference room, the
paediatric seminar room, and I think that meeting on the 1st, looking at those documents, was in the
boardroom in which case I am not sure if that was the time I heard Mr Cross say that. But at some
stage, one of those meetings, and I can't give you the day around the end of June/beginning of July,
Mr Cross -- I was at a meeting where Mr Cross talked about the difficulties that might be caused by
the police coming to investigate.
DE LA POER: Do you want to just tell us best as you can recall what it is that he was saying?
GIBBS: That it would just be disruptive for the neonatal unit.
DE LA POER: And --
GIBBS: I also said in my statement I think he said it again the following year in June but I might
have -- and I qualified it in the statement, we met a then QC called Mr Medland and looking at what
he had said from his notes it almost mirrors what I thought Mr Cross has said to us around that time
in 2017. So I might -- it might not have been Mr Cross back in 2017. But it was around this time in
2016.
DE LA POER: And Mr Cross is saying it is disruptive?
GIBBS: Yes.
DE LA POER: I mean, was that just a statement to be weighed into the balance or was that a decisive
factor as to why the police shouldn't be called? What was the context for that assertion?
GIBBS: I took it to be that's one of the consequences of involving the police.
DE LA POER: Was there any discussion at that stage when the comment was made about well, yes, it
will be very disruptive but this is more important, or is that not how the conversation
developed?
GIBBS: Not that I recall. But to me it made no difference whether it be disruptive or not; involving
the police to investigate possible murders is going to have a massive impact particularly on the
parents concerned.
DE LA POER: Moving to 4 July. You say in your statement there was a meeting with the Chief
Executive. Again I can give you the reference but all that I wish to remind you is what you say in
the statement is you were told in that meeting there would be a review while Letby was on
holiday?
GIBBS: Yes, an internal hospital review and we knew at that time, and I don't remember exactly which
date, we knew there was going to be a Royal College review as well.
DE LA POER: Yes, we have seen that may have been one of the first things that Mr Harvey said to
Stephen Brearey, but we will hear about that --
GIBBS: But this is the hospital's own internal rapid, rapid inquiry to get done before Letby came
back from leave.
DE LA POER: What you say in your statement about this is that: "The Consultants agreed with the
senior managers to
delay calling the police and undertaking internal investigation as not aware anyone had witnessed
harm being caused." Would you like to turn that up or does that just accord with --
GIBBS: No, I accept that, yes. But at this stage, we knew Letby was off the unit and we hadn't
decided definitively what else we would do. But having Letby not on the unit was the right thing and
that did give us time to then consider other investigations. The problem was she going to come back
and that -- that cropped up later.
DE LA POER: Yes. Well, we will just have a look, spend a few moments looking at the review process.
Before we do, we just need to bring up an email dated 5 and 6 July INQ0002693. I am going to bring it up on screen and then I am hoping I will be
able to deal with it by way of summary, but it will be here if you need to check. This is an e-mail
thread, which you can see at the bottom of the first page, is about the comms message and if I can
summarise what we will see if we looked at it, there was concern within the Consultant body about
the way in which the hospital was characterising what was happening at the Countess of Chester; is
that right?
GIBBS: Yes.
DE LA POER: We can scroll?
GIBBS: Maybe minimising it a bit.
DE LA POER: Minimising it?
GIBBS: But I don't know -- personally I can understand trying to be careful how you put out a
message not to cause panic and unnecessary alarm.
DE LA POER: So if we just scroll down so that we --
GIBBS: That's different from misleading people.
DE LA POER: Absolutely. So if we just pause it there. The discussion which precedes this as I am
sure you can confirm was about the accuracy of that message and in particular the suggestion that
this wasn't outside expected statistical variation. That's the focus?
GIBBS: Yes.
DE LA POER: This is Dr Holt drawing specific attention to Regulation 20, the duty of candour. Was
the duty of candour something that you thought was engaged by the situation that was under
discussion?
GIBBS: I can't remember seeing this particular email. But it's fine, I mean, I knew of the doubt of
candour, so -- sorry, your question was?
DE LA POER: The question was: At this time were you thinking in terms of the duty of candour or
...
GIBBS: I find it difficult to know if -- and it came up much later as well when the police were
getting
involved and we knew we were moving towards the police getting involved, how much the duty of
candour might be compromised -- the answer could be never at all, might be compromised if you are
going through police and criminal investigations, how much you tell everyone about that?
DE LA POER: That of course is arising at the point at which the police are involved?
GIBBS: Yes, yes.
DE LA POER: So if we --
GIBBS: But without -- just the statistical bit because that's come up quite a lot, not just from
what the hospital said about these rises. Statistics are complicated and can easily use the wrong
statistics and come to the wrong conclusion. In these emails I was saying I wasn't sure -- we are
not saying they weren't, but actually increased -- the fairly substantial increased rate we had
would be statistically significant. Why on earth 13 deaths in that year period compared to 1-3
normally, why wouldn't that be significant? It is because you have to compare it to the 3,000
deliveries a year and the 400 babies that go through the neonatal unit and it is not so much the
numbers of deaths that was the concern. It was the nature of the deaths that was the worry. You
could have lots of reasons, genuine reasons, why you have an increased death rate and you would
expect the same sorts of death to happen but just more of them. These were unusual deaths. That was
the clue. So by saying there is not a statistical increase, I felt that wasn't -- I wasn't sure, I
felt it wasn't necessarily untrue to say that.
DE LA POER: If we just scroll to page 2, please. We will see that you --
GIBBS: Yes, I am sort of saying that, yes.
DE LA POER: You are saying exactly that in the final paragraph, I am not saying that we don't need
to take action. You are just querying whether factually the press release is incorrect?
GIBBS: Yes.
DE LA POER: And then you say this: "Even if the increase in neonatal mortality is actually not
statistically significant, and I am suggesting this might be the case, we should still be very
worried about it"?
GIBBS: Yes. It is almost like saying: we have a couple of extra deaths this year, that is not that
many above the normal. But they were both murders. We shouldn't worry about it because it is not
statistically above the normal death rate. It is nature of the deaths
that worried us, not just the fact there were more of them.
DE LA POER: Thank you very much indeed. We can take that down. I am going to just consider now the
review that you and Nurse Anne Martyn, as she was, conducted, and I am sure you will agree, having
looked at it all it, is quite involved and quite complicated?
GIBBS: Yes.
DE LA POER: Fortunately for us, you gave an explanation at the time, or certainly in early 2017 as
to how we should all understand it and we will just bring up that email as a way, I hope, of
shortcutting this. So we will go to INQ0005336 and to pages 6 and 7, please. 6 and 7, please. So does that look
familiar to you, that email?
GIBBS: Yes.
DE LA POER: Again we don't need to go through it, it can be looked over in greater detail. But is
that your best explanation for what that document means and does it represent your best recollection
of how that document was created?
GIBBS: Yes.
DE LA POER: Well, as I say --
GIBBS: But could I add? You mentioned I had
submitted a main statement and then a second statement --
DE LA POER: Yes.
GIBBS: -- on 6/9. I did submit a third statement on 20/9, I don't know if it got through, I can't
see it on the list here, and that is a re-analysis of this particular review.
DE LA POER: Well, I haven't seen that but that may well be my fault so please don't feel --
GIBBS: Right. It just changes things slightly. Most of what it says here is true. I realised, having
looked at the image of the handwritten notes that Anne Martyn had taken that the red text in the
transcript, which Anne Martyn and I hadn't done, the transcript had been made from Anne's written
notes, the red text does not indicate all the patients in whom we had concerns. I had to go back to
the original handwritten notes and there were six patients that we had concerns about. They were not
quite the six I am talking about here, four of them were the same, there were two others. It is
explained in my second supplementary statement I'm afraid.
DE LA POER: Well, can I thank you very much indeed for that statement and I am sure that it can be considered in due course.
LADY JUSTICE THIRLWALL: Did you say it was 20 September?
GIBBS: 20 September.
LADY JUSTICE THIRLWALL: Of this year?
GIBBS: Yes, yes.
LADY JUSTICE THIRLWALL: Thank you.
GIBBS: It wasn't that long ago, sorry.
LADY JUSTICE THIRLWALL: No, that's all right. That may explain where it is. We will have a look for it.
MR DE LA POER: We can take that document down. Let's just, if we can, headline this review. You and
Anne Martyn were asked to investigate babies who had been transferred out of the unit?
GIBBS: Yes.
DE LA POER: My phrase, not yours, but that was a proxy for unexpected collapse or potential
unexpected collapse. Wasn't it?
GIBBS: Yes, a proxy for a limited type of unexpected collapse.
DE LA POER: A subset of unexpected collapses and the thinking went, if I have understood it
correctly, that it is very difficult to work out unless you go through line by line of every note
and you were acting under pressure when there were unexpected collapses?
GIBBS: Yes.
DE LA POER: But one way of identifying some of the unexpected collapses was to identify those who
had been transferred out of the Countess?
GIBBS: Yes.
DE LA POER: You could then examine those.
GIBBS: Yes, and find which of those had had unexpected collapses, they weren't all unexpected
collapses leading to transfer.
DE LA POER: No, but it was as I say a proxy --
GIBBS: Yes.
DE LA POER: -- as a way -- a shorthand way of trying to look at least some of the unexpected
collapses?
GIBBS: Yes, that is right.
DE LA POER: As you have made clear, there were limitations to this exercise because unexpected
collapses for babies who weren't transferred out wouldn't be captured by the work that you did?
GIBBS: Yes.
DE LA POER: You deliberately didn't look at the staffing for those babies; is that right?
GIBBS: That's correct. I was told a staffing analysis would be done afterwards.
DE LA POER: And the upshot --
GIBBS: I was looking at the -- I was looking at the
medical notes so I could see which doctors had written the notes. So to be fair I knew the doctors,
I didn't know anything about which nurses had been involved.
DE LA POER: You, with the support of Ms Martyn, who was helping you with the exercise but it was
your clinical judgment that counted, identified six unexpected collapses which you regarded as being
of concern?
GIBBS: I would say unusual collapses. Probably I have to go back to all six, probably some of them
unexpected, others were unusual in some way. But that was a quick review of the notes. I didn't
examine all the notes in any detail and I have to mistake one admission: Baby F [Child F] was one
the babies transferred out and Baby F [Child F] is the one that had the abnormal insulin results and
I said any of us could have seen it at any time, including during this review. But Baby F [Child F]
was transferred out when he was entirely well because the Family lived outside West Cheshire and he
was going back home. So as soon as we saw that, we stopped looking at him in the review.
DE LA POER: So I am sure you will be the first to agree, not a forensic analysis?
GIBBS: Certainly not.
DE LA POER: And in fact not an analysis that resulted in any kind of formal report from you in
writing?
GIBBS: No, because the notes -- Anne gave the notes to another colleague and I mention in my
statement who I think it was, but that's who I think it was, so I don't know it was that person and
it went off for -- to be further analysed.
DE LA POER: Your expectation was that a staffing analysis would then be done based upon the work
that you had done?
GIBBS: At least a staffing analysis, yes.
DE LA POER: In paragraph 93 of your statement, you state that you presented the findings to the
Medical Director and other Consultants in mid-July?
GIBBS: Sorry?
DE LA POER: Presented the findings to the Medical Director and other Consultants in mid-July, would
you like to look at the reference?
GIBBS: No, I never presented the findings. The findings were presented in mid-July.
DE LA POER: They were presented, forgive me.
GIBBS: The findings of the hospital's internal review was presented on 13 July. Now, I was part of
that review doing this particular review of patients transferred out of the unit. That didn't
actually feature in the presentation. I thought it was going to.
DE LA POER: When you handed over the notes, which
certainly to a layperson are not the easiest to follow because they are your working notes, did you
say in terms: look, there are six children here that we think need a closer look?
GIBBS: No. We said, as far as I remember handing it over, we have identified some of the babies in
whom we think there are unusual reasons for transferring them out.
DE LA POER: Then left it to others to read your notes?
GIBBS: Yes.
DE LA POER: Work out which ones those were?
GIBBS: Yes.
DE LA POER: And to go from there?
GIBBS: Yes.
DE LA POER: A meeting took place on 13 July of 2016 and you deal with this at paragraph 388 of your
statement. You give the date there as 13/6/2016 but it may be that's a typo?
GIBBS: Sorry, where is that?
DE LA POER: 388 on page 110.
GIBBS: Where's the typo, sorry?
DE LA POER: The date is 13 June 2016, I am suggesting?
GIBBS: July.
DE LA POER: It is 13 July?
GIBBS: That's a typo, sorry, I thought I got the year wrong. No, the month is wrong, sorry.
DE LA POER: Month. Yes, and you have had a chance to see the handwritten notes of that meeting and,
broadly speaking, do they accord with your recollection of what occurred at that meeting?
GIBBS: Yes.
DE LA POER: And you deal in your statement with some of the discussion. One of the things that Mr
Chambers is recorded as saying you deal with this at the end of the paragraph: "There is a
correlation with nurse but [recorded in block capitals in the notes] we know a change in acuity and
activity plus staffing levels were challenged"?
GIBBS: Yes.
DE LA POER: I just wanted to ask you there about a position paper that was written which has a number of graphs and so on in it because you talk about a presentation being made in terms of the activity and acuity. We don't need to look at the whole position paper, we just need to identify it. INQ0003492. Unfortunately it is on its side.
LADY JUSTICE THIRLWALL: Do you know how to rotate it?
MR DE LA POER: It may be, because this can form part of the Inquiry record, it doesn't matter. If
we
could just go to page 11, and I apologise, Dr Gibbs, this is hardly the ideal circumstances, but
this is a document that has been sent to you before, I believe?
GIBBS: Yes.
DE LA POER: We can see some findings presented there about acuity and activity and on the preceding
pages there are a number of graphs?
GIBBS: This position paper is useful and quite helpful and I only saw it when it came through with
the Inquiry documents.
DE LA POER: That was really my question, whether or not this position paper itself was presented to
you or whether the PowerPoint presentation that you speak about was something different?
GIBBS: Just the PowerPoint presentation.
DE LA POER: Just the PowerPoint?
GIBBS: Yes, I saw this particular paper for the first team when the Inquiry Team sent it through.
DE LA POER: I understand, thank you very much indeed. We can take that down.
GIBBS: The emphasis of that presentation was, as we have just seen there, there was some increased
activity, numbers of babies, there was some increase in illness on average with those babies and
what we knew already, we were not up to the normal staffing levels like most of
the other units weren't. But that that was 2015/16. Those graphs also show those same problems in
2014 where there had been very few deaths.
DE LA POER: So were you unpersuaded by what was being suggested was the correct interpretation?
GIBBS: Yes, yes.
DE LA POER: You were?
GIBBS: Yes, but I did accept that because -- because of those reasons, that could cause a few more
deaths but if you had a few more deaths because you were very busy, didn't have enough staff and so
on, by and large those would be the same sorts of deaths you would normally see but a few more of
them unfortunately. And if you are busier, you might just get the extra death because you had more
patients.
DE LA POER: What you say in your witness statements is that the Consultant paediatricians pointed
to the fact it wasn't just the increase but the fact that deteriorations were unexpected and
sudden?
GIBBS: Yes, and from the handwritten notes of that meeting on the 13th, you can see some comments
that say exactly that.
DE LA POER: Now, in terms of what the Executives' view at that meeting was, can it be summarised in
this way that
it was wait for the Royal College's visit and report?
GIBBS: Yes, it seemed to be accepted that those graphs, with the changes we have mentioned, could
explain the increased death rate and yes, they could explain an increase in the death rate. I don't
want to get stuck in the statistics, which are always difficult. I am not sure it would have
explained quite such an increase in the death rate. It did not explain the unusual nature of the
deaths and that was mentioned at the meeting. But even so, we had agreed, we Consultants -- and I
was one of them who agreed -- we would look at the Royal College's review of our service.
DE LA POER: What you say at paragraph 403 is: "Several of us, including myself, considered that
since our concerns about Letby were purely circumstantial and the hospital's investigation had
indicated an appreciable increase in workload pressure that might explain the higher rate of adverse
outcomes, that it would be best to wait for the RCPCH review of our neonatal service to see whether
it supported the findings of the hospital's hurried investigation and then to decide on police
involvement"?
GIBBS: Yes.
DE LA POER: Now, just help us to understand how on the one hand your view was that the charts that
you were being presented with didn't provide an adequate explanation?
GIBBS: Didn't seem to.
DE LA POER: Didn't seem to?
GIBBS: Couldn't say absolutely not.
DE LA POER: No, but that was your impression at the time, and that they failed to capture the thing
that was uppermost in your mind which was the sudden and unexpected unusual cases that you were
dealing with. Why in those circumstances were you content to wait until the RCPCH had reported
rather than saying: this data is not what you think it is, we need to go to the police now?
GIBBS: Two reasons: we were hopeful the RCPCH review would clarify whether the deaths were unusual
and could be explained by what they were going to examine as stresses and pressures in our unit. And
secondly, as came up in this meeting, what we hadn't ensured before, which we should have done, that
we did not want Letby back on the unit until this had been sorted out. Now, that delayed getting
answers for the parents whose babies had been harmed, it prevented any more babies being harmed
while these further assessments were ongoing. We had hoped we would have an answer by mid/end of
September after the College review at the beginning of September.
DE LA POER: What you say at paragraph 404: "All of us Consultant paediatricians were adamant that
if the police were not to be involved at this stage and if Letby was to continue on the NNU, she had
to be closely monitored in case she had harmed babies"?
GIBBS: Yes.
DE LA POER: So is this right, that at least your position and the position you understood of
others, was that Letby could return to the unit but only under close supervision as opposed to
requiring that she be excluded altogether?
GIBBS: Yes, at that time. But close supervision was CCTV cameras and/or she had to be supervised by
another nurse all the time. I didn't think that was likely to be possible. They would not get --
CCTV cameras are an issue that the Inquiry is looking at. We would never have got them up by the
time she was back from holiday in a few days' time even if they would rush in a set of CCTV cameras.
So in a way it was a slightly convoluted way of just trying to make it rather difficult for her to
come back.
DE LA POER: We know, in the event, no supervision could be found and she did not in fact return
--
GIBBS: Yes.
DE LA POER: -- to the unit as a practising nurse when she
came back from holiday. If we just keep moving through. On 19 July, Dr Jayaram sent an email. We can
bring it up if you need to, but if I summarise its content for you. He suggested that the
paediatricians thought the Neonatal Network should be involved in what was occurring --
GIBBS: Yes.
DE LA POER: -- at the Countess?
GIBBS: Yes.
DE LA POER: Did that accord with your view at the time?
GIBBS: Yes, we had hoped the College review that was due in September might help to clarify matters.
But particularly for the hospital's own internal review it would be useful if outside the hospital
but still within the region, neonatologists could offer some advice on the graphs that we had seen.
DE LA POER: And when did you learn that the Network would not be involved?
GIBBS: I didn't find out whether they would or wouldn't afterwards, no. But Dr Subhedar, who had
been involved back in February 2016, did get involved later.
DE LA POER: Absolutely, when we come to February/March.
GIBBS: He represents part of the Network but I don't think he was involved at this time. But that
was either
him or the whole Network, I think as Dr Jayaram mentions in his email it was the intention of trying
to get those people involved again to offer advice to the Trust.
DE LA POER: If we then move forward to 1 September and the interview with the RCPCH. You deal with
this at paragraph 411 having -- and we thank you for this -- gone through all the notes of the
discussion which took place. What you say is: "The main issue discussed as needing fixing was the
concern that we expressed over the number of deaths in 2015 and the first half of 2016. Many were
unexpected and frequent poor response to the resuscitation was unusual and few babies exhibited
strange mottling of the skin." Then you go on: "Babies who deteriorated several times on our NNU
seemed to be stable once transferred elsewhere. The cause of death was uncertain in some cases even
after a postmortem. The increased number of deaths and non-fatal collapses had caused significant
distress among the medical and nursing staff. "Finally we mentioned that we hoped we could again
move back to being a Level 2 NNU and that we all like working with neonates."
GIBBS: Yes.
DE LA POER: Just pausing, just a footnote to that. In July the unit had been downgraded --
GIBBS: Yes.
DE LA POER: -- to a Level 1?
GIBBS: Yes.
DE LA POER: This is a reference to the fact you wished to return to Level 2?
GIBBS: Yes, by "downgraded", less beds and not the most intensive babies; so lower risk babies, less
of them.
DE LA POER: Now you then go on to say: "Neither the handwritten notes of this interview nor the
typed transcript record concerns about Letby"?
GIBBS: Yes.
DE LA POER: "I cannot remember if we mentioned her by name but I thought we had told the review
team that we were worried about a particular nurse being associated with most the deaths and also
non-fatal collapses. Perhaps we mentioned this to the review team outside of our interview
session."
GIBBS: Yes, there was a comment I mention there. It is hard to decipher and understand what was
meant but Dr Saladi, one of my colleagues, might be able to add to that. He made a comment that is
recorded in his handwritten notes that may allude to a problem with
a member of staff. But the Royal College paediatrician and neonatologist and specialist nurse
weren't there to do a staffing analysis or look at individual staff. So if we didn't mention her,
that wouldn't have bothered me. We wanted their opinion on the nature of the deaths and whether it
could be accounted for by pressures on our unit.
DE LA POER: Now, at paragraph 411 you were asked to comment upon what you had said to Facere Melius
in terms of the RCPCH review feeling like a bit of a waste of time?
GIBBS: Yes.
DE LA POER: Do you want to just tell us what you did in fact think the value or otherwise of the
RCPCH visit was?
GIBBS: Right. The main value was that it did not -- the reviewers did not find any clear explanation
for why we had an increased death rate and the unusual nature of the deaths and they felt that the
-- that those questions could not be properly answered until a detailed external expert had reviewed
the deaths. And the bit about -- I am sort of rude to the Royal College of which I am a member or a
Fellow. We were hoping they would pass some sort of judgement on that. But they did say when they
came that they weren't
going to look at individual deaths but I think they did see an overview of the deaths which might
have been something like that thematic review but I am not sure. We knew they were not going to look
at staffing -- well, they looked at staffing levels. They were not going to look at individual
members of staff and say who did what, or anything like that. But it is just disappointing that they
didn't pass opinion on whether they felt the deaths were explained by pressures on my unit.
DE LA POER: You do say, however, you found it reassuring they recommended an external review?
GIBBS: Yes.
DE LA POER: That being a reference --
GIBBS: Yes.
DE LA POER: -- as it turned out to be to Dr Jane Hawdon?
GIBBS: That was good. But the disadvantage was that it prolonged the whole assessment, but that's a
necessary thing to do.
DE LA POER: When you learned that there was going to be further delay having hoped that there would
be a response or a conclusion by September did you return at any point as far as the Executives were
concerned to the idea that the police needed to be called at that stage or were you content to let
it run its course?
GIBBS: Content to let it run its course because Staff Nurse Letby was not on the unit. As I say a
bit earlier, as you pointed out, we had decided if she did come back we would have to take dramatic
action, which would probably mean going to the police, but we didn't have a definite plan of when
and how we would do that.
DE LA POER: Just help me with that. At what point best you can say was there an agreement between
some or all of the Consultants that if she did come back on the ward, you would go directly to the
police?
GIBBS: I don't think we had a formal agreement about that, that was just a discussion between us
because what comes up later is when after these reviews were looked at and presented to us by Senior
Executives there was a plan to bring her back and we had some discussion about what would happen
then.
DE LA POER: If we come forward to October 2016 and in particular to the grievance process that we
know that Letby had commenced, you deal at paragraph 418 and make comment upon matters that have
been drawn to your attention in relation to what Eirian Powell had said?
GIBBS: Sorry, which paragraph was this?
DE LA POER: 418 unless?
GIBBS: 18 -- 18, right.
DE LA POER: Yes.
GIBBS: 417 onwards.
DE LA POER: 417 onwards, yes, forgive me. That's the context. I am less interested in what Eirian
Powell was saying about you in that, more about what you say you were doing at 418. You say this:
"However, I advised that we should be cautious in necessarily attributing a causal relationship with
Letby and mentioned the case of a nurse accused of patient harm at Stepping Hill Hospital in
Stockport?"
GIBBS: Yes.
DE LA POER: And you say that in the context of Eirian Powell's comments about you in October. Can
you just help us with when you were advising that caution?
GIBBS: Oh right, I don't remember and I thought that was relatively early on.
DE LA POER: So this isn't now --
GIBBS: No.
DE LA POER: -- after the Executives had been contacted?
GIBBS: No, no. Well, I have no idea. I don't know why Eirian Powell made that comment given that
Consultants never listen to nurses and so on. I don't know why she made that comment about me. But I
am only speculating why she might have made that.
DE LA POER: You give us a bit more detail in 419 so
I think you should see that. Although you say you don't remember, you say that in terms of your own
approach: "As suspicions about Letby increased in late 2015 and into 2016 I avoided discussing this
concern openly on the NNU with the neonatal nurses because I felt this was inappropriate and
unprofessional."
GIBBS: Yes.
DE LA POER: You go on to say that you may have discussed Stepping Hill Hospital with Eirian
Powell?
GIBBS: Yes, or amongst the Consultants, but obviously Eirian, if she is saying -- if that's why she
said I was a voice of reason she must have heard that. So it might have been one the meetings when
she was there that we had on the Monday lunchtimes.
DE LA POER: Again your focus there when talking about Stepping Hill is about the nurse who hadn't
--
GIBBS: Yes.
DE LA POER: -- killed anyone rather than the nurse who had poisoned patients?
GIBBS: Yes.
DE LA POER: Why do you think that was your focus from that incident?
GIBBS: Well, it's simply saying there is a correlation between a nurse and being present at
certain incidents, that's what led to the wrong nurse being arrested initially in Stockport.
DE LA POER: So it was the parallel what was being said about Letby specifically in terms of
association --
GIBBS: Yes.
DE LA POER: -- that brought --
GIBBS: Yes.
DE LA POER: -- the innocent nurse at Stepping Hill to mind as opposed to the guilty nurse?
GIBBS: Yes, yes, and I think we don't want to go there too much because of what's been said about
the Letby trials, but there are other nurses who have been accused of harming children because they
seem to be around at the wrong times that then there's been doubt cast afterwards.
DE LA POER: Well, in terms of what you were saying --
GIBBS: But this was the Stepping Hill.
DE LA POER: You were talking about Stepping Hill?
GIBBS: Yes.
DE LA POER: Now, 10 November 2016 is the date on which Dr Brearey tells us that he reviewed the
RCPCH report and he described circumstances where he was given an hour and he says that you were
present at that. Is he right about that, that you in November reviewed the RCPCH report for an
hour?
GIBBS: I don't remember being there. No. And actually when these reports were presented to us by the
Senior Executives on 26 January 17, there is a comment in the handwritten notes from Mr Harvey
saying that Dr Jayaram and Dr Brearey had reviewed the notes in his office, he didn't say me, I
don't remember it being me. If you say am I absolutely certain I didn't see them there, no, I don't
remember it though.
DE LA POER: Certainly we are going to come now to that meeting on 26 January and you deal with this
at paragraph 423 at page 121 onwards. There are notes of the meeting which I think you have had an
opportunity recently to consider although you didn't see at the time and there is no part of those
notes that you think is wrong?
GIBBS: That's correct, yes.
DE LA POER: Whether or not they capture the full tone and content of the meeting is really what I
want to ask you about. Can you just give us a summary of that meeting and your experience of it?
GIBBS: Yes. I -- many of the -- some of the notes of meetings I was at including that one, when I
look back at the notes, although I am trying to think back seven years or something, they don't seem
to capture everything and I think some were just writing notes down, not by shorthand, we will never
get everything down that's said in a meeting unless you have someone as in the Inquiry doing it word
by word. But I suppose they don't convey the emotion of that meeting and I found it quite an
emotional stern meeting. You don't get that from just the notes written down. Do you want me to run
through the meeting?
DE LA POER: Absolutely. In terms of, firstly, was it a discussion sort of meeting or was it the
paediatricians making a presentation or was it the Executive Directors making a presentation?
GIBBS: It is Executives making a presentation telling us the findings and then telling us the action
that needed to be taken without any discussion. I think there was a chance for discussion at the
end. I think Dr Brearey and Dr Jayaram just managed to ask: can we see these reports? I was too
stunned to ask anything at the end of that meeting. My head was swirling. I didn't quite understand
what had happened.
DE LA POER: What stunned you?
GIBBS: The nature of the meeting because I thought we were going to that meeting for the first time,
because I don't think I had seen those the College report briefly in Mr Harvey's office, although
maybe I did, but we were going to see the two reports, the College report
and Dr Hawdon's external expert review of the deaths and a few of the collapses and we would have a
discussion about it. I didn't realise we were going just for a brief presentation summary of those
reports and then to be told what needed to be done.
DE LA POER: Now, one of the matters recorded in the notes of the meeting is words to the effect
were said: "review by a high power team didn't call out any criminality, draw a line".
GIBBS: Yes.
DE LA POER: Does that capture the sort of thing that you were being told by the Executive
Director?
GIBBS: Yes. What we were told initially by the Medical Director was that the College report had
shown poor leadership on the unit, poor communication, and it just sounded so negative. And I felt
so bad that that's how our unit was perceived, but perceived by eminent peers who had come in to
review our unit. Then Dr Hawdon's report hadn't shown any concerns, I think it was no common factor
to account for the deaths. I don't think Dr Hawdon had any staffing analysis or anything, but no
common factor from the medical side. And then we were -- I say it was emotional, a letter was read
out from Letby by one of the senior
nurses in a quite emotional tone and then we were told how much we had upset Letby by the Chief
Executive and told firmly that the board had accepted the findings that there had been no evidence
of any wrongdoing and that Letby was exonerated -- I don't know if he used the word "exonerated" --
but no evidence against her and that a line was being drawn under this and that was said quite
firmly. I thought the Chief Executive finished by saying, "Is that clear?" as he looked round the
room at each of us. I think some of my colleagues thought he said something slightly differently but
they can report on that.
DE LA POER: We are interested of course in your recollection --
GIBBS: But it was clear that was the end of it. The board had accepted these reports had shown no
wrongdoing and we were to apologise to Letby.
DE LA POER: You used the word "shocked" in your witness statement.
GIBBS: Yes.
DE LA POER: Particularly by reference to the fact that you hadn't reviewed at that time either the
RCPCH or the Dr Hawdon report?
GIBBS: Yes.
DE LA POER: I mean, in the ordinary course of things --
and I do recognise in my question that this wasn't the ordinary course of things -- but are
management generally open with Consultants in relation to the content of expert reports before they
discuss that content with the Consultants?
GIBBS: I am not sure because I hadn't had experience of this situation with those managers. It had
been my experience as a Clinical Director some years earlier that the managers then were more
consultative and for example would have probably shown us the reports and had a discussion about it?
DE LA POER: So you were told a line had to be drawn under it?
GIBBS: (Nods)
DE LA POER: Under the Letby issue, as sometimes it is characterised. But you and your colleagues
wrote a letter to Mr Chambers four days later and we will just bring it up, INQ0003095. Signed by you all. You asked specifically what the board's
understanding of the reason for the increased number of unexpected and unexplained deaths on the
neonatal unit between June 2015 and July 2016 and "the actions that you and the board now expect us
paediatricians to take". And go on to say that you want to read the RCPCH report and the Casenote
Review and give an assurance that it will be kept confidential?
GIBBS: Yes.
DE LA POER: What was your thinking behind asking specifically for the board's understanding of the
reason for the increase, what were you trying to achieve by asking that very direct and specific
question?
GIBBS: Well, we paediatricians couldn't understand the increase. Interestingly, the board could, and
we wanted to know their reasons for accepting why there had been an increase. Obviously it would
help us to have read the actual reports to try and understand it.
MR DE LA POER: Thank you. My Lady, would that be a convenient moment?
LADY JUSTICE THIRLWALL: Yes, thank you very much indeed, Mr De La Poer. 20 past 3. (3.04 pm) (A short break) (3.20 pm)
MR DE LA POER: We had reached 30 January of 2017 and is this right, there were two issues
confronting the Consultant paediatric body: on the one hand you hadn't at that time read the reports
which had only been summarised to you in a particular way?
GIBBS: (Nods)
DE LA POER: But also was it your understanding at that time that Letby would be returning to the
ward?
GIBBS: Yes.
DE LA POER: And how imminent was it did you have the impression that that was going to happen?
GIBBS: I wasn't sure. Within the next week or two I presumed, not that day.
DE LA POER: So I am going to come now to a WhatsApp chat which I think you have been asked to
consider as part of your preparation. We can deal with it in summary. It is a discussion between you
and your Consultant colleagues between 5 and 7 February in which you are effectively discussing
between yourselves why it is only some of you will be permitted to view the report and others would
not be able to?
GIBBS: Yes, which dates again, 5 February onwards?
DE LA POER: 5 February onwards.
GIBBS: I think that's probably referring to the Hawdon report. I think we were all given the Royal
College report.
DE LA POER: Well, we know on 7 February you were in fact all given access to the RCPCH report.
GIBBS: Okay, right.
DE LA POER: Perhaps it doesn't matter terrible.
GIBBS: One or both reports only a few of us were
going to see originally.
DE LA POER: Yes, and did you also at about that time get access to Dr Jane Hawdon's report?
GIBBS: Around that time, yes. I thought we had the Royal College report a day or two report before
the other report, but a few days apart. It didn't really make any difference.
DE LA POER: You obviously had the opportunity to consider both reports?
GIBBS: Yes.
DE LA POER: What you say? Your statement is once you got access to both, you realised that
deliberate harm had not been excluded?
GIBBS: Yes.
DE LA POER: When you read them, how obvious to you was that conclusion?
GIBBS: Fairly obvious from -- I mean, deliberate harm hadn't been confirmed either. From Dr Hawdon,
the expert review that four were unexplained deaths, sort of similar to what -- not necessarily
four, similar to we felt these were unusual deaths, it wasn't just the number, it was the nature.
DE LA POER: Those being category 2?
GIBBS: Yes, four patients.
DE LA POER: Which she recommended for broad forensic
review --
GIBBS: Yes.
DE LA POER: -- or local forensic review depending on which part of the report we are looking
at?
GIBBS: Yes.
DE LA POER: Again just bookmarking an event without going to the detail, records indicate that you
contacted the British Medical Association on 7 February?
GIBBS: (Nods)
DE LA POER: Why did you do that?
GIBBS: Because I realised I could be in conflict with senior managers and potentially I might be
disciplined or suspended or lose my job and that's also why I contacted the MDU.
DE LA POER: What was it that you thought you might do at that time that was going to put you in
conflict with the managers?
GIBBS: Go against what the managers had clearly advised; that that's the end of the discussion about
Letby.
DE LA POER: So in other words that you wouldn't accept that a line had been drawn under it?
GIBBS: Absolutely, that's why we sent the letter a few days later to the Chief Executive knowing it
might get us into trouble.
DE LA POER: That was the letter of 10 February 2017?
GIBBS: We sent one a few days earlier, the one at the end of January.
DE LA POER: 30 January we looked at?
GIBBS: Yes.
DE LA POER: That's where you asked specifically for the board's understanding of the
explanation?
GIBBS: But even at that stage we had not drawn a line under it and we defied what we were told and
we were starting to ask questions, and again on the 10th.
DE LA POER: If we bring up the 10 February letter, INQ0003117. So this letter written following --
GIBBS: Having read the reports.
DE LA POER: Exactly so. You give the dates 3 and 7 February?
GIBBS: (Nods)
DE LA POER: The substance of the letter goes on to urge a Coronial investigation?
GIBBS: Yes.
DE LA POER: Why did you think that the Coroner was the right person in these circumstances?
GIBBS: Because the Coroner is supposed to examine deaths to try and ascertain why they occurred and
we thought if he had access to Dr Hawdon's report and knew of our concerns, that that would ring
major alarm bells
for the Coroner.
DE LA POER: So --
GIBBS: And in a very loose way -- and I might have got this wrong, I am not a legal person -- I
thought going to the Coroner is not the same as going to the police, but I thought they were closely
linked. If you had deaths you could not explain and that we were raising the sort of concerns we
paediatricians were raising.
DE LA POER: At the end of the second paragraph: "The reports have not reassured us that all these
deaths and collapses are explicable by natural causes"?
GIBBS: Yes.
DE LA POER: What isn't said in terms in this letter is: we remain suspicious of Letby.
GIBBS: Yes.
DE LA POER: Is there any particular reason why that express statement of the sort of the concern
was not included in this letter?
GIBBS: Well, maybe we were being a little bit cowardly. We didn't want to ask to be sacked so we had
been told this was the end of the matter and the board decided it was the end of the matter. We were
clearly pushing it and without -- we didn't feel we had to explicitly say we still had the same
concerns that
patients had been harmed and that it may be Letby doing it because we had been told to leave it. But
we felt this sort of letter implied the same thing without stating it.
DE LA POER: Of course to the informed reader the Executives who had heard your concerns articulated
that would be implicit when reading it?
GIBBS: Yes.
DE LA POER: But as we will get to, this letter was -- it was a request that the letter be given to
the Coroner?
GIBBS: (Nods)
DE LA POER: The Coroner, do you agree, wouldn't, reading just this letter, understand the specific
nature of your concern?
GIBBS: Yes, but we hoped, did we say just the letter to be given to the Coroner?
DE LA POER: No --
GIBBS: I think we wanted the Coroner to do a full investigation so maybe this letter but also the
thematic review and other things. We didn't think the Coroner would be given one letter and be
expected to do a full investigation.
DE LA POER: That's what I was coming to: were you expecting this letter would be a broader
explanation to the Coroner?
GIBBS: Yes, yes, and I suppose we should have made it clear and there is a lot of things we didn't
make clear, it would have been quite useful if we had all gone to speak to the Coroner but you may
ask: why didn't we do that anyway? We were trying to do it through the managers and we knew at this
stage Letby was not on the unit and we suspected, but did not know, that by sending letters like
this one and the following one at the beginning of March, that would probably stop her coming back
until this had been sorted out.
DE LA POER: 12 February, an email that we don't need to look at, we can take it down. You deal with
it in some detail in your statement. You will know the one I mean, it is a reference to Howie?
GIBBS: Yes.
DE LA POER: Who is Dr Howayda Isaac?
GIBBS: Howie Isaac, I think.
DE LA POER: And Dr Issac is a Consultant Community paediatrician and the named doctor for
safeguarding in the paediatric department?
GIBBS: Yes.
DE LA POER: And you raise in that email, I am sure you can recall the fact that Dr Isaac was
considering intervening in what was going on?
GIBBS: Yes.
DE LA POER: And you were discussing with your colleagues whether that was a good idea or not?
GIBBS: I am not sure a good idea whether we could show her the reports because we had been given the
reports and told to keep them highly confidential. I thought we could give them to her because she
was a fellow paediatrician, albeit a community rather than a hospital. Some of my colleagues felt it
better that she go via the Executives which in normal practice I would have given the report to a
colleague who is another paediatrician.
DE LA POER: Was one of the attractions of Dr Isaac having the reports because Dr Isaac had a
safeguarding role?
GIBBS: Yes, and she may raise concerns as well, it is up to her once she has seen the reports.
DE LA POER: So does it follow from that that at this time you were seeing safeguarding as a
possible way of ensuring the concerns were properly investigated?
GIBBS: No. I think Dr Isaac felt she ought to be involved and we thought she should be involved. We
thought we would raise safeguarding issues quite clearly to the senior managers who have a
responsibility for safeguarding in the Trust. It didn't necessarily need Dr Isaac as well, but it
was fine if she wanted to join in. We weren't expecting her to raise the issues for
us. We thought we had raised them clearly enough already.
DE LA POER: When you raised them, and here we are talking about with the Executive Directors, had
you so far as you can recall expressly referred to them as a safeguarding concern?
GIBBS: I can't remember if we did. I thought it's fairly obvious they were.
DE LA POER: Continuing with our chronology, 16 February 2017, a letter from Mr Chambers confirming
that the letter had been sent to the Coroner, do you recall that letter, or shall we --
GIBBS: Yes -- no, I recall it, yes.
DE LA POER: What was your reaction to the actions that you were being informed the Executives were
taking at that time?
GIBBS: Pleased the letter had been sent to the Coroner, weren't clear if that meant the Coroner
would investigate all the deaths but at least some action had been taken. I think it fair to say I
can say for myself and I think my colleagues will express their own opinions, trust between
ourselves as Consultant body and the Senior Executives was breaking down at this stage.
DE LA POER: There was mention in that letter about the fact that there had been a meeting and there
was to be
a meeting with the Coroner?
GIBBS: Yes.
DE LA POER: So trust was breaking down. Is that a polite way of saying you didn't believe that your
concerns would be fairly represented?
GIBBS: I wasn't sure that our concerns would be slanted in the correct way. It was clear from
previous meetings going right back to July 13 2016 when we were given the results of the Trust's
internal investigation that the Senior Executives' interpretation of data was different to our
paediatric interpretation of data. We didn't know quite what view had been given to the Coroner.
DE LA POER: On 24 February, you had a meeting with Mr Harvey?
GIBBS: Yes.
DE LA POER: Am I right in suggesting that that meeting was because Mr Harvey contacted you saying
he wanted to talk to you about your July 2016 report?
GIBBS: Yes, and we had asked to see that report in our earlier letter to the Chief Executive. When
we sent letters to the Chief Executive, we assumed, but maybe we shouldn't have done, probably the
Medical Director and nursing director would have been shown those by the Chief Executive.
DE LA POER: Were you told by Mr Harvey anything of what he had done so far as the Coroner was
concerned in that meeting on the 24th?
GIBBS: Yes, he mentioned he had seen the Coroner with Mr Cross, the corporate and legal advisor for
the Trust, and that they had shared our concerns with the Coroner, they had copies of our letters to
the Chief Executive and the Chief Executive had mentioned the letter going to the Coroner in his
letter which at that time reassured me that hopefully a resolution may be coming for our concerns,
that the Coroner would consider these concerns in the forthcoming inquests which were on three
babies. I know two of them were [Child O] and [Child P]. I am not sure who the third one was,
possibly a child not in the indictment.
DE LA POER: So at that moment in time when Mr Harvey told you that, did you consider that you had
taken the matter as far as you needed to and it was now in the hands of someone else, or did you
think more needed to be done?
GIBBS: I thought the Coroner must take some action once he has been told all of this.
DE LA POER: Did you suggest to your colleagues that the ball was now in the Coroner's court?
GIBBS: Yes, yes because we had said in our letter to the Chief Executive of 10 February that we
wanted the Coroner to investigate all the deaths.
DE LA POER: Were your colleagues as satisfied as you were that it was appropriate to take a step
back at that point?
GIBBS: No, they weren't and I quickly realised the error that I had made. I think my colleagues fed
back Dr Jayaram was on holiday at the time which prevented us getting together for a few days. I
think it was yet another of these informal meetings in our office and I don't think it is minuted.
It's just that my colleagues felt that we did not know exactly what had been sent to the Coroner
and, as I said before, what sort of slant had been put on it and also it was discussed and I
realised this is probably true and I was wrong to think we are wrong to get a resolution, get a
proper investigation, if the Coroner is just considering at an inquest for individual children, and
it can take many months for those inquests to take place, would the Coroner really look at all the
deaths or consider all the deaths in that, and we couldn't be sure what would happen and it could
take a long time. My colleagues were adamant then that we ought to go to the police, not just leave
it to the Coroner although we had earlier said we wanted
a Coroner's investigation. I think my colleagues were quite clear that trust has broken down between
us and the Senior Executives at that stage and in that discussion, I agreed they were right, I was
wrong; we had to go to the police.
DE LA POER: 28 February, you met together with some of your colleagues with Mr Harvey?
GIBBS: Yes.
DE LA POER: I am not going to go into the detail of it but you will recall that Dr Brearey sent an
email following it setting out his version of what happened, Mr Harvey replied effectively saying
that he had matters to add to that?
GIBBS: (Nods)
DE LA POER: Having considered those two emails, do you agree with either of them or both of them,
what's your view?
GIBBS: I can't remember all the details now.
DE LA POER: No.
GIBBS: But the meeting we had with Mr Harvey and Dr Subhedar again from the Neonatal Network was
looking at the review of all the babies and instead of just the four that had been highlighted as
unexpected, with Dr Subhedar's input and our Consultants' input, we decided there were eight babies
with unexplained deaths
and I think at that stage Mr Harvey was going to look at how they could be further investigated and
get hold of Dr Hawdon to find out what she meant by forensic review but we felt we were getting
somewhere slowly at this stage.
DE LA POER: The same day -- we will just bring it up -- 28 February 2017, INQ0003187 -- the seven of you Consultants wrote a letter of apology to
Letby?
GIBBS: Yes.
DE LA POER: Let's just be clear about this. You I am sure have been over the text of this many
times both before it was sent and afterwards. Were you accepting when you sent that letter that you
didn't think Letby had done anything wrong?
GIBBS: Sorry, can you pose that question again?
DE LA POER: Do you want to just read it and then ... (Pause)
GIBBS: Sorry, yes. We were not saying she had done no wrong here, we were just apologising for the
stress that has been caused. In fact, did we say to her or not? "You", it says, yes. We were sorry
for the stress we had caused all the other nurses on the unit as well. So we are apologising for the
stress, we weren't apologising for the -- I think from my colleagues saying we never accused her of
anything, I think we implied
quite strongly what we were accusing her of. But we didn't apologise for having raised concerns that
she may have harmed patients.
DE LA POER: Thank you, we can take that down. 1 March another letter to Mr Chambers, INQ0006816.
GIBBS: This in a way is emphasising the fact we have reviewed Dr Hawdon's report with Dr Subhedar
and there were now eight unexplained deaths, we felt. We were pointing that out to Mr Chambers.
DE LA POER: We will just bring it up but you have got there without needing to see it. Was that the
purpose of this letter, just to say: look, we have got to a particular position. It is not four,
it's at least eight?
GIBBS: Yes, do we say that in this letter? I thought we had, but ...
DE LA POER: I think you will see it over the page.
GIBBS: Right.
DE LA POER: If my recollection is ... The second bullet point.
GIBBS: Yes. So we are saying there are eight cases altogether.
DE LA POER: Exactly so.
GIBBS: And saying this needs to be investigated.
DE LA POER: Thank you very much indeed. Now, there is an email chain which ends with you sending an
email on 19 March 2017 which I can bring up if you need to, but if I give you the context. It
appears to be a discussion about a draft letter that is going to be sent to Mr Harvey identifying
specific cases of concern. Do you know the --
GIBBS: Yes.
DE LA POER: One of the matters under discussion was [Child K].
GIBBS: (Nods)
DE LA POER: I am not looking to go into the detail of this with you, but you will know that Dr
Jayaram has spoken about an occasion in relation to [Child K] that he was concerned about.
GIBBS: Yes.
DE LA POER: Had Dr Jayaram told you that there was an incident connected with [Child K] and Letby
that he was concerned about?
GIBBS: I think he had at that stage, yes. When I say I think he had a bit evasive -- I mean, I was
very well aware later on that he had and I knew about the two trials for that baby. I can't remember
exactly when it was Dr Jayaram raised that, but I thought he had raised that not long after he had
been involved in that incident back in January 2016.
DE LA POER: So you think that's something that he mentioned to you?
GIBBS: I think it was back that early. But my memory is a bit confused because it's been mentioned
so many times since.
DE LA POER: Well, certainly in this email chain -- we can look at it but I am sure you will take it
from me that one of the things you say about [Child K] is I know you are concerned about this case,
Ravi?
GIBBS: Yes, yes --
DE LA POER: So at least at 19 March?
GIBBS: Absolutely, I knew it by then, yes.
DE LA POER: Was that a case or an event that you encouraged him to tell the managers about?
GIBBS: I can't remember that because as I say, I can't remember exactly when I heard about it. But
from this email I did know by this time. But this is 2017.
DE LA POER: This is 2017?
GIBBS: It happened in February 16 so I can't remember between February 16 when it happened and this
email at what point I learned about it. All I can say is I knew about it by the time of this email.
DE LA POER: You don't --
GIBBS: I don't think in particular -- there were
quite a few cases that concerned us. I don't think [Child K] -- just pause for a second. I was going
to say I don't think [Child K] was a major case, except of course it's the only one where anyone
might have seen Letby doing something but rather it was not doing something, so I suppose that's
important. But I don't remember talking to Dr Jayaram about raising it with the managers, no.
DE LA POER: We will move forward to the meeting with Simon Medland QC, as he was then. This was on
12 April 2017 and you have had a chance to see now His Honour Judge Medland's note of that
meeting.
GIBBS: Yes.
DE LA POER: All that I really need to ask you about that was going into that meeting, what was your
expectation about its purpose?
GIBBS: Mr Medland was to help us to decide how to present our case to the police.
DE LA POER: So implicit in that is a decision had been made to contact the police?
GIBBS: The police were going to be called in, how were we to do that?
DE LA POER: Who had you got that impression from?
GIBBS: I think it was Dr Brearey, it is a chain of events, Dr Brearley got it from someone else. So
you
would have to talk -- I know who he got it from but he can tell you that.
DE LA POER: When you got into the meeting with Mr Medland, what were you told he thought the
purpose of the meeting was?
GIBBS: To decide whether there was enough reason to go to the police. We made it clear to him,
because we were getting a bit fed up the way things were just not going the way we thought, we
thought we had been told one thing and something else was happening. We made it very clear to him at
the beginning of the meeting it doesn't quite come across in his notes which are otherwise a very
good summary of the meeting, very clear that we felt he had been misled and we had been misled. And
he apologised for that, then we carried on as it says in his record of that meeting.
DE LA POER: One of the suggestions that Mr Medland makes in that meeting as recorded in the notes
is that you make a list of your best points?
GIBBS: Yes.
DE LA POER: Now, on the face of it, that would be a good way to bring together all of your concerns
on paper in one place?
GIBBS: (Nods)
DE LA POER: That hadn't been -- correct me if I am wrong -- a thought that had occurred to any the
Consultant paediatricians before that point, other than that email that was being drafted to Mr
Harvey a couple of weeks earlier; is that correct?
GIBBS: That's true. But I thought in various discussions we had had over the previous year that we
had covered most the points that we would put to the police.
DE LA POER: So is it the position that if not in writing, you had communicated the best points
already to the Executives?
GIBBS: Yes, we hadn't hidden anything from the Executives that we revealed to the police and not to
them.
DE LA POER: Could you at the time see the benefit in setting everything out in writing?
GIBBS: Yes, it is obviously very good to have some documentation of what went on, yes.
DE LA POER: And --
GIBBS: In a way, we had set -- we hadn't identified each patient, we had set out our concerns in
writing in these letters to the Chief Executive to the last two letters we sent. But maybe yes, we
should have set it out in writing like that much earlier. But we had hoped by talking to people, by
telling someone they might take
action even though we didn't send a letter saying the same thing. But maybe we were wrong to have
assumed that.
DE LA POER: We know that in fact on 10 May, to use Mr Medland's language, a document containing
your best points was sent to the Cheshire Police?
GIBBS: Yes.
DE LA POER: Was that a direct result of Mr Medland's advice or was that something that you had all
reached the conclusion by then you would need to do in any event?
GIBBS: We thought we were heading very close to doing that anyway, as we were indicating in our
letter to the Chief Executive. But Mr Medland also suggested maybe if you wanted to talk to the
police, we talk to the police officer as part of the local Child Death Overview Panel and that had
happened before the 15 May.
DE LA POER: 10 May --
GIBBS: It happened -- it wasn't myself, I wasn't there. Some of my colleagues met with the police
officer from the Child Death Overview Panel and as a result of that, the police were very interested
and that letter documenting concerns about individual patients went to the police.
DE LA POER: We can just bring that up. INQ0006136, 13 April 2017 so the day after the meeting with Mr Medland?
GIBBS: (Nods)
DE LA POER: And if you look at the third paragraph of Dr Jayaram's email: "We feel that his
suggestion of speaking informally with Detective Superintendent Wenham from the CDOP would be very
helpful and would like this to be facilitated as soon as practically possible."
GIBBS: Yes, and that meeting was arranged.
DE LA POER: Yes, we know that meeting -- I hope I get this right, 27 April is when it occurred?
GIBBS: Was it? I would have to check. It was around then, yes.
DE LA POER: Two more matters from me, Dr Gibbs. Thank you, that can come down. The first is to move
outside of our time period that we have been focused on and just draw your attention to the spring
of 2018 and in the spring of 2018, a table was sent to Mr Chambers providing a list of the
Consultants' concerns --
GIBBS: Yes.
DE LA POER: -- one after another in terms of how the whole situation had been dealt with. Were you
a party to the
creation of that table?
GIBBS: Yes. We -- it was circulated amongst all the Consultants -- paediatricians.
DE LA POER: And we know that Mr Chambers replied also in tabular form, it would seem?
GIBBS: (Nods)
DE LA POER: And that there was a further column setting out what the response to the reply was?
GIBBS: Yes.
DE LA POER: So far as you were concerned, do you stand behind the concerns that -- as they
ultimately landed within that document?
GIBBS: As far as I can remember, generally yes. I did feel by the time we had this to and fro of
letters that we probably weren't getting anywhere and we had said enough at that stage. The police
were currently investigating and I felt our focus should be on what the police found. This wasn't
part of the attempt and the Chair of the Trust was getting -- Sir Duncan Nichol was getting involved
at around this time, of trying to repair the relationship between us Consultant paediatricians and
senior managers.
DE LA POER: And in terms of your response to Mr Chambers's reply to your concerns, did you think
that moved the relationship closer together or further apart?
GIBBS: No, I felt it just -- it angered people really and that's why I felt we weren't gaining much
from continuing this process. Every letter that he wrote to us we could criticise it line by line
and I felt that wasn't constructive, although I was part of reviewing the letters.
DE LA POER: Thank you. The final topic is just in isolation, if you like, and that's certainly how
it appears in your statement. I am looking here at paragraph 474 on page 137 of your statement. You
were asked specifically about interactions with the Cheshire Coroner?
GIBBS: Yes.
DE LA POER: We can just move through it. Before June 2015, you had only had direct contact with the
Coroner on a couple of occasions, is that right?
GIBBS: Yes.
DE LA POER: You contacted the Coroner's office regarding two babies because you didn't know why
they had died and one of those babies was [Child C]?
GIBBS: Yes.
DE LA POER: You set out in your --
GIBBS: Most of my contact with the Coroner's office -- sorry, was through the Coroner's officer not
the Coroner himself.
DE LA POER: Yes. And you set out at 475 that you think having -- you pass on the information the
Coroner's officer discussed the case with the Coroner and phoned you back to tell you that [Child C]
would be a Coroner's case?
GIBBS: Yes.
DE LA POER: As a result you completed a form?
GIBBS: Yes. I mean, the fact the form was completed and sent off and a copy should have been in
[Child C]'s notes -- I think it was -- indicates that that process had taken place.
DE LA POER: But as you have told us, at the time that you are doing this, there were no concerns
that you had -- or suspicions is perhaps a better way of putting it -- about [Child C]'s death?
GIBBS: Yes, my concern was trying to find the cause of [Child C]'s death and that was a concern, not
only suspicions of harm at that stage.
DE LA POER: [Child I] you deal with at 476 and you say you believe you were Consultant of the week
at that time who reported [Child I]'s death to the Coroner?
GIBBS: Yes.
DE LA POER: And although you considered [Child I]'s deterioration to be unusual in the hours prior
to death, [Child I] had suffered previous multiple deteriorations
and required several interhospital transfers and that caused you at the time to suspect an
underlying medical problem rather than deliberate harm?
GIBBS: Yes, and as I mentioned a little earlier [Child I], like [Child G], I didn't realise some of
those deteriorations had been caused by Letby but that led me to believe this was a vulnerable child
who was prone to deteriorating because they decompensated quickly, which some babies can if they
have multiple problems and have been trying to deal with them for some time.
DE LA POER: Now, you say at 477, effectively summarising the position, that you don't think
additional information should have been provided by the babies who died in 2015 because there was
not sufficient suspicion that the deaths were not natural?
GIBBS: Yes.
DE LA POER: That at least being a reflection of your view at the time of both of those deaths?
GIBBS: Yes.
DE LA POER: If we look at 478, however: "At the time of the deaths of [Child O] and [Child P] in
June 2016, there was concern about the possibility of deliberate harm. I do not think this concern
was mentioned with when a colleague reported those deaths to the Coroner possibly because we
paediatricians were
seeking agreement from the senior managers on how to deal with our concerns and we knew the NNU
nurse manager was adamant that our suspicions about Letby were misplaced. Furthermore, since we were
uncertain how to proceed as a group at that time, it was difficult for the individual reporting a
death to the Coroner to take sole responsibility for raising this concern outside of the
hospital."
GIBBS: Yes.
DE LA POER: It is really just to help us to understand in terms of your responsibilities as a
paediatrician, I appreciate this is not you being the final arbiter of the decision because you are
not the one in contact with the Coroner but you appear to be speaking for the view that you took at
the time?
GIBBS: Yes.
DE LA POER: Just help us to understand a little bit more about your reasoning there about why
because of uncertainties how to manage a situation, and I am obviously summarising what you are
saying there, you didn't think it was appropriate that the Coroner be told at the time of
notification of O [Child O] and P that there were suspicions?
GIBBS: I suppose I wasn't sure if my colleague had conveyed those suspicions and I was trying to
explain why I thought they might not have done. I think that colleague is one of the Consultants who
will be giving evidence here and may be able to answer that.
DE LA POER: So --
GIBBS: And I think in the end, because just from documents I have seen from the Inquiry Team, I
think when those forms to the Coroner or to the pathologists doing the PM on behalf of the Coroner
were sent, I think -- but my colleague could answer this, I think there might have been some mention
of unusual unexpected deaths having occurred several times on the unit. I think that was the case.
DE LA POER: Well, given, as you have explained to us, that that isn't a representation of your view
but rather an attempt at explanation at somebody else's thought process, I won't take that any
further. Can I just say this as far as my questioning is concerned. Dr Gibbs, you devote a
substantial part of your statement, if I may say so, to part 4, your reflections. That is going to
be published on the Inquiry website rather than us taking you through it now. I wouldn't want you or
anyone else to think that we were not enormously grateful to you for the time and care you have
taken over those reflections, but they
will stand as part of the Inquiry record and can be considered and referred to in the future. So
thank you very much indeed.
GIBBS: If I could briefly add, because I know time is against us -- I quite accept I wouldn't want
any of those recommendations implemented unless other people feel likewise so it's -- and it is up
to the Inquiry to decide which to decide which of those get implemented.
MR DE LA POER: Dr Gibbs, that concludes the questions that I have for you. As you know there are some further questions to come on behalf of one of the Core Participant groups.
LADY JUSTICE THIRLWALL: Mr Baker.
MR BAKER: Good afternoon, Dr Gibbs. I ask questions on behalf of a number of the Families, in
particular Mother C, so I am going to ask you some questions about the history of [Child C] and your
interactions with Mother C. Now, I appreciate in doing so that involves quite a substantial change
in track to the questions you have just been answering?
GIBBS: (Nods)
BAKER: I am also conscious of the fact that your witness statement was written a number of years
after
the event, so your witness statement for this Inquiry is written in 2024, describing events that
took place in 2015. So where I think seek to draw out differences between your recollection and
Mother C's recollection, please don't see that as being anything other than a question about
recollection rather than probity.
GIBBS: Okay.
BAKER: I want you to go, if you can, please, to paragraph 104 of your witness statement on page 30.
This may help orientate you in relation to the background for [Child C]. You see here you say [Child
C] was born prematurely at 30 weeks. Just to put a marker down there, 30 weeks in 2015 was by no
means the extremes of prematurity, was it?
GIBBS: No, it wasn't.
BAKER: I can take you to the entry in the medical records, but it is also correct to say that
[Child C] was born in a good condition?
GIBBS: Yes.
BAKER: Required very little resuscitation, if any?
GIBBS: Yes.
BAKER: In a general sense, would you expect a baby born in good condition at 30 weeks to
survive?
GIBBS: Yes. Slight qualification for Baby C [Child C] is that he was particularly small for a 30
weeker. He should
have been one and a half kilos roughly and he was around half that size.
BAKER: So he was around the second percentile?
GIBBS: Yes, half the average size for his age.
BAKER: Yes.
GIBBS: So that does increase risks a bit.
BAKER: Yes. I mean, I think the advice you gave to Mother C at least insofar as her recollection is
concerned that you would have expected [Child C] to survive?
GIBBS: Yes.
BAKER: And the risks of prematurity in general, I don't mean the risks of being attacked by a
nurse, but the risks of prematurity in general, would they centre around problems with the bowel,
the risk of infection, respiratory difficulties?
GIBBS: Yes, and sometimes problems with bleeds in the brain.
BAKER: Yes. So, I mean, at 30 weeks in a baby who had had I think antenatal steroids, you would not
ordinarily expect the risk of a germinal matrix haemorrhage?
GIBBS: No, that's correct.
BAKER: So the risks would be Respiratory Distress Syndrome, sepsis and Necrotising
Enterocolitis.
GIBBS: Yes, and particularly for [Child C], necrotising enterocolitis because of the problems with
poor growth in utero and poor umbilical placental blood flow. That does significantly in increase
the chance of NEC.
BAKER: I am going to look at his condition in respect of each of those pathologies, if you will,
but from a respiratory point of view in the days leading up to [Child C]'s collapse, he was
improving?
GIBBS: Yes.
BAKER: His oxygen requirements had gone down substantially?
GIBBS: Yes, I wouldn't have thought he would experience any significant problem at that stage from
his breathing.
BAKER: No. And insofar as sepsis was concerned he had had, I think, a raised C reactive protein
which is a marker of infection or inflammation, should I say. But he had no other signs or symptoms
of infection?
GIBBS: No. He did have a high blood lactate level which is a sign of poor perfusion which can be
related to infection. But his blood cultures didn't show any infection. But sometimes babies have
infection with all the clinical signs but a negative blood culture.
BAKER: Yes, because they may be colonised by a particularly fastidious bacteria?
GIBBS: Yes, and the small sample of the blood we can get out of the baby doesn't always identify the
organism even when it is there.
BAKER: Yes, but cultures taken before and after his death didn't reveal any signs of bacteria?
GIBBS: No, it didn't look like he died from infection, neither did his postmortem.
BAKER: His respiratory rate and temperature were normal?
GIBBS: I thought they were and Dr Hawdon points out he had a slightly fast respiratory rate, but
that wouldn't bother me knowing he is a 30-weeker prone to Respiratory Distress Syndrome. We knew he
needed support for his breathing that was gradually reducing so that would explain the slightly
raised respiratory rate.
BAKER: If I put it this way. Given the signs of infection that were present, raised inflammatory
marker, would you expect that to result in a sudden collapse and death of a baby in and of
itself?
GIBBS: I just missed the very last bit.
BAKER: Just a raised C-reactive protein?
GIBBS: Yes.
BAKER: In and of itself, you would not expect that to be the thing that caused a baby to collapse
and suddenly die, would you?
GIBBS: No. It depends. The raised C-reactor protein is an indication of possible, not always
infection, possible infection. It would depend on whether the baby showed signs of severe infection
with poor circulation and gradual deterioration. He didn't show those signs, so I would not expect
him to die from infection just because of the raised CRP.
BAKER: Indeed the CRP was mildly raised?
GIBBS: Yes.
BAKER: I think it was a little over 20?
GIBBS: Yes.
BAKER: In severe infection, it can get up to over 300, cant it?
GIBBS: Yes. But not -- unlikely in a little baby but nearer 100, yes.
BAKER: So necrotising enterocolitis.
GIBBS: Yes.
BAKER: There was no evidence of that prior to the collapse?
GIBBS: I didn't think so and this was discussed a little bit at his trial. One of his x-rays the day
before he died did show slight distinction in his abdomen which I think the radiologist reported as
possible bowel obstruction. I felt it was quite consistent with a baby that had
been having respiratory support that blows air and oxygen down the nose and mouth and actually fills
up the tummy a bit. But you could say that -- you just worry a little bit, could that slightly
unusual bowel pattern be the very beginning of NEC.
BAKER: Yes.
GIBBS: The postmortem didn't show NEC at all.
BAKER: No, there was no sign of it on the postmortem and also NEC doesn't appear out of nowhere and
cause a death, does it, it evolves?
GIBBS: Usually.
BAKER: Usually?
GIBBS: Sometimes babies can deteriorate within a few hours with overwhelming NEC and they perforate
the bowel. But usually it's a few days of being ill and some babies do die of NEC usually after a
few days of being very ill and not improving.
BAKER: And bowel perforation presents in a typical way which wasn't present here?
GIBBS: Well, a bowel, a bowel perforation which can happen for various reasons, and affected one of
the other babies in the indictment, can happen suddenly and cause a sudden quick deterioration. But
Baby C [Child C] did not have a bowel perforation at postmortem. We didn't suspect it in life and he
didn't have it. Because the reason for doing a postmortem -- sorry to rush, but I can see the time
-- sometimes you find conditions that you did not diagnose in life and it explains the problem. We
didn't have a -- we had no explanation from the bowel at postmortem for Baby C [Child C]'s collapse.
BAKER: And looking at the raised lactate at the time of his birth, one of the things that was
raised at postmortem was myocardial ischaemia.
GIBBS: Yes.
BAKER: Now, lactate can raise in the presence of heart failure?
GIBBS: Yes, any -- any poor perfusions and heart failure is one of those causes, yes.
BAKER: Yes, but in [Child C]'s case the lactate was elevated at the start?
GIBBS: Yes.
BAKER: And then improved to normal --
GIBBS: Yes.
BAKER: -- by the time he collapsed?
GIBBS: Yes and we know from the antenatal scans of the baby -- and that's why the baby was delivered
-- that perfusion was poor from the placenta to the baby and that could well explain the raised
lactate which then improved in the early days of life.
BAKER: But looking at heart failure as a potential cause of the collapse, would you say that
improving a normal lactate is inconsistent with heart failure as a cause of collapse?
GIBBS: Probably. It's not that common to encounter heart failure in little premature babies. It does
occur obviously, so I don't have a good understanding of the relationship between lactate and heart
failure.
BAKER: It's extraordinarily unusual for a baby to --
GIBBS: Yes, yes --
BAKER: -- die of myocardial ischaemia?
GIBBS: -- so I am not confident with answering that, you know, improving lactate means you can't
have heart failure because we don't see heart failure that much -- I don't see heart failure, I
haven't recognised heart failure that often in babies.
BAKER: I mean, that may in and of itself tell us a great deal.
GIBBS: Yes. Well, heart failure does happen in babies when they have got overwhelming problems like
generalised septicaemia, which affects all the organs including the heart, and then you will have a
raised lactate but that's because the baby is very ill with very poor perfusion due to the sepsis.
BAKER: Yes.
GIBBS: But that is not the scenario in Baby C [Child C].
BAKER: I mean, the reality with [Child C] is that his collapse came completely out of the blue.
GIBBS: Not completely. Well, yes is the short answer. The slightly longer answer: we knew Baby C
[Child C] was at risk of NEC. We know afterwards with the postmortem he didn't have it. Baby C
[Child C] was having a few regurgitations and a few bar stain regurgitations earlier on the day that
he died and there was a worry that one of the nurses had just given a small milk feed just before he
collapsed and you wondered whether the milk had gone the wrong way. But it was such a small feed it
shouldn't have caused a problem even if had gone into the lungs. So that's why I am qualifying it a
bit. It wasn't completely out of the blue; it was largely out of the blue.
BAKER: Yes, so a potentially vulnerable baby but in terms of his observations they were all stable
or improving prior to the collapse?
GIBBS: Yes.
BAKER: And a collapse may occur suddenly and unexpectedly, but you would ordinarily in the neonatal
context expect to be able to resuscitate that baby or reverse the collapse?
GIBBS: Yes, well, particularly in a baby where it
happens suddenly because they haven't been compromised for some time.
BAKER: Yes. So children or babies who are stable or improving who suffer collapses in the neonatal
setting it's generally reversible with resuscitation?
GIBBS: It's generally reversed?
BAKER: Reversible.
GIBBS: Generally, yes.
BAKER: So two factors here that were unusual about [Child C]. First of all, his observations were
stable or improving and, secondly, he couldn't be resuscitated?
GIBBS: Yes.
BAKER: These were two unusual features.
GIBBS: Yes, but the unusual feature of not being resuscitated might have been explained by his
postmortem report because Dr Kokai felt that myocardial ischaemia, the heart damage, had predated
his collapse.
BAKER: Yes.
GIBBS: In which case that could have caused the collapse.
BAKER: I will come on to that in a moment. Were deaths due to sudden unexpected collapses common in
the neonatal unit before June 2015?
GIBBS: No.
BAKER: And how long had you worked there?
GIBBS: 21 years.
BAKER: When you say they were uncommon, bordering on never happening at all?
GIBBS: Sudden unexpected deaths? No, no. Occasional, every few years.
BAKER: Yes.
GIBBS: I mean, some babies, like adults, can die suddenly and nothing is found at postmortem and
increasingly as genetics is improving a gene is discovered, sometimes found in the family years
later, that causes cardiac dysrhythmia. So there can be rare causes of collapse which aren't
explained at postmortem which do cause sudden -- cause sudden death.
BAKER: So I am going to come on then to -- first of all you had a conversation with Mother C where
you said there would need to be a postmortem --
GIBBS: Yes.
BAKER: -- because the death had been sudden and unexpected and also you couldn't explain the death
--
GIBBS: Yes.
BAKER: -- so a postmortem was necessary?
GIBBS: Yes.
BAKER: And you had a meeting with Mother C on 21 August 2015 by which time a postmortem examination
had been carried out, but the report hadn't been published?
GIBBS: Yes.
BAKER: So you had a conversation with Dr Kokai, who was a pathologist, before you spoke with Mother
C?
GIBBS: Yes.
BAKER: Which I think you concede in a letter was a slightly irregular thing to do, but you wanted
to be able to explain this to her?
GIBBS: Yes, yes, and Dr Kokai, like the other pathologist, was quite helpful in giving preliminary
results of postmortems. But I think strictly they are not supposed to do that until the Coroner
gives permission -- I hope I'm not getting Dr Kokai into trouble -- and that can be weeks or months
afterwards.
BAKER: Yes.
GIBBS: Many months afterwards.
BAKER: It was something done so that Mother C might have answers?
GIBBS: Yes, but I think it was (redacted). I don't know what -- I don't think the Coroner would have
objected, but I don't know if the Coroner knew.
BAKER: Let us not worry too much about that. But I would say that Mother C's recollection of the
meeting is that you said the following: that [Child C] was
not expected to die, his collapse at the time and in the way that it happened was not expected, that
you found it unusual that [Child C] had not responded at all to vigorous resuscitation but had later
shown signs of life, that the postmortem had not revealed an obvious cause of death, but that there
was an unusual finding of patchy myocardial ischaemia, which you thought was more likely to have
been the consequence of the collapse but not the cause of it, and that Mother and Father C were left
with an uncertainty about what had happened. They felt you had their best interests at heart and
were open about your sense of uncertainty also as to the cause of death.
GIBBS: Yes, and I think, maybe I didn't, I thought I had indicated the pathologist felt that
myocardial ischaemia explained the collapse and death.
BAKER: Yes.
GIBBS: He thought it was likely to have occurred six to eight hours before the death, which would
have been an hour or two before the collapse.
BAKER: Yes. What you say in your witness statement, and if I can go back to paragraph 71, you refer
here to the postmortem results and you say that it was shown that: "~... [Child C] had died of
myocardial ischaemia,
damage to heart muscle from a lack of blood and oxygen. This provided a reasonable explanation for
[Child C]'s death, although later as I became concerned about deliberate harm on the NNU in 2016 I
wondered if the PM had revealed the true cause of death." I appreciate it's semantics, but I want to
be clear about whether you thought that the myocardial ischaemia provided an explanation for the
collapse, a reasonable one, rather than the death?
GIBBS: For the collapse, I wasn't sure that it did. But I knew it might, if Dr Kokai was right, and
knowing that [Child C] had had a raised lactate and very poor perfusion before birth, that might
have damaged the heart.
BAKER: So I --
GIBBS: But I did tell the parents I didn't think that was the likely explanation, but I wasn't sure
and when we have all the mortality reviews the results of the postmortem are given there and the
death certificate quotes myocardial ischaemia as the cause of death.
BAKER: So I accept that you may have felt that perhaps the pathologist knows better. But what you
said to the parents, and I suggest it's what also you felt at the time, was that this explanation
didn't seem to make sense as a cause for the collapse to you that the --
GIBBS: Yes, I wasn't sure that it did explain the collapse.
BAKER: And if we look back --
GIBBS: I don't think I was explicit -- I don't think I was adamant it does not explain the collapse.
I wasn't sure it did explain it.
BAKER: So if we look, please, at INQ0008978, this is to refresh your memory. This is a letter, if we go on to
page 3, this is a letter from you to Mother and Father C on 24 September, dictated on 21 October --
sorry, 21 August and it follows on, you can see in the first sentence, from a meeting on 21 August
2015. If we look on to page 2 and if you begin reading down, please, from -- thank you -- the second
paragraph or the first substantial paragraph on this page, you can see: "Although there were several
risk factors in [Child C] that would increase the probability of death following his delivery, it
still was not expected that he would die ..." If you could just read it to yourself in its entirety.
(Pause) Then if you could let us know when you have finished.
GIBBS: I've finished that paragraph, yes.
BAKER: Yes. If you could read then the following
paragraph and it may help if I read a bit of it out: "The pathologist was impressed by the patchy
myocardial ischaemia in [Child C]'s heart and until I have discussed the PM with him by phone, he
had felt this could have caused [Child C]'s collapse. He based this assumption on the fact that
there was a sudden cardiorespiratory collapse. This would lead to myocardial ischaemia but it takes
some hours for the cellular changes (histological changes) to become apparent. Therefore because
[Child C] had clear signs of patchy myocardial ischaemia the pathologist had assumed this problem
must have developed during the few hours before he suddenly collapsed because if he died at or
shortly after the resuscitation this would not have allowed time for the ischemic changes as a
result of that collapse to become obvious when later examining the heart. "However, when I pointed
out to the pathologist that because of the slightly unusual, prolonged nature of [Child C]'s
resuscitation even though the latter part of the resuscitation was only intended to be a relatively
token effort pending the baptism, some signs of life had returned and it was some hours later that
[Child C] died. This would probably have allowed the myocardial ischaemia that would have been
expected at
the time of [Child C]'s collapse and during his resuscitation to have become established
histologically since [Child C]'s death did not occur for some hours after his collapse and
resuscitation." Then on to the following page again, you are setting out there more of the same. But
you go on to say: "I am sorry to have gone over in some detail over the finding of patchy myocardial
ischaemia in [Child C] and it is entirely understandable why the pathologist thought this might have
been the cause of [Child C]'s collapse. But on taking his history into careful consideration,
particularly the fact that he died some time after the resuscitation, raises the distinct
possibility that those ischemic changes followed the sudden collapse rather than preceded it." So
again, I mean you are expressing scepticism in this letter as to whether the myocardial ischaemia
was the cause of the collapse --
GIBBS: Yes.
BAKER: -- rather than a product of the collapse?
GIBBS: Yes.
BAKER: And that's also something you had said to Mother C and Father C in the meeting --
GIBBS: Yes.
BAKER: -- that followed --
GIBBS: Yes.
BAKER: And also, and I appreciate this may be conflating things we later find out, but if we look
at INQ0001993, on to page 14, paragraph 54. We can see here this is a section of
your police statement. If we look at that paragraph again, it's saying the same thing. If we look to
the bottom, please, that would be particularly helpful. So you can see a sentence that begins:
"Nevertheless these residual signs of life for several hours prior to the eventual death would have
been associated with extremely poor blood supply to [Child C]'s heart muscle ..." And then finally:
"~... taking [Child C]'s unusual circumstances into account related to prolonged but mild
resuscitative efforts pending his christening in my opinion it is more likely that the ischemic
changes noted at postmortem were a consequence of rather than the cause of his collapse ..." And
that's a position you had reached in 2017?
GIBBS: Did I, in this -- just if we go on a little bit. Did I then explain that Dr Kokai disagreed
or was it not in this statement?
BAKER: It's not in this statement certainly in this section.
GIBBS: Oh.
BAKER: It's perfectly reasonable. I mean, what I am suggesting to you is that when you were
discussing with Mother and Father C you explained to them what Dr Kokai had said but expressed
scepticism as to whether --
GIBBS: Yes.
BAKER: -- that was the cause of death, do you agree?
GIBBS: Yes.
BAKER: Thank you. That scepticism I would say persisted and we come on to or you came on to have a
neonatal perinatal morbidity and mortality meeting on 11 February 2016. It is described as a
thematic review meeting elsewhere, I think.
GIBBS: The thematic review when -- when 10 babies altogether were included, is that the one?
BAKER: Yes.
GIBBS: Yes, I wasn't at that meeting.
BAKER: But you also have a meeting. If we can go mean to INQ0005449. So this is the neonatal perinatal morbidity and mortality meeting
record and we can see that your name is fifth in the list of attendees. Can you see that?
GIBBS: Yes.
BAKER: The first child who is discussed within that list is [Child C] and we can see the third line
down in the middle box discussion and learning from the case. It says, "Sudden collapse ?
cause."
GIBBS: Yes.
BAKER: And, again, would you have been presenting the circumstances of [Child C]'s death to this
meeting given that you were his treating neonatologist or paediatrician?
GIBBS: I might have been. I can't remember. It's not necessarily always the Consultant who presents.
Sometimes as a learning exercise one of our training doctors presents but we consultants add in
comments.
BAKER: Yes. Is it fair it say given what you have just said about Dr Kokai's cause of death that
"sudden collapse ? cause" probably came from you?
GIBBS: It's likely, yes.
BAKER: And --
GIBBS: But sometimes in this discussion and learning from the case, we are just summarising what the
case was and Baby C [Child C] died of a unknown cause on the day of his death.
BAKER: Yes, but if you were in a position by 11 February 2016 of accepting that the cause of death
was, one, a widespread hypoxic ischemic damage to the
heart and that that had also been the cause of the collapse, we wouldn't see "sudden collapse ?
cause" here, would we?
GIBBS: Well, Dr Kokai felt the ischemic heart problems caused the collapse, I wasn't sure. So there
is a difference of opinion there so those two come together.
BAKER: Yes. So the actual cause of death is recorded and it has "PM" for postmortem before it, so
indicating where the source is --
GIBBS: Yes, yes.
BAKER: -- but the narrative section to the right of that puts "sudden collapse ? cause", which
suggests a degree of scepticism as to the cause of the collapse?
GIBBS: Yes.
BAKER: And --
GIBBS: Can I add also, sorry, there was a letter I sent to the parents in December, I can't remember
the date in December, once the final postmortem report had come through and that was after my
discussion with Dr Kokai, who was going away to discuss with colleagues, and knowing what I told him
about my scepticism, well, the question to him about: did the ischaemia really start before the
collapse? And I don't know what discussion he had with which colleagues, but that's what
he was going to do. His subsequent formal death certificate, well, I'm sorry, his subsequent
postmortem report then said -- he presumably discussed it or thought about it -- myocardial
ischaemia was the cause of death.
BAKER: Yes, I don't think there is any doubt that that's what Dr Kokai felt. But you I think you
have agreed were sceptical about that as the cause of collapse?
GIBBS: Yes.
BAKER: Dr Brearey in his evidence says that at this meeting, and he says it in a police interview,
he says that you presented the circumstances of [Child C]'s death to the group.
GIBBS: All right, okay.
BAKER: And that you put up a slide, or at least otherwise showed the group [Child C]'s observation
charts preceding the collapse, which were all stable and normal.
GIBBS: Yes and that's why it surprises me Dr Hawdon in her report says his observations weren't
normal, but...
BAKER: But certainly, can I suggest this; that by 11 February 2016, there were audible noises being
made within the group of Consultants that somebody may be deliberately harming patients?
GIBBS: Yes.
BAKER: At this meeting, you held up a slide of [Child C]'s observation charts to show the sudden
and unexpected nature of the collapse because of a concern that [Child C] may be one of the children
who was deliberately harmed?
GIBBS: It wasn't expressed like that at the meeting as far as I remember. Sorry, I held up a chart
saying that he was one the children that we were concerned about deliberate...? Because I didn't
think we discussed deliberate harm to patients in a forum with the junior doctors. That had been
discussed with the ward manager by Dr Brearey as the neonatal lead and then with more senior
managers.
BAKER: But here we have a meeting occurring after a point where I think you would accept that you
had been concerned about deliberate harm whether or not you could identify the individual?
GIBBS: Yes, at this point I was wondering could Baby C [Child C] have been harmed, that's correct.
BAKER: Yes.
GIBBS: I don't remember expressing that in the meeting. I wouldn't normally do it in a meeting with
junior doctors and midwifery team and the obstetric
people that are mentioned in the attendee list.
BAKER: Okay, so --
GIBBS: I would discuss that with the other consultants. Dr Brearey was discussing it with the
neonatal ward manager and then shortly after this date in February he was escalating it to senior
managers in the hospital.
BAKER: But certainly by this time, you were concerned that the sudden collapse against a background
of stable or improving observations --
GIBBS: Yes, we were concerned about that from when he -- yes, right from his death.
BAKER: But to be precise, had been caused by somebody rather than being some unknown natural
process. That was what was concerning you as of certainly by February 2016?
GIBBS: Yes. Baby C [Child C] and Baby I [Child I] I started to worry about were those natural
deaths, that's correct, yes.
BAKER: Just a final point in relation to Mother C, sorry, Mother F who I also represent.
GIBBS: I know you didn't ask this question, but just when I mentioned earlier that I might be guilty
of not following a duty of candour. When one starts suspecting could criminal activity have taken
place, I wouldn't normally share that with
the parents at that stage. Now, that -- maybe I am at fault for not being candid -- I think has to
go through other channels and then later on, if the police get involved, the parents need to know.
BAKER: Thank you.
GIBBS: So I am not quite sure what the concern is at this stage; that I had said it or hadn't said
it?
BAKER: No, the concern is just identifying what your state of understanding was in relation to
[Child C].
GIBBS: Yes, I was wondering by February 2016 whether [Child C] might have been harmed, but I didn't
feed that back to the parents, no, and that's -- and it can be accepted as a failure of duty of
candour. But I had mentioned a bit earlier that I'm not sure whether you can be completely candid
with parents when you are thinking you might be heading towards police investigations until those
police investigations start and their child is involved.
BAKER: Thank you. Mother and Father E F had a conversation with you about [Child F] and the cause
of [Child F]'s collapse and their recollection is that you told them that he had collapsed because
of an infection in his lung line and they never found out about hypoglycaemia. Is that a fair
observation for them to make?
GIBBS: When did I have that discussion with them? On the morning, on the morning when he had
collapsed?
BAKER: Well, he was transferred out, so it was before he was transferred to Arrowe Park.
GIBBS: Right. My recollection, and in my statement my involvement with [Child F] was on the morning
he'd started to become unwell in the early hours of the morning. One of the registrars was involved,
phoned me at home, I saw him at 8.30 in the morning. If that, just after that was the time I spoke
to his parents. I indeed thought that he was suffering from an infection at that time and I think
later on, when his lung line was taken out, it did have -- it had a bacteria on it and it was
thought that could have been causing him an infection. I think that was the -- I think it's Baby C
[Child C], yes. So at that time I did think he was suffering from an infection and hypoglycaemia is
a common consequence of infection in premature -- well, in babies.
BAKER: But in fact I appreciate the insulin results were never seen by you. You were taken to some
versions and I just wanted to make sure you saw the correct version of how it was published. It's at
INQ0000844.
GIBBS: But is this blood insulin and blood c-peptide result, is it? Yes.
BAKER: It shows, it's a printout within [Child F]'s records of the issue?
GIBBS: Yes.
BAKER: But it is a printout. It shows an insulin of 4657.
GIBBS: Yes.
BAKER: And c-peptide of less than 169?
GIBBS: Yes.
BAKER: I think -- I mean, that's a very, very high level of insulin, isn't it?
GIBBS: Yes, it is.
BAKER: I think you said that you would have needed to work out why somebody might have high insulin
levels and low c-peptide levels. But as a paediatrician if you had seen 4657 as the insulin level
and a c-peptide of less than 169, you would have known that that was highly abnormal?
GIBBS: Yes, and if I wasn't sure, which I think I wasn't because I knew when I saw that result two
years later doing the police statement, I had to check what would the normal level of c-protein be
because premature babies sometimes have different levels and we are not always given the correct
level for a premature baby when the result comes back. That would have confirmed this is likely to
be exogenous insulin, yes, that's correct.
BAKER: But you would have known that the c-peptide should have risen alongside the insulin --
GIBBS: Yes, those results suggest injected insulin, yes.
BAKER: Yes. And, again, if you had seen that you would have investigated why the high insulin and
low c-peptide in the way that you did subsequently?
GIBBS: Well, those results came back a week later. I didn't see those results when they came back
and Baby F [Child F]'s blood sugars had returned to normal about 24 hours later, roughly, maybe
slightly longer. So there was no further investigation really to do in the baby at that time. But
that was a decision from one of my colleagues that saw the results.
BAKER: All I am saying is if you had seen that result, and I know you didn't, but if you had seen
the result, you would have regarded it as highly abnormal and warranting further investigation?
GIBBS: I think I would have done. The reason I say I think I would have done, I did not see those
results and I have admitted I had to check the significance of the low c-peptide when I saw the
results two years later.
BAKER: Yes, but you realised that the c-peptide shouldn't be low and the insulin shouldn't be
high?
GIBBS: Yes, yes. And if you see any results in a baby that you don't fully understand, you look up,
you check, double check and that would indicate this is likely to be injected insulin, that's true.
BAKER: Yes, thank you, my Lady.
GIBBS: But I didn't see those results.
BAKER: No.
GIBBS: But I accept it's a collective failure, as I said in my statement, of all of us on the unit
particularly the Consultants who are meant to have the most experience not to have recognised that
abnormal result in Baby F [Child F].
MR BAKER: I am grateful, thank you. Thank you, my Lady, I have no more questions.
LADY JUSTICE THIRLWALL: Thank you very much, Mr Baker. Does that conclude the evidence of Dr Gibbs?
MR DE LA POER: It does unless you have any questions, my Lady.
LADY JUSTICE THIRLWALL: No thank you. Dr Gibbs, thank you very much indeed for being so patient and
careful in the way you have given your evidence today. It has been a long session and we are very
grateful to you.
GIBBS: Thank you.
LADY JUSTICE THIRLWALL: You are free to go now, as is everyone else, and we will meet again tomorrow morning at 10 o'clock.
(4.34 pm) (The hearing was adjourned until 10 o'clock on Wednesday, 2 October 2024)
LADY JUSTICE THIRLWALL: Good morning. Ms Langdale.
MS LANGDALE: My Lady, may I call Dr Lambie.
DR RACHEL LAMBIE (affirmed)
LADY JUSTICE THIRLWALL: Do sit down, Dr Lambie, thank you for coming.
MS LANGDALE: Can you give us your name and qualifications?
LAMBIE: My name is Dr Rachel Lambie and I am a community paediatric Consultant.
LANGDALE: Dr Lambie, you helpfully provided the Inquiry with a statement dated 28 June 2024, do you
have that with you?
LAMBIE: I do.
LANGDALE: Can you confirm for us that the contents are true and accurate as far as you are
concerned?
LAMBIE: Yes, I can.
LANGDALE: You are one of a number of Registrars or at least Registrars at the time of the event we
are looking at giving evidence today. Can you tell us firstly what being a Registrar involves, the
rotations, shifts, how it works and what you are doing now?
LAMBIE: So a Registrar is coming towards the end of your training as a junior doctor. So I had
completed a more old-fashioned style of training so I was a house officer and a senior house officer
and then moved on to Registrar. The training changed and that renamed us ST, so I was what's known
as an ST6, which is a middle grade Registrar. So my role in Chester would have been immediately
below the Consultant, so if there is no Consultant on shift I would have been the most senior doctor
in that department. My role would have been to look after the children and the babies but also I was
responsible for the house officers and the SHOs below me and then I was also responsible to the
Consultants on-call for that day.
LANGDALE: You worked at the Countess of Chester 27 April 2015 until 1 September 2015?
LAMBIE: Yes.
LANGDALE: So what wards or units did you rotate amongst in that role?
LAMBIE: During that time? What was called cross cover, so for Chester you covered paediatrics and
neonates. So during the daytime you were either one or the other, but on-call you would cover both.
So during a nightshift, for example, you cross covered both.
LANGDALE: The paediatrics, is that what they call the children's unit?
LAMBIE: Children's unit, yes.
LANGDALE: So children and neonate. So you have experience of both units or wards?
LAMBIE: Yes, as part of your training as well.
LANGDALE: If you go to your statement at paragraph 5, we asked you about the culture and atmosphere
of the neonatal unit in 2015 to 2016. What do you say about that?
LAMBIE: So I felt the culture was very positive. I was asked very specifically the relationships
between different people. So personally I thought the relationship between the junior doctors and
the Consultants was very open, very supportive. I also found the relationship between the nursing
staff and the junior doctors very open and supportive as well.
LANGDALE: You say at paragraph 6: "I recall the Consultants routinely seeking the nursing staff's
opinions and views on the children's care and welfare." Is that on the children's unit or the
neonatal unit as well?
LAMBIE: Both, on the neonatal unit as well, I particularly remember it in Chester, if they were
doing a ward round it was quite normal for the Consultant to actively seek the opinion of the nurses
which in my experience you didn't always see. I have worked in a number of different units, Chester
did stand out as one where that relationship was particularly prominent.
LANGDALE: How regularly were those Consultant ward rounds taking place?
LAMBIE: Every day.
LANGDALE: Every day, once a day?
LAMBIE: I would have thought so. I can't recall exactly. But at least once a day, I would have
expected them to have been once a day.
LANGDALE: Did you always attend those when you were on shift?
LAMBIE: If -- I would be expected to, yes, there might have been an occasion where I was called
away, so again you are part of a wider team so if during a ward round there is an incident somewhere
else, I might be asked to go and care for that child or baby but then I would always attempt to
return to that ward round. But I would be part of the normal ward round team, yes.
LANGDALE: You say there was: "... an overall positive training culture where junior doctors spoke
openly with their Consultants"?
LAMBIE: Yes, very much so.
LANGDALE: So could you tell them if you were a bit fearful about doing something new or worried
about how it was going on?
LAMBIE: Yes. As a general -- as a group of Consultants, yes.
LANGDALE: You do say the relationship between the midwives and nursing staff and clinicians could
be more difficult at times and you would describe as a frequent experience of hostility directed
from members of midwifery staff towards medical and nursing staff?
LAMBIE: Yes.
LANGDALE: Can you expand upon that, what are examples of that hostility?
LAMBIE: I want to make it clear that I didn't find that any different to or particularly different
at any other unit that I have worked on in the country. In my personal experience I found that quite
commonly that there was some difficult relationship between the midwifery, particularly if they were
asking for medical support. The impression I personally had is it was almost seen as a failure that
something had gone wrong for us to be called, which obviously was not always the case.
LADY JUSTICE THIRLWALL: Seen as a failure by whom?
LAMBIE: By the midwife, but that's my perception. So in my experience it was not uncommon to have an
air of difficulty between -- between the two teams.
MS LANGDALE: You do describe it as a frequent experience of hostility, which isn't the same as them
feeling perhaps disappointed at asking for medical assistance. What did you mean by "hostility"?
LAMBIE: Again it's my perception but, yes, hostility is the best way I can describe it. It was -- I
perceived it as a feeling of failure that you weren't really wanted, that if the medics were there
that was -- that was seen as a bad thing even though it wasn't. We were there to very much support
and offer our expertise.
LANGDALE: You say that's in common with your experience in other hospitals; that wasn't unique to
Chester?
LAMBIE: Yes, I wouldn't have said Chester was different.
LANGDALE: What about the levels of communication? We have heard from parents of babies named on the
indictment that they would have to rely on midwives perhaps to take them down to the neonatal unit
and phone calls being made between neonatal staff and the midwives to help the post-caesarean
section mother get down to the unit. Are you saying those -- what would expect interest that kind of
interaction, that that would be --
LAMBIE: No, I wouldn't have expected hostility there. It was -- the hostility I personally perceived
was very much if you were called for an acute situation. So if you were called to the midwifery team
or obstetrics to help with a baby it was not uncommon for there to be -- it wasn't every single time
but it wasn't unusual for there to have been some hostility, almost the feeling that you weren't
welcome that something had gone wrong that you shouldn't be there. It was always seen as a negative.
LANGDALE: You do say: "I did not feel that this impacted on the quality of care delivered to the
babies on the NNU"?
LAMBIE: No.
LANGDALE: Can you be confident of that?
LAMBIE: I can only be confident of my perception. So personally, no, I can't think of an instance
where there was a delay in calling us, for example, which would be one time that I think that might
have impacted. I can't say I have experienced that. It was very much a -- it made communication a
little bit more challenging at times, but not in a way that I felt would have impacted the care of
any of the babies in my experience, no.
LANGDALE: You say at paragraph 8 you: "... recall being aware of increasing levels of
anxiety following the death of [Child A] and collapse of [Child B] soon afterwards largely due to
the unexpected and similar natures of their collapses and the appearance of the unusual rash." And
you say: "As ... babies become unexpectedly seriously ill, (collapsed) or died, I recall medical and
nursing staff reporting to each other they were nervous at the start of their shifts." I am going to
ask you about Babies A [Child A] and B [Child B] first and then come back to that, if I may, and
what your level of concern was at that time?
LAMBIE: (Nods)
LANGDALE: Dealing with Baby A [Child A] you set out from paragraph 9, can you tell us when you were
called to Baby A [Child A]?
LAMBIE: So Baby A [Child A] was at the start of my nightshift so I was not on the unit. From memory
I would have been in handover and there was a crash call put out so I would have been very close to
the neonatal unit, most likely on the paediatric ward which is immediately next door, so I would
have arrived within a few minutes at most and from recollection, CPR, cardiopulmonary resuscitation,
was already under way and I attended very much to assist. CPR was being led by my colleague. I can't
recall whether I took part in the airway or the cardiac side of things. But I do remember assisting
for a very short period of time until my Consultant or Consultants arrived.
LANGDALE: You say you recall Dr Harkness and Dr Jayaram being present and another doctor writing
down events, a designated scribe, you call this?
LAMBIE: Yes, so Dr Harkness was my Registrar colleague who was leading the event. He was with the
child when they became unwell, and Dr Jayaram was the Consultant who called in, who attended very
quickly.
LANGDALE: You we know gave the handover the next day to Dr Ogden. Can I ask, please, to Ms
Killingback, if we can have on screen, Dr Ogden's statement which is reference 0102019, page 3. So
0102019, page 3. It is paragraph 12. Scroll down to paragraph 12: "We were informed in the handover
the next day by Dr Lambie (Paediatric Registrar) about [Child A]'s death. I was surprised. I do not
recall the details of exactly what we were told in that handover other than he had died. I don't
recall specifically who else was in the handover that morning or whether there was any further
discussion but the morning handovers were normally attended by the day and night medical teams." He
continues:
"It came completely out the blue. I was surprised by his death. I didn't expect him when I left on 8
June to die that same day." Do you remember, does that refresh your memory of the handover and the
discussions that you had or?
LAMBIE: I don't recall that particular handover in detail but what she has written would -- would
make sense, that is what would normally have happened. So I would have handed over everything that
had happened the night before to the day team including any patients that were due to come in, but
certainly a significant event of that nature, yes, I would have handed it over to the day team.
LANGDALE: We know from his statement your colleague Dr Harkness, I think, had to take some time
off, he found that very upsetting, didn't he, that death?
LAMBIE: Yes.
LANGDALE: Various witnesses, Nurse Taylor, Nurse Bennion, Nurse T, Dr Harkness, have given
statements to the Inquiry about their surprise at that death and it was certainly unexpected, Dr
Harkness says. Do you remember the discussion that morning about that or did that happen
subsequently, the discussion about it being unexpected?
LAMBIE: Sorry, do you mean the discussion I had with
Dr Harkness in particular?
LANGDALE: With any of them, either that night or the next day about the unexpected nature of [Child
A]'s death?
LAMBIE: Not the following morning. I do recall speaking with Dr Harkness after [Child B] had
collapsed. I can't remember exactly when that was but it was certainly within a few days because we
were both very concerned about the similar nature of the collapse but particularly the unusual rash
that neither of us had seen before. The children were also in very close proximity to each other, so
we did discuss those concerns, were they related.
LANGDALE: Paragraph 14 of your statement, you detail your involvement in the care of [Child B]?
LAMBIE: Yes.
LANGDALE: Can you tell us about that?
LAMBIE: Yes, so again it was -- so this was the following night, I was on nights, the second night
of the night shift. It was soon after midnight. I had a crash call, so a very urgent bleep to attend
to the unit and I was informed that [Child B] was having difficulty breathing and was having support
-- was being given support for her breathing. I had been made aware that she had been well
beforehand, she was not highlighted to me as a child that I needed to be particularly worried about,
for her in particular. She was covered in a very unusual rash, the only way I can describe it a
Registrar that we sometimes see with children a condition called meningococcal septicaemia, it is a
very blotchy rash, but that diagnosis didn't fit in this situation so nothing made sense.
LANGDALE: Why not?
LAMBIE: The rash didn't look exactly the same, the rash was moving which isn't what tends to happen
with a child with meningococcal sepsis, children with meningococcal sepsis tend to be -- not always,
but tend to be -- don't become so acutely ill so quickly. She also responded remarkably quickly
which is not the case for children with meningococcal sepsis. So there were lots of factors that
didn't make sense.
LANGDALE: You say at paragraph 15 you didn't fully understand why she had collapsed and you were
concerned that she could deteriorate quickly again because you didn't know why it happened?
LAMBIE: Absolutely, it wasn't an obvious it wasn't a spot diagnosis, there wasn't a single event
that I could pin everything on which meant that I didn't know how she was then going to react to the
treatment I was giving her or whether she would then go on to deteriorate. If this was an unusual
infection or a contamination, something like that, it could -- she could potentially deteriorate
again, so I was very keen to make her as safe as possible which is why I screened her and treated
her as if it was an infection as generically as possible. I made sure she was placed on a ventilator
so I had full control of her breathing, I gave her morphine, which is what we do for children who we
anticipate to be a ventilator for a more prolonged period of time. So I was trying to safeguard her
as much as a possible in case she then deteriorated again.
LANGDALE: Letby's evidence at the criminal trial was that at the collapse of B she says she was
joined by Rachel Lambie and was asked to get the unit camera to take a photo of the colour change.
Do you remember you or indeed anyone else at the resuscitation scene asking Letby to get a camera to
take a photo?
LAMBIE: No, I don't and it's not something that I would routinely do. It would be -- I can't think
of an example and it would have to be an exceptional circumstance for me to ask anyone to step away
from an active resuscitation to the point where I can't think
of an example where I would do that. It was also -- the rash was also moving, it was very brief. So
no, I don't recall asking Lucy Letby or anybody to either step away from the resuscitation or to get
a camera.
LANGDALE: Was the rash and its unusualness being discussed between you all at the time?
LAMBIE: When mean at the time?
LANGDALE: When you were with [Child B] and you could see it?
LAMBIE: So I recall the nurse that was with [Child B] saying to me: this is the same thing that
happened to [Child A] yesterday and recalling that the rash was the same.
LANGDALE: So one of the nurses on duty with you said that at the time?
LAMBIE: Yes, one of the nurses that was present with me during the resuscitation I remember them
saying: oh no, this is what happened yesterday or last night and the rash was similar, that was
mentioned, yes.
LANGDALE: At paragraph 18 you explain: "I was concerned that there may have been a link between the
collapse of [Child A] and [Child B] primarily due to the recurrence of the unusual rash." So it was
your colleague that had pointed out the
similarity that raised that concern with you?
LAMBIE: Yes. So I can't recall -- I honestly can't recall whether I knew about the rash when [Child
B] collapsed. I think I must have but I don't -- I don't recall.
LANGDALE: Just pausing there, you tell us you don't remember seeing it on [Child A] yourself or
clocking it, if you like?
LAMBIE: No, no, I don't think I saw it on [Child A] and I can't recall whether that was discussed in
particular. I suspect it was, but I don't -- I certainly didn't go into [Child B]'s collapse
thinking "oh, this rash looks similar", that was the first time I had seen that rash was on [Child
B]. But I do recall talking to Dr Harkness in particular but other members of staff, nursing and
medical, soon afterwards about the similar nature of the two babies.
LANGDALE: You say at paragraph 18: "I was concerned that they were geographically close to each
other and wondered if there could be a link, such as an infection that both children carried, or
could be in the environment or some form of product contamination. I recall discussing this with the
Consultant the following morning, particularly the similar rash ..."
LAMBIE: Yes.
LANGDALE: Which Consultant was that, Dr Newby or a different one? We know you speak to Dr Newby
later?
LAMBIE: Yes, that was later. I would need to check the medical notes to be certain but I believe it
was Dr Saladi that was -- it was the daytime Consultant.
LANGDALE: So you were raising your concerns to Dr Saladi, you also did with Dr Newby?
LAMBIE: So Dr Newby was later, Dr Newby -- would you like me to talk about that?
LANGDALE: Yes, please tell us?
LAMBIE: So I recall Dr Newby coming to find me, it was days or weeks later. She came to find me and
I believe it was in the coffee room, it was not a formal sit-down conversation, she came to find me
specifically to ask me about the rash. She had either heard about a similar incident or been
involved in a similar incident and was very keen to speak to me firsthand and ask me to describe the
rash, I do recall that. But that was some time afterwards.
LANGDALE: You tell us at paragraph 20: "I recall her [that's Dr Newby] that's Dr Newby telling me
that this was being discussed amongst Consultant colleagues who were aware of, and shared, concerns
raised by junior staff and nursing colleagues as outlined above". So you understood the Consultants
were sharing those concerns?
LAMBIE: Yes, and I raised my concerns with the Consultants a number of times and each time I had a
very positive response and I was very much under the impression that they were listening, they
shared our concerns and they were being dealt with.
LANGDALE: Indeed Dr Gibbs was taken to an email -- perhaps Ms Killingback, we can go to it,
0025743, page 2. That's page 1, if we can go to page 2, thank you. Dr Lambie, you will see Dr
Gibbs's email to his fellow Consultants: "Rachel Lambie came to see me this morning, I think because
I was the only person in the office when she came, to say the Registrars were very concerned about
the recent neonatal deaths and collapses. [Child B] where all the infants showed a strange purpuric
looking rash rash that probably wasn't true purpura ..." And then he says: "Although I have
mentioned we are looking into this, I am not sure exactly how this is being done but I didn't say
this to Rachel." So pausing there. What did you say to Dr Gibbs and
was there any action described to you or not or just a "we share your concerns"?
LAMBIE: So I don't recall this specific conversation, but I do recall speaking to a number of the
Consultants about my personal concerns and also expressing the concerns of others because it was a
topic of conversation almost every day, particularly as we got later into the events.
LANGDALE: Pausing there, you tell us about A [Child A] and B [Child B] and we are only interested
in the indictment babies, I think you were also concerned about an earlier death --
LAMBIE: Yes.
LANGDALE: -- as well, I don't want the details of that as it is not on the indictment, but an
earlier death; was that right?
LAMBIE: No, an earlier incident.
LANGDALE: Incident.
LAMBIE: So there was a child that predated [Child A] by about 10 to 14 days and again I would need
to check the medical records, I am pretty sure it was Dr Gibbs I spoke to about that incident. It
was a very, very unusual incident, something I have never experienced before or since. That was
immediately prior to -- well, 10 to 14 days before [Child A]. So I was already -- I was
already quite anxious going into [Child A] and B [Child B] because I had had that particularly
unusual event.
LANGDALE: You have provided a statement to the police about that event as well, have you?
LAMBIE: Yes.
LANGDALE: I am not going to ask you about that. So at this point you are worried about an earlier
incident and you are worried about A [Child A] and B [Child B]?
LAMBIE: Yes.
LANGDALE: And we see you speak to Dr Gibbs on 23 June. If we go to page 1 of that document, page 2
is currently on screen, if we go back to page 1. We see there Dr Lambie, an email from Dr Brearey to
Consultants and you can see he says: "There is a PMM tomorrow afternoon." I presume that's Perinatal
Mortality Meeting?
LAMBIE: Yes.
LANGDALE: "Please encourage all juniors and nurses to attend and discuss in this forum rather than
privately." Were you ever invited to a Perinatal --
LAMBIE: Yes, I would have been. I don't believe I attended, I had a look at the minutes, I presume I
was on leave or on shift elsewhere. I am not quite sure but I didn't attend that but yes, we would
have been routinely been invited to attend, we often presented at
them.
LANGDALE: Can you remember attending one where [Child A] or B were discussed?
LAMBIE: No, I believe that's the meeting that I wasn't -- I didn't attend. I presume I was on leave
or on another shift, I am not sure --
LANGDALE: Do you remember being invited for one to discuss those babies?
LAMBIE: It wasn't -- it wasn't a case you were formally invited, you were expected to attend. They
were month -- I am pretty sure they were monthly and it was -- particularly as part of your training
you were expected to attend and as I said, we quite often were asked to present. It was part of -- a
recognised part of our training.
LANGDALE: One record the Inquiry has found about a clinicians' meeting, you are not there -- well,
let me take you to it. It's INQ0036166, page 1. This is a meeting you can see Consultants Jayaram, Newby,
Saladi, Gibbs, Ann Murphy, I think she was head of children's unit, wasn't she?
LAMBIE: (Nods).
LANGDALE: Eirian Powell. If we look at the second page, look at the middle two paragraphs: "Eirian
also raised first of all as an aside an issue that neonatal staff felt that parents were not getting
updates regularly enough from Consultant staff. Bit of a debate around this, generally the Paed of
the week is available and if parents need to be updated the nurses should be able to ask the
Consultants to come down. Consultant may not be free at a particular time but clearly if there is a
sick child it is anticipated parents would be updated anyway. I have asked Eirian to get the nurses
to document specific examples where this is happening. Consultants at the meeting were slightly
unclear as to what the issue was." Were you aware of that kind of issue?
LAMBIE: No, no, I wasn't, it was -- in my experience it was common practice to speak with the
parents on occasions the parents were present during ward round and certainly my memory is that was
encouraged, particularly for the very unwell children. It was not unusual for families to phone
during the daytime. It was slightly dependent on how busy you were who would answer the phone and it
certainly was unusual personally for me to say "I am in the middle of something at the moment but I
will contact them back" or maybe give a message to the nurses to speak to them. So I can imagine at
times families would find that
difficult that we were not able to speak to them immediately, but my experience was that as a team
we would always try and get back to them or speak to them the following day.
LANGDALE: And if you look at the paragraph below that one: "There was also an issue raised around
the fact that with the three recent neonatal deaths the Registrars had been quite worried and feel
that nothing is being done. Behind the scene reviews are going on but it is felt formal debriefs
should probably take place rather than in a specific meeting to discuss all three." This is Monday,
29 June, so by then I take that to mean the reference to A, C and D's deaths, the babies we are
concerned with. Were you aware what was being done in terms of reviews or anything else that were
looking at deaths?
LAMBIE: No, no.
LANGDALE: You of course -- and indeed you say you had a concern about an earlier incident, a
deterioration incident, you were concerned about B's deterioration and an earlier deterioration. Do
you think those were discussed formally, appropriately, to gather learning from those events?
LAMBIE: Do you mean with myself?
LANGDALE: Yes, with yourself?
LAMBIE: So I don't recall formal debrief for these children. Again, in my experience, a formal
debrief tended to happen more often when there was a death or a -- I was going to say unusual
incident but yes, much more with a death. If you had an acute deterioration, I would sometimes
expect a debrief if it was very traumatic or there was a particular reason to do so. But I would not
-- I not wasn't surprised that there wasn't a formal debrief for all of the children. I don't know
if there was a formal debrief for [Child A]. I had very little involvement and as such I wouldn't
necessarily have been expected to have been invited to the debrief. I would have expected that to
focus more on Dr Harkness and the other team that were more involved. But for the other children,
no.
LANGDALE: It looks like the clinicians' meeting on 29th is only speaking of the deaths and Baby B
[Child B] is lost in that, isn't it, because it is a focus on deaths?
LAMBIE: That's also a Consultant meeting which as an ST6, so a middle grade Registrar, I wouldn't
have expected to have been invited to. I don't know how it worked in Chester, but certainly as you
get closer to finishing your training, I was in Leighton as an ST8,
which is the final year, and as an ST8 I was regularly invited to more management-led meetings or
Consultant meetings. I don't know if that happened at leighton because I was only an ST6, but I
certainly wasn't involved in those meetings.
LANGDALE: It looks like long after you had left the Countess of Chester in April 2016, you were
asked to furnish a statement to the Coroner about Baby A [Child A]. If I can ask Ms Killingback for
0008894, page 1. Do we see here that's page 1, if we go to page 2, a brief statement prepared by you
in April 2016, confirming the notes and your involvement, such as it was with Baby A [Child A]?
LAMBIE: Yes.
LANGDALE: Can you remember who asked you to supply that, what they sent you, what their request
was?
LAMBIE: No, not at all. Just looking at the date, I would have been -- I left, I was working in a
different hospital at that point. I don't recall being asked to produce this. I mean, I clearly did
looking at the information but I don't have direct memory of it, no.
LANGDALE: It looks pretty perfunctory, doesn't it, just a few facts, dates, et cetera?
LAMBIE: Yes.
LANGDALE: One of the questions my Lady is examining in the context of this Inquiry is the adequacy
of information provided to the Coroner and indeed how that's put together by the unit in providing
it. But it sounds like you didn't really have a brief about what you were required to send or what
information you were trying to provide?
LAMBIE: Specifically related to the Coroner, no.
LANGDALE: No. Do you know as a matter of interest what information the Coroner is interested in or
should have? It is not a test, by the way, you may not, I just ...
LAMBIE: From the point of view of the Consultant or the Registrar or just general?
LANGDALE: From a Coroner's point of view, what information might be relevant to a Coroner?
LAMBIE: So, I mean, the situation leading up to the deterioration or deaths of the prior 24 hours,
the background to the case, you know, the detailed medical background of that child. But also who
was involved, what was undertaken, so things like CPR can have, you know, anatomical consequences.
So they would need to take that into account. But also it depends where the death has happened:
whether it is in hospital or out of hospital.
LANGDALE: Of course one of the key issues might be whether it is an unexpected death, an
unexplained and
unexpected death?
LAMBIE: Yes.
LANGDALE: Can you remember when you were asked to put that together -- you may not remember
anything about it -- whether that was something you were asked to comment on or not?
LAMBIE: I honestly can't remember.
LANGDALE: Okay. You say at paragraph 22: . "As the number of unexpected events increased (sudden
collapses and deaths) I was concerned and spoke to the Consultants at handover. I recall possible
causes being discussed between junior doctors and nurses ..." Can you tell us what those were? I
think you have to an extent, but I just want to see if that developed as more deaths or events
occurred?
LAMBIE: Yes. So as a doctor, you are very much trained to work through differential diagnosis, and
you would naturally go to what is common and then as you decide that isn't the case, you would have
to raise your concerns to more unusual problems. And at this point, I think everyone felt that the
normal -- you couldn't explain it through normal channels, so more unusual events such as an unusual
virus, is this an unusual mould or fungus or some sort of infection, particularly
with A [Child A] and B [Child B] in particular being so close together? You know, is there something
in the immediate environment that we are not aware of? And then moving on from that, is there
anything else linking the two, such as TPN or feeding -- liquid feed products or fluids? Is there a
contamination in the bag? Then you escalate through what becomes less and less obvious or less and
less common.
LANGDALE: You say at paragraph 23 when you left in September 2015, you -- well, tell us what you
set out there?
LAMBIE: So is this referring to ...
LANGDALE: The nursing staff in a small huddle?
LAMBIE: So I remember towards the end when I left in September, as I have already said we were
discussing about, you know, is there something going on that we can't explain and I recall before I
left walking through the Intensive Care Unit and there was a huddle of nurses in the corner over the
computer and I asked what they were doing and one of the nurses replied that they were going through
the rota just to make sure that there wasn't somebody that was on for each one. I can't recall
precisely what she said, I am paraphrasing. But it was very much: it is an awful thing to think, but
we are just looking.
LANGDALE: So these were nurses?
LAMBIE: Nurses specifically, yes.
LANGDALE: Specifically.
LAMBIE: Neonatal nurses.
LANGDALE: Neonatal nurses. Do you remember which ones?
LAMBIE: No, I don't.
LANGDALE: So a group of nurses trying to work out, were they looking for the deaths?
LAMBIE: I don't know.
LANGDALE: You don't know?
LAMBIE: They were huddled over the computer and one of the nurses said to me: we are looking through
the rota to see if anyone was on for all of them, and I don't know what "them" they referred to in
particular.
LANGDALE: And what did you say to that, if anything?
LAMBIE: I don't recall saying anything. I remember being quite shocked and thinking, you know, oh. I
agreed that it's an awful thing to think; I mean, it is the unthinkable. But that's what they were
discussing.
LANGDALE: But by September 2015 it sounds like people were thinking it. Thinking the unthinkable,
there maybe a link here with a person?
LAMBIE: Yes, they were starting to think the unthinkable.
LANGDALE: Were you at any time in your training made aware of the case of Beverley Allitt and the
murders in Grantham?
LAMBIE: Not within training. I was aware of it as a public citizen from the news.
LANGDALE: So can you just tell me when you say "thinking the unthinkable", can you just expand on
that?
LAMBIE: So for me personally "thinking the unthinkable" in this case was that there might be a
person who's deliberately causing harm.
LANGDALE: So by their actions you are saying the nurses were thinking about that by trying to look
at a rota and see who's there for these specific events?
LAMBIE: It was starting to become part of their thought processes yes.
LANGDALE: And you didn't ask which events they were putting together for this?
LAMBIE: No, I recall walking through -- I was in the middle of a shift, I recall walking through the
unit, so I was working at the time.
LANGDALE: But you described to us as far as A,B and the other incident you have referred to, it was
the unexpected and unusual nature of them that was significant, it is not just that there was a
death of [Child A], it was an unexpected death?
LAMBIE: Yes, and the unusual nature of what we saw and what I personally experienced.
LANGDALE: Did you understand, and you may not have asked, that the task they were undertaking was
simply linking a person with deaths or was it following specifically unexplained, unexpected events
and seeing if the person was there?
LAMBIE: I don't know, I just recall them saying -- checking who was on for all of them, is how --
what I remember them saying.
LANGDALE: You say in terms of review of deaths and adverse events at paragraph 25, the review held
on 2 July by Dr Brearey relating to the deaths of [Child A], C and D you weren't aware of that
meeting or what was discussed when those three babies were discussed? Had you been there, you would
have been able to assist with the commonality of the rashes, wouldn't you, between A [Child A] and B
[Child B]?
LAMBIE: It depends what you mean by "assist". They were fully aware of my concerns and of my
colleagues', yes, I would have been very happy to have attended and I would have been very happy to
have described the events again, but it would have been repeating what I was very aware the
Consultants already knew.
LANGDALE: So whether that meeting refers to Baby B [Child B] or
not as far as you are concerned, the Consultants were aware of the rash on B being similar to the
rash on A?
LAMBIE: My impression was yes. If this -- does this postdate when I spoke with Dr Newby? I am not
sure of the timeline.
LANGDALE: 2 July yes, it does. You speak to Dr Newby --
LAMBIE: So they would have been, yes, as far as I am aware, yes.
LANGDALE: We asked you at paragraph 27 about how deaths are investigated in the neonatal unit and
you say you are not certain how they are investigated. What's your sense now, what do you think --
you are a Consultant now, are you?
LAMBIE: I am a community paediatric Consultant which is very different to an acute hospital
Consultant. So I don't have any experience as an acute hospital Consultant having experienced
something like this. So I have never been involved in a child death as a paediatric Consultant, so I
am not overly familiar with the processes.
LANGDALE: So when you were working there, you wouldn't know what an unexpected death should trigger
or events in terms of referrals or generally?
LAMBIE: Not in detail, no.
LANGDALE: When you say "not in detail", what did you
think? You clearly raised your concerns with --
LAMBIE: I was aware that the Coroner would be informed, I was aware the parents would be informed
and I was aware that the Consultants would be discussing it amongst themselves and my impression was
raising that through the normal processes through the hospital management.
LANGDALE: When you were at the Countess of Chester, what safeguarding training did you get either
from the hospital or generally?
LAMBIE: So you have a mandatory induction when you join any hospital and Chester was no different
and part of that is safeguarding training. It is from memory generalised, but within our paediatric
training, we have paediatric-specific safeguarding training to our grade. So the safeguarding
training you have as a house officer, an SHO, is slightly different to a Registrar which is slightly
different to a Consultant. It depends what your level of experience is. And that's mandatory, you
have to do that and it's checked and monitored.
LANGDALE: Was it useful in the sense that you would know who you had to go to talk to? Sometimes we
know what policies say, but we don't know who we have got to go and talk to. So would you have known
Dr Mittal, I will tell him any concerns I have got or somebody else, Paula Lewis, whoever it may
have been, I don't know?
LAMBIE: I mean, I probably would have known at the time, just because I knew who the consultants
were, but my memory of working in Chester is such that I would have felt happy to approach almost
all the Consultants so even if I didn't know who to go to specifically, I would have been quite
happy to have asked almost all of them, you know: I have got these concerns, what do I do, who do I
speak to?
LANGDALE: Indeed we see that you do go to the Consultants and say what you think?
LAMBIE: Yes.
LANGDALE: You say that towards the end of your placement -- going back in your statement to the
very beginning, you say: . "As further babies became unexpectedly seriously ill, I recall medical
and nursing staff reporting to each other that they were nervous at the start of their shifts. I
personally recall being nervous at the start of a set of night shifts towards the end of my
placement as I was almost expecting something bad to happen."
LAMBIE: Yes.
LANGDALE: I want to get to a sense of how widely this was discussed, so it is not just you as a
junior Registrar, who else you are sharing this information
with and discussing with? So you are saying nurses on the neonatal unit shared some of these
concerns?
LAMBIE: Yes.
LANGDALE: Who else? You say you spoke to someone out of the unit once as well, another doctor that
wasn't on the unit?
LAMBIE: Yes, so I certainly remember within the hospital -- within our team at handover it was a
regular topic of conversation, at handover for a day or a nightshift I remember on more than one
occasion almost the heartsink feeling of: oh, gosh, what's going to happen today? The unit felt -- I
don't know if busier is the right way to describe it but it felt different and there was almost an
air of anticipation of what's going to happen.
LANGDALE: Were you doing night shifts mainly?
LAMBIE: No, no, I was on a normal rota.
LANGDALE: But you say it was at nights?
LAMBIE: I think I just gave that as an example.
LANGDALE: Okay, so you hadn't made a connection between night shifts and what's happening in the
day at all, it is just --
LAMBIE: Not at that point, no.
LANGDALE: Okay. So nurses on the ward, doctors in other
units in the hospital?
LAMBIE: No, not in the hospital. So I spoke with a doctor who didn't work at the hospital, just in
an anonymous way, just to express my concerns.
LANGDALE: When did you do that, what month roughly?
LAMBIE: I think that was more towards the end, towards the end of my placement.
LANGDALE: So I don't want the name of the person, you did it anonymously anyway, was it a mentor or
someone else that you trusted or someone more senior, what was the connection?
LAMBIE: No, a medic that I trusted.
LANGDALE: A medic you trusted. So you took it on yourself to speak with a medic you trusted on the
phone or meet with the, or? On the phone?
LAMBIE: No, no, I met with them.
LANGDALE: You met with them. Tell us how that conversation went?
LAMBIE: So it was -- because it was something that was playing on my mind a lot, that I spoke with
him just to not necessarily ask advice, but just to speak about my concerns and as -- he is a medic
but he is not a paediatrician and he was able to appreciate that it was an unusual series of events
and was asking, you know, what -- what is happening? Are you -- making sure
that I was raising concerns. It was more an ear to speak to because it was -- it was a very
significant series of events in my lifetime.
LANGDALE: Did the prospect of the police becoming involved --
LAMBIE: At the very end of my placement, I do recall having a conversation with him saying: it
doesn't sound like we are getting to the bottom of this, and they are carrying on. We did discuss
the it felt like a hypothetical possibility that, yes, at some point we might be needing to get the
police involved. If we can't suddenly find that there is a virus or there's some contaminant or
something, you know, we are getting to the point where we might need to be considering speaking to
the police. That was more towards the end of my placement.
LANGDALE: Was that with this person that you trusted that you had that conversation?
LAMBIE: Yes.
LANGDALE: So you didn't have that with Consultants in the hospital?
LAMBIE: No.
LANGDALE: Just the person you trusted to go to with your worries?
LAMBIE: Yes, it was very much a hypothetical conversation of, you know: This is continuing to be
really unusual and I am very uncomfortable, as is everyone else I am working with, rather than: this
weird thing happened and now it settled. It was persisting. But again I need to stress that I was
very aware that everybody was talking about it and the Consultants were listening and reporting back
-- well, not reporting back, but like Dr Newby coming to speak to me, there was to and fro
conversation.
LANGDALE: Do you remember when, if at all, when you were there if Letby was mentioned by name?
LAMBIE: Not to me, no.
LANGDALE: Who -- did you hear her name via somebody else, someone else in the --
LAMBIE: The first I was aware -- I don't recall when that was first mentioned to me other than it
was after I had left so I believe it was when I was contacted by the police to give a statement.
Certainly I am very clear that when I left in September, other than seeing the nurses huddled
overlooking at a rota it was never -- it was not suggested to me that it could be a single person
and the name Lucy Letby was not mentioned to me.
LANGDALE: Did you stay in touch with anyone that was still working there who filled you in later on
down the road about anything or not?
LAMBIE: Yes, there was one other Registrar who had left before I had and I remember speaking to him
many, many months later, I cannot even recall if we overlapped but he had worked at Chester. But no,
I didn't keep in touch with anyone in particular from Chester.
LANGDALE: And in 2015, you didn't hear any names about Letby or anybody making comments about her
in a derogatory way?
LAMBIE: Whilst I was working on the unit?
LANGDALE: Mm-hm.
LAMBIE: No.
LANGDALE: But you are clear that there was discussion about the unthinkable and looking for
somebody as a common denominator between --
LAMBIE: Only amongst the nursing staff on this particular period. I don't -- I don't recall a
conversation amongst the doctors or a suggestion that it was one particular person by the time I
left in September 2015, no.
LANGDALE: So where did their concerns start and end by the time you left in 2015, how would you
summarise it amongst the doctors? Concerns about unexpected events and not knowing why they
happened?
LAMBIE: Yes, there was established concerns that there were a series of events that were unusual and
unexpected
and serious and that they were persisting and that at that time we couldn't explain what was
happening but there was full appreciation that we needed to look into what was causing these events,
so this was not something that could be dismissed.
LANGDALE: In your role, did you have any dealing with the parents of Babies A [Child A] and B
[Child B] or C [Child C], generally, to talk about these events or not; would that have been
somebody else who spoke with them?
LAMBIE: I don't recall specific conversations. From memory, [Child B]'s collapse was so acute and so
unusual, my normal practice would be to have called the parents in. I haven't documented the notes
that I spoke to them so I can't recall and it could easily have been that I was so busy that I
delegated that to somebody else. I am pretty certain the daytime Consultant spoke to them. The
Consultant I called in overnight might well have spoken to them, I can't recall. My normal policy
would have been to involve them. I tended to involve parents quite frequently.
LANGDALE: You have described the unit as being busy on a couple of occasions. Did that affect
communication either with parents or across teams of professionals -- nurses, doctors -- or not as
far as you are concerned?
LAMBIE: I am sure it would have at time to time as it
would in any unit, unfortunately particularly with parents. So again as a doctor I would always have
to prioritise the needs of the baby or the child in front of me. Even if I very much wanted to speak
to parents, it would be wrong of me to prioritise that over an acutely unwell child, and there are
times when you have to do that. But I would always make a concerted effort to either ask somebody
else to speak to them at the time, ask them to wait, or get back to them as soon as possible. The
same with speaking to other medics. If you -- on occasion you might miss a handover, if there's an
acute resuscitation, you might send one of your colleagues to hand over and get secondhand
information that way. But it's something that would always try and be avoided if at all possible.
But you simply had to prioritise the needs of the children in front of you.
LANGDALE: Did you have any dealing with any of the managers when you were the Registrar?
LAMBIE: No.
LANGDALE: From what you say, that would be typical for your role --
LAMBIE: In my experience, yes, in my experience for my stage of training that was quite normal.
LANGDALE: Did you hear the Consultants or anyone else talking about management in any way?
LAMBIE: No.
LANGDALE: So nothing negative, nothing positive. It just didn't feature in your daily --
LAMBIE: No.
LANGDALE: -- life on the wards?
LAMBIE: No.
LANGDALE: Reflections. You offer various reflections in your statement of events now. One of the
issues you were asked about was CCTV and you say a number of things including: "... I am not sure I
would like to work in that arena. I would be concerned it may negatively affect doctors' and nurses'
actions and how they interact with staff, colleagues and families." Of course, the police now wear
body cameras when they go into emergency scenes and they can provide very useful information and
material for later scrutiny of events. Do you think that could become normalised in the same way it
has had to be for officers if --
LAMBIE: I think a lot of that will depend on the outcome of this Inquiry. I would be very interested
to see what the recommendations are. It certainly is something we could consider. I think the way
it's used in the police force is
very or my impression, because I don't have direct experience of it, might be quite different. If it
was a case that we were wearing CCTV that you could then turn on in a certain circumstance and you
had control over that, personally, I can only speak for myself, I would be quite happy and
comfortable. I'd need to get used to it, but I would be happy to do that. But the notion of having a
camera constantly recording in an environment where you have women who have just given birth,
fathers who are new fathers, you are breastfeeding, you are encouraging kangaroo care where you are
having direct skin-to-skin contact, I do worry significantly that having a camera there all the time
would negatively impact that. It's also important that people are -- feel confident to speak freely
and openly and a neonatal unit can be a very heated circumstance, both between medics and families,
and it's important that everyone is happy to be open. That might be a case of just getting used to
having CCTV but I think the way it's used in the police force is somewhat different to having a
camera fixed in the unit all the time.
LANGDALE: If there was somebody in the incubator, so it's effectively the baby that's monitored in
the incubator, of course the staff in the surrounding areas
or environs wouldn't be seen, would they, until they came close to the baby or were handling the
baby?
LAMBIE: Yes, I think it's something that I can understand why it's being considered and I can
certainly see the positives. I think it's something that would need to be thought of -- just the
logistics of it would need to be thought out very carefully again. Particularly for the impact it
would have on the parents, I would be most worried about.
LANGDALE: This Inquiry has heard evidence from the parents of the babies who were post-caesarean
section not able to get to the neonatal unit to see their babies at all --
LAMBIE: Yes.
LANGDALE: -- and to be on another unit, having sight of your baby would be very comforting,
wouldn't it?
LAMBIE: Yes.
LANGDALE: So I see for the mother who is able to be next to the baby breastfeeding, there are other
issues that presumably --
LAMBIE: Yes.
LANGDALE: -- can be dealt with but for these mothers separated from a baby on a unit it would be a
positive advantage, wouldn't it, to be able to see them in the way that --
LAMBIE: Absolutely.
LANGDALE: -- parents --
LAMBIE: If it's used in that way, then I can definitely see a lot of positives. I just worry about
the negatives as well.
LANGDALE: You say the most: "Reflecting on the whole case I feel the most effective way to have
prevented Letby from harming as many children as she did would have been for the hospital management
team to have acknowledged and acted on the significant and exceptional concerns repeatedly raised by
the NNU Consultant body." Pausing there before we go to that. The first area of course is for the
doctors to express those concerns in a unified way, isn't it --
LAMBIE: Yes.
LANGDALE: -- to link the medical facts together in the way that you say they were by the end of
September when you left, discussing --
LAMBIE: That's the impression I had.
LANGDALE: That's the impression you had.
LAMBIE: Yes. Like I say, I wasn't present at those meetings so I don't know firsthand what was said
by whom to whom. But my impression very much was that the Consultants were aware, understood our
concerns and shared those concerns.
LANGDALE: You say: "All the staff on the NNU that I discussed these cases with at the time
uniformly agreed that something exceptional was happening, with severe consequences."
LAMBIE: Yes.
LANGDALE: And you are clear about that?
LAMBIE: Yes.
LANGDALE: You also refer in the same paragraph to the discussion you had with the non-paediatric
doctor anonymously: "~... and we both theorised that a police investigation may need to be
considered if the current events could not be explained by a number of possibilities including
environmental toxin or rare infections." So that was being considered, this pseudomonas, what else
might have been going on in the hospital, those things were being looked at?
LAMBIE: From -- well, from the conversations I had I knew they were being considered because I
personally had raised them and I'm aware other colleagues of mine had. As to whether -- what
investigations were actively being undertaken, I don't know. I wasn't party to that
information.
LANGDALE: Did you talk much with Eirian Powell about investigations?
LAMBIE: No.
LANGDALE: Did you have much of a -- much to do with Eirian Powell.
LAMBIE: No.
LANGDALE: You say: "During the court case, I became aware of the significant difficulties the
neonatal Consultants had faced in raising and escalating their concerns ... I felt upset and angry
as I had relied on trusted the wider management of the hospital to follow an appropriate process
once I had raised my concerns with the Consultants." Would you like to expand upon that, what you
heard, what your view is about that?
LAMBIE: So yes, I wasn't aware of the difficulties that the Consultants were having at raising their
concerns and continuing to escalate them until much later and closer to the court case. Certainly at
the time, I wasn't aware that they were having difficulties. From my perspective, as a trainee, I
had concerns, I had escalated them appropriately to the Consultants, I was very confident that they
were listening to me and
my colleagues, and acknowledged and shared those concerns and were escalating them and I had faith
in the hospital process that it would be escalated appropriately and I didn't -- I had no idea that
that was not the case.
MS LANGDALE: Yes, thank you. My Lady, I have no further questions.
LADY JUSTICE THIRLWALL: Thank you, Ms Langdale. Dr Lambie, may I just take you back to one
document. I hope I have got the reference right. It is 0008894, which is the report to the Coroner.
Thank you. I have understood your evidence correctly, I think, that this was April 2016 when you
were asked to do this.
LAMBIE: (Nods).
LADY JUSTICE THIRLWALL: And you left the Countess of Chester in September.
LAMBIE: '15.
LADY JUSTICE THIRLWALL: 2015.
LAMBIE: Yes.
LADY JUSTICE THIRLWALL: Do you know why you were asked to do this?
LAMBIE: I don't know for certain other than I was one of the clinicians named. So during the
resuscitation one of the -- it's usually one of the more junior doctors or one of the nurses is
usually asked to scribe.
LADY JUSTICE THIRLWALL: To write everything down.
LAMBIE: And I am aware that the house officer at the time wrote my name. I wasn't -- I didn't write
in the patient's notes at the time so the only documented evidence that I had attended was my
colleague writing my name and then I was asked to provide details of my involvement. I have written
here, "I have been asked to prepare a statement detailing my involvement." I can only assume it's
because I wasn't able to write in the notes at the time but I don't recall exactly why I was asked
to, no.
LADY JUSTICE THIRLWALL: And you weren't there throughout the incident, were you?
LAMBIE: No, I was there at the very end.
LADY JUSTICE THIRLWALL: Yes. So it seems a slightly unusual choice of person to ask because you
were the one -- you came in and assisted very near the end.
LAMBIE: (Nods).
LADY JUSTICE THIRLWALL: You didn't make any notes. I think, was it Dr Harkness who was there?
LAMBIE: Dr Harkness was the lead, so I didn't make any clinical decisions.
LADY JUSTICE THIRLWALL: No.
LAMBIE: He led the resus and I helped.
LADY JUSTICE THIRLWALL: Yes. One of the things that we have been looking at in the course of your
evidence is the nature of collapses and you have described them as unusual, unexpected and serious.
But that doesn't come across in relation to [Child A] in this report. Is the reason, there could be
a number of reasons for that. Presumably if you come in later you only know it's unexpected if
someone tells you that afterwards?
LAMBIE: Yes and it looks like I was asked to prepare a statement detailing my involvement
specifically.
LADY JUSTICE THIRLWALL: Yes.
LAMBIE: So I would have replied with my involvement was literally I arrived, I helped with the CPR,
whatever else I did, Dr Jayaram the Consultant then stopped the resuscitation and then I left to
continue my shift and that -- the answer to the question, that was my involvement.
LADY JUSTICE THIRLWALL: Yes.
LAMBIE: I wouldn't have then reflected on the nature of the collapse because that would have been Dr
Harkness's involvement.
LADY JUSTICE THIRLWALL: Yes, thank you. We are just being reminded of Part 2. I think you agree
that
it was a perfunctory statement in the sense that --
LAMBIE: Yes.
LADY JUSTICE THIRLWALL: -- you said everything you knew but that wasn't all that much in the
circumstances.
LAMBIE: No.
LADY JUSTICE THIRLWALL: Thank you very much indeed, Dr Lambie. Is there anything else you want to ask?
MS LANGDALE: No thank you, my Lady.
LADY JUSTICE THIRLWALL: In that case, that completes your evidence. Thank you very much for coming, you are free to go. As for the rest of us, we will take a break and start again at 11.15.
MS LANGDALE: My Lady, I was going to suggest if we start at 11.30? All of the witnesses today I think will be less than an hour. All have been timetabled in different ways so it may be an opportunity to take a slightly longer break.
LADY JUSTICE THIRLWALL: I don't think anyone is going to complain about that, so we will start again at 11.30. (10.59 am) (A short break) (11.30 am)
LADY JUSTICE THIRLWALL: Ms Browne. MS BROWNE: Yes, my Lady, if we could call Dr Neame, please.
DR MATTHEW NEAME (Affirmed)
LADY JUSTICE THIRLWALL: Do sit down, Dr Neame.
MS BROWNE: Could you please give your full name.
NEAME: Matthew Thomas Neame.
BROWNE: And, Dr Neame, you have been provided a witness statement to the Inquiry dated 23 June 2024
and is that statement true to the best of your knowledge and belief?
NEAME: Yes.
BROWNE: Dr Neame, I am going to start just briefly by going through your career. You graduated with
a medical degree from the University of Liverpool in 2008?
NEAME: Yes.
BROWNE: You gained full membership of the Royal College of Paediatrics and Child Health in
2014?
NEAME: Yes.
BROWNE: I think your medical foundation training was completed at the Royal Liverpool University
Hospital between 2008 and 2010?
NEAME: That's correct.
BROWNE: Having then progressed on from foundation
training to your specialist paediatric training, you spent, as was usual, six month rotations at a
number of hospitals and that included Alder Hey, Liverpool Women's Hospital, Arrowe Park and the
Countess of Chester?
NEAME: Yes.
BROWNE: If you could just explain, Dr Neame, did that mean that when we are looking at the doctors
at the Countess of Chester on the paediatric and neonatal unit below Consultant level, they would,
like you, generally have been there on a six-month rotation period?
NEAME: Usually, yes.
BROWNE: Currently you are a Consultant general paediatrician at Alder Hey Children's NHS Foundation
Trust?
NEAME: That's correct.
BROWNE: When did you commence that role?
NEAME: Two years ago, August 22.
BROWNE: And I think it is the case that in your current role as a Consultant general paediatrician,
that does not encompass neonatology now?
NEAME: That's correct, yes.
BROWNE: If I can turn now to the period that you spent at the Countess of Chester during your
paediatric training. You in fact undertook three periods of your paediatric training at the Countess
of Chester, six months from August 2012 to February 2013 right at the start of your training when
your clinical supervisor was Dr Saladi; is that correct?
NEAME: Yes.
BROWNE: Then you returned for six months, September 2015 to March 2016, with under the clinical
supervision of Dr Gibbs and that's obviously the period we are going to be looking at in some more
detail. Then you returned for a third time, I think this time working not full time but on the 60%
contract in 2021 from March to September and on that occasion your clinical supervisor was Dr
Brearey?
NEAME: Yes.
BROWNE: Dr Neame, was it an active choice on your part to return to Chester on three occasions for
your rotations?
NEAME: Yes, I applied to work there again. It is close to where I live.
BROWNE: Other than geography, was it a rotation you actively chose because you had a positive
experience or was there another reason why you chose to return three times to the Countess of
Chester?
NEAME: I had had a very positive experience during my first placement there which I think encouraged
me to list it as a preference for a subsequent placement and
I think the third occasion was for practical reasons, primarily.
BROWNE: You said you had a very positive on your first occasion. Was that not the case with your
second six months?
NEAME: Well, it was more challenging and I don't have happy memories of that placement.
BROWNE: Yes, and obviously we will go through that in detail. Just looking at the level of
experience you had when you went in 2015 to 2016, you were an ST5. Can you just explain how many
years' experience in paediatric and neonatal practice that meant when you were at the hospital in
2015?
NEAME: So I had had by that point four years of primarily paediatric experience with two six-month
placements in the Liverpool Women's Hospital where I was just working in neonatology.
BROWNE: Just to make clear, so four years of specialist training but of course you would have had
your few years foundation training. I think you did an many additional year as well prior to
that?
NEAME: That's correct, yes.
BROWNE: What were your responsibilities as a Registrar at the hospital?
NEAME: Primarily to undertake clinical work on the
general paediatric children's ward, help them with admissions of new patients and assessments of
previously admitted patients and covering the neonatal unit, the postnatal ward and the delivery
suite as well.
BROWNE: In that split of your duties insofar as you are able, if you are able, what was the
percentage of time or the approximate split between the time you would spend on the paediatric wards
and the time you would spend on the neonatal unit?
NEAME: Obviously it depended on the clinical need at the time. Typically, on a typical shift,
particularly out of hours, the majority of time would be spent on the children's paediatric side,
managing new admissions which would happen quite frequently.
BROWNE: So would it be the case that generally you would be called in to the neonatal unit from the
paediatric ward?
NEAME: Yes, more usually out of regular office hours that would usually be the case.
BROWNE: Just to put in context your time at Chester, the previous six months before commencing at
Chester in 2015, you had spent six months I think on a neonatology rotation at the Liverpool Women's
Hospital under the supervision of Dr Yoxall?
NEAME: That's correct.
BROWNE: The Liverpool Women's Hospital was a Level 3 unit. Could you just explain the significance
in terms of the babies cared for and how that differed to the Countess as a Level 2 unit?
NEAME: So the team at the Women's Hospital would admit more unwell babies, they would accept babies
who had been born earlier in the gestation, so more premature than the babies admitted to the
Countess of Chester.
BROWNE: And at Liverpool, my understanding is your rotation was purely neonatology so you would
have come to Chester having had six months purely dealing with very premature babies and babies who
needed neonatal care?
NEAME: That's correct.
BROWNE: And you have talked about your split of time spending time on the paediatric ward and then
being called into the neonatal unit as required. What was your experience of Consultant rounds on
the neonatal unit, how often do you recall they took place?
NEAME: I think they were scheduled for twice weekly during the week and possibly one of the weekend
days. I may have misremembered the precise number.
BROWNE: And would that be part of your regular duties if you were there at the time of Consultant
round that you would assist in that?
NEAME: Yes.
BROWNE: Just looking at the comparison with the Liverpool Women's Hospital a little further. You
say in your statement at paragraph 11: "I would describe the culture on the Neonatal Unit at the
Countess of Chester as being slightly more informal than at the Liverpool Women's Tertiary Neonatal
Unit ..." You did give some explanation in your statement but could you just expand a little on what
you meant by "slightly more informal"?
NEAME: So an example would be that the ward rounds at the Women's would be conducted by the team who
had been working overnight or led by that team of Registrars and SHOs. There would be an expectation
that each baby on the unit would be presented by the night team to the Consultant working that day
with a full explanation of the management of that baby overnight and the full summary of that baby's
care prior to that point. That -- those processes were conducted on a daily basis and it was a very
regular, routined way of conducting the department.
BROWNE: Did you consider that the informality that you observed, did you consider that impacted on
the standard
of care in any way?
NEAME: I thought it was typical of the way that care had been provided in the district general
hospitals that I had worked in, it didn't feel abnormal or inappropriate but it felt on reflection
different to the way things were conducted at the Level 3 unit.
BROWNE: But did you have at the time, or indeed on reflection, any concerns about the care the sort
of babies the Countess was caring for, did you have any concerns about the standard of care they
were receiving?
NEAME: Not the general standard of clinical care. There were times where I felt that we were
managing babies who were more unwell than I might have expected to or where we managed babies who
had deteriorations and then were not necessarily transferred off the unit in the way I might have
expected them to be.
BROWNE: When you say about caring for babies who are particularly unwell, was that something that
you observed was a difference from when you had been working on the unit in 2012 to 2013, did you
observe there to be a difference or had that always been the case?
NEAME: I don't think the processes or culture had necessarily changed but I think there were more --
a greater number of unwell babies during my second placement so perhaps it was more noticeable but I
didn't
get the sense that the culture or standard practice had changed significantly between the two
periods.
BROWNE: Setting aside the incidents we are going to be dealing with today, but in terms of the
babies who were being admitted, were you aware of any reason for this why you say that you were
conscious of babies being particularly unwell?
NEAME: No, I wasn't aware of any reason.
BROWNE: In terms of pressure on nursing staff or on doctors, how did that contrast or did it
contrast at the Countess of Chester compared to other hospitals where you had worked? I think you
had been at quite a number by now: you had been at Alder Hey, Wrexham Maelor, Arrowe Park, for
example, as well as Liverpool?
NEAME: I thought the staffing pressures were very typical of the pressures that I have encountered
at other organisations, I don't think it is unusual to -- to feel those pressures.
BROWNE: Turning now to the relationships between staff. How would you describe the relationships
between nurses and doctors on the neonatal unit in 2015 to 2016?
NEAME: I didn't notice anything unremarkable about those relationships or interactions during my
time there.
BROWNE: So nothing particularly good but nothing
particularly bad, do I take from that?
NEAME: Yes, that's correct.
BROWNE: Were you aware of any sense of resentment from nurses on the neonatal unit that the doctors
were perhaps less present on the neonatal ward and spent perhaps more time on their paediatric
duties?
NEAME: I wasn't aware of that.
BROWNE: In terms specifically of relationships, I have been talking about relationships between
nurses and doctors, I was thinking of doctors in your -- of your level of seniority. But the
relationship between nurses and Consultants, did you see that as a positive relationship or again
was it -- I think you used the expression "unremarkable"?
NEAME: Yes, I didn't notice anything unusual or remarkable about that.
BROWNE: Again, just reflecting back to your earlier period in 2012/2013. Any difference in the
relationships between nurses and doctors between those two periods?
NEAME: No.
BROWNE: Just very briefly, you returned of course in 2021, this time Letby had been charged with
murder. Were there differences then in the relationships between nurses and doctors that you were
conscious of?
NEAME: No, I don't think so. The atmosphere was, particularly for me, I found it slightly unusual
working there but not in terms of unusual relationships between colleagues.
BROWNE: Turning then to the relationship between midwives and doctors and nurses. You say in
paragraph 6 of your statement that you -- part of your duties included attending high risk obstetric
deliveries. Can you just give an indication of the sort of extent of involvement you would have had
with midwives and those working on the obstetric unit in terms of a proportion of your time? How
frequently would you be involved working on the obstetric unit or with midwives?
NEAME: So I would suggest that on most shifts we would be called to at least one or two deliveries
where it was anticipated there may have been some challenges or committee cases and probably
similarly called to the postnatal ward once or twice per shift to review a baby.
BROWNE: When we are looking at being called out then you are talking about how often you were
called to the obstetric -- how often can you relate that to the neonatal unit, how often as a
general rule would you be called there?
NEAME: Much more usual to be called to a neonatal unit, but that would be typical in any setting I
have
worked in.
BROWNE: So several times in a shift, would you be expecting -- in every shift, would you spend some
time on the neonatal unit, for example?
NEAME: Yes, usually.
BROWNE: And what was your perception of the relationships between nurses and midwives or indeed
between midwives and doctors on the neonatal unit, did you have any observations about those
particular relationships?
NEAME: No. I wasn't aware of any difficulties or challenges.
BROWNE: We have just heard evidence that Dr Lambie experienced some she described as hostility from
midwifery staff towards medical staff. Was that something that you were aware of?
NEAME: It is not something I experienced.
BROWNE: Looking now at the relationships between your fellow doctors, so those at a similar level
of you who are completing their paediatric training. What were the relationships that you had or you
felt were usual between the other doctors also undergoing their training?
NEAME: I think I would describe them as aimiable, productive, healthy working relationships.
BROWNE: And how many doctors were there approximately in your six-month intake? Paediatric
trainees, that is?
NEAME: I think perhaps seven.
BROWNE: And sort of aimiable professional relationships, would you discuss your cases, seek advice
from those at similar levels of seniority?
NEAME: Yes, we would have regular discussions and handovers about care.
BROWNE: Dr Lambie ended her six-month rotation at the start of September just when you were
starting. Was there a system of handover, did you have a handover from Dr Lambie or have any contact
with her or would that have been normal?
NEAME: No, I wasn't fully aware of who had preceded us on the rotation.
BROWNE: So there wasn't a settle-in day where you spoke to the Registrars who had been there for
the six-month period before?
NEAME: There is an induction but it is provided by the Consultant and nursing teams, not by training
doctors.
BROWNE: You say in paragraph 8 of your statement. "Colleagues seemed supportive during more
challenging periods, for example following episodes where babies had become unwell or collapsed or
had sadly
died." In practical terms, how were your colleagues supportive?
NEAME: In sort of typical human ways, I suppose, checking in and acknowledging that those situations
are difficult and being friendly and open to further discussion.
BROWNE: So would it be normal to have a discussion with one of your fellow Registrars if you had
had to experience a baby dying or collapsing having to undertake a resuscitation?
NEAME: Perhaps not extensive discussions but certainly to acknowledge it as a difficult situation.
BROWNE: And did you personally seek that support, do you recall those sorts of conversations with
colleagues after the collapses of H or the collapse or indeed the death of [Child I], both of which
you were involved with?
NEAME: I don't think I sought those conversations or support, but I am sure I discussed those, you
know, challenging episodes with colleagues informally at times.
BROWNE: But do you have any specific recollections of discussions you would have had about those
incidents with anyone in particular?
NEAME: I recall during the week that [Child I] had had a number of episodes having a discussion, I
think it was a morning handover just reflecting on the fact that it had been a difficult challenging
week and in many ways had been more -- far more challenging than a typical week on a neonatal unit.
BROWNE: We are going to go through that in a little bit more detail now. As part of those
discussions, those sort of supportive discussions, I have asked you about specifics, [Child H] and
[Child I]. Were there any discussions that you had with any of your colleagues, whether at your own
level or more senior, about concerns you had about the number of collapses or deaths that were
occurring?
NEAME: Only in very general terms similar to the way I have described it just now, just reflecting
on the fact that it was more that that week in October when [Child I] had a number of collapses in
particular was busier and more challenging than I had expected.
BROWNE: You have said when you alluded to the period overall, the six months you spent 2015 to 2016
to being a difficult period. Was it your impression not only for you but for others working on the
unit at that time that they too would have said this was a period where there were an unusual number
of collapses or deaths and that
was something that was known and was affecting those working in the unit?
NEAME: Yes, I think that was acknowledged informally by the doctors I was working with.
BROWNE: Can you give a little bit more detail in terms of that would have been discussed at breaks
or whether you recall any meetings where that was specifically raised?
NEAME: I -- I don't recall specific detail around those conversations and I certainly don't recall
any sort of formal acknowledgement or processes for reflecting upon that general observation.
BROWNE: But your experience of this being a difficult six months when there was an unusual level of
collapse or deaths was something that you would have felt was commonly held by those who were at
your level --
NEAME: I think it was understood that it had been a surprisingly busy period.
BROWNE: By "busy" you mean a surprising number of babies collapsing or dying?
NEAME: Correct, yes.
BROWNE: Just looking at the relationship with Consultants. How would you describe the relationship
between trainee doctors such as yourself and the Consultants?
NEAME: I felt that I had good relationships with them. I felt that they were approachable and
supportive.
BROWNE: So had you had any concerns or difficulties, concerns about procedures or concerns about a
particular case you were dealing with, was that something you felt freely able to raise with a
Consultant?
NEAME: Yes.
BROWNE: Did you ever go to your supervisor, Dr Gibbs, with specific concerns or queries, either in
relation to [Child H] or [Child I] or indeed just the number of collapses that were occurring at
this period?
NEAME: No, I didn't raise any specific concerns.
BROWNE: Why was that? Was there any inhibitor in you going to speak to Dr Gibbs or was it something
that you felt they were aware of, he was already aware of? We have heard Dr Lambie did raise those
concerns, was that something you considered?
NEAME: I didn't feel that there was anything preventing me from doing that. I think I was focused
on, you know, the possible clinical reasons for deteriorations that I had noted and focused on my
clinical performance and I don't think I was sort of thinking far beyond that in terms of the
broader or systemic factors on the unit.
BROWNE: Just so that we can understand how the relationship with the clinical supervisor worked,
would you be -- would you have a scheduled regular meeting where you would raise any concerns or
would it be an ad hoc situation where if you had a concerns you could go to them?
NEAME: So both -- we would have regular scheduled supervision meetings and I would use my clinical
supervisor as a first point of contact if I had other specific issues that I wanted to discuss
between those episodes.
BROWNE: Do you recall discussing [Child I] or [Child H] in any of those supervision meetings with
Dr Gibbs or indeed any of the other Consultants that you may have spoken to?
NEAME: No. I possibly would have completed some reflections or some supervision discussions with
Consultants around the management, but I think that would have been from a sort of clinical learning
perspective, not from a concerns about practice on unit perspective.
BROWNE: Obviously one of the hierarchies that exist in hospitals is that when a Registrar feels the
situation warrants it they will call out a Consultant. Was that something you felt very freely able
to do?
NEAME: Yes, I did do that freely.
BROWNE: And you didn't feel there was any inhibition on calling a Consultant when that was --
NEAME: No.
BROWNE: Their level of expertise was needed?
NEAME: No, no inhibition.
BROWNE: In terms of relationship with managers, did you have any interaction at all with managers
at the hospital whilst you were there in 2015/16?
NEAME: Not that I recall.
BROWNE: And just so that we can get a feel of that, would you for example have known, recognised,
Ian Harvey the Medical Director or the Chief Executive, would you have known who they were?
NEAME: No, I don't think so.
BROWNE: The Board of Directors, as far as you are aware, did they ever come on the unit, did you
have any contact with any of those individuals, even if not to speak to them, but aware of their
presence?
NEAME: Not that I was aware of at that time.
BROWNE: So it would be fair to say, would it, that as far as you were concerned, they weren't
visible to you working on the unit?
NEAME: Yes, I wasn't aware of them. They weren't visible to me.
BROWNE: Just before we turn on to another topic, finishing off the issue of relationships between
staff. We have said and looked at the way training worked going through rotations of a number of
hospitals. Is there anything you want to add, I think your evidence is that it was relatively
unremarkable but how the Countess compared in terms of relationships between doctors nurses and
midwives to other places you had worked?
NEAME: Just very typical of a district general hospital.
BROWNE: Thank you. Turning to the issues of what you had had in terms of reports before you started
at the Countess. You say in your statement to the Inquiry, this is paragraph 12: "Prior to starting
my role on the Countess of Chester's neonatal unit in September 2015 I had heard reports of the
neonatal team having 'a bad time'. My understanding was that this was a reference to episodes where
babies had either died or required unexpected escalations of care or transfer to tertiary Neonatal
Units." Can you recall approximately when you were hearing these reports?
NEAME: No, I -- I can't, I'm afraid, it's about as
detailed as that in terms of memories I have of --
BROWNE: I am just going to put a suggestion to you and you can either say that seems right or that
you simply have no recollection, we know now that four babies died in under two months between early
June and early August 2015 and we have heard from Dr Lambie that those issues were being discussed
at the Countess of Chester, so that would have been the August, the month -- your last month at
Liverpool before you moved to Countess of Chester. Does that seem about right in terms of when you
were hearing these reports of the bad time?
NEAME: Possibly, or I think one of my colleagues in the Registrar group had been working in Chester
prior to me starting there, so possibly from him. I'm afraid I just have a sense of being aware that
episodes may have happened, but it's not more specific.
BROWNE: You say you were you had heard reports. How widespread was your impression that those
reports were amongst the community, for example at the Liverpool Women's Hospital, was it something
that was being generally discussed?
NEAME: I don't recall it being discussed there. I am not sure if it was amongst trainees or possibly
when I started at Chester that I became aware of it. I just
recall having a sense of being aware of that but no details, I'm afraid.
BROWNE: So you are not able to assist as to who you heard these reports from, was it colleagues at
your own level or was it from nursing or Consultant level?
NEAME: I -- my sense is it would have been from discussions with colleagues at my level.
BROWNE: You have said that when you were at Liverpool, you were under Dr Yoxall. Was it, as far as
you know, something that he was aware of or that you ever discussed with him as a concern as your
current supervisor about to go on to Chester, did you discuss with him that you had heard these
reports and that was causing you any concern?
NEAME: No, not as I recall.
BROWNE: You say in terms of the reports they were having what you had heard was they were having a
bad time. Just to go into that a little further. As a doctor, presumably there would be some
speculation as to the cause of babies dying or collapsing. What is your recollection that people
were speculating or discussing as being the cause of the bad time that was being experienced at
Chester?
NEAME: I don't recall any speculation about the cause. I think the assumption, or certainly my
assumption, would have been that that was bad luck and a bad -- a bad run I have no recollection of
discussion of a cause for those.
BROWNE: So just in case this prompts your memory, no discussion of infections, concerns about the
standard of care?
NEAME: No, I don't, not aware of anyone expressing those concerns.
BROWNE: Just to look at a wider historical situation. We know that in May 2015 there had been a
nurse at Stepping Hill who had been sentenced for murdering patients by the admission of insulin.
Was there ever a sense when you heard "a bad time" that there were discussions even only speculation
or rumour that there might be someone involved in criminal action?
NEAME: No.
BROWNE: Once you arrived at the Countess of Chester, and I think you are unsure -- you say prior to
starting the role you had heard the "bad time", whether that was at Liverpool or in fact whether
just as you were arriving at the Countess of Chester, do you have any clearer recollection of what
was being talked about in terms of increased mortality or concerns once you arrived at Chester in
September 2015?
NEAME: No. We weren't briefed or I don't think it
was addressed specifically at any point.
BROWNE: So you might have not been briefed about it, but was it something that -- amongst your
seven or so trainees who were all starting together, was it something that was a topic of discussion
between you?
NEAME: I don't think in any more detail than the general sense that I tried to convey in my
statement. Certainly I don't recall any discussions about specific clinical cases or circumstances
around those, those deaths or episodes.
BROWNE: Because the impression that Dr Lambie gave, obviously she was there at an early period and
had been involved in some child deaths which I appreciate was not the case of you in September, but
that impression was of it very much being discussed on the unit and something that was being
discussed at Consultant and indeed at Registrar level. Was that an impression you had when you
started in September or not?
NEAME: No, that's not my impression and not my recollection.
BROWNE: In relation to [Child H], I think you have had an opportunity to review the medical notes
and you refer to two collapses of [Child H] that occurred during the night of 26 and 27 September
2015, so this was within
the first month of you starting --
NEAME: (Nods)
BROWNE: -- at the Countess of Chester. The first occasion you were bleeped at 2051 and attended
Nursery 1 and on that occasion -- we don't need to go in the details but on that occasion, a
breathing tube was replaced and [Child H] stabilised quite quickly?
NEAME: Yes.
BROWNE: Then turning to the second occasion. You were called out then a second time at 1.30 in the
morning and if we go to paragraph 16 of your statement where you deal with this, you say: "I
reported that in relation to the second episode there was 'a sense of being more concerned on this
occasion [as compared to an early deterioration] because it wasn't completely clear while she [Child
H] had deteriorated. There wasn't as clear an explanation'." What did that make you feel, the lack
of explanation, what was your response to that?
NEAME: That she needed some further assessment and further investigations in order to try to
identify the cause.
BROWNE: You called I think Dr Saladi, the Consultant, at home?
NEAME: (Nods)
BROWNE: You had to do chest compressions and I think adrenaline was administered?
NEAME: That is correct.
BROWNE: Can you give an indication of how unusual that was to have to call out a Consultant from
home, chest compressions, administration of adrenaline? You had obviously been there only under a
month at this time but was that something you had experienced before, was that a very infrequent
occurrence having to call the Consultant in in those circumstances, just so that we can have a feel
of how unusual that was as an incident, let alone the fact that this one you say you were unsure as
to the cause, but as an event how unusual was that?
NEAME: So I wouldn't describe it as being unusual to have to call the Consultant for advice or
further support. I would say that it's relatively unusual to need to use adrenaline as part of
resuscitation of a neonate.
BROWNE: Insofar as you can recall, and I appreciate you won't have gone over every medical note of
every child you saw, was that the first time as far as you recall that had happened since you
started at the beginning of September?
NEAME: Yes.
BROWNE: Looking back, for example over the period you spent in Chester in 2012/13, can you recall
that sort of incident having occurred then?
NEAME: I -- I can't recall, I'm afraid, and I think I would have been working at a much more junior
level where I wouldn't have been as involved in episodes like that one.
BROWNE: But it is fair to say this was sufficiently unusual that it very much stuck in your mind,
the administration of adrenaline with [Child H]?
NEAME: I don't think I can recall every episode where I have used adrenaline in my career, it is not
unheard of.
BROWNE: Yes.
NEAME: In the -- difficult to quantify.
BROWNE: You say in your statement at paragraph 19: "My reaction to [Child H]'s collapse episodes
was that they were challenging and unexpected episodes of deterioration." What would you have done
in that situation at the handover, what discussion would have taken place regarding the collapse of
H, given as you say the challenging nature the unexpected episode, and it not being clear to you why
[Child H] had deteriorated? What discussions would flow over that at handover or indeed beyond
handover?
NEAME: So it would be a discussion of her previous medical care, her background and then a summary
of the events and then a recommendation in terms of ongoing assessments or investigations and
ongoing management.
BROWNE: You have told us that you had heard discussions of the bad time before you started. You are
now in a situation where you have been involved in what you describe as an unexpected episode of
deterioration for which there wasn't a clear explanation. Did you make an association with what you
had heard and what was in fact now happening to you and feel that was something that you needed to
raise with those senior to you raise with the Consultant body?
NEAME: No, I didn't see those events as being associated.
BROWNE: That translates I think to being that that wasn't something you would have discussed with
other doctors and nurses, you didn't raise it with Consultants but was that a concern that you
raised with your fellow Registrars?
NEAME: No, I don't think so. I had called Dr Saladi early in the second episode so I was confident
that one of the Consultant team was -- was aware and it would have been handed over to colleagues in
the morning in terms of the plan and I think the plan was for
a transfer so I think I felt satisfied that the episode was understood.
BROWNE: If I could just turn you to paragraph 20 of your statement. You say there: "In a witness
statement provided in relation to the investigation of [Child H]'s collapse episode I reported being
'surprised by how many poorly babies there were (at the Countess of Chester Hospital) but I did not
think it was suspicious'. I do recall having a subjective sense there had been a higher than
expected frequency of episodes where babies required stabilisation or resuscitation during my time
at the Countess of Chester Hospital." So you seem there to be linking in some way [Child H]'s
collapses and your subjective sense that there was a higher than expected frequency?
NEAME: Yes, I don't think that statement refers to that period in time, I think that's possibly
further on in my placement.
BROWNE: So at the stage of H's collapse, your concerns there hadn't developed to the point and we
will go on to deal with [Child I] in a moment?
NEAME: I would agree with that.
BROWNE: In relation to H, you were -- there were also
going on at this period unexpected collapses of [Child G] that had happened in advance of [Child H].
Were you aware of that, was that something that was being discussed?
NEAME: I am sure I would have had or I suspect I would have had awareness through handover processes
and those discussions. But I -- I couldn't recall details of those episodes.
BROWNE: Did you ever consider at this stage -- just on H, we will come later to [Child I] -- that
there was any safeguarding issue and that concerns for the child themselves meant that you should be
reporting the matter to anyone other than discussing it at the handover, which I think is your
evidence, that it was discussed at the handover?
NEAME: No, I didn't.
BROWNE: You say in your statement at paragraph 21: "I do not recall attending a formal debrief or
discussion between doctors and other medical staff in respect of the collapses that [Child H]
experienced on 26th to 27th ..." You have said that it was an unexpected episode and in paragraph
18, you have described some of the steps that were taken to investigate potential causes, x-rays,
blood test, ultrasound. Do you think on reflection that there should have been a debrief if only
from a learning perspective for you and others involved as to what had occurred and what was the
cause of the collapse of [Child H]?
NEAME: Well, I certainly think there could have been I suspect -- her, as I understand it, prompt
recovery may have a factor in that not happening.
BROWNE: But would you say that was usual at the time that there was not a debrief. Were you
surprised there was no debrief in the case of [Child H]?
NEAME: No, that didn't surprise me and I think that's probably because, as I understand things, she
made a good recovery soon after that episode.
BROWNE: And we have heard that debriefs tended to be more common in a situation where a child died.
Would that be your experience too?
NEAME: Yes.
BROWNE: Paragraph 22 you say: "... I did not have any concerns that [Child H]'s collapse had a
suspicious cause. I was not aware of any colleagues who may have had suspicions about the cause of
[Child H]'s collapse." Is it right that you weren't conscious then of the sort of anxiety about
working on night shifts that we were hearing from Dr Lambie?
NEAME: So I think night shifts as a trainee are
always more challenging. You are less well staffed and less well immediately supported, I felt
supported in terms of being able to access Consultant colleagues, but they weren't in the building
so I think most trainees experience anxiety about working night shifts.
BROWNE: But the situation with H, as far as you were concerned, didn't lead to particular
heightened anxiety either your own or others who were discussing that situation?
NEAME: No, not that I am aware of.
BROWNE: Turning then to [Child I]. I think you knew [Child I] because you had been working at
Liverpool Women's Hospital when [Child I] was born?
NEAME: Yes.
BROWNE: On 13 October, you were bleeped to attend [Child I], chest compressions were needed and Dr
Newby was called in as a Consultant?
NEAME: (Nods)
BROWNE: And you say at paragraph 24 of your statement talking about the collapse on 13th that it
was unusual for a baby to deteriorate so quickly.
NEAME: Yes.
BROWNE: Were you aware at that stage that [Child I] had previously collapsed unexpectedly on 30
September?
NEAME: I suspect I would have had some awareness of
that, but I don't recall how.
BROWNE: What would be your normal practice where there is a collapse in terms of looking at notes,
would you -- would you examine the notes to look back and see their past history?
NEAME: Yes.
BROWNE: After this unusual collapse on the 13th, was that something that was discussed at the
handover as I understand it, is that correct?
NEAME: It certainly would have been raised at handover. I don't recall that discussion.
BROWNE: But did you consider it should be raised in any other forum or did you -- having had the
experience of [Child H] which was now unexplained and now a further unusual collapse, did you feel
this was something that you should now be raising at Consultant level?
NEAME: Well, I think I was confident -- well, I was confident that Consultants knew about the
episodes as I had called Dr Newby in and she was there. I think similarly I was quite focused on the
potential clinical explanations and ...
BROWNE: Did Dr Newby or indeed any other Consultants discuss with you concerns they had, wider
concerns beyond that specific collapse of [Child I]?
NEAME: No.
BROWNE: On the following night, 14 October, [Child I] collapsed again and on this occasion Dr
Jayaram was called out and again chest compressions commenced and adrenaline was given?
NEAME: (Nods)
BROWNE: Again, Dr Neame, can you indicate or give some indication of how unusual it was in your
experience to have that experience of consecutive collapses on consecutive nights requiring chest
compressions of a severity that Consultants needed to be called in?
NEAME: Well, I think it that's slightly more challenging from a clinical perspective because I think
there are cases where babies are unstable due to an underlying clinical condition and that might
precipitate further events, that was certainly my interpretation of what was happening by that
stage. So using adrenaline in a resuscitation situation in a district general hospital was unusual
but managing very unwell children and seeing complications of further -- of periods of instability
represented by further periods of instability felt plausible clinically.
BROWNE: If I could take you to paragraph 26 of your statement, you say there: "... I recall formal
discussions ([for example] during ward rounds and during discussions with colleagues from tertiary
neonatal centres and the Alder Hey surgical team) and informal discussions amongst the clinical team
relating to the unusual course of [Child I]'s presentation." Then you go on to say: "My recollection
is that although [Child I]'s death was surprising and unexplained there would be an ongoing attempt
to try to identify the cause through a postmortem assessment." So was it your understanding that
indeed matters were being looked into in relation to [Child I]?
NEAME: Yes, that was my perception through that period, was that we, the team, were searching for a
clinical explanation for her instability and episode.
BROWNE: Thank you, Dr Neame. If we just could put up INQ0000536. This is tab 8, my Lady, in your bundle. That is the witness
statement of Dr Rachel Chang who was a Registrar and if we can just go down towards the bottom of
the page. It says there in the last paragraph talking about this period on the handover of the 15
October: "Matt Neame was having a really difficult stretch of nights with [Child I] as she had been
very ill. Night after night he was really shattered. He was glad to be
finishing nights, I think, but I can't remember any comment or concerns from him about the three
nights he had looked after her. He was just very glad to be finished as it had been so
understandably stressful". Then if we could turn over to page 7. Scroll down to page 7 and we see
there in the penultimate paragraph: "Matt Neame had been resuscitating poor [Child I] every night
shift, then every morning at handover I would be like 'Oh my God, poor [Child I] and poor you', then
we would have a day shift of where we would say, 'Oh she's not been too bad' as she had seemingly
recovered quite quickly." So what Dr Chang seems to be saying is that there was an apparent pattern
where [Child I] would deteriorate at night, bounce back to some extent into the day and you were
involved in those episodes?
NEAME: (Nods)
BROWNE: If we can go now to 0099075 at page 12 and this is tab 10, my Lady, in your bundle. So
that's 0099075 and page 12. At paragraph 36, this is the statement of Nurse ZC that's been given to
the Inquiry. She says: "The second instance was with Dr Matthew Neame who similarly had a run of bad
shifts. My understanding was he had in fact previously completed a rotation at
Liverpools Women's Hospital's NNU which cares for some the sickest neonates in the Northwest. He
returned to the NNU at the Countess of Chester earlier and has made comment that he had used more
adrenaline during these night shifts than he did in six months at the Liverpool Women's. He again
made a comment along the lines of 'it's always Lucy that ends up with these babies too'. Again,
there was no further discussions or him suggesting anything was with intent." So that's one
additional aspect to the pattern. We have looked at the fact that these were deteriorations that
happened at night, that [Child I] then seemed to recover during the day, and then we are adding to
that that you had observed that Letby was on duty at the same time. Did you draw any conclusions
from that or did you have any concerns arising out of that?
NEAME: No.
BROWNE: We have heard from Dr Lambie back in September that there was a suggestion of nurses
huddling and looking at who was on duty on a rota. Was that something that you were aware of, other
nurses or anybody suggesting to you that should be considered of who was on duty when these
collapses occurred?
NEAME: No, I wasn't aware of any of those discussions.
BROWNE: The Inquiry are considering an issue of whether there was an instruction that was given on
the afternoon of 14 October, so after the second of the consecutive collapses, experienced by [Child
I] that Letby be taken off caring for Baby I [Child I]. Did you have any knowledge that Letby was or
there was a suggestion that Letby should be taken off caring for Baby I [Child I]?
NEAME: No.
BROWNE: Just staying again with Baby I [Child I]. It appears that it was the death of [Child I] and
indeed the -- which happened on 23 October, I think you weren't involved on that occasion; is that
correct?
NEAME: That's correct.
BROWNE: But the death of [Child I] and indeed the previous collapses that raised Dr Brearey's
concern, and indeed to some extent Dr Gibbs's concerns we heard yesterday, at about this time, too.
Do you have any recollection of either Dr Brearey or indeed of any Consultant coming to you and
asking you for your views as the doctor involved in these collapses as to your views on the reason
or any concerns you had?
NEAME: No, I don't recall that.
BROWNE: I think it follows, but I must ask you, did anyone come to you and ask you about who were
the nurses who had been on duty during those collapses?
NEAME: No.
BROWNE: In the case of [Child H] and [Child I], they were significant collapses, where the child
required resuscitation. Did you consider making a Datix entry for any of those collapses?
NEAME: No, I didn't.
BROWNE: Why was that?
NEAME: I think at that time my perception of the Datix would have been that it would be used if
there had been a mistake or a clinical error or a problem with the equipment and I didn't perceive
that to be the case during those episodes.
BROWNE: Maybe you can help. Had you felt there was a reason for a Datix would that be something
that you would have been filling in or would that be something that would be generally done by the
nursing staff?
NEAME: Often there would be a discussion about who had identified it and who had the most useful
information about the incidents but certainly it is something I would have felt comfortable and
confident to do.
BROWNE: But it was nothing that either occurred to you or was suggested by anyone that a Datix
should be entered for any of those episodes, the [Child H] or the
[Child I] collapses we have been discussing?
NEAME: No, it wasn't suggested as far as I recall.
BROWNE: If we could now look at 000526, page 10, which is tab 7. Sorry, no, I'm afraid that's an
incorrect reference. It's 0003288001. This is a neonatal mortality meeting that you attended in
relation to [Child I]. We see your name there "Attendees" at the top. Do you have any recollection
of this meeting?
NEAME: I don't think I recall that meeting. I think I recall an informal debrief discussing [Child
I], but I don't think I recall a formal mortality meeting.
BROWNE: Because we see there, certainly in the middle of the page, we see a summary of the case and
we see there that the collapses on the 13th and the 14th are recorded there and obviously that was
something that you would have had direct evidence about?
NEAME: (Nods).
BROWNE: And I think it's correct, is it, Dr Neame, that you had concerns and didn't have an
explanation as to why those arrests had occurred at this stage?
NEAME: I think certainly the immediacy of the first episode was very surprising. As I tried to
express earlier, I think the subsequent episodes were less unexpected in that [Child I] was less
stable by that point
and had frequent clinical signs that could have subsequently caused a deterioration. I think they
were still surprising in terms of how severe they were. But, I hope that's a fair way of expressing
it.
BROWNE: We see in the paragraph in the middle box "Discussions and learning from the case". There
is no discussion about the collapses. Were those meetings meetings where there was a free discussion
about any concerns? I'm trying to understand why there was nothing in that discussion and learning
in relation to the collapses.
NEAME: So I don't have a clear recollection of this Morbidity and Mortality Meeting. Other mortality
meetings that I have a sort of vague recollection of at Chester I think were quite Consultant-led
perhaps and quite focused on presenting key events without input from junior colleagues. That --
that's a vague recollection of some meetings that I had attended at my time there.
BROWNE: So just to interpret that if I can. That -- was that a meeting, would it have been led by
Dr Brearey, first of all, would that be your recollection?
NEAME: Well, the only meeting that I am certain I can
remember to do with [Child I] was a quite informal debrief and discussion amongst the team around
her course on the unit. But I -- I don't recall that as being a formal Morbidity and Mortality
Meeting with an in-depth discussion of the clinical course.
BROWNE: So you, as far as you are aware, can't recall this neonatal mortality meeting that would be
discussing, as is apparent from it, the period from August to October and the deaths that had
occurred in that period. That's not a meeting that you recall?
NEAME: I don't recall it, no.
BROWNE: Thank you. If we could just turn, while we are looking at the recording of incidents, to
000526 and page 10 of that and this is tab 7, my Lady, in the bundle. Dr Neame, this is an extract
from a statement that you gave to the police and if you could go to page 10 and you deal here with
some of the note-taking in relation to [Child I]. We see there, are we on page 10, yes, that you
were called to attend [Child I] and that's at the top of that paragraph and that's relating to --
it's not immediately apparent from this page -- but that's relating to 15 October and then going
down the page, we see: "My next note was then 19 October at 09:50 hours." And if we could go to the
next page, please, we see that's dealing with the note, the continuation of the note that you were
filling on 19 October and it says: "I discussed her [that's Child I] with the surgical team at Alder
Hey and the Registrar there who had discussed her with the on-call Consultant. There was a query
about arranging another investigation for her to have a barium x-ray of her tummy to see if there
was any explanation for her tummy problems. A barium x-ray can give a clearer picture of any
blockages in the bowel." Then at the bottom of that page, your next notes were on 22 October at
11:30 and then if we can go on one more page, so this is still the note of 22 October, you say there
at the end of the first paragraph: "The plan was to chase up the previous investigations, the
contrast enema and keep her nil by mouth until then." Were you aware, Dr Neame -- obviously sadly
[Child I] died the following day, but were you aware why these tests that you were chasing up had
not taken place prior to that?
NEAME: My recollection is that during that period it was very -- it had been very difficult to get
her transferred over to Alder Hey to have a further assessment and to have those investigations
completed.
BROWNE: You say then at the bottom of the page: "I don't recall ever there being a good explanation
or understanding of [Child I] as to why she had episodes where she became unwell so quickly and
sadly died." Does that accurately set out your view?
NEAME: That's a good summary of the overall feeling I have about her care. I think there were
episodes where I felt there was certainly a plausible clinical explanation. But I think reflecting
on the overall, you know, on her care and her course overall I think that's a fair summary.
BROWNE: And if we could go just to paragraph 40 of your statement. I think if we could put that up
on screen, that's INQ0102351 at page 10, and again this is somewhat of a summary really of your
evidence -- of your witness statement: "I recall developing a subjective sense of concern about the
number of deaths and unexpected deteriorations on the Neonatal Unit during my placement there in
2015-2016. I recall discussing these concerns informally with colleagues, for example highlighting
that shifts had been unexpectedly busy at Consultant handover meetings but I did not raise these
concerns formally. In part, I believe this is because I was confident that these observations had
already been noted
by the more senior cohort of medical and nursing colleagues, and in part this was because I held the
assumption that the episodes were related to unexplained or unexpected medical factors rather than
being caused by factors related to deliberate harm or incompetence." Just looking at that, you say
you were confident that observations had been noted by a more senior cohort. What was the basis of
that confidence?
NEAME: The fact that I had, you know, been escalating the concerns directly to Consultant colleagues
as they arose. They were often present as I was managing the challenging clinical situations and I
felt confident that they would have found them, you know, challenging as I did and my perception was
that they were a, you know, relatively close coherent group who would be familiar with how much
pressure the unit was experiencing.
BROWNE: And then you, just looking at the expression you use there, "unexplained or unexpected
medical factors". In effect, that means that simply there was no explanation for these. That's what
that's saying, isn't it, there was unexplained or unexpected, is that correct?
NEAME: Well, it's saying that my perception was that they weren't immediately explainable, but that
with
further assessment or investigation that we would identify medical causes.
BROWNE: Do you now considering, looking at this with hindsight, was that a situation where there
should have been consideration of whether there was a non-medical factor, either deliberate harm or
negligence, for why those were happening? Is that something that should have been within the range
of possibilities that was considered?
NEAME: Well, I think absolutely it -- it should have been and I think it's hard to know when, when
that threshold should have been met. But, yes, I think it's difficult to disagree with that given
everything we know now of course.
BROWNE: But at that stage for you, Dr Neame, you hadn't reached a point where you were considering
non-medical explanations, is that correct?
NEAME: No, that's correct.
BROWNE: Then just dealing briefly with safeguarding. What was the training that you had received in
relation to safeguarding training either at the Countess of Chester or indeed prior to that?
NEAME: So I can't remember precise details of the training I had undertaken. But I remember clearly
that by that stage of my training, I was required to have a good understanding, well, have a clear
understanding of the typical presentations that might indicate that a child had been subject to
deliberate harm or a non-accidental injury. That would have included reflecting on clinical cases,
discussing them with senior colleagues and also attending training courses designed to promote the
recognition and response to -- to child protection issues.
BROWNE: Did you at any stage in this, particularly by the stage towards the end of your period in
February when you had dealt with the issues of the collapses of [Child I], did you at any point
consider that there was a safeguarding issue that was developing here?
NEAME: No.
BROWNE: Turning finally then to your reflections and, Dr Neame, you set out in your witness
statement your reflections which will of course be considered. But I just wanted to look at one of
those that you deal with at paragraph 6 and you say that you would like the Inquiry to recommend
that: neonatal units should aim to enable the parents of babies to stay with their babies around the
clock and that you think more contact between babies and families would make it harder for staff to
perpetrate criminal actions and that closer
contact between family members improves clinical outcomes. Is that something you just want to expand
upon very briefly as to why you feel that is so important with your additional experience obviously
now as a Consultant paediatrician?
NEAME: I just think that's not just my experience. I think there's evidence that babies have --
experience better outcomes when they spend more time with their caregivers. With respect to the
particular issues in this, this case, I think it would have made it much harder for a medical
professional to behave abnormally or with -- cause harm if there was a parent with the child. I
think the neonatal settings that I have worked in previously have not been well set up in terms of
the sort of architecture or layout in terms of making it easy for families to spend large amounts of
time with their children. I think efforts are made with comfortable chairs and so on, but that's
very different to, you know, being able to stay with your child which would be the norm in a
paediatric ward or a children's hospital.
BROWNE: And the lack of that was something that you were conscious of when you were at the Countess
of
Chester?
NEAME: I think that's something I have reflected on since being involved in this case.
MS BROWNE: Thank you very much. You may have some further questions from my Lady.
LADY JUSTICE THIRLWALL: No, I have no questions for you. Thank you very much indeed, Dr Neame, and
in particular for your reflections which are extremely helpful. I know that you have made a number
of statements including the ones we have been looking at today. Thank you for all of that and you
are now free to go.
NEAME: Thank you.
LADY JUSTICE THIRLWALL: I think, Ms Browne, the next witness is attending by videolink.
MS BROWNE: Yes.
LADY JUSTICE THIRLWALL: So that is fixed for 2 o'clock. So if everyone could be back in the room just before 2 o'clock so we can get started on time. (12.43 pm) (The luncheon adjournment) (2.00 pm)
MS LANGDALE: My Lady, may I call the next witness Dr Mayberry who is giving evidence over the link and needs to be sworn.
LADY JUSTICE THIRLWALL: Welcome, Dr Mayberry the next voice you will hear will be from my clerk who is going to administer the affirmation.
THE WITNESS: Sure.
DR HUW MAYBERRY (affirmed) (Evidence via videolink)
MS LANGDALE: Can you give us your name and qualifications, please?
MAYBERRY: Sure so my name is Dr Huw Francis Mayberry, I hold a Certificate of Completion of Training
in Paediatrics (Paediatric Intensive Care) from the General Medical Council. I have also completed a
Special Interest Module, or a SPIN, in Paediatric Cardiology. I am a member of the Royal College of
Paediatrics and Child Health. I have held memberships with the Paediatric Critical Care Society and
the European Society for Paediatric and Neonatal Intensive Care. My degree is an MUDr awarded by
Charles University in Prague in 2011.
LADY JUSTICE THIRLWALL: Just pause there, Dr Mayberry. Can everyone hear sufficiently well? No. I wonder if you could move forward, I gather there is a problem with the sound so if you can move forward, that might be the best thing to do.
MS LANGDALE: Shall we try that? (Pause) That sounds better. If you can't hear me, Dr Mayberry, at
any point just raise your hand and I will do the same for you so we don't keep speaking into a
vacuum of people not hearing us.
MAYBERRY: That sounds good.
LANGDALE: Thank you. You have provided helpfully the Inquiry with a statement dated 9 April 2024.
Can you confirm for us that the contents are true and accurate as far as you are concerned?
MAYBERRY: As far as I am aware yes, the contents are true and accurate.
LANGDALE: You have it with you, I believe, Dr Mayberry, so I can take you through it today?
MAYBERRY: Yes, I do yes.
LANGDALE: Can I ask you a couple of questions before I do. We know from your CV that you were
working at the Countess of Chester between March 2016 and September 2016 in specialist paediatrics;
yes?
MAYBERRY: Yes.
LANGDALE: Did you know Dr Ogden or Dr Lambie, those who had come before you, in Dr Ogden's case
March
to September 2015 and the same I think for Dr Lambie?
MAYBERRY: I haven't met Dr Lambie to the best of my recollection. Dr Ogden is somebody who I have
met in other contexts. I can't remember if I knew Dr Ogden before the Countess, before I worked at
the Countess, but I am -- I do know who she is and I have met her on other occasions.
LANGDALE: I notice it is obviously not uncommon as Registrars or trainees you move around. Arrowe
Park, in your case, Alder Hey, Countess of Chester and also Liverpool Women's. So presumably there
is sometimes overlap or connection or communication between Registrars rotating in their roles?
MAYBERRY: Yes, there can be. To the best of my recollection, I don't think I worked with Dr Ogden
before I worked at the Countess of Chester.
LANGDALE: Dr Ogden, I will ask for it to be put on the screen so you can see it Dr Mayberry, she in
here statement -- the reference number is INQ0102019, page 8. It is paragraph 32 of her statement. It doesn't refer to
you, Dr Mayberry, but I want to draw to your attention what she says at paragraph 32 on page 8.
MAYBERRY: I don't have that on screen currently.
LANGDALE: You will shortly, don't worry, I think it should be coming. Can you see it now?
MAYBERRY: Yes.
LANGDALE: We can't see you while you are looking at it but I will take it down as soon as I can, Dr
Mayberry. If you look at paragraph 32, Dr Ogden says when she was at the Countess: "I do recall
finding the numbers of collapses or deaths on the unit at that time as unusual and concerning. I am
unsure specifically when this appeared to me as unusual but it is likely to be around the time of
several of those collapses/deaths that occurred within a few weeks of each other in June 2015.
Whilst I do not recall that I specifically approached any Consultant in particular to raise specific
concerns I believe the whole department was discussing this informally as being unusual and that the
senior Consultant team were raising this and investigating what could have caused this." That can
come down from the screen, Dr Mayberry.
MAYBERRY: Sure.
LANGDALE: I can tell you that we heard from Dr Lambie this morning that in the same period in
around June, she says she does: "... recall being aware of increasing levels of anxiety following
the death of [Child A] and collapse of [Child B] soon afterwards largely due to the unexpected
and similar natures of their collapses and the appearance of the unusual rash. "As further babies
become unexpectedly seriously ill, (collapsed) or died, I recall medical and nursing staff reporting
to each other they were nervous at the start of their shifts. I personally recall being nervous at
the start of a set of night shifts towards the end of my placement as I was almost expecting
something bad to happen". When you arrive, were you aware of that concern or discussions, sense of
unease that both have described in their statements?
MAYBERRY: I think on arrival it wasn't something I was particularly aware of. As I have written
later on during my statement Dr Brearey did tell me that historically the Countess had had a low
mortality rate, that that had increased over the period before I had arrived and that they had
started asking for other people to be involved with that. I don't recall exactly when that
conversation took place. It was an informal conversation. But I wasn't aware of a growing sense of
unease at the time.
LANGDALE: I think it is paragraph 12 of your statement, Dr Mayberry, you set that out, you say: "As
time went on I do recall growing anxiety about the mortality rate. From what I understood Chester
traditionally had a low mortality rate compared to the rest of the region and it wasn't understood
why that had changed."
MAYBERRY: Yes.
LANGDALE: So you can anchor yourself and everyone in the room can, Dr Mayberry, when you were there
we know that L,M, N and Q suffered deteriorations and O and P died. So when you were there, O and P,
the triplets which we will come to later, died, but you say nevertheless you were aware from Dr
Brearey some growing anxiety about the mortality rates. I just want to unpack that. When you say
"mortality rates", does that mean simply death rate or did you have any sense or unease about
unexpected death rate or discussion about that?
MAYBERRY: Sure. To the best of my recollection, all that was referred to was the mortality rate as
opposed to anything unusual about the deaths.
LANGDALE: So it was the crude indicator, a mortality rate full stop and the number?
MAYBERRY: Yes.
LANGDALE: You understood from Dr Brearey that that was being investigated because it was
higher?
MAYBERRY: Yes.
LANGDALE: Or it had changed?
MAYBERRY: Yes, it increased, yes.
LANGDALE: Was he a supervisor of yours or a -- I don't know what you would call it?
MAYBERRY: He was my -- he was a Consultant so he is somebody I guess would supervise me in the sense
he was the most senior person on-call or on a number of occasions. My designated supervisor was Dr
Gibbs though.
LANGDALE: Did Dr Gibbs ever say anything to you about mortality rates?
MAYBERRY: If I am honest, I don't fully recall. A conversation I recall most clearly was the one
with Dr Brearey.
LANGDALE: Was that soon after you arrived, later on? I mean, you arrived in March 2016?
MAYBERRY: Yes.
LANGDALE: When did that conversation roughly take place with Dr Brearey?
MAYBERRY: I think it probably would have been within the first couple of months but I find it hard
to be more specific than that.
LANGDALE: Fair enough, but you knew soon after your arrival there was concern about that number and
what it represented?
MAYBERRY: Yes.
LANGDALE: But nobody ever spoke to you about what it might represent or anything like that?
MAYBERRY: No, I think Dr Brearley said they didn't understand why it had gone up and that's why they
had sought external opinions and advice.
LANGDALE: What external opinion did you think that they were getting?
MAYBERRY: So I thought that they were getting a Network review, so a review from the Neonatal
Network, and then later on a review from the Royal College of Paediatrics and Childcare.
LADY JUSTICE THIRLWALL: I'm sorry to ask, would you mind just keeping your voice up a little bit
more and a bit closer to the microphone, thank you.
MAYBERRY: Sure, sorry, so my understanding was that it was a Network review, so a review from the
Neonatal Network in the area and a review from the -- later on from the Royal College of Paediatrics
and Child Health.
LANGDALE: And in what context did Dr Brearey give you this information, was it in a passing
conversation, in an informal discussion, what kind of set-up was it where you learned this?
MAYBERRY: I believe it was an informal discussion but I can't remember too much more context to it,
sorry.
LANGDALE: Informal discussions, presumably they take
place between doctors, doctors and nurses and people all the time walking around a hospital? When
you catch a moment, you catch someone, you have a conversation, is that how it is?
MAYBERRY: Yes, you do have informal conversations.
LANGDALE: Did you have any discussion with fellow Registrars about the mortality rate?
MAYBERRY: No, not really. The -- I am getting a lot of feedback, does everyone -- are you having
trouble hearing me?
LANGDALE: We are not having trouble hearing you. I'm sorry that you are getting feedback. Can you
hear me?
MAYBERRY: Yes, I can hear you. So I didn't have a conversation with other Registrars, to the best of
my recollection about it was quite low on the number of Registrars on the rota and by its very
nature I think at times we were down to 3.5 working equivalent Registrars on an eight Registrar
rota. You wouldn't necessarily see the other Registrars on a very regular basis.
LANGDALE: Did you ever ask "what are the numbers" when you were told there was an investigation or
consideration, I should say, into the mortality rate, did you say, "Well, how many is it usually,
what's it now?" or ask any questions out of curiosity. I am not saying you should have done, but
were you curious what that was about?
MAYBERRY: No. At this point this was my first year of being a Registrar and it was my first job
working in a designated neonatal unit as a Registrar and I think I was probably focused largely on
making sure my own practice was as good as it could be and up to date and I understood that there
were processes taking place in the background to look into what had happened and why it had
happened.
LANGDALE: Understood. At that stage in your career, Dr Mayberry, did you know whether and if so
there was a difference between what should happen when a child dies in hospital and when a child
unexpectedly or without explanation dies in a hospital, would you have known that or been aware of
that important distinction then?
MAYBERRY: I think I would have had some awareness of it but probably I would have had some awareness
but not as extensive perhaps as I do now.
LANGDALE: Sure. What's given you a greater awareness now: training, knowledge, experience?
MAYBERRY: I think probably a combination of all of those things.
LANGDALE: Did you, at the time you were at the Countess
and generally, know very much, if at all, about the case of Beverley Allitt the nurse in Grantham
Hospital who had been convicted of murdering patients? Did you know anything about that case when
you started medical training?
MAYBERRY: I knew historically just from general sort of news about some of Beverley Allitt's case
but it's something that didn't come through training or anything like that. It was more a from sort
of general news.
LANGDALE: And in general, would that heighten any awareness in you or colleagues generally or do
you think it was sort of consigned to the past and just a case or what do you think?
MAYBERRY: I think it's something that you did sort of think of in -- as something to be aware of in
the background. I am not sure it's something that came into day-to-day thinking, though.
LANGDALE: So background knowledge but not day-to-day thinking because that seems unthinkable, or
how would you define thinking about a nurse murdering patients?
MAYBERRY: I think because it's -- potentially it was more historic, it was something that was
relatively -- well, it was rare in its nature, and I guess they are probably the main -- the main
things that it was historic and it was rare and so it's not something you
would think about on a day-to-day basis and there were a number of other things which were more
likely to affect and -- affect children and put their lives at risk.
LANGDALE: We asked you, Dr Mayberry, about the culture and atmosphere of the neonatal unit in 2016.
You tell us Dr Gibbs was your assigned supervisor and was responsible for helping you with any
difficulties you might face. Did you find Consultants, particularly Dr Gibbs, helpful to you in
their capacity as Consultants? Were the relationships good and harmonious as far as you are
concerned?
MAYBERRY: Yes, I didn't have any problem or any issue with any Consultants there. When I was on-call
and I needed help, the Consultants would often come in even middle of the night they would happily
come into help. I didn't have any problems.
LANGDALE: That was a super clear answer, Dr Mayberry, so wherever you are sitting now is a good
place to be. It was very audible, thank you. You also say in your statement at paragraph 8: "...
Consultants didn't really discuss the interactions with management with junior members of staff."
You are a junior doctor, you are setting out on
your career at this time. What role did management play, if any, in your understanding of your
career and your future ahead, what did you make of the role of management and how the Consultants
got on with them?
MAYBERRY: So I didn't hear a great deal about how the Consultants got on with management. I think
what I did hear was probably limited to their attempts to increase the number of Registrars on the
rota and that seemed to be the extent of my interaction, my knowledge of management interaction with
Consultants.
LANGDALE: That they did increase the number?
MAYBERRY: No, that the Consultants were trying to get more Registrars on that rota and that they
were approaching HR and management to try and do that.
LANGDALE: Did you think that would be a good thing, to have more Registrars?
MAYBERRY: Absolutely, yes.
LANGDALE: What was your shift pattern like?
MAYBERRY: My shift pattern in itself was fairly standard, I recall. Having said that, what you
needed to do on a shift was much more difficult and hectic than you would have had to do in another
district general hospital and I think that was down to the fact that they were so short on numbers
of people on that grade rota with there only being 3.5 working time equivalents on an eight -- what
would normally be eight doctors fulfilling this role and the Countess was a busy hospital. It had a
large range of services to cover as a paediatric trainee and it meant that you had to do what would
be expected normally of eight Registrars with 3.5, so it was busy.
LANGDALE: You were going into the children's unit, neonatal unit and A&E as well?
MAYBERRY: A&E and other clinics, yes.
LANGDALE: You say the interactions you experienced between medical, nursing and midwifery groups
were always friendly and professional. Did you ever sense tension anywhere between midwives and
doctors, nurses and doctors, or not?
MAYBERRY: Not -- not really, no.
LANGDALE: You say: "From a medical perspective ... Dr Brearey was the lead and would promote the
latest and most up-to-date neonatal medicine, encouraging trainees to read and follow the ...
(British Association of Perinatal Medicine) guidance." So did he encourage best practice in
individual sessions with you or just generally signpost what was going on or how did what work?
MAYBERRY: He did it in a variety of ways. He would
often discuss changes in guidance. In terms of things like individual practice he would also help
with that as well. I think at the time for example one of the things was around UVC incision, the
umbilical venous catheters. BAPM had changed what they suggested in terms of how you insert them and
how you secure them and he was saying, you know, we should -- if you do it like this, then that's a
bit of an older practice. We should try and do it in this new way with the BAPM guidance, so he
would provide individual feedback as well as promoting good practice in general.
LANGDALE: You say that the nurses, you had a good relationship with the nurses, they were friendly
and professional, your interaction was good with them?
MAYBERRY: Yes, I believe it was, yes.
LANGDALE: You also say that the culture in the Countess compared very well to other hospitals you
have worked in that's Arrowe Park, Leighton Hospital, and you also say it had a good reputation.
What was it about the Countess of Chester that had a good reputation as far as trainees who wanted
to apply to work in those units were concerned?
MAYBERRY: I think it had a -- what was known to be a very supportive Consultant body, people who
would help you with help and guidance and it had a fairly friendly
atmosphere that people were encouraging in terms of development of junior staff and would try and
promote up-to-date guidance and help push things forward.
LANGDALE: You say the Consultant body were known to be clinically sound, supportive towards juniors
and pleasant to work with. So there was no sense, was there, from your perspective of arrogance or
they know best and not listening to concerns or voices around them?
MAYBERRY: No, not at the time I worked there. No.
LANGDALE: Did you ever witness them being dismissive or not concerned about matters raised by
nurses or patients or anyone else?
MAYBERRY: It's not something I recall witnessing, no.
LANGDALE: You say you had little direct interaction with senior management but you did attend a
corporate induction. Can you tell us about the corporate induction and what you say at paragraph 15
you were taught about?
MAYBERRY: Yes. So my memory of corporate inductions has become a little bit more hazy but one of the
things that stuck out to me was -- one of the things that stood out was the importance of not losing
your handover sheets. Now, every doctor knows that your handover sheet has a lot of important
information for patients on it
and that you would never want to lose that because you don't want to breach confidentiality of a
patient. But one of the things that came up was the fines that the Countess would go through if you
-- if you lost a handover sheet, however much money that was and that this was unacceptable. I
thought that was very unusual. Everyone at induction goes through, like, make sure you don't lose
confidential information and Caldicott guidelines and things like that, but no one in any other
corporate induction I had attended had mentioned the cost of fines and I thought that to be very
unusual.
LANGDALE: Was this in 2016, so was this early on in March, the beginning or a bit later on in your
...
MAYBERRY: At the beginning.
LANGDALE: So your induction very much told you about the importance of handovers. Can I just
understand at that time, were the handovers written and on paper, you know, was there something you
could physically take?
MAYBERRY: Yes. So normally, handover consisted of two things. You would have a piece of paper which
would have a short summary of the most important points about why a patient was there and what jobs
they needed -- what investigations they had had done and what jobs they needed doing and that's
fairly standard at the time across all the NHS Trusts. That would allow you to also write additional
notes next to it to help structure your day and help make sure that you did everything that the
patient needed to have done. There was also accompanied with that a verbal handover from the junior
doctors with the Consultants present to say what was going on with each patient and potentially
patients who were due to come in as well.
LANGDALE: At the criminal trial it was made clear, Dr Mayberry, that Letby had handover sheets for
a number of children in plastic bags under her bed at home; in fact kept 231 handover sheets. At the
induction was it being highlighted that if you took them, there was a fine and would you have
expected as a doctor working there that someone would notice when you have taken a handover sheet or
not, are you not looking retrospectively or how does it work?
MAYBERRY: So the handover sheet, normally the way it worked is the handover sheet gets printed, you
write your stuff down on it and then at the end of the day there is a confidential waste bin where
your handover goes in to, then that is taken securely it is in the sort of waste bin of it and
shredded and destroyed so that patient confidentiality is kept, you know, safe.
It's not that every handover sheet is necessarily tracked in some sort of a way. If it were that you
ended up, you know, taking them home I am not sure somebody would -- it would be a good way of
tracking that based on the --
LANGDALE: Don't worry, I am not asking about tracking it. It was more that the hospital are telling
you there are fines for it because of patient confidentiality and you were not expecting that. Have
you had that kind of induction anywhere else since?
MAYBERRY: Yes. In terms of -- not in terms of fines specifically but everybody knows that you should
be getting rid of your handover sheets and disposing of them in the secure, you know, bins where you
throw them away.
LADY JUSTICE THIRLWALL: Dr Mayberry, can I just ask you, I didn't quite hear and I am not sure that
the transcriber did either: when you were talking about the induction, and that everyone is aware of
the guidelines, did you say "Caldicott Guidelines" or some other sort of guideline?
MAYBERRY: So yes, Caldicott and information about how to how to make sure that you -- only the right
people have the right information and you dispose of any
confidential waste properly.
LADY JUSTICE THIRLWALL: Thank you very much. Sorry, Ms Langdale.
MS LANGDALE: Thank you. In that induction, either that one or any other, did you have any
safeguarding advice about who to speak to if you were concerned about a child, concerned potentially
because of a member of staff's treatment or family members; anything, concerns for a child, child
protection, was there a generalised induction around that?
MAYBERRY: Yes. There was an induction around child protection, I think it was one of the community
paediatricians who did it.
LANGDALE: Would you have known the name of the community paediatrician or the person to go to if
you had a safeguarding concern?
MAYBERRY: So safeguarding concerns out of hours at the Countess of Chester I believe were discussed
with the duty Consultant paediatrician.
LANGDALE: Did you have any discussion at any time around Datixes and what the importance of a Datix
was after any event and what type of event?
MAYBERRY: I think there were some discussions around Datix and that if you saw things which you
thought were
a risk to patients, or -- not or -- or caused patient harm then you should fill out Datix forms to
make sure that those concerns could be addressed and followed up with.
LANGDALE: You tell us, going back to the topic of management, you briefly interacted with
management about the cap on locums for junior doctors at a significantly reduced rate. Can you tell
us about that?
MAYBERRY: So in terms of the Registrar rota and some of the Level 1 rotas, so the rota below the
Registrars, there were a lot of gaps obviously because there is designed for eight people and only
3.5 people were at times running on that rota. The -- at the time I think or it might have been a
bit before this there was a cap put on locum fees with the aim of trying to -- I don't know, trying
get expenditure and things down. It became clear that the cap across the region wasn't working and
people weren't going to work for a reduced rate and most hospitals in the region lifted that cap and
went back to the rates that they had traditionally paid people. At the Countess, that approach
wasn't taken during certainly the early part while I was there and they remained steadfastly holding
on to that cap. It meant that people in other parts of the region when locums came up were being
offered significantly more money to go and work in another hospital, like Alder Hey or Arrowe Park,
and so people -- if you had a choice of where to work, people weren't taking up the locum offers at
the Countess of Chester.
LANGDALE: Did you raise that with other doctors or managers individually?
MAYBERRY: Yes. So that was raised with a number of different Consultants who knew about it. As I
said, I didn't really have a relationship with the managers so I didn't have somebody I could really
speak to about that on a management level and the Consultants assured me that they were pushing hard
to fill the gaps on the rota and had also asked for the cap to be raised.
LANGDALE: We are aware there was a medical staff committee, was that something you were aware of or
would have had any relevance here or not?
MAYBERRY: No, it's not something I was aware of.
LANGDALE: Okay. Moving now, if I may, to [Child N] in paragraph 19 of your statement. Looking at
your Inquiry statement and your police statement, I don't need you to go to your police statement,
it is clear that you are speaking about events on 15 June 2016, at paragraph 19.
We now know of course that Letby has been convicted of the attempted murder of Baby N [Child N] with
inflicted trauma to the throat. Taking yourself back to the evening obviously you didn't know that
then, but can you set out for us your involvement with Baby N [Child N] as you set it out here?
MAYBERRY: Sorry?
LANGDALE: As you set it out here, I don't need the pages of your police statement, just what you
set out here.
MAYBERRY: So I think most of my involvement was with [Child N]. I believe it was in the afternoon,
actually, and I was holding the emergency bleep for the neonatal unit. To the best of my
recollection I wasn't assigned to the neonatal unit, but I think --
LANGDALE: Sorry, we lost you there, Dr Mayberry. To the best of your recollection, you weren't
assigned to Baby N [Child N]?
MAYBERRY: Sorry, I wasn't assigned to the neonatal unit.
LANGDALE: To the neonatal unit.
MAYBERRY: I covered the bleep for a brief period of time from one of the doctors who was assigned to
the neonatal unit that day and I believe I was assigned to the paediatric ward. Whilst holding the
bleep, the emergency crash bleep went off and there was a call to the unit because
[Child N]'s oxygen levels had dropped to 44% and 3ml of blood had been aspirated from the
nasogastric tube beforehand. I can't remember which member of staff initiated the call. I used an
airway manoeuvre and a NeoPuff device ventilated [Child N] until their oxygen saturations were 100%
and I requested the crash bleep to Dr Saladi, given that the previous Registrar had had a lot of
difficulty in attempting intubation. Whilst awaiting the arrival of Dr Saladi, I instrumented the
airway and saw a large swelling at the end of the epiglottis only just see the bottom of the vocal
chords which is the area where you would normally put a breathing tube in. At this point Dr Saladi
arrived and given the difficulty with the airway, I handed over [Child N]'s care to him. I don't
remember much more about who was present and what was happening as my sole focus was to improve the
oxygen levels in the critically unwell child.
LANGDALE: Did you discuss what you saw at the back of the throat at the time then with anyone?
MAYBERRY: Yes, I did. I can't remember if I discussed it with Dr Saladi at that point when he came.
I did later on discuss it when I came back to the neonatal unit later on, and there was a Consultant
anaesthetist
present who was Dr Campbell, who I wanted -- who I discussed it with because I hadn't seen anything
like this before and I was wondering as somebody who is more experienced with airways what her
thoughts on it were and if there was anything else that I could do in the future to improve my
practice if I came across the situation such as that. She told me that the view on the airway was a
Grade 4 which is the most difficult grade of intubation and that she had been unable to intubate the
child. I believe an ENT team and a paediatric intensive care team were mobilised from Alder Hey and
they did not find any difficulty in intubating the child. At some point I asked Dr Gibbs about what
they found and he told me it was a Grade 1 airway and that they hadn't had any difficulty in
intubating the child.
LANGDALE: You say: "I do not recall attending a debrief for [Child N]." Was there any informal
discussion between doctors and nurses who had been present that day or at that time about [Child
N]?
MAYBERRY: There was obviously that informal conversation that I have referred to.
LANGDALE: You and the anaesthetist?
MAYBERRY: Yes, and with Dr Gibbs subsequently. But I don't recall a debrief. There may have been one
but I don't recall it.
LANGDALE: The Inquiry is aware that Dr Brearey had sent an email to Eirian Powell and his fellow
Consultants on 11 May 2016 saying: "If you come across a baby who deteriorates suddenly or
unexpectedly or needs resuscitation on NNU please could you let me and Eirian know. We will keep a
record of these cases and review them as soon as practicable". As far as you were aware, were you
invited or asked to say what your involvement was or what you had seen or what you may have been
concerned about at any review?
MAYBERRY: No.
LANGDALE: [Child O]. At paragraph 23, you tell us you were working nights. Tell us of your
involvement with [Child O] and when you learned of [Child O]'s death and how you felt about
that?
MAYBERRY: So for [Child O] I was on the night of 22 June 2016 and I was working as a middle grade
doctor, so on the Registrar rota. "At some point in the night, I don't remember the exact time,
Sophie Ellis, who was the nurse looking after [Child O], requested a review of [Child O]'s abdomen
because it was mildly distended. Although she was not
worried about him, she felt he looked slightly uncomfortable. When examining [Child O] I could feel
that his abdomen was soft although it was slightly distended, he wasn't uncomfortable. This would be
a common finding in a child on high flow nasal cannula oxygen and I wasn't particularly concerned
about him. As I finished examining [Child O] and left his nursery, the emergency bleep went off and
I had to immediately attend to that. I realised that I didn't have time to document my findings and
so I quickly told Sophie what I had found and asked her to document the information in her notes, ie
what I had found, and then I left to attend to the emergency." I subsequently found out about [Child
O] coming back for the following shift the next evening, I did originally believe that that was with
a -- with --
LANGDALE: You weren't sure who told you about it originally, were you?
MAYBERRY: No.
LANGDALE: So, leaving aside who told you about it, what were you told when you came back on shift
to -- how did you learn about it, what did they say?
MAYBERRY: So what I was told was that [Child O] had deteriorated during the day and suddenly there
was a concern about NEC and that the child --
LANGDALE: Sorry, we are losing you there a bit. You say you returned, you learned there was a
concern?
MAYBERRY: About NEC, and that the child had deteriorated very quickly.
LANGDALE: And you say at paragraph 26: "... 'I had a brief conversation with Sophie where I
expressed my shock at what had happened. Sophie also agreed that he had been fine for the rest of
the previous shift and she stated she was also shocked at what had happened'."
MAYBERRY: Yes.
LANGDALE: You can't recollect further details other than what you have said previously to the
police and what you have repeated in part now. So can you remember how you were shocked or why you
were shocked?
MAYBERRY: I was shocked because nothing seemed unusual on that nightshift and with the initial
concern about NEC that wouldn't normally fit in that kind of timeline.
LANGDALE: You then go on in your statement to speak about [Child P] and your involvement with him
on that next night. Tell us about that.
MAYBERRY: So in terms of my involvement with [Child P], received a call from one of the nurses in
the neonatal unit but I don't recall who it was. There was a concern about a large amount of milk
being aspirated from the
nasogastric tube. This was a relatively common occurrence normally. There was no other concern about
[Child P] at the time. But given what had happened to [Child O] and that these were triplets, I
thought that the best thing to do was stop all the feed and start some intravenous fluids to replace
that. Upon arrival in the neonatal unit, my crash bleep went off indicating an emergency was taking
place and as I was standing in the corridor I checked with the nurse who was there at the time to
see how the triplets were doing and they told me that apart from the aspirate, they were otherwise
fine in themselves and I knew that I didn't have time to review them so I asked them to put in place
the IV fluids.
LANGDALE: So did you have any cause to be clinically concerned about [Child P] that night?
MAYBERRY: With the exception of what had happened with [Child P]'s sibling, no. The -- and the child
was otherwise well and checking back during the night, I think I called from Resus to the neonatal
unit, things seemed to be going okay since and everything had been settled and blood gases had been
fine up to that point. So no, I didn't have a reason beyond that to be concerned. I think Dr Gibbs
to the best of my recollection had started antibiotics which would be the other -- the other thing
to think about, but that was already covered.
LANGDALE: When did you learn [Child P] had died?
MAYBERRY: Again coming back on the next nightshift I learned that [Child P] had passed away, had
died.
LANGDALE: Are you all right, Dr Mayberry?
MAYBERRY: Yes.
LANGDALE: So paragraph 34, you say: "I felt devastated, shocked and bewildered. I felt and still
feel deep sadness for the two babies involved and their parents. I had only been doing two and a
half years of paediatrics but I hadn't come across anything like this. Triplets are rare and I
thought they must have had some sort of common genetic or gut problem. "I remember those present
being in a state of shock, deep sadness and bewilderment." Who did you speak with on the day of
learning of P's death when you say you remember shock and bewilderment? The Inquiry has heard
evidence from a number of people in written form and orally, but who were you talking to about
that?
MAYBERRY: I spoke to Jess Birkett I remember about it and she was probably the main person I spoke
to at the time about it. I don't recall who else I spoke to but
I remember the atmosphere in the handover room was distinctly different to how it normally was.
People were normally fairly chatty and bubbly but there was a lot of quiet and a lot of upset.
LANGDALE: Can we have document, please, Ms Killingback of INQ0004891, page 1. This is an email from Dr Brearey to you, Dr Mayberry: "You
reviewed the triplets' care and I think at least [Child O] and probably [Child P] will go to an
inquest. You may be asked to produce a statement for the inquest. It is probably best to get it
ready now rather than wait six months when they ask you and it is not fresh in your memory. I can
help with format et cetera if you need help. Dr V and Dr U are doing the same and have the notes. I
can let you know when they are finished with them." Did you ever get the notes -- that can come down
now, Ms Killingback, thank you -- and did you ever do a statement?
MAYBERRY: I didn't receive the notes. So I was aware that Dr U and Dr V -- sorry, from what I
recall, had the notes at the time and they were the people who were preparing a statement. I was
also keen to prepare a statement but the notes never appeared. I did ask for the notes again but
at the point where I asked them further and people went to look for them, they said that they had
gone to the Coroners already and I believe I discussed it again at a later point with Dr Brearey in
person, not via email and to say I have tried to get hold of the notes but they don't -- we don't
have them and I think his -- at the time he said I think it's very unlikely that you were likely to
be called about this given that you weren't there at the point where they deteriorated, so not to
worry too much about it.
LANGDALE: Were you aware at that time whether there were suspicions or not about a particular
member of staff being involved in causing deliberate harm to babies?
MAYBERRY: No.
LANGDALE: How well did you get on with all of the nurses on the unit?
MAYBERRY: I got on well with all of the nurses, I didn't have, as far as I am aware, any problems
with any of the nurses.
LANGDALE: On 30 June 2016, we know from a text message sent from Dr U to Letby -- sorry, from Letby
to Dr U. Letby says: "Had a nice chat with Huw, said I should go for a Band 6 and take the unit
forward, I am one the nicest nurses he has worked with."
Can you remember saying that to Letby at any point, encouraging her in her career and saying she is
one the nicest nurses you have worked with?
MAYBERRY: I don't -- I don't recall specifics at this point in time. She wasn't somebody who
outwardly -- outwardly she appeared to be a competent nurse who when you asked for things, you know,
she did them and she wasn't somebody who appeared, you know, incompetent and she generally had a
fairly friendly demeanour towards other members of staff.
LANGDALE: Did you ever have any suspicions or concerns yourself about her?
MAYBERRY: No.
LANGDALE: Were you aware whether others did?
MAYBERRY: I don't -- I think I have written in my statement about the only other occasions. One was
-- sorry, I just need to make sure I refer to them by the right acronym -- Nurse ZC who worked in
the paediatric ward who had told me that Lucy Letby had been her student and that she hadn't seemed
particularly engaged, I think was the -- was the term that she used and she asked me how she was
getting on. I guess the only other conversation was the deputy ward manager in the paediatric ward
had mentioned, and I think this was after -- I can't remember the exact time but I believe it was
after the issue with the triplets, that Dr Brearey had thought that Lucy Letby was a bit odd and
that the fact that both the triplets had died was a bit odd. That's the extent of everything that I
recall being said.
LANGDALE: So what's the name of the deputy ward manager, can you remember who you are talking about
there?
MAYBERRY: I -- I don't know if they have an acronym which I should refer to as in a -- the name, am
I allowed to say their name in full, as in I don't know if they have -- if they have an anonymity.
LANGDALE: If you -- you can let us have the name afterwards, okay, so we can take the name from you
via email. So the deputy ward manager, someone spoke to you, but this looks as though that was after
O and P had died because it's a reference to what Dr Brearey said, yes?
MAYBERRY: Yes.
LANGDALE: What about Nurse ZC, was that at an earlier stage that she said as a student Letby hadn't
seemed engaged and what did you think of her in effect. When was that conversation with Nurse
ZC?
MAYBERRY: The truth is I can't remember the exact time it was. I believe it was probably earlier
than that,
but I couldn't tell you an exact time, sorry.
LANGDALE: You tell us in your statement at paragraph 46: "In terms of investigations, neonatal
deaths were not investigated by doctors at my level." You weren't invited to provide a statement or
comment, just for internal review about the deaths of O and P. So was the first time you provided
anything in writing to the police?
MAYBERRY: Sorry, could you repeat the last part?
LANGDALE: Was the first time you provided anything in writing about your care of the babies to the
police when you did a police statement? Had you written anything before then?
MAYBERRY: No.
LANGDALE: Nothing. Because we have seen Dr Brearey say while it's fresh in your mind, write stuff
down. But that for one reason or another didn't happen.
MAYBERRY: Yes.
LANGDALE: Paragraph 59 of your statement, "Speaking up and notification of police and other
external bodies". You have had some training on the Sudden Death in Infancy process but you say: "I
do not think it was sufficient to deal with the situation which arose at the Countess. I did not
receive any training on Child Death Reviews."
Are you talking historically when you say you hadn't had any training on child death reviews or now?
Just expand on that paragraph, if you can.
MAYBERRY: Predominantly historically at that point in time.
LANGDALE: When you say you have now had training on the Sudden Death in Infancy process but you
don't think it is sufficient to deal with the situation, in what way was it lacking?
MAYBERRY: I think much of the Sudden Death in Infancy process is focused externally. Much of it is
focused on children who die in the community and come into hospital either moribund and about to
arrest or arrested and dead. There doesn't appear to be a sufficient -- a significant proportion of
much of the SUDiC process which is associated with what if a child dies unexpectedly as an inpatient
in hospital.
LANGDALE: In terms of that not just with your experience at the Countess of Chester, how
comfortable would it feel to express concerns about a colleague that they are causing deliberate
harm in some way?
MAYBERRY: I think in my experience that's probably changing a lot over -- over the course of my
career and training.
I think that -- I think it's becoming more common to speak up and to voice concerns as -- as things
go on. I think that is -- is changing as a process.
LANGDALE: In what way?
MAYBERRY: I think it's -- it's encouraged more now to than ever to speak up for when you see things
which aren't right or if you are worried about a process. And I think people of my level, as in my
experience and below, feel more empowered and encouraged than before to speak up when you are not
happy with a situation.
LANGDALE: I mean it sounds from what you said about Nurse ZC she was trying to do exactly that;
just check in with you if you had any concerns. She just says, "I didn't find her engaged. What do
you think?" Did that conversation, as it took place, feel an appropriate conversation, someone just
sharing concerns or did it feel something out of the comfort zone what you were being asked there.
How did you receive that?
MAYBERRY: I think it was somebody who was wondering about how somebody who was their trainee had
progressed and whether they were somebody who had become more engaged with time and as they got more
interest in the job and took on more. I think that was probably the context in which I took it.
LANGDALE: So you didn't think it was a deeper request, "Are you worried about anything else?" Just
if they are engaged properly?
MAYBERRY: Yes.
LANGDALE: We asked everybody including you, Dr Mayberry, thank you for providing them, for
reflections and comments. On CCTV, you say effectively you don't think it would have been effective
or halt what she did, paragraph 64 and 65, and you don't think CCTV would necessarily be
effective.
MAYBERRY: I think -- so there is a number of aspects to the CCTV question. One is I am not sure it
would have dealt with a lot of the ways in which she killed people and it may have given false
reassurance that things were right and I think in my statement I particularly reference the point of
her injecting air into -- into children's bloodstreams. I think --
LANGDALE: What you say there, just to make that clear for those who haven't seen that paragraph,
you say -- well, expand on that because it's hard to tell. You wouldn't be able to tell looking.
MAYBERRY: I think -- so -- so in terms of if you look at syringes that are used to give children
medications, one of the common syringes is a 1ml syringe, which is often made out of glass, and at
the point where that is filled
with fluid sometimes it can be really hard to tell looking directly at it is there fluid in this or,
you know, is it misfilled with air? So part of my job in what I do now as a paediatric intensivist
is that sometimes I have to provide anaesthetics for children having procedures done on the unit and
I'm responsible for administering those medications. So I would always check that you could see that
there was -- that you could push fluid to the end of the syringe and coming out of the top of it
before you -- before you gave that medication to a child to make sure that it was all okay and that
there wasn't any air in it. But I am not sure if you would be able to tell from a digital image
further away in the same way that you, you know -- if you are doing that check because if you are
looking at it really closely you still might not be able to tell whether there is air or fluid
there. I think the other thing that has crossed my mind since I wrote that statement is that at the
time when all of this happened the Countess was very short-staffed on the medical rota and in order
to provide, undoubtedly what needs to happen is further oversight and overview in some way. But you
also need to have staff present
who can do those investigations who have the time and I think having safe staffing has got to be an
integral --
LANGDALE: Sorry, I missed that. Have a safe ~...?
MAYBERRY: Having safe staffing, sorry.
LANGDALE: Safe staffing.
MAYBERRY: It's got to be an integral part of making sure hospitals and units are safe and you will
be able to do further investigating and more safety checks when you have sufficient staffing.
LANGDALE: What sort of staffing for babies in intensive care? Do you think one-to-one nursing is
enough or it should be two-to-one, two nurses to every patient?
MAYBERRY: I am probably -- I am probably -- I think one-to-one is the ratio that has normally been
used in both neonates and paediatric intensive care units. Part of it is about -- so you should
always ensure I think that there is a minimum of one-to-one as best you can. But it's also not just
about the numbers alone. I think it's about having experienced people who are present and
experienced people who can look and say: wait, what's going on there? And: what are you doing there?
And wondering, and -- and can raise suspicions from that point of view.
When you are continually stretched as a service, as this service was I think back then, it's
increasingly hard to pick up on smaller things which are happening which may be untoward.
LANGDALE: Are you aware whether some of the neighbouring hospitals had advanced neonatal nurse
practitioners operating on the intensive care units and is that something that you are referring to
when you say greater experience of people?
MAYBERRY: I think -- I think neonatal nurse practitioners are very helpful in that they have a lot
of experience in neonates and they are somebody who is there as a constant on a unit. Doctors will
often rotate round to build up their experience in different hospitals and different areas. But
having a member of staff who's there constantly, who knows the practices of the hospital inside out
and has that experience over time in the unit, would be helpful.
LANGDALE: So stability and consistency within a unit?
MAYBERRY: Yes.
LANGDALE: You set out at 67 a number of recommendations you think would be beneficial. Your first
is a broad cultural change within the Ministry of Health and executive boards mandating that
concerns of senior clinicians are listened to and that patient safety is prioritised over all else.
Would you like to expand on that?
MAYBERRY: Yes, sure. I think with regard to that comment what -- maybe what I haven't said
explicitly there is that the level, firstly, the level of staffing wasn't sufficient; certainly at a
Registrar level and that while it seemed from my level like the Consultants were trying to improve
that situation how much engagement there was further up, I am not entirely sure and that's probably
a question I guess for them. Certainly the thing about locum caps and things like that it wasn't a
particularly safe initiative to -- to drive down the supply of doctors looking -- looking for
locums. And I think the last thing I am referring to in it is probably whether it's been broadly
publicised now of Consultants raising their concerns at an earlier point in time. From what I can
tell in what's been written in the media felt that that wasn't addressed in sufficient time.
LANGDALE: You also say: "In cases where clinicians feel they are not being listened to by the
board, they should be encouraged to 'break the glass' and contact police directly"?
MAYBERRY: Yes.
LANGDALE: You say things are changing. Do you think the culture now as a doctor, would you feel
able or unable to do that if you were sufficiently concerned or suspicious of the conduct of another
member of staff?
MAYBERRY: I think the GMC in its guidance does say that people should be protected in terms of
raising concerns. I think it probably now has shifted more and more towards people being -- feeling
like they are more protected if they do raise concerns.
LANGDALE: You say there should be education for staff on how to spot concerns where another member
of staff is harming patients. What kind of education are you referring to there? Something different
from medicine training, which obviously you all have. What is it?
MAYBERRY: I think that there is some guidance into I don't know whether -- I think that there is
some guidance into how people can pick up on things which are untoward with other staff members in
terms of them doing other things. If there is some learning that can come out of this Inquiry and
other things of things that you can -- might be identifiable in those patients then that should be
widely disseminated.
LANGDALE: So heighten awareness of other attributes?
MAYBERRY: Yes.
LANGDALE: Characteristics that people might need to be more vigilant about?
MAYBERRY: Yes.
LANGDALE: You also say: "Consideration should be given to mandating the presence of security
systems relating to drug access in neonatal units." What are you particularly referring to
there?
MAYBERRY: I think a lot of units now have electronic security systems relating to dispensation of
drugs, so that you know who is accessing those drugs and they have to provide their, you know,
thumbprint or whatever to get access to the drugs. I think in terms of things like, you know,
insulin and -- which Lucy Letby was convicted of putting into TPN bags that that would have provided
more evidence if -- if that was something that had had to be released from -- from an electronic
system.
LANGDALE: Dr Mayberry, those are all my questions. Is there anything else you would like to add or
supplement to your evidence thus far?
MAYBERRY: So there is nothing I think from an evidence point of view. Just I would like to express
my deep sorrow to the families who were involved and I can't imagine what they have had to go
through.
LADY JUSTICE THIRLWALL: Thank you very much indeed, Dr Mayberry. We can see how much you have
thought about this over a long time and thank you. There was just one point I just wanted to clarify
with you if I may, when you were talking about the possibility of having some training so that
people could pick up signs in relation -- and you spoke a lot about -- in a few sentences about
things that may be untoward with other staff members. Then you went on to say if there is some
learning that comes out of this Inquiry or other things that you might be able to identify in
patients then that should be widely disseminated, and I just wanted to make sure that I had
understood that correctly. So, on the one hand, flagging behaviours by staff, for example, but then
did you mean to say something about patients?
MAYBERRY: Staff. Sorry, I -- I think staff was probably what I was referring to.
LADY JUSTICE THIRLWALL: No, I completely understand. We all use the wrong word, some of us quite frequently. But anyway, thank you very much indeed, also for your other reflections and for being with us this afternoon. Thank you. You are free to switch us off. THE WITNESS: Thank you.
LADY JUSTICE THIRLWALL: Thank you.
MS LANGDALE: My Lady, can we resume at 3.35? We will still complete the evidence in good time this afternoon.
LADY JUSTICE THIRLWALL: All right. So we will rise now until 3.35. (3.08 pm) (A short break) (3.36 pm)
LADY JUSTICE THIRLWALL: Ms Langdale.
MS LANGDALE: May I call the next witness.
DR CASSANDRA BARRETT (affirmed)
MS LANGDALE: Can you give us your name and qualifications, please.
BARRETT: My name is Cassandra Barrett. I am a paediatric general paediatric Consultant. I gained my
CCT last year in the summertime. I have a special interest in respiratory medicine.
LANGDALE: Dr Barrett, you provided us with a statement dated 28 June 2024. Have you got that with
you?
BARRETT: I do, yes.
LANGDALE: Can you confirm if the contents are true and accurate as far as you are concerned?
BARRETT: Yes.
LANGDALE: We see from this that you worked at the Countess of Chester between March 2016 and
September 2016 as an ST1?
BARRETT: I did, yes.
LANGDALE: You followed that -- you then went on to Liverpool Women's Hospital and your supervisor
there was Dr Yoxall?
BARRETT: That's correct.
LANGDALE: You are the last of four Registrars to give evidence today. I think you have heard the
evidence of the last two?
BARRETT: (Nods)
LANGDALE: Can you just briefly tell us, what stage were you at at the ST1 stage?
BARRETT: So this was the first year of my paediatric training, so although it's termed an ST1, this
is often called a SHO, so a senior house officer. So I had done a placement in paediatric A&E at
Alder Hey Children's Hospital and then rotated to Chester Hospital.
LANGDALE: So just got going?
BARRETT: Just got going.
LANGDALE: You probably -- I don't know, did you know
Dr Lambie or Dr Ogden?
BARRETT: I did not know Dr Lambie, I had met Dr Ogden at a previous placement I had done.
LANGDALE: So did you know Dr Ogden at the time when you were working at the Countess or did you
know her subsequently?
BARRETT: I think I had met her before but she wasn't somebody I was in regular contact with.
LANGDALE: I won't take you to the same bit, you have heard me read out how Dr Ogden says in June
2015, that she had found: "... the numbers of collapses or deaths on the unit at that time as
unusual and concerning. I am unsure specifically when this appeared to me as unusual but it is
likely to be around the time of several of those collapses/deaths that occurred within a few weeks
of each other in June 2015. Whilst I do not recall that I specifically approached any Consultant in
particular to raise specific concerns I believe the whole department was discussing this informally
as being unusual and that the senior Consultant team were raising this and investigating what could
have caused this." Did you ever have a chat with Dr Ogden or did she ever say anything to you about
that?
BARRETT: No, I hadn't spoken to Dr Ogden about it. All
the feedback I had had from other trainees was very positive about the department.
LANGDALE: So when you went there so in March 2016, had you had feedback then from other
trainees?
BARRETT: Just when you told people what placement you were going to next they would say: oh, that's
a lovely place to work, you will have a really good experience.
LANGDALE: Is that the medical grapevine, people who have just qualified and know each other?
BARRETT: Yes.
LANGDALE: Or the people still working there or were they round and about in the vicinity?
BARRETT: This was the people that I was working with at that time, so different levels of doctors
who had worked there before.
LANGDALE: When you went on to go to Liverpool Women's Hospital, what were the differences you
noticed between the two hospitals, if any, and particularly their neonatal units?
BARRETT: So the neonatal unit at Liverpool Women's Hospital is significantly bigger. They have got
many more cot spaces. As it is an intensive care department they have more staff, you just solely
cover the neonatal unit and not cross covering between paediatrics and neonates.
LANGDALE: When you say "more staff" how does that work for the baby? So in the neonatal intensive
care set-up how many nurses would be looking after a baby at Liverpool and how many in Chester?
BARRETT: I believe it was one to one and then there would be a shift leader as well that would have
an oversight of the unit too.
LANGDALE: So in Liverpool one to one shift leader. What about in Chester when you got there?
BARRETT: I can't remember fully because I have only worked there for six months, whereas I had done
a whole year at Liverpool Women's and that was more recently. I believe in the higher intensity room
it would have been one to one but I don't know for definite.
LANGDALE: And a shift leader as well or you don't know? Best to ask the nurses?
BARRETT: I don't remember that, sorry.
LANGDALE: You heard Dr Mayberry giving evidence earlier about the position for registrars and
locums and Chester's approach to that. Did you hear that evidence?
BARRETT: I did, yes.
LANGDALE: Does that accord with your experience when you were there in 2016, that it would have
been helpful to have more Registrars?
BARRETT: I think I remember that there was a shortage
of Registrars but we had a good group of Registrars that were very supportive. I don't remember
there being a shortage on the rota that I was on, the SHO rota.
LANGDALE: You don't know whether there was an issue of getting good locums, it is not something you
were sighted on anyway --
BARRETT: No.
LANGDALE: Culture and atmosphere. You say at paragraph 8 of your statement the lead Consultant
during your period working there was Dr Brearey. How did you get on with him?
BARRETT: I would say we had a good working relationship. He appeared to have a very detailed
knowledge of neonates and it was clear he was the lead and his presence was often felt or requested
at times.
LANGDALE: Dr Mayberry said he encouraged learning via the materials that were available to you all.
Did you do that?
BARRETT: Yes, he did. I think Dr Mayberry probably had a closer relationship with him as the
paediatric Registrar that would have been doing lots of the procedures, at times I was more there
observing.
LANGDALE: Dr Brearley also had a conversation with Dr Mayberry, you heard, about the mortality
rates. Did he have that conversation with you at any point?
BARRETT: Not that I recall.
LANGDALE: Were you aware of that? It is clear from Dr Ogden and Dr Lambie and Dr Mayberry people
were being made aware of a raised mortality rate or concerns about that. Were you ever made aware of
it?
BARRETT: That wasn't something that was discussed amongst the SHO body that I was part of.
LANGDALE: Okay. Did you have discussions with nurses or anyone about that?
BARRETT: No, not that I can recall.
LANGDALE: You heard Dr Lambie say again she was more senior than you, wasn't she, but she had seen
nurses in a group and had a discussion with them about that issue. Did you ever have such a
discussion with nurses or Consultants or anyone else?
BARRETT: Not that I can recall.
LANGDALE: You said the medical professionals appeared to have a good working relationship with all
members of the MDT. Does that mean multi-disciplinary team?
BARRETT: Yes.
LANGDALE: So who is in the multi-disciplinary team?
BARRETT: So that would be the doctors, nurses pharmacists, any of the ward clerks and cleaners.
Everybody that is on the wards at the time.
LANGDALE: Okay. You say you had no contact with the
managers. Did you know who they were? Would you know who the board was or the managers?
BARRETT: No, no.
LANGDALE: Did you get much patient contact?
BARRETT: On the neonatal unit?
LANGDALE: Yes. So our shifts were slightly different to the Registrars so we covered either a long day or short day on the children's ward in A&E and then there was the neonatal unit, but we would go to the deliveries and call for a Registrar if needed and spent a lot of time on the postnatal ward doing newborn baby checks. So we would aim to be on the neonatal ward round alongside the Consultants and the Registrars.
LANGDALE: And how frequently were the Consultants doing the ward rounds, as far as you
remember?
BARRETT: I can't recall this. I do remember that on a weekend they didn't go every day because they
were covering paediatrics and neonates and I didn't think that they were there every day on the
neonatal unit either.
LANGDALE: But in the week you think so?
BARRETT: I don't recall them doing a ward round every day on the neonatal unit.
LANGDALE: So who did you go to if you were particularly concerned about a patient then?
BARRETT: The paediatric Registrar.
LANGDALE: Then the paediatric Registrar can contact a Consultant if they wanted to?
BARRETT: Yes, yes.
LANGDALE: Were you ever aware of that system failing and not getting hold of a Consultant?
BARRETT: No, that was never something that I had seen witnessed on my shifts.
LANGDALE: You set out at paragraph 15 your involvement in the care of [Child M] on Saturday, 9
April and as you know Letby was convicted of the attempted murder of [Child M] and his twin brother,
L, on 9 April. Can you tell us, as you do there, you set out your involvement with [Child M]?
BARRETT: So I had been upstairs on the postnatal ward and remember coming down and using the
computer and as I was on the computer I heard a shout from Nursery 1 for help and as I entered the
room the child was in full cardiac arrest receiving full resuscitation. My role was then to assist
with the resuscitation whilst Dr Ukoh, the paediatric Registrar, was leading the situation and Dr
Ravi Jayaram arrived after he had been called from home.
LANGDALE: You say in your statement: "I didn't have any concerns about M's deterioration
as I had not been involved in [Child M]'s care that day prior to the deterioration." So you didn't
have any understanding of what was happening?
BARRETT: No.
LANGDALE: You were a responder in that situation?
BARRETT: That's correct.
LANGDALE: And with others more senior than you taking the lead?
BARRETT: Yes. So Dr Ukoh had done the paediatric ward round that day so he had already seen the baby
and knew the case, so he was leading.
LANGDALE: Are you aware whether there was any consideration of completing a Datix in relation to
this event or not?
BARRETT: I didn't hear it mentioned.
LANGDALE: Did you know at that time what a Datix was?
BARRETT: Yes, I did know what a Datix was. I think my understanding of a Datix and when to complete
is has probably increased throughout my training, but it is something that even at our very junior
levels we do know about.
LANGDALE: What did you, at that time, think a Datix form was about?
BARRETT: I thought it was there to document, well, to
record any errors that had happened, whether that be a prescription error or the wrong drug being
given to the wrong patient, and any potential near misses as well as that -- any breaches of
confidentiality too for the case to be reviewed.
LANGDALE: Would you have thought any unexplained event should go on a Datix just because you didn't
know what had happened or not? Would that fall into the category?
BARRETT: I don't think that would have fallen into the category for me at that time, whereas now it
definitely would.
LANGDALE: Now it would?
BARRETT: Now it would.
LANGDALE: What's your understanding now as you sit here about the importance of Datix or what's
supposed to be recorded there?
BARRETT: So now as a paediatric Consultant we have -- all of the Datixes in our Trusts are sent to
us so therefore we attend the meetings where these cases are discussed. It's useful to pick up any
learning points and to see if there is anything that can be changed or made different and to get
input from all the different members of the multi-disciplinary team that attend that meeting. But it
picks up on themes.
LANGDALE: Did you ever, when you were at the Countess of
Chester, see a nurse or a doctor or anyone fill in a Datix or hear them talking about that?
BARRETT: Not that I can recall.
LANGDALE: No. Did you have -- we heard again Dr Mayberry talking about induction. Did you have
induction at the beginning of your training on any issues?
BARRETT: So we would have been at the same paediatric induction.
LANGDALE: Okay. So you had the same warning of a fine for the handover note?
BARRETT: I actually don't recall that, but obviously Dr Mayberry does.
LANGDALE: What do you recall being trained about?
BARRETT: I have been to so many inductions that I can't specifically say what was in that induction.
LANGDALE: Do you think child protection or safeguarding was one of the topics, can you remember
now?
BARRETT: I can't remember now, but it often is. On every rotation that we do it's part of it.
LANGDALE: Do you share Dr Mayberry's observation that it would be useful to know as a doctor what
might assist you to spot when those around you might be deliberately harming children?
BARRETT: Yes. So I think at the paediatric ST1 level I was, I didn't have any knowledge about
Beverley Allitt. So I think if -- if that was openly discussed and themes came out that were -- and
how they picked it up and what she was doing that might then help to trigger us to think about it in
complex situations.
LANGDALE: So by the time you were working there, you didn't know about that case or the misuse of
insulin and all of --
BARRETT: No.
LANGDALE: -- the other things the Beverley Allitt case tells us about?
BARRETT: No.
LANGDALE: When did you first learn about that case?
BARRETT: I think it was after Lucy Letby's case came to the press.
LANGDALE: One of the recommendations that followed the Beverley Allitt case, there was an Inquiry
into that, and one of the recommendations was that there should be a heightened awareness of that
case and what the nurse had done in that case. From what you are saying, that doesn't seem to have
translated through to the NHS, does it, at --
BARRETT: No.
LANGDALE: -- your time of working?
BARRETT: No.
LANGDALE: You were at the hospital when Babies O and P were -- died and Letby subsequently found
guilty of their murder. Can you remember when you were first told about the death of O and P?
BARRETT: I was on shift the day that Baby P [Child P] died but I wasn't covering the neonatal unit.
So that's how I had heard about it happening.
LANGDALE: How many people expressed surprise or upset? Tell us what the atmosphere was.
BARRETT: I think generally after the death of any child, expected or unexpected, there is often a
feeling of sadness amongst the team and it would be evident that something had happened to upset the
team.
LANGDALE: Nurse Lightfoot, as you know, says that she recalled when there was a set of triplets and
two of the siblings died on consecutive days: "I cannot be date specific but I walked past Dr
Barrett in the corridor and she spoke directly to me and said words to the effect of 'Nurse Death's
on again.'" You tell us you did say that.
BARRETT: I did say that at the --
LANGDALE: Do you know when you said that, which day or what --
BARRETT: I can't remember exactly, but I think it might have been the days after the second triplet
had died when I had been allocated the neonatal unit to cover. At the time of saying that, I didn't
have any awareness about the suspicions amongst the Consultant body with regards to Lucy Letby
actively causing harm. Never did I think the unthinkable, as we have mentioned earlier in the day,
that somebody would be going to work to actively harm babies that we were going to work to help.
LANGDALE: What association had you made about her though to say "Nurse Death is on again"?
BARRETT: I had noticed that she was there at a couple of the unexplained collapse and child deaths.
LANGDALE: So O and P.
BARRETT: P.
LANGDALE: Or others?
BARRETT: Not sure about O, and the baby that we discussed earlier. So I had noticed she was there,
but I thought that was more of bad luck rather than her being the causative agent.
LANGDALE: Was that the first time you said that to someone in the hospital?
BARRETT: Yes.
LANGDALE: Had you been thinking that before because --
BARRETT: Not --
LANGDALE: That she was associated with events that were concerning?
BARRETT: Not that I can recall. I think having to go to the neonatal that day I was -- the neonatal
unit, I was anxious and it was a comment that I made but it wasn't something that I was regularly
saying.
LANGDALE: I think another nurse and Nurse Lightfoot says that Nurse ZC may have been involved in
that discussion with you, but you don't remember that?
BARRETT: No.
LANGDALE: Do you remember saying it to Nurse Lightfoot?
BARRETT: Yes.
LANGDALE: Were you saying it to her or did she hear you saying it?
BARRETT: Yes.
LANGDALE: Was it a direct conversation with her?
BARRETT: A direct conversation.
LANGDALE: You are confident about that?
BARRETT: Yes.
LANGDALE: And what was her response to you when you said that?
BARRETT: She didn't respond.
LANGDALE: Did anyone after that come and speak to you -- anyone, Dr Brearey, a manager, anyone --
and say, "You shouldn't be saying that about a colleague."
BARRETT: No.
LANGDALE: "And we know that you've said it", or not?
BARRETT: Not that I can recall.
LANGDALE: And it's not something you said to other doctors or you generally spread about the unit,
if I can put it that way?
BARRETT: No.
LANGDALE: Did you know the number of deaths on the neonatal unit between 2015 and 2016?
BARRETT: No.
LANGDALE: Did you know how many unexpected or unexplained deaths had happened on the unit?
BARRETT: No.
LANGDALE: How many deteriorations or collapses of babies were you aware of? You were obviously
aware of O and P, you have told us that, but they are babies murdered. What about babies that had
collapsed or deteriorated, did you know about any of those other than M?
BARRETT: So I can remember being on night shifts particularly with Dr Mayberry where there would be
an unexpected collapse. But I had never done neonates before to know whether that was normal or not
normal to happen.
LANGDALE: Was that the one he was talking about today?
BARRETT: I don't know because I've not seen the notes, sorry.
LANGDALE: Right. So you had been present for another night shift unexpected collapse?
BARRETT: (Nods).
LANGDALE: And you had learnt of the deaths of O and P?
BARRETT: Yes.
LANGDALE: Did you know, as Dr Mayberry knew, that there were described as investigations but the
RCPCH completing a report in relation to the unit, did you know about that?
BARRETT: I think I learnt about it after I had left the neonatal unit.
LANGDALE: Who told you about it after you left?
BARRETT: I am not sure whether it was Bill Yoxall, who was then my clinical supervisor at Liverpool
Women's Hospital.
LANGDALE: Yes. So he was your supervisor as we highlighted earlier in September 2016 to March 2017.
Did Dr Yoxall when you were working at Chester, did he go between the hospitals at all? Did you see
him in both hospitals or just when you were --
BARRETT: No, I never saw him at Chester Hospital.
LANGDALE: So what did he say to you when you were there
at Liverpool about what had happened?
BARRETT: So as part -- every placement that we start with our new clinical supervisor, we would have
a meeting and they discuss where you had been on your last placement and obviously he had an
understanding at that point of the increased number of deaths and unexplained collapse. So he just
acknowledged that I had been in Chester and that it had been a difficult time.
LANGDALE: So he's taking -- you are coming to the hospital, he is your supervisor, and he says, "I
know you have had a difficult time, there has been collapses and deaths at Chester"?
BARRETT: Yes.
LANGDALE: He says that at the beginning in September 2016, does he, when you first go there?
BARRETT: Yes.
LANGDALE: So you understand him to be aware of what is going on in Chester at that point?
BARRETT: Yes.
LANGDALE: Did you speak of the earlier collapse that you say you knew about in the night of those
sorts of events to anyone in the children's unit or elsewhere?
BARRETT: Not that I can recall.
LANGDALE: There must have been conversations though,
mustn't there, between the wards about what was going on? These are upsetting events, aren't they?
We can see that.
BARRETT: Yes.
LANGDALE: So normal conversation might lead one to relay what's happened the night before or the
day before?
BARRETT: Yes, and I think there were those conversations and, like we have heard earlier, you know,
within handovers you would find out what had happened the day before. Because overnight and on an
evening, the doctors would cross-cover paediatrics and neonates. The nurses might have said on the
neonatal side, "Oh, the doctors were busy last night on paediatrics" or vice versa.
LANGDALE: You heard Dr Lambie this morning -- it may seem a long time ago now -- was saying that by
September 2015, the thought of someone causing deliberate harm had crossed her mind. Indeed she was
speaking with somebody who she trusted outside of the hospital. When did that thought cross your
mind? Don't worry about comments and what they might have meant or not. Just honestly reflect. When
did you think about that?
BARRETT: When Lucy Letby was taken off clinical shifts and we noticed a difference.
LANGDALE: So when she was moved from the ward to working in the risk units. Are you okay?
BARRETT: (Nods).
LANGDALE: You noticed a difference. Do you want to expand on that?
BARRETT: It became evident that there was less deteriorations and less cardiac arrests.
LANGDALE: Did you discuss that with colleagues at that point?
BARRETT: (Shakes head).
LANGDALE: You just held that view?
BARRETT: Yes.
LANGDALE: Had you been told not to discuss her with colleagues? Was there any sense that you
couldn't do that because there was other stuff going on, you know, she was being moved around the
hospital?
BARRETT: I don't think we were specifically told not to discuss it. I think the Consultants
recognised that it was a difficult time for everybody that had been involved, but I don't recall
them asking us not to discuss it.
LANGDALE: Did you know what the managers' involvement was, if any, at this time or that was nothing
to do with you?
BARRETT: No, nothing.
LANGDALE: That was the consultants?
BARRETT: Yes.
LANGDALE: You tell us in your statement at paragraph 42 when you were at Countess of Chester you
did notice there were frequent deaths on the neonatal unit: "~... but this was my first exposure to
neonates and therefore I didn't realise that the deaths were beyond what would be expected." Were
you aware at the time it wasn't that there were deaths; that they were unexpected deaths and people
were surprised by them? What sense of that did you get when you were there; that these weren't
babies that people thought were going to die?
BARRETT: I think it was clear that they were unexpected because people would often afterwards be sat
down trying to think about any potential causes, looking solely for medical causes. I specifically
remember with the triplets everybody was thinking of different metabolic conditions, how they are
inherited, could there be any genetic predisposition for those babies as well. But you could tell
people were surprised.
LANGDALE: And people, no doubt we've seen evidence of this, started worrying if they had done
something wrong.
You know, maybe they'd put the long line in the wrong place, maybe they had done something
different. Was that the atmosphere, that people got very worried about everything?
BARRETT: I think naturally as doctors we always worry if we have done everything possible that we
can. So yes, it was, you know, it was --
LANGDALE: A tense time?
BARRETT: Yes, yes.
LANGDALE: You tell us: "As a senior house officer, I was the most junior team member and I was not
aware of the investigation process for deaths in the neonatal unit and what happened following the
deaths or when postmortems were being requested." I don't think you're alone there, Dr Barrett, at
any age. But, what did you think at the time? Was there a discussion about that?
BARRETT: I do remember the Coroners being discussed and -- but I wouldn't know which patients were
being referred to the Coroner. Now I have a much better understanding of the SUDiC, Sudden
Unexplained Death pathway and it's something that I have to use within my role. I don't remember
that ever being discussed or used for these
babies.
LANGDALE: And at the time, did you understand that an unexpected death in hospital is an unexpected
death the same as anywhere else and it triggers various referrals or was that just not something
that seemed to be appreciated?
BARRETT: I don't think I appreciated that at the time.
LANGDALE: You say you don't recall attending any debriefs or discussions following clinical events
for the babies named on the indictment. Do you think there should have been debriefs or discussions
between all those involved in the care to share observations and see what people thought?
BARRETT: Yes. I think debriefs have a really important role, not only for the kind of psychological
well-being of all the staff that have been involved in these traumatic events but to try and pick up
on any common themes or pattern recognition and look at how we can improve care for the future.
LANGDALE: You tell us you didn't turn to any professional body for advice with regards to events at
the Countess. Did you feel supported by the Consultants there and generally did you feel like you
needed help or advice from anyone else?
BARRETT: Yes, so the Consultants were very supportive. I didn't turn to anybody particularly at the
time because I didn't feel I needed any extra support than what they were already giving us.
LANGDALE: We have asked people about reflections or potential recommendations. You have heard me
discuss a number of them today. One of them is CCTV perhaps in the incubators for newborn babies in
neonatal units. What do you think about that as an option?
BARRETT: So I think initially when I had read about the CCTV I thought it would be a CCTV camera
within the room and I share the same feelings as Dr Lambie as, you know, with the families and
breastfeeding, expressing milk, it felt like an invasion of their privacy but I think if it was in
the incubator that seems like a good idea to me. But like Dr Mayberry commented as well, it's
difficult even on those cameras as to whether you would be able to see there was air in syringes or
that it was insulin being given, not the saline flush.
LANGDALE: Do you have any other reflections about how the healthcare environment could be improved
to avoid what's happened at the Countess of Chester happening again?
BARRETT: I think as I said before I had no understanding about the Beverley Allitt cases. So I think
education around that and picking out any common themes that have come up from -- from previous
Inquiries and education even in medical school. During paediatric training we have a lot of
safeguarding training but a lot of it is about parents causing harm to their child and we are very
much skilled at recognising that but I don't feel like we are trained in how to recognise that
another healthcare professional that you trust has been causing harm.
MS LANGDALE: Yes, thank you, Dr Barrett, those are my questions.
LADY JUSTICE THIRLWALL: Thank you very much indeed, Dr Barrett. It's a good job we didn't take a
break because now you are finished. Thank you for coming and in particular for your reflections as
to what might help and also the way you have thought through, first of all, what a CCTV camera might
do and also what it might be very useful for. Thank you very much indeed and you are free to go
now.
BARRETT: Thank you.
MS LANGDALE: My Lady, that concludes the evidence for today and we have three Consultants giving evidence tomorrow.
LADY JUSTICE THIRLWALL: Very well. So we will rise now and we will start tomorrow at 10 o'clock.
(4.07 pm) (The Inquiry adjourned until 10.00 am, on Thursday, 3 October 2024)
LADY JUSTICE THIRLWALL: Mr De La Poer.
MR DE LA POER: My Lady, our first witness today is Dr Newby. May I ask her to come forward, please.
LADY JUSTICE THIRLWALL: Thank you.
DR ELIZABETH NEWBY (affirmed)
LADY JUSTICE THIRLWALL: Thank you very much, Dr Newby, it is not easy but now you have got the oath
out of the way, do sit down.
NEWBY: Thank you.
MR DE LA POER: Dr Newby, can you confirm that you have given a witness statement to the Inquiry
dated 4 June 2024?
NEWBY: I have.
DE LA POER: Is the content of that witness statement true to the best of your knowledge and
belief?
NEWBY: It is.
DE LA POER: We are going to begin by briefly reviewing your medical career. You qualified in 1998;
is that right?
NEWBY: I qualified from medical school in 95.
DE LA POER: You subsequently undertook paediatric training at a number of hospitals, including
Alder Hey on
a number of occasions, Manchester Children's Hospital and Liverpool Women's Hospital?
NEWBY: Yes, that's correct.
DE LA POER: You joined the Countess of Chester Hospital in 2005 in general paediatrics and
neonatology; is that correct?
NEWBY: Yes. Yes, I -- I did my final training post at the Countess in 2005 and then I became a
Consultant there in 2006.
DE LA POER: So does it follow from that that you had more than a decade of experience working in
the paediatric department and indeed the neonatal unit before June 2015, most of which time you were
a Consultant?
NEWBY: That's correct, yes.
DE LA POER: Whilst you were working at the Countess of Chester, did you sit on the Medicines
Management Committee?
NEWBY: I did.
DE LA POER: Now, a case that we have heard something about involved a nurse being convicted of
murdering patients at Stepping Hill?
NEWBY: Mmm hmm.
DE LA POER: Was that something whilst you were at the Countess that you were aware of?
NEWBY: Yes.
DE LA POER: We know that that particular nurse was administering drugs as a weapon against
patients?
NEWBY: Mm-hm.
DE LA POER: Did the Medicine Management Committee ever discuss that case that you can recall to
talk about how there may be steps to be taken to put further protections in place for medicines?
NEWBY: No, no. I suppose the remit of that committee was to look at new guidance that was produced
within the hospital that pertained to treatments which would include drugs, et cetera, and to
discuss any issues around those drugs from a pharmacy point of view, procurement, supply, et cetera,
administration.
DE LA POER: So management didn't include, for that committee's purpose --
NEWBY: No.
DE LA POER: -- risk management --
NEWBY: No.
DE LA POER: -- in relation to medicines?
NEWBY: No.
DE LA POER: Thank you very much. Returning to your career, you left the Countess of Chester in
February of 2016; is that right?
NEWBY: Yes.
DE LA POER: You took up a Consultant post at Stockport NHS
Foundation Trust?
NEWBY: Yes.
DE LA POER: At least as at the date of your witness statement, you were still there?
NEWBY: I am still there, yes.
DE LA POER: Is your role the Clinical Director of Paediatrics?
NEWBY: It is.
DE LA POER: I have already mentioned the Stepping Hill Hospital. That's the hospital within the
Foundation Trust that you moved to in the spring of 2016?
NEWBY: (Nods)
DE LA POER: Although we are jumping in a sense to the end of our timeline here as we are dealing
with your career, when you arrived at Stepping Hill it was less than a year after the nurse had been
sentenced for using medicines as a weapon?
NEWBY: (Nods)
DE LA POER: Was that a topic of conversation within Stepping Hill at that time?
NEWBY: Yes, to some degree still, yes, it had been relatively recent, yes.
DE LA POER: When you arrived there and were among the people who were directly witness, many of
them, to those events, did that provoke any thought process on your part about the experience that
you had just had at the Countess of Chester?
NEWBY: Yes, yes, of course. I -- the -- the case in -- in Stockport, I believe, there had been some
a lot of evidence, there was insulin missing, insulin found, et cetera. There was a lot more
procedures in place in Stockport around drug safety, lock -- you know, medicines locked away et
cetera as a result of that, that incident.
DE LA POER: So I suppose one specific thought process that may have occurred to you, and you tell
us whether it did, is I wonder if insulin was being used at the Countess of Chester and whether that
might have explained the experience that you had just had. Was that a thought process that you
had?
NEWBY: I -- at that time I didn't believe -- I didn't think of insulin, no.
DE LA POER: So we will come and have a look at the detail of each of the events at the Countess.
But before we do, let's just deal with -- here it is paragraph 5 of your witness statement if you
want to turn it up, so we are just going to deal with some particular matters relating to the
arrangements and situation at the Countess of Chester. The first matter you deal with is you talk
about
the divisional structure and we have heard something about this already but in summary, the Inquiry
knows that there came a point in time when the paediatric department was put in the Urgent Care
Division and that resulted in it being separated in terms of the divisional structure from the
obstetrics --
NEWBY: Yes.
DE LA POER: -- which was in Planned Care?
NEWBY: Yes.
DE LA POER: Just tell us from your perspective, whether you thought firstly that that change was a
good thing?
NEWBY: No. We -- we were all quite concerned about it at the time because of the -- the obvious link
between obstetrics and neonates and a lot of the need for shared risk and governance and being in
two different divisions seemed to make that difficult, really.
DE LA POER: Was that something that you or any of your Consultant colleagues to your knowledge
raised at the time?
NEWBY: I believe so, yes.
DE LA POER: Do you know with whom it was raised? Was it just raised within the division or do you
know whether that concern went higher than that?
NEWBY: I don't know if it went higher.
LADY JUSTICE THIRLWALL: Where did the idea come from?
NEWBY: I don't know, to be perfectly honest.
LADY JUSTICE THIRLWALL: I'm sorry to ask you that out of the blue.
NEWBY: No, no it's okay. I think it was to -- I this is an assumption, but to sort of streamline the
-- the number and layers of management tiers.
LADY JUSTICE THIRLWALL: Thank you.
MR DE LA POER: Speaking in general terms, do you think that divisional change made any impact,
positive or negative, on how the events on the neonatal unit were managed and resolved whilst you
were there?
NEWBY: I -- I think it -- I think it perhaps gave us less of a voice at the table higher up, if you
like. When we were a separate division and we were Women's and Children, we -- you know, we were
more equal in a way to the medical or the surgical division and then we got swallowed -- that's not
really the right word, but swallowed up into Urgent and Planned Care and I think that probably made
things difficult, yes.
DE LA POER: Staying with general matters of operation and practice. Just dealing very briefly with
the debrief process that took place on the ward: you tell us in your witness statement -- you don't
need to turn it up unless
you want to, and I will give you the reference if you do, but it was usual to have a debrief after a
death but not after non-fatal collapses?
NEWBY: Yes, I suppose -- I suppose that would be the case. I -- I don't know if that would be the
case now but I think that was, that was the case at the time, yes.
DE LA POER: Staying with the formal response to particular incidents, I would just like to ask you
a few questions about the Datix system.
NEWBY: Mm-hm.
DE LA POER: In your own words, what was your understanding at the time about when it was
appropriate to fill in a Datix form?
NEWBY: So if you were concerned that care hadn't gone as it should have done and there was something
particular that you wanted to highlight, for example a drug error or an administration error or a
piece of equipment that was faulty during a resus situation which would have impacted on the teams'
ability to manage that patient.
DE LA POER: What about being specific here. If there was a sudden and unexpected death on the
neonatal unit but there weren't any identified at the time, errors of care, would that serious event
in and of itself prompt a Datix?
NEWBY: Yes, it would, yes. Yes. Certain serious events would produce -- would always produce a Datix
anyway because whether there was anything apparent at the time, it may be that things become
apparent when that case is reviewed.
DE LA POER: What about where there is a very serious but non-fatal collapse, perhaps requiring
resuscitation. Was that a sufficiently serious event that it could prompt a Datix even if there was
no error in care or potential error in care identified?
NEWBY: I think that would probably be a little bit more of a grey area. Some people might say yes,
some people might say no.
DE LA POER: Had you received any formal training and refresher training about the filling in of
Datixes or was this just a culture that developed and feeding off your colleagues and seeing what
they did?
NEWBY: Yes, it was something that we -- we did in our every day practice. The Datix system is
clunky, I think is the right word. It -- in filling in a Datix it can be quite difficult to do it
because the system only allows for a number of drop down boxes and you have to kind of put your
incident into a category and sometimes you think, well, the category doesn't exist for this
incident. So it's -- it can be quite a difficult system to work with sometimes.
DE LA POER: Whose responsibility did you understand it to be to fill in a Datix when an event
requiring one occurred?
NEWBY: So if it -- so it's everybody's responsibility to submit and fill in Datix at the end of the
day if they have flagged up something that's of concern. But I suppose things like deaths which were
serious incidents, they -- it would tend to be the shift leader or the nurse in charge after the --
after the death because the -- the medical staff and the nursing staff were -- were busy dealing
with the aftermath and so on.
DE LA POER: In your experience, was there any co-ordination between people who were involved in an
instance where a Datix might be needed to say "This is going to need a Datix, would you mind being
the one to fill it in or will you make sure that one is filled in?" Did that sort of conversation
happen or was it just assumed people would go back to their places of work and some or more of them
may fill in such a form?
NEWBY: No, we would have just expected that would have happened because it was -- it was a mandatory
reportable Datix.
DE LA POER: But you would have expected the nursing staff or the nursing managers to do it --
NEWBY: Yes.
DE LA POER: -- rather than it being your responsibility in that situation?
NEWBY: Yes.
DE LA POER: Dealing with relationships within the department and you deal with this at your
paragraphs 16 and following if you want to turn it up. That's on page 4.
NEWBY: Mm-hm.
DE LA POER: You say this: "I felt that, as a group of Consultants we had a good relationship with
the paediatric and neonatal nursing teams."
NEWBY: (Nods)
DE LA POER: Now, I would just like to give you an alternative perspective on that for your comment.
Eirian Powell, the nursing manager, has suggested that "Consultants thought all staff members worked
cohesively because staff did exactly what they were told to do by the Consultants without
challenging them". What would be your reaction or comment on that characterisation of the
relationship?
NEWBY: I -- I am quite surprised at that, to be
honest. That wasn't the impression I had at all.
DE LA POER: She suggests that doctors were quick to criticise nurses when errors were made. Again
was that your experience?
NEWBY: No.
DE LA POER: You were also asked to comment about the relationship with management. Now, you didn't
have any managerial role yourself, so what was your impression about the attitude of the paediatric
Consultant body about the senior managers in terms of how receptive they were, how engaged they
were, how helpful they were, those sort of things? Was there a shared opinion about senior
management and how approachable they were?
NEWBY: So I suppose I -- as you say, I wasn't in a leadership role at the time so I was a little bit
removed from it. Dr Jayaram was the Clinical Director at the time. But there was always the
impression that paediatrics didn't have much of a voice at the table. I think that can be true up to
a point in quite a lot of district general hospitals. It's quite a small part of the hospital, if
you like, compared to the larger adult medical and surgical specialties. But I think my experience
in Chester is different to my experience in Stockport from that point of view.
DE LA POER: That precisely anticipated my next question. You describe in light of your experience
at Stockport that the culture at the Countess was, to use your word, "impersonal"?
NEWBY: Yes.
DE LA POER: I was just going to ask you just to amplify what you mean by that, please?
NEWBY: I suppose it -- that the -- the higher management tiers, it didn't feel welcoming, it didn't
feel like you would -- you know, you would just walk up and bang on their door and say "I have got a
problem". You know, they seemed perhaps a bit detached and not visible.
DE LA POER: So we are going to turn in a moment to look at the timeline of events, starting in
2015, but just two areas of policy and procedure to ask you about. The first is safeguarding
training?
NEWBY: Mm-hm.
DE LA POER: Now had you received safeguarding training whilst you were at the Countess of
Chester?
NEWBY: Yes, we -- we all underwent mandatory safeguarding training, yes.
DE LA POER: Were you aware, if not of the detail, but of the generality of working together?
NEWBY: Yes.
DE LA POER: Had you had any specific training in relation
to what to do if you suspected a member of staff of posing a threat to patients?
NEWBY: No.
DE LA POER: Looking back on it now, do you think that is something that you should have had some
training on?
NEWBY: Yes.
DE LA POER: How did you view the role of the safeguarding department within the hospital, what did
you think it was there for?
NEWBY: To give advice on safeguarding matters. We would go to our safeguarding team to discuss
children that we had seen on the ward, where there was perhaps an allegation of physical abuse, for
example.
DE LA POER: The way you were thinking about safeguarding at the time, did you view a member of
staff posing a risk to a patient, particularly a vulnerable neonate, as being a safeguarding
issue?
NEWBY: I -- I suppose I didn't think about it that way at the time. But it obviously is, it is. Yes.
DE LA POER: Just trying to get under --
NEWBY: Yes.
DE LA POER: -- why that might be the case. Why do you, what do you think the explanation is for why
you didn't view it in safeguarding terms?
NEWBY: I suppose a -- a safeguarding investigation
would be led by social care, children's social care, whereas in my head I supposed I perceived that
if it was a matter of wrongdoing and harm being caused by a member of staff, then that was a police
matter.
DE LA POER: Were you aware that in a multi agency response to a safeguarding, you get both --
NEWBY: Yes, of course.
DE LA POER: -- the local authority and the police?
NEWBY: Of course yes, of course. No, I completely understand the police would be involved in a
section 47 investigation.
DE LA POER: The second area of policy and procedure is Sudden Unexpected Death in Infancy and
Childhood and procedure and you deal with this in your witness statement so we can take it
reasonably shortly, I believe, but was your position understanding at the time that the SUDiC
process didn't apply to babies who died in hospital?
NEWBY: I suppose, no, no. No. No.
DE LA POER: Have you followed any of the Inquiry evidence that has pointed to Working Together and
the Pan Cheshire guidance?
NEWBY: (Nods)
DE LA POER: Can you see the point that's being made about that?
NEWBY: Yes, of course, of course, yes.
DE LA POER: So again just trying to understand how you may have come to understand that it didn't
apply, what do you think the explanation for that is?
NEWBY: So for the [Child D] whose -- whose death I was involved with, I felt at the time that the
correct course of action was to phone the Coroner and discuss the unexpected death with the Coroner
as I felt at the time I was working within -- although it was very unexpected, that I was working
within a medical model, there was evidence of sepsis and I -- you know, although, although it was
unexpected, she had been unwell and therefore I -- I discussed that with the Coroner and I thought I
was working within that model rather than it was a completely unexpected and unexplained death.
DE LA POER: We are going to come and have a look in a little bit more detail of [Child D] now, so I
think that would be convenient for us to do. You deal with your involvement in [Child D]'s care from
paragraph 27?
NEWBY: Mmm mm.
DE LA POER: Which is on page 6 of your witness statement. What you tell us is that you have some --
and I am looking here at paragraph 28 -- independent recall of the case, although you have of course
provided statements to both Coroner and the police about [Child D] as you say, as the 24 hours was
so difficult and therefore memorable, can you just help us to understand what stood out in terms of
your memory of that last 24 hours and why it is that period is still with you today?
NEWBY: We -- you know, it's very unusual to get a death on a neonatal unit, particularly a child
that's not known, for example, to have significant congenital abnormalities. It was -- it was a very
difficult and traumatic event that night for all the staff that were dealing with it.
DE LA POER: Your response, as you tell us, to those very difficult circumstances once [Child D] had
died was to contact the Coroner?
NEWBY: Mm-hm.
DE LA POER: Just help us with what your discussion was, what it was that you wanted to tell the
Coroner or the Coroner's office, officer, about the death and what you were expecting to happen as a
result of that conversation?
NEWBY: So I would have -- I can't remember the -- the details of the conversation, to be honest, but
my --
I would have discussed -- I would have given him the case history and discussed that I couldn't,
that it was an unexpected event that I couldn't fully explain and I would, and I -- I -- I wanted a
postmortem in order to for everybody, really, for myself and for the family to -- to help everybody
to understand what had happened.
DE LA POER: One of the things you say in terms is that this as a death was unexpected?
NEWBY: Yes.
DE LA POER: Having had your conversation with the Coroner, did you also discuss it later that
morning, the case, with Dr Brearey?
NEWBY: I did, yes.
DE LA POER: Was Dr Brearey's view based on what you told him that it was the death had most likely
been caused by sepsis?
NEWBY: (Nods)
DE LA POER: Was that a view that at the time, not being a firm conclusion, that you tended to agree
with?
NEWBY: I did, yes.
DE LA POER: Did the discussion include what you describe as lesions on [Child D]'s abdomen?
NEWBY: Yes.
DE LA POER: What you tell us at paragraph 33 is that you tried to arrange an immediate debrief, you
say you don't
recall that but having looked at the email correspondence?
NEWBY: Yes, I obviously did.
DE LA POER: That is --
NEWBY: Yes.
DE LA POER: But you don't have a recollection of whether or not that debrief took place?
NEWBY: I think, I think I don't recall, I think I don't recall it because it didn't take place in
the end. Everybody worked shifts, the nursing staff, the -- the trainees and I think I -- I must
have tried to arrange it but in the end it was impossible to get everybody together, for everybody's
shifts patterns to align and it didn't and it never came together.
DE LA POER: Should there have been a debrief? I mean, how important was --
NEWBY: It's definitely -- without a doubt it is good practice to have a debrief it allows people
that -- a safe space after an event to -- to offload a little bit because it's -- you know, these
events are very traumatic. So it allows for some offloading and some emotional support. But also for
people to say and bring any immediate thoughts to the table about what could have done better or
what went well.
DE LA POER: Of course the context for [Child D]'s death was
that just earlier in the month [Child A] had died and [Child C] had died and we also know, and we
will come to in a moment, [Child B] had collapsed. Were you aware of those -- those events even if
you weren't directly involved in them yourself?
NEWBY: Yes.
DE LA POER: So [Child D]'s death compounded, is this fair to say, what everybody was feeling in
terms of the distress and worry about those events?
NEWBY: Yes.
DE LA POER: So is it fair to say that in those circumstances at the very least it is unfortunate
that there was no debrief for everybody to come together --
NEWBY: Yes.
DE LA POER: -- and decompress?
NEWBY: Yes, I -- we wouldn't, we didn't manage to come together as a group but I certainly would
have had individual conversations with people.
DE LA POER: We are going to look at some of those in a moment. In fact, we will come to one now.
You are aware that Dr Lambie says that she spoke to you, just paraphrasing what she said, that it
was some time later, and that she says that you were very interested in the sudden colour change
that you had observed and that you said that you had witnessed something similar in another infant
patient around the same time. Do you have a recollection of that conversation and what you might
have been talking about?
NEWBY: I don't, to be honest. I don't recall seeing the lesions in another patient, no.
DE LA POER: Was the rash something that at the time from a medical point of view you were very
interested in?
NEWBY: Yes.
DE LA POER: Or interested to understand?
NEWBY: Oh no, yes, yes, we spent a lot of time discussing it on -- on the night of the events myself
and the Registrar that was on -- on-call spent some time discussing what could possibly be the
aetiology of it and we did as a group afterwards as well.
DE LA POER: Do you know who that Registrar was?
NEWBY: Dr Brunton.
DE LA POER: Doctor?
NEWBY: Brunton.
DE LA POER: Brunton, thank you. We are going to move forward to 23 June and an email and I wonder
if this can be brought on screen at INQ0025743. If we can go to page 2, please, this is an email which you are
sent by Dr Gibbs?
NEWBY: Mm-hm.
DE LA POER: And he talks about, and we don't need to go over all the detail, I hope that you
recollect from the papers the Inquiry provided you with seeing this email. But he is raising the
fact that Dr Lambie had come to see him and was very concerned about all four cases A,B,C and D and
drawing attention to the strange purpuric looking rash, as he describes it?
NEWBY: (Nods)
DE LA POER: He goes on to say that the junior doctors were looking for something to be done about
it.
NEWBY: Mm-hm.
DE LA POER: What was your feeling at the time about whether something should be done about these
four cases?
NEWBY: Yes. No, no, definitely, I knew that the trainees were very concerned about it and we were
very concerned about it as well. Each baby had appeared to be infected, septic, we, we were
concerned that we had some bug on the unit, maybe contamination of some equipment, one of the
ventilators, for example, so we were extremely concerned about it.
DE LA POER: If we scroll up, we might need to stay on the full page view because it is the bottom
of the page that we will be interested in, we are going to see an email from you. So if we go to the
-- we can see you reply
copying all your colleagues in to it: I agree, you say. "I have just been grilled by Dave Harkness."
Dr Harkness?
NEWBY: Mm-hm.
DE LA POER: "This is causing a lot of concern/upset. Can we pull something together fairly soon? I
think we need to meet with both, probably separately would be better." What do you recollect that Dr
Harkness was saying to you?
NEWBY: That he was also -- that he was also obviously very concerned about the three deaths and he
also mentioned the link between the -- the rashes that were seen on each baby.
DE LA POER: Thank you. We can take that down but we are going to put another document up and we are
going to move forward about a month in time. This is INQ0036166. If we go, this is a meeting, so you can see between the senior
clinicians, you are indicated as being present second from the top of the list, and if we go over
the page, there are a number of matters discussed at that meeting on 29 June, I think I said we move
forward a month; in fact we have only moved forward three days. If we look at three paragraphs up
from the bottom: "There was also an issue raised around the fact
that the three recent neonatal deaths, the Registrars had been quite worried and felt nothing had
been done. Behind the scenes reviews are going on but it was felt that formal debriefs would
probably take place rather than any specific meeting to discuss all three." So that's the discussion
between you all as recorded in the notes?
NEWBY: Mm-hm.
DE LA POER: Are you able to help us with why it wasn't thought a good idea to discuss all three
deaths together?
NEWBY: No, I don't -- I don't know. I don't recall that. I do -- I do recall a decision being taken
to ask Dr Subhedar, who is one of the Consultant neonatologists at the Liverpool Women's Hospital to
come and review them all. So no, I -- I don't know what I can't recall that.
DE LA POER: Thank you, that can come down. If we move forward in your witness statement to
paragraph 37, which is where you deal with a Neonatal Mortality Meeting on that, on 29 July. There
was a review of [Child D]'s death. You talk there about the discussion which took place and in the
final sentence of paragraph 38, you say the consensus at that time, and pending Dr Subhedar's review
and any other investigation that was ongoing, was it was likely that [Child D] had died of
sepsis?
NEWBY: Mm-hm.
DE LA POER: It also appears, and we can bring up the INQ at this point, 0003297, please, that
[Child D] is the one just over the page, we don't need to turn to that. We can see that [Child C]'s
death was discussed?
NEWBY: Mm-hm.
DE LA POER: We can see at the top the period of assessment is June 2015. Taking that on its face,
that would include [Child A]'s death?
NEWBY: Mmm.
DE LA POER: But [Child A] doesn't appear to have been discussed at the meeting?
NEWBY: Mmm.
DE LA POER: We have just looked at a meeting that happened a month earlier where it seems to have
been resolved that all three deaths wouldn't be considered at the same meeting. Are you able to shed
any light on why [Child A] wasn't also discussed where the period of assessment appears to include
the date of [Child A]'s death?
NEWBY: I don't know to be honest. I really don't.
DE LA POER: Can you, sitting here now, see any advantage of all three deaths possibly with [Child
B] as well-being discussed given what had been said in the earlier
emails, all being discussed together formally being minuted and everybody sharing their different
impressions, thoughts and plans for how it should be managed, can you see that as being a good
thing?
NEWBY: Of course, yes.
DE LA POER: So if we take that down, we will move forward in our chronology. [Child E] was murdered
on 4 August.
NEWBY: (Nods)
DE LA POER: On 5 August, [Child F] experienced a deterioration. Now, I don't think you were
involved in the care of [Child F] at that time but I just want to ask you about something that Dr
Gibbs has said about it. Are you aware of the insulin and C-peptide result that came in a week later
from the Liverpool laboratory?
NEWBY: I wasn't aware of it until almost -- after Letby was arrested and we were coming up to the
trial.
DE LA POER: Dr Gibbs has characterised that as a collective failure of the Consultants. Is that an
opinion that you would subscribe to too?
NEWBY: At the end of the day it was there, it was a result that was in the department and any of us
could have looked at it at any time.
DE LA POER: We will move forward, please, to a meeting that you had with the parents of [Child D].
The Mother of [Child D] has given evidence and I just want to tell you
what she has said. She said that you told her that the evidence pointed towards sepsis?
NEWBY: Mmm mm.
DE LA POER: She said, "what were the test results? Did she have an infection?"
NEWBY: Mm-hm.
DE LA POER: Her recollection is that you replied "no, she didn't", and then she goes on to say you
couldn't explain.
NEWBY: Yes.
DE LA POER: Now doing the best you can, do you have a recollection of meeting the Mother of --
NEWBY: I do definitely remember meeting with the parents, yes, yes.
DE LA POER: And just having heard what her recollection of events is, do you have a recollection of
saying that, does that sound like something that you might have said based upon the facts or do you
remember things differently?
NEWBY: I think I would have been explaining about blood culture results and that although we felt
that she did have an infection and she was septic as she presented that way, the blood cultures
hadn't proven that. But that is something that is often the case in
neonates.
DE LA POER: Now, we have mentioned Dr Subhedar already. He, as you tell us at your paragraph 48,
came to present the findings of his review?
NEWBY: Mm-hm.
DE LA POER: You say that was on a Wednesday or Thursday lunchtime teaching session. You say this:
"I remember that it was felt that, although it was unusual to have such a cluster of deaths on a
neonatal unit, there was medical explanation for each death and no major deficiencies in care were
found." So that's your recollection of your response to the presentation given by Dr Subhedar?
NEWBY: (Nods)
DE LA POER: The first thing is, doing the best you can, do you know whether that presentation was
before or after the death of [Child I] in late October 2015?
NEWBY: Gosh. I -- I don't. I think it was before to be honest. But I -- I -- yes.
DE LA POER: So far as [Child A] was concerned, and I appreciate that was not a child who you were
directly involved in the care of, but you say that there was a medical explanation for each
death?
NEWBY: Mmm.
DE LA POER: Are you able to help us with what the medical explanation was being said at that time
for the death of [Child A]?
NEWBY: I can't remember, to be honest.
DE LA POER: There was, we know, on 12 October and you deal with this in your witness statement, a
table top meeting to review the case of [Child D] following the postmortem findings?
NEWBY: (Nods)
DE LA POER: Do you have any recollection of what you thought upon reading the postmortem findings
of [Child D]'s?
NEWBY: I suppose I -- it confirmed my belief, there was evidence on the postmortem of congenital
pneumonia, ie infection, and therefore a medical model of sepsis seemed reasonable and appropriate.
DE LA POER: So if we just take stock at this moment in time about what you were thinking was
happening on the neonatal unit, before the death of [Child I].
NEWBY: Mm-hm.
DE LA POER: Were you concerned about the deaths which had occurred?
NEWBY: Yes, very.
DE LA POER: Were you suspicious at that time that any of the deaths were unnatural?
NEWBY: No.
DE LA POER: Before the death of [Child I], did anybody else suggest to you that they were
suspicious that the deaths might not be natural?
NEWBY: No.
DE LA POER: So we move forward to [Child I], please. I am picking up here starting at paragraph 51
of your witness statement, which is on page 11. You tell us you have some limited recollection of
events on 13 October. Now, [Child I] died on the 23rd and [Child I]'s death was preceded by a number
of deteriorations or collapses?
NEWBY: Yes.
DE LA POER: You tell us that your recollection is that you were called in urgently on 13 October;
is that right?
NEWBY: Yes.
DE LA POER: That you found Dr Neame performing resuscitation?
NEWBY: (Nods)
DE LA POER: That [Child I] responded to the resuscitation and was transferred to intensive
care?
NEWBY: Mm-hm.
DE LA POER: One of the matters that the Inquiry is investigating is whether or not it was the case
that Letby was moved from having responsibility for [Child I] over the period that [Child I]
collapsed in relation to one specific shift?
NEWBY: (Nods)
DE LA POER: Is that something that you were aware of if it happened at the time?
NEWBY: No.
DE LA POER: Now, had it been the case that somebody on a neonatal unit thought that Letby should be
moved off the care of [Child I] for [Child I]'s protection, so not to do with Letby's welfare but
for [Child I]'s protection, is that something that you should have been told about?
NEWBY: Yes. Yes. Yes.
DE LA POER: What do you think your reaction would have been if you were told that such a step had
been taken?
NEWBY: I have -- I would have wondered what on earth was going on really and if, if -- that we --
did not more than that need to be done?
DE LA POER: Now, [Child I] died on 23 October 2015. That was thought of as a sudden and unexpected
death at the time?
NEWBY: (Nods)
DE LA POER: If that was the thinking, in your view should a Datix have been completed?
NEWBY: (Nods) Yes. Sorry.
DE LA POER: Now, you tell us at paragraph 54 that you can recall a discussion with Dr Gibbs, plus
Dr Brearey and/or Dr Jayaram?
NEWBY: Yes.
DE LA POER: You say in terms of the date of it: "... following my involvement with the collapse of
[Child I] in October 2015"?
NEWBY: Yes.
DE LA POER: So we know your involvement was the 13th?
NEWBY: Yes.
DE LA POER: We know [Child I] died on the 23rd?
NEWBY: Yes.
DE LA POER: Was that discussion before [Child I] died or after [Child I] died?
NEWBY: I have -- I can't recall. I -- I can't recall. It -- yes, I can't.
DE LA POER: Well, if you just think about it, if --
NEWBY: It can't have been, it can't have been before, it can't have been.
DE LA POER: I was just going to suggest that.
NEWBY: Yes, it can't have been, yes.
DE LA POER: Because if that had occurred before and then [Child I] had died, that would have
been?
NEWBY: It can't have been yes, it couldn't have been.
DE LA POER: And as best you can, just tell us what your recollection is about what was said to you
and by whom in that discussion?
NEWBY: I can't remember precisely who started the conversation. I was asked if Letby had been there
on the night that I was called in to that resuscitation and I replied that I had seen her. The
conversation was then around the fact that she was always on duty when these events had happened and
then also some counter arguments that we were in fact a very small unit with a very small pool of
nursing staff, so it was not inconceivable that the same poor person might be on duty for a, for a
number of events. Yes, but, I -- I felt the idea that anyone was suggesting that someone was doing
this quite difficult. Yes.
DE LA POER: Was the possibility that it was deliberate harm that was occurring said out loud?
NEWBY: No. It was more that she was always there.
DE LA POER: So that was an implication that you took?
NEWBY: Yes, an implication that -- that this -- this pattern had been noted. I -- Dr Brearey was
reviewing and Eirian Powell were reviewing all the deaths and I knew that they were looking at
things like which incubators each of the baby was in, which equipment was used, which staff were on
duty et cetera because that had all been discussed when Dr Brearey had reviewed the first three
deaths.
DE LA POER: What you say in your statement at paragraph 54
in the middle: "I found it hard to comprehend that a health care professional could be deliberately
harming babies and I remember expressing that at the time. However what was happening on the unit
was clearly not normal so it had to be considered. They wanted to raise their concerns to the
Hospital. I do not know exactly when this happened or the sequence of events that led to the RCPCH
review into the neonatal unit or the sequence of events that led up to the Hospital calling in the
police to investigate as I left the trust at the end of February 2016"?
NEWBY: Yes.
DE LA POER: That's what you say in your witness statement?
NEWBY: Yes.
DE LA POER: They wanted to raise their concern with the hospital. Was that something that was
expressly discussed at the meeting?
NEWBY: Not, not at that time I think. That was -- I suppose as 2015 went on and into 2016, the
thought that something awful could be happening kind of, you know, solidified in people's minds
really. It was completely out of normality that we should have so many deaths on the unit.
DE LA POER: So does that -- am I to understand from that
answer that there were more conversations after that first one as the concerns coalesced?
NEWBY: Yes.
DE LA POER: Who was involved among your Consultant colleagues with those conversations, was it just
the same three people you have named or were any of the other Consultants involved?
NEWBY: Mainly the three named, yes.
DE LA POER: When you say "mainly", that might suggest that --
NEWBY: I can't remember who else was involved.
DE LA POER: A possibility of others?
NEWBY: I wouldn't be able to, you know, name --
DE LA POER: Did there come a point at any time in your presence when anybody actually articulated
out loud: maybe she's doing this on purpose?
NEWBY: No.
DE LA POER: Now what Working Together talks about in terms of the need for a response is if
somebody may pose a risk.
NEWBY: Mmm.
DE LA POER: Is that in fact what was being said in these conversations that you were a party
to?
NEWBY: Yes.
DE LA POER: So given that that was what was being said,
should something have been done immediately that that was said?
NEWBY: In -- in hindsight yes. It -- it was very difficult. There was an air of disbelief about it.
The only -- the only thing that we could say at the time was that she happened to be on the -- she
happened to be on all the shifts. No one had ever seen anything, heard anything. There were lots of
counterarguments that she was a very, very competent nurse, everyone had observed good practice, et
cetera. So I suppose we -- we -- it just became a very difficult situation as to -- to -- know where
to go.
DE LA POER: Just so that we are clear about the time period, we know that you left at some point in
February 2016?
NEWBY: Yes.
DE LA POER: The first conversation, the other end of the bookend, is at the end of October 2015,
are you able to be any more specific than that date range as to when things really coalesced in
terms of the index of suspicion or concern?
NEWBY: I suppose the beginning of 2016.
DE LA POER: You aren't sure if any of your other Consultant colleagues other than Dr Brearey, Dr
Gibbs and Dr Jayaram were involved in this? Why do you think at that stage all seven of you didn't
get together to talk about it?
NEWBY: I don't know really. I suppose it was just there was a bit of disbelief about it, really.
DE LA POER: Now, your statement to the Coroner is date-stamped as being received on 26 October 2015
but you tell us in your witness statement you in fact wrote that statement at the time of [Child
D]'s death?
NEWBY: Yes.
DE LA POER: So when you wrote it, none of this was in your mind?
NEWBY: No.
DE LA POER: And obviously we know [Child I]'s death was on the 23rd so there are only three days in
which you may have had a conversation before the Coroner received that statement. So that's the
background.
NEWBY: (Nods)
DE LA POER: Bearing in mind that [Child D]'s case was with the Coroner, do you think that there was
any point when you should have been contacting the Coroner to say: there is this concern which at
least my colleagues have about what was going on in the NNU?
NEWBY: Yes. At the end of the day, yes.
DE LA POER: We have talked about your colleagues' concern.
Can we just be clear. In terms of your personal opinion, obviously you were hearing what they were
saying, did there ever come a stage whilst you were at the Countess of Chester where you suspected
or was it the position that you were listening to the suspicions of others but holding a different
opinion yourself?
NEWBY: Yes. I suppose I -- I did -- I did struggle with the idea that somebody was doing this, yes.
DE LA POER: So again this is a difficult question perhaps to answer directly. But if somebody had
said to you: might Letby be harming children?, having heard all of the arguments, were you in a
position of saying: yes, I did think she might be, or were you thinking: no, on balance I don't
think she might be? Or were you just: I don't know?
NEWBY: I just don't know. It was -- yes.
DE LA POER: So it isn't the position then that you were you can say with certainly "I was
suspicious"?
NEWBY: Yes, yes.
DE LA POER: Just a couple more events to review. We know that in January 2016, Eirian Powell
produced a chart of --
NEWBY: Mmm.
DE LA POER: -- which nurses were on duty and which nurses were allocated to babies and on the chart
produced in
January, Letby's name is highlighted in red?
NEWBY: Mm-hm.
DE LA POER: Is that a chart that you saw whilst you were at the Countess of Chester?
NEWBY: No.
DE LA POER: Was that a chart that anybody who had seen it talked to you about and said: a chart's
been done and her name is there?
NEWBY: (Shakes head)
DE LA POER: Sorry --
NEWBY: No, sorry.
DE LA POER: Not at all, you don't need to apologise at all. Now the thematic review of Neonatal
Mortality Meeting attended by Dr Brearey, Dr V and Dr Subhedar occurred on 8 February 2016, when I
think you were on the cusp of leaving the hospital?
NEWBY: Yes.
DE LA POER: You left later that month?
NEWBY: Uh-huh.
DE LA POER: Were you aware of that meeting taking place at the time?
NEWBY: No.
DE LA POER: Although you had spoken to Dr Gibbs, Dr Brearey and Dr Jayaram about those concerns or
suspicions that they may have had, the meeting that was to look at the detail of all of the deaths,
that wasn't something that they had spoken to you about?
NEWBY: I can't remember it, no.
DE LA POER: So, for example, your view wasn't sought beforehand about what you wanted said at the
meeting about babies that you had had care of?
NEWBY: No.
DE LA POER: Presumably if you can't remember it you also don't have a recollection of anyone
telling you afterwards what happened at it?
NEWBY: No.
DE LA POER: We are now right on the cusp of your departure, we know that the CQC did an inspection
in the middle of February and they spoke to Consultants on 17 February 2016?
NEWBY: (Nods)
DE LA POER: Were you one of the Consultants who attended that or did you not go to that
particular?
NEWBY: I didn't attend.
DE LA POER: Do you feed anything into that, so did you say to any of your Consultant colleagues who
you thought might attend: please can you tell them about this or that?
NEWBY: No.
DE LA POER: Then some time around late February, possibly even mid-February, is it right that you
left the Trust?
NEWBY: Yes. I -- I can't remember precisely when but my leaving date was the end of February, but I
no doubt took some leave and I don't know when my last working day would have been.
DE LA POER: So if we just come to some general matters. I am looking here at page 12 of your
witness statement and paragraph 59. You say this: "I would have expected the Hospital to have been
extremely concerned about the number of deaths irrespective of the cause of them and undertaken a
review. It may be that the RCPCH review constituted that review but I was not party to those
discussions."
NEWBY: Mm-hm.
DE LA POER: When you say the hospital?
NEWBY: Mmm.
DE LA POER: In terms of human beings --
NEWBY: Yes.
DE LA POER: -- who are you meaning?
NEWBY: Well, the -- the, the senior leadership team would -- we were -- we were holding regular
Mortality Meetings under the governance framework and I rightly or wrongly at the time thought that
those would have been fed up the governance chain to the Urgent Care Division
and, therefore, to -- to the Exec Team. And -- and as with I suppose any incident reporting system,
Datix reporting system, individual incidents in themselves are really important but it is trends in
a way that are more important because they help you to identify a system issue or a -- whatever may
be causing the problem and those trends should be put together and viewed at a higher level.
DE LA POER: In light of what you have been told by Dr Brearey, Dr Jayaram and Dr Gibbs, in terms of
their index of suspicion, what, if anything, did you think they were doing by way of notifying the
senior management of the hospital, following the articulation of that suspicion to you?
NEWBY: I -- I suppose at that time in October it was more just a "we have noticed she is always
there". You know, could -- you know ... Then I suppose as time -- as time went on those concerns
started to coalesce. I know around the time I left or whether it was just after, it sort of becomes
a bit hazy as to what I actually was there for and then what I was told had happened by my
colleagues afterwards in a way, that Dr Brearey and I assume Dr Jayaram as well had asked for a
meeting with the senior management team to discuss what was happening on the neonatal unit.
DE LA POER: That may be something that you think you were told when you were there, but it may be
something you have learned subsequently?
NEWBY: Yes, I mean I obviously kept in touch with my colleagues after I had left and it was around
February time. But I say whether that was just before or just after I left, I am not sure.
DE LA POER: Was there any discussion between yourselves about whether the police should be
contacted if there were discussions about the need to raise it with the senior management?
NEWBY: We -- no, I suppose we felt that we needed to we needed to discuss -- you know, discuss the
concerns and then they would help and guide us with what to go with what to do next. It was
difficult. As I say, we didn't -- no one had ever seen anything happen. It was just a feeling that
she was always there.
DE LA POER: What you say at paragraph 61 is that you don't know the exact date that they raised
their concerns with the senior management but that should have triggered a request for a police
investigation by the hospital as this should have been taken very seriously. So was it your
expectation that one thing would lead to another?
NEWBY: (Nods) Yes.
DE LA POER: At your paragraph 63 you say: "I was extremely concerned about the number of deaths and
collapses on the neonatal unit as we all were as a group of Consultants." Then a little bit further
down, about halfway down: "I did find it hard to comprehend that a health care professional might be
responsible but what was happening on the neonatal unit was not normal. Everything needed to be
considered so I backed them in raising concerns. I did not raise these concerns personally but I was
aware that Dr Brearey and Dr Jayaram would raise them they acted as spokesperson for us group of
consultants. I do not know at what point they raised them." Does that really summarise what your
position is?
NEWBY: Yes, yes, I think that refers to that end period, around February. Yes.
DE LA POER: Now, after you left, the Coroner instructed Dr Mecrow to conduct a review of the case.
Did you ever see Dr Mecrow's report?
NEWBY: Not, not at the time. But, no, no.
DE LA POER: So that report is dated 9 June 2016. Now, let's be clear, Dr Mecrow does end up
agreeing with the pathologist, although points to areas of inconsistencies see but Dr Mecrow
described [Child D]'s death as disturbing due to her collapse being so sudden and unexpected. Would
you associate yourself with that description in relation to [Child D]?
NEWBY: It was very unexpected. Yes.
DE LA POER: The final matter I wanted to ask you about, Dr Newby, were your reflections.
NEWBY: Mmm.
DE LA POER: You were asked by the Inquiry to consider CCTV?
NEWBY: Mmm.
DE LA POER: If I just pick out one phrase, it is paragraph 82, you say "very difficult to
answer".
NEWBY: Mmm.
DE LA POER: I just would like you, please, just to speak to that about what your thoughts are about
the utility, value or challenges of CCTV on a neonatal unit?
NEWBY: Yes. I could -- I could completely understand why the question would be raised. I -- to --
whether you could set up a system that could capture absolutely everything and would mean that, you
know, for example someone appearing to give one medicine but giving another, how, how would C -- I
don't know. And, you know, there is an awful lot of very private and intimate care that goes on on a
neonatal
unit. Whether CCTV is -- whether families would feel CCTV is appropriate in that setting, but then
these events have -- have been really shocking and awful and I am sure families seek to feel
reassured.
DE LA POER: Are there any other matters that you would like to draw to the Inquiry's attention in
terms of you having had an opportunity to think about this very deeply and also have the experience
of being a Clinical Director at a different hospital?
NEWBY: Yes, yes, I think -- I think there was just this feeling of not knowing what to do and I
think in a way it almost made it a little bit more, more difficult to come up with a name because
having come up with a name and a person being put forward, kind of led to this counter narrative
being put forward as well; that it couldn't possibly be because she was so lovely, she was such a
competent nurse, you know, no one had ever seen ... And therefore it perhaps allowed for this
doctors versus -- it became sort of an almost adversarial thing that the doctors were accusing the
nurses and everyone was sort of digging in their position whereas maybe what we had to say was: this
isn't right and could it be that someone is, I don't know, maybe, maybe that -- I don't know if that
would have been easier and not allowed this
real adversarial position that developed, that developed to happen. If we had just perhaps taken a
step back and reported the -- and reported the incident rather than trying to work out who had done
it, if you like.
DE LA POER: So to raise the possibility of unnatural death at the first instance, but not to
ascribe it to any one person?
NEWBY: Yes, because we didn't there was no, at the time there was -- there was -- there was no --
there didn't appear to be any evidence.
MR DE LA POER: Dr Newby, thank you very much. Those are all the questions I have, my Lady.
LADY JUSTICE THIRLWALL: Thank you, Dr Newby, for your very thoughtful evidence. Can I just take you
back to something that you said quite early on when you were being asked about the change in the
divisional structure, the sort of relegation of paediatrics?
NEWBY: Mmm.
LADY JUSTICE THIRLWALL: To move from the top table, which I understand. You said that it was a
small part of the hospital so you could understand possibly the thinking behind it. But you said: my
experience in Chester was different from my experience in Stockport. I just wondered what was your
experience in
Stockport?
NEWBY: I suppose that paediatrics does have more of a voice.
LADY JUSTICE THIRLWALL: Was that the case when you went there?
NEWBY: Yes.
LADY JUSTICE THIRLWALL: Yes.
NEWBY: Yes, and, and we are -- we always remained Women's and Children in Stockport, although at one
stage we gained Diagnostics and then lost them again. But it -- I think that divisional structure
was more helpful than it is than the two large Urgent and Planned Care divisional structure that we
had at the Countess.
LADY JUSTICE THIRLWALL: Yes. Thank you very much indeed.
NEWBY: Thank you.
MR DE LA POER: My Lady, we are slightly ahead of where we would normally be for our break, but what that really means is that we are absolutely on target for our plan for today. Can I invite us -- or invite my Lady to direct that we resume at half past?
LADY JUSTICE THIRLWALL: Yes, certainly. So Dr Newby, that completes your evidence, thank you very much indeed and you are free to go. We will resume at 11.30. (11.10 am) (A short break) (11.30 am)
LADY JUSTICE THIRLWALL: Mr De La Poer.
MR DE LA POER: My Lady our next witness is Dr Saladi.
LADY JUSTICE THIRLWALL: Would you like to come to the desk, Dr Saladi.
DR SATYANARAYANA MURTHY SALADI (sworn)
LADY JUSTICE THIRLWALL: Do sit down.
MR DE LA POER: Could you please give us your full name?
SALADI: My name is Satyanarayana Murthy Saladi.
DE LA POER: Dr Saladi, is it correct that you have provided a witness statement to this Inquiry
dated 17 June of 2024?
SALADI: That is correct.
DE LA POER: Thank you very much indeed. Can you confirm for us, please, that the content of that
witness statement is true to the best of your knowledge and belief?
SALADI: That is correct.
DE LA POER: Reviewing your career, did you start your medical training in India obtaining MBBS in
1991?
SALADI: That is correct.
DE LA POER: And an MD in paediatrics in 1996?
SALADI: Yes, that is correct.
DE LA POER: Did you subsequently train in the United Kingdom and obtain membership of the Royal
College of Paediatrics and Child Health in 1998?
SALADI: That is correct.
DE LA POER: A Certificate of Completion of Specialist Training in April 2009?
SALADI: Yes.
DE LA POER: Just before you completed that, so in November 2008, did you join the Countess of
Chester Hospital as a paediatric Consultant?
SALADI: That is correct.
DE LA POER: And to bring us up to date, did you continue in that role until June of 2023?
SALADI: That is correct.
DE LA POER: So I am just going to deal with what you can tell us about your perception of
relationships between different people working at the Countess of Chester and the focus here,
please, Dr Saladi, is on the period 2015 to 2017. So at the start of that period, please, how were
relationships between the Consultants?
SALADI: Very good.
DE LA POER: The Consultant body and the junior doctors?
SALADI: Very good.
DE LA POER: The Consultant body and the nurses?
SALADI: Good, very good.
DE LA POER: You were in the hearing room when I read out to your colleague Dr Newby what Eirian
Powell has said of her perception of the relationship?
SALADI: (Nods).
DE LA POER: I will just remind you: "that Consultants thought all staff members worked cohesively
because staff did exactly what they were told to do by the Consultants without challenging them".
What can you tell us about your experience of that and your comment upon her view?
SALADI: No, I think it -- it was a cooperative unit and we could challenge each other easily and
they did challenge us in -- where they thought it was appropriate. It was not antagonistic, we
worked as a team. It was a cohesive team. And I am proud to be a team member of there.
DE LA POER: So far as how any change that may have taken place in 2016 is concerned, did you
perceive any change with any of the relationships that I have just talked about between the
Consultants, between Consultants and doctors, or between Consultants and nurses?
SALADI: Not in terms of the relations. Obviously the Consultants, us as a body, were under stress
but I suspect that applies to all groups because we were understaffed and we were having busy
periods and during that time there were more unwell children. But not in terms of the relations.
DE LA POER: In the period 2015 to 2017 what was your view of the senior management of the
hospital?
SALADI: I did not have any direct contacts with the senior management. The managers I see are the
business manager, which we meet in the Monday meetings. But I didn't think they had much authority
to change things. They needed to take it up higher level to get any things changed and the people
who are actually making changes I wasn't sure who -- who had that.
DE LA POER: So in 2015, if the Chief Executive Tony Chambers had walked on to the paediatric unit,
would you have known who he was?
SALADI: Yes, yes.
DE LA POER: Had you had any direct communication with him?
SALADI: Not directly with him.
DE LA POER: What about the Medical Director, Mr Harvey?
SALADI: Yes, I know, but not direct contact with him. It's not as if there were -- I think there
were -- they didn't come to -- we are in a different building in the hospital so maybe they were --
we don't -- we don't see them often apart from the emails. They used to communicate to us but not
sort of person-to-person contact but that's maybe we are a small department in a different building.
DE LA POER: Do you think that the fact that you were a small department in a different building
made any difference to how connected you were to the whole management structure of the hospital?
SALADI: As I said, because I was not in a management role, I didn't know the difficulties my
colleagues were facing, but I could easily interact with other Consultants, we used to meet in the
meetings and things like that. So -- but, yes, I didn't have much contact directly with the senior
management.
DE LA POER: If a problem had arisen in 2015 that you thought you would need to take to the senior
management, what was your expectation about how that particular group of people would have dealt
with it?
SALADI: I probably wouldn't have taken it directly myself. I would have raised it through my leads
which was Dr Jayaram and Dr Brearey and usually -- they used to take them up so I didn't need to
directly email or contact the senior managers at any stage, except in probably -- that was in June
or July 2016, that's when
I probably directly contacted some of them.
DE LA POER: We will come to that.
SALADI: Yes.
DE LA POER: Moving away from the topic of relationships. Safeguarding. Had you received training in
safeguarding?
SALADI: Yes.
DE LA POER: Had you received any training in terms of how you should deal with a situation where
you suspected a colleague of posing a risk to patients?
SALADI: I think the important point here is suspicion because safeguarding training is all related
to when do we suspect babies are harmed, are coming to harm. So we know what to do when we are
already having suspicion, I think. But we know what sort of situations we need to suspect babies
coming to harm, we had training, but that's mainly related to child protection in the community and
I suspect we did not have that sort of training when to suspect that sort of -- that sort of thing
in the hospital itself. We were told if you see abusive behaviour, if you see a Consultant or a
colleague coming drunk and things like that, which is easy to understand. But I don't think we had
what are the situations where you need to
suspect apart from these obvious situations where you are seeing a racist behaviour, or sort of
bullying behaviour, or a drunken behaviour, that sort of things, we know that is wrong and it is
easy to suspect and it is easy to raise concerns. But I don't think beyond that we had any sort of
training.
DE LA POER: So far as the process for Sudden Unexpected Death in Infancy and Childhood was
concerned, what was your understanding in 2015 as to whether that applied to deaths of neonates on
the neonatal unit?
SALADI: Yes. I understood that it applied and when we were having unexpected deaths we were
following the route which my understanding is to discuss the concerns with the Coroner.
DE LA POER: What we can see from the guidance is that a number of steps are identified at an early
stage when following that procedure including contacting, for the Countess of Chester, Dr
Mittal?
SALADI: (Nods)
DE LA POER: And for the convening of a multi agency meeting, which would involve local authority
and police. Did you understand that aspect of the Sudden Unexpected Death in Infancy and Childhood
to apply?
SALADI: I suspect my understanding was that was more related to outside the hospital because inside
the
hospital we were thinking more in terms of the Coroner, because I suspect -- the suspicion I think
that is where, where we are, the suspicion of something unusual or, yes, maybe I am not framing it
correctly. But my thinking was the right person to discuss this is Coroner because they are the ones
who sort of we contact immediately within the first -- probably if it is daytime straight away or if
it is something happened in the nighttime, then first thing in the morning. We do discuss with the
-- Dr Mittal but that's more of there is something called Part B to complete that forms which needs
to be done in sort of 24, 48 hour's time whereas Coroners is immediate because they are the ones
making a decision whether they are ordering a Coronial postmortem or they are leaving it for us to
discuss with the parents to whether they want a hospital postmortem. So I didn't think I was giving
more importance to Coroner, informing the Coroner rather than going in that other route.
DE LA POER: Who did you understand within the hospital had responsibility for making sure that you
followed the right procedures when it came to those sudden unexpected deaths?
SALADI: I suspect we discussed all deaths and all the morbidity in our Perinatal Morbidity Mortality
Meetings and if there was -- if we thought we were not following I thought that would have been
where we would have -- could maybe we should have done differently. I am not sure whether I am
following your question or whether my answer is what you are asking.
DE LA POER: I understand you to be saying that you relied upon your colleagues to at those meetings
to correct any failure to follow the correct procedure, is that what you said?
SALADI: Yes, when we are discussing with the Dr Mittal our safeguarding team which is not usually
not in the context of safeguarding, it is because of unexpected death, we do discuss but that is not
usually immediate when they are next available which may be in a couple of days' time. But that's
mainly about information, saying that we had an unexpected death and we have discussed with Coroner
and this is what is happening. And then I will fill the form when it comes so that you know what our
clinical thinking was.
DE LA POER: In 2015, were you aware of the crimes of Beverley Allitt?
SALADI: Yes.
DE LA POER: Were you aware of the situation at Stepping Hill Hospital where a nurse had been using
insulin to
kill patients?
SALADI: I cannot remember now whether I was aware at that time.
DE LA POER: Now, we are going to turn please, Dr Saladi, to look at what you say in your statement
about events.
SALADI: Mm-hm.
DE LA POER: Can I say at the outset that I do understand that a number of occasions you have
asserted you don't have a memory, I am going to try and help you with that as far as possible?
SALADI: Okay.
DE LA POER: So at paragraph 12 on page 2, you deal with [Child A] and [Child B] and in particular
at paragraph 13, you make a number of statements about [Child A] and I am just going to read those
out so if you have got them in front of you: "I was not involved in the care at the time of the
deterioration and death of [Child A]. At the time it was unexpected but we were thinking if it was
related to maternal health. "I do not recall any discussions about unusual patterns of
discolouration of [Child A]. "I did not have any concerns about [Child A] apart from if it was
related to maternal health condition. "I do not remember if I attended any debrief."
Doing the best you can, do you remember providing any care to [Child A]?
SALADI: Yes.
DE LA POER: You do?
SALADI: Yes.
DE LA POER: Can you help us, please, with your recollection of [Child A]'s condition when you
provided that care?
SALADI: Well, I attended -- [Child A] is one of the twins and I attended the delivery when the twins
were born and I think I was resuscitating -- I am not sure without seeing the notes, but I think I
am resuscitating [Child B] who was more sicker at the time of birth and my colleagues were
resuscitating [Child A] but I know [Child A] is much more stable than [Child B] at the time of
birth.
DE LA POER: So at the time of birth, did you have any sense at all that [Child A] might die?
SALADI: No.
DE LA POER: We are going to come in a moment to some contemporaneous records about [Child A], not
in the medical notes, but before we do, [Child B] suddenly deteriorated on 9 June of 2015 and you
say this at your paragraph 14: "In relation to [Child B]. "At the ward round on 10 June I was
looking for
medical causes which caused the deterioration and if it was related to maternal health condition. "I
cannot recall what I was thinking at the time I was probably thinking was it related to sepsis which
can give rise to rashes rather than related to maternal health condition which was one of the
parental concerns at the time. It was also possible the rash seen by me was much different to the
rash seen by the junior doctor earlier as some rashes change with time."
SALADI: Mm-hm.
DE LA POER: Now, Dr V's record notes: "Purple discolouration almost resolved ??? cause." Were you
sighted on the fact -- sorry, I will ask that question different. Were you aware of Dr V having seen
the rash and did you talk to Dr V about the rash?
SALADI: I do not remember if I have seen -- I have discussed about the rash with the Dr V. But I
think again not based on the recollection of the event but looking at the notes, I know that the
child had rash the previous night which had subsided and by the time I think I have documented the
notes that it is quite localised only in some areas and usually for paediatricians there are lots or
different types of rashes. The worrying type of rashes are the rashes because of serious infections
and usually those rashes are progressive, that means they are getting worse in front of you or they
are becoming much more like a bruise and things like that. Whereas something which sort of
disappears or not usually are not usually a concern. At least at that stage because there are lots
of causes for the rash and some of the rashes can happen in the newborn period as well. So probably
that's why you didn't stick it -- stick out to me that much.
DE LA POER: This rash was associated with a sudden and unexpected deterioration in [Child B]. Does
that make it potentially more significant because?
SALADI: Yes, I would be thinking of infection and I would now check whether we have looked for
infection and whether we have covered the baby with antibiotics.
DE LA POER: I think you have told us that in an infection the rash will progress or turn into a
bruise. In fact, the --
SALADI: Not necessarily all the time.
DE LA POER: But the opposite was happening in this case that the rash was resolving and becoming
more localised?
SALADI: Yes, but it doesn't mean infection and rash has to always progress. It can decrease as well.
DE LA POER: Did you take any steps to try to investigate
the reasons for [Child B]'s collapse?
SALADI: At that stage, there was a lot of concern whether it is related to maternal health
condition, though our initial reading from the -- from the literature is probably not. But we were
trying to contact the various specialists whether it is in fact related to it or not, so we were
trying to contact the teams in London and I can't say definitely at London but definitely we are
trying to contact different teams, whether that can explain this sort of deterioration and we
thought we had treated for the other possible causes for the rash like infection.
DE LA POER: We are going to have a look at a document which we looked at this morning, INQ0025743. This is an email from Dr Gibbs the day after [Child D] died. And
it is on the second page. Thank you very much. We can see that that you are one the recipients of
this email; do you see that?
SALADI: Yes, I can see that.
DE LA POER: Again, just by way of summary, Dr Gibbs is talking about Dr Lambie coming to talk about
the concerns of the Registrars?
SALADI: Mm-hm.
DE LA POER: Were you aware before this email came into
your inbox of the concerns of the Registrars?
SALADI: No.
DE LA POER: Did you speak at any time to any Registrar about them being worried about the deaths
and/or the rashes?
SALADI: No.
DE LA POER: When you received this email, did you note the fact that according to Dr Gibbs, there
seems to have been a rash in [Child A], [Child B] and [Child D]? So he says that [Child C] didn't
have the rash, so that's what Dr Gibbs is saying in the first paragraph?
SALADI: Sorry, what was the question?
DE LA POER: So the question was: did you note when you read it that Dr Gibbs was bringing together
those four cases?
SALADI: Yes.
DE LA POER: Saying in the case of three of them, there was this rash?
SALADI: I cannot remember whether -- whether what I was thinking when I saw this email because I was
reminded of this email only when I received through the Inquiry. So I cannot remember what I thought
at that time.
DE LA POER: Because you had been involved in the care of both [Child A] and [Child B]?
SALADI: Yes.
DE LA POER: And you had information you could provide about what you had seen about [Child B]'s
rash; is that right?
SALADI: Again, as I said, the rash I have seen I did not think it was anything serious, so probably
that's why it didn't trigger anything. So probably that's why this email, I did not remember this
email until you sent me through the Inquiry because the rash I have seen is based on what I -- what
was documented in the ward rounds, did not sound very serious.
DE LA POER: So do you have any memory of speaking to any of your colleagues to try and understand
their experience of the rashes for any of these four babies to see if you could further understand
what Dr Gibbs was talking about?
SALADI: No.
DE LA POER: Again, we looked at it this morning. There was a meeting a few days later, INQ0036166, and I will just help you with the part so that you have it in
front of you. We can see at the top there that it is a meeting that you attended and over the page
just to remind you, Dr Saladi --
SALADI: Mm-hm.
DE LA POER: -- that third paragraph from the top again mentioning that the Registrars had been
quite worried. That's twice in a week that either there is an email discussion or there is a
discussion in person about the junior doctors being worried. What did you think about the concerns
that you were being told about?
SALADI: See, I don't think at this stage the junior doctors were describing what they were seeing.
The -- I suspect because this meeting again I do not have any recollection of it because I suspect
if they said some junior doctors have seen a rash, and there is a concern, obviously there were
concerns for all of us at that stage because for all the taps in the neonatal unit we had filters
and there were growing pseudomonas from the taps even though I do not remember we actually grew that
bug from any of the babies. So maybe I was thinking that is that related to the neonatal unit, the
taps and things like that rather than this is a different type of rash which is different to what we
see in infections because again until you sent me this, this summary of the meeting, I didn't -- I
didn't recollect it. I suspect that's because what was discussed in the meeting was we were thinking
maybe it is related to the taps and things like that.
DE LA POER: So in terms of how you felt about the
situation at the end of June on the neonatal unit, and by that I mean the fact that there had been
three deaths in quick succession plus a collapse of the twin of one of those who had died, were you
worried?
SALADI: Yes. In the sense we know in the neonatal units deaths can happen, particularly if there is
any outbreak of infection so there can be grouping of the deaths and I suspect we were all thinking,
or at least I was thinking that this is all related to are we missing some bug, something else which
was happening. But that's why we are having these bad faith with the more --
DE LA POER: From your point of view, is that you doing your best to reconstruct your memory or is
that something that you have a positive recollection of thinking at the time?
SALADI: Is there a difference between those two?
DE LA POER: Well, one is "I can remember thinking that" and another is saying, "Well that's
probably what I was thinking, I don't actually remember".
SALADI: Yes, second one. I don't actually remember but I would have thought having a few deaths
grouped together is not unusual. It's rare but it is not unusual and usually the sort of things
which when we are investigating is some sort of bug or something like
that.
DE LA POER: But in fact none of the investigations came back --
SALADI: That is correct.
DE LA POER: -- to say that that was the explanation for the cluster, did they?
SALADI: That is correct.
DE LA POER: So let's move forward in our timings. Were you aware of the death of [Child E] at the
beginning of August 2015?
SALADI: I know -- I was involved in one death of the baby during this entire period, I was directly
involved in the resuscitation and death of one baby which is not in the indictment and I was
involved indirectly with the death of Baby A [Child A] because I was taking care of the -- I was
involved with the resuscitation of the baby in the previous 24/48 hours. Most of the other babies I
was not directly involved in. So I would have known them from when I am coming back next day to the
work that we had this death or when we were discussing the deaths in the Perinatal Morbidity
Mortality Meetings.
DE LA POER: Did the fact that there was now a fourth death in a very short period of time increase
the level of concern that you had about there being a potential
problem on the neonatal unit?
SALADI: Probably. I cannot remember. But, yes.
DE LA POER: The day after [Child E] died, [Child F] had a deterioration and we know now, and it was
available shortly afterwards, so about a week later, that the insulin and C-peptide levels relative
to each other indicated that external insulin had been administered?
SALADI: Mm-hm.
DE LA POER: Dr Gibbs has described that as a collective failure that was serious in terms of all of
the Consultants. Do you agree with that?
SALADI: I do agree because if the babies have been in the unit for a few weeks, if babies are being
in the unit for two months, all of us would have seen those babies in our hot weeks at least twice
and in the other times, we would be in -- we would be knowing about those babies only when we are
on-call. So it depends on how long the baby stayed. If the baby has stayed for at least two months
we would have opportunity to go to review the notes and we could have seen the results but it may
not have picked up an abnormal result when we are looking at the trends because of the system we
had. But we could have seen -- I suspect we would have looked for it more if the baby was unwell or
if there were continuing concerns about the baby. But, yes, we -- we could have seen, we should have
spotted. But I accept that as a collective failure.
DE LA POER: Returning to your witness statement, paragraph 20 on page 4. You speak about [Child H].
What you say in relation to [Child H] at paragraph 22: "It was not clear why [Child H] had
deteriorated hence why I sought help from the tertiary unit as documented in the notes. Any
[unexpected] deterioration in a child is worrying."
SALADI: Yes.
DE LA POER: At the time that you were contacting the tertiary unit, and you were worried as you
tell us about the unexpected deterioration, did you think back to the events which had happened just
in the last few months and in particular the deaths and sudden deterioration of [Child B]?
SALADI: I don't think our mental focus would be going that far when we are seeing a sick child, what
we would be considering is: is it something which is so unusual that we are not seeing? So is it an
uncommon presentation of an uncommon condition so that we are not seeing or we don't have experience
managing and that's the reason to discuss with the tertiary units where they, they do the
neonatology every day so they might
have experience in seeing this condition. So it is in terms of getting that advice, I don't think in
that situation I would have the presence of mind to think about all the deaths which have gone on in
that year.
DE LA POER: So after this unexpected unexplained deterioration had occurred, you didn't go to see
your colleagues to say "why does this keep happening", or anything along those lines?
SALADI: So we are now discussing only about the deaths, but I suspect at that stage we are not
seeing the babies who are having collapsed and deaths but we also have other patients as well so I
suspect I cannot see how my mind was working. But maybe we weren't putting all the information
together. Maybe we weren't discussing, we were discussing that particular child at that time rather
than maybe we were or maybe we were discussing the patients who are coming in that Perinatal
Morbidity Mortality Meeting rather than taking a bigger overview. Maybe that's why we, we probably
missed looking at it because we -- here we are discussing only about these babies. But we were
discussing about all the other patients where we had question marks and where we had morbidity
issues, not just in the neonatal unit on the
children's ward as well. So I don't know whether I am answering you properly.
DE LA POER: I am going to just move forward because it may be that we are going to have an example
of such a discussion in a moment that I want to ask you about.
SALADI: Okay.
DE LA POER: So we will move forward to [Child I] please, October 2015. As I understand it, you had
some involvement in [Child I]'s care when [Child I] died; is that right?
SALADI: [Child I]'s care during the stay, yes.
DE LA POER: Yes. Did [Child I]'s death cause the concern that you have told us there was about the
cluster back in June, did that have any effect on the concern you had about the neonatal unit more
widely at that time?
SALADI: I suspect we were always looking at medical causes. So I remember this baby because we were
seeing this baby with abdominal distension and we are sending them to the regional units and they
are coming back because they are not finding anything. So we were scratching our head. Are we
missing something else or are the surgeons missing something else? Why is a baby suddenly
deteriorating here and goes and they are doing investigations, they are saying
they are not finding anything and coming back. So I suspect that should have raised concerns. But I
think our focus is still looking at medical conditions and I suspect we were still thinking there is
something medical condition which we have not yet understood. So I don't think we sort of connected
with all the other previous deaths.
DE LA POER: Now, you will have heard Dr Newby this morning talk about a conversation that she had
with Dr Gibbs, Dr Brearey and/or Dr Jayaram as she describes it following death of [Child I]. Did
any of your Consultant colleagues come to you to talk to you about their concerns following the
death of [Child I]?
SALADI: I was definitely discussing with the Dr Brearey about the babies I was involved in,
particularly a baby who died with cardio cause, whether the death -- the cardio cause can explain
actually the death and he was trying to get the information from the cardiologist so we were having
discussion. But I suspect he was discussing with the -- the colleagues or the discussions were not a
group discussions but with the concerned colleagues who were involved in the care or the
resuscitation at the time. So I -- I wasn't aware of ...
DE LA POER: One of the things that formed part of the discussion we are told is the fact that Dr
Brearey was pointing out that one member of staff appeared to be a common factor at these recent
events. Did he have such a conversation with you about that?
SALADI: I do not remember having such conversation until that email, until the seniors meeting on
the Monday -- June or July.
DE LA POER: So that's 27 June, we will come to that meeting which was the --
SALADI: Yes, before that I wasn't -- I don't think I was aware because I don't think I was aware. I
am saying that because I was sleepless for two nights after the seniors meeting and that's what
sleepless in thinking and then trying to write that email. So I don't think I would have heard Lucy
Letby's name before that.
DE LA POER: Now, if I move forward and I am moving over [Child J] here because it may be that Mr
Baker has some questions for you about [Child J], to early 2016. It may be you have already answered
this question, Dr Saladi. We know that in January of 2016 a chart was produced showing which staff
or nursing staff were on duty or allocated to babies and Lucy Letby's name was marked in red as it
appeared on the chart. Did anybody talk to you about that work being done?
Were you told that that sort of staffing analysis was under way?
SALADI: In June 2016.
DE LA POER: January 2016?
SALADI: January?
DE LA POER: So six months before that meeting.
SALADI: I don't think so. I am not sure whether, was there -- was it there in the meeting?
DE LA POER: So it is a document that was produced.
SALADI: Okay.
DE LA POER: There is no email that suggests that you received it. I am just wondering whether you
-- anybody spoke to you about it or anything like that that you can recollect?
SALADI: I cannot recollect.
DE LA POER: The thematic review of Neonatal Mortality Meeting took place on 8 February. Were you
asked, you didn't attend?
SALADI: I didn't attend.
DE LA POER: Were you asked to give any input to that meeting beforehand, did Dr Brearey ask for you
to formally say to him what you wanted raised at the meeting?
SALADI: As I said, he did discuss about the deaths where I was involved in and we were having
discussions
but I -- I don't think he specifically asked me about other babies or whether -- I don't recollect
me being asked to contribute to that thematic review.
DE LA POER: We know that the thematic review was circulated to all the Consultants on 2 March?
SALADI: Mm-hm.
DE LA POER: We can look at it if we need to but I am sure you will take it from me that one of the
first key theme or common theme that's identified is the sudden and unexpected deterioration of all
of the babies that the document reviews?
SALADI: Mm-hm.
DE LA POER: Did you notice that at the time that you received the report?
SALADI: I think so.
DE LA POER: What was your reaction to seeing all of those babies put one after another with that
apparently being a common theme?
SALADI: Well, again, unexpected deaths, when we think it is unexpected we discuss with Coroner and
they go to the postmortem. By the time the results come, it will take anywhere between three to six
months time and so that's when we will know for sure what was the reason. So I suspect, I am
thinking that the Coroner's postmortem will give an answer because at least in the
patient I was involved in, it did give an answer even that there is a cardiac cause. So I -- that
would have been my thinking, that, yes, the postmortem might give an answer.
DE LA POER: So to put that answer another way, do you agree with this: didn't seeing that make you
more concerned about what might be happening on the neonatal unit?
SALADI: Well, there is concern that we had increased deaths, there is also a concern that as I
mentioned about the taps. So we are thinking probably of still medical conditions. So we were
thinking or at least I was thinking that whether we are going through a bad patch.
DE LA POER: Were you aware of any plan to speak to the senior hospital management about the
increase in deaths on the neonatal unit?
SALADI: At what time?
DE LA POER: Well, in early 2016.
SALADI: I do not recollect that. I don't know, I don't think so.
DE LA POER: So certainly nobody told you that as far as you can remember: we are going to need to
--
SALADI: As far as I can remember.
DE LA POER: "We are going to need to raise this with senior management"?
SALADI: Yes, I cannot remember now.
DE LA POER: If we move forward to [Child L] in April 2016, again Dr Gibbs has characterised the
fact that the C-peptide insulin ratio did not lead to immediate action as being a collective failure
which was serious. Do you agree with that also in the case of [Child L]?
SALADI: If as -- as I explained before if the baby was in the unit for a few weeks all of us would
have seen and all of us would have had opportunity to look at the results, though they may not be
obvious when we are looking at the trends. Because we would be looking at the results of the last
couple of days and then if there is still concern, then we will be looking at the trends. I don't
think it would have shown up in the trends and I don't think we would be looking at the trends
unless there is still concern about the baby. So I am not -- I agree that it is a character failure
but I do not remember at what stage I became aware of that.
DE LA POER: On 11 May of 2016 Dr Brearey met with Mr Harvey, the Medical Director, and Ms Kelly,
the Director of Nursing and Safety. Did you know that that meeting was happening at the time that it
happened?
SALADI: As Clinical Leads he will be meeting so I wouldn't have suspected that being any -- anything
different.
DE LA POER: So do you have a memory of him telling the Consultants, you in particular: I am going
to meet with the Medical Director to discuss the neonatal unit and the rise in mortality?
SALADI: I cannot remember now.
DE LA POER: It may follow from your last answer but I will ask to be sure. Do you have any
recollection of Dr Brearey speaking to you after that meeting and telling you what was discussed at
the meeting?
SALADI: Is that in --
DE LA POER: In May of 2016?
SALADI: I do not remember.
DE LA POER: We do know that Dr Brearley sent an email after that meeting talking about it. INQ0005721. I will just remind you, it is up on screen now. Again this is an
email that's sent to you and other Consultant colleagues in which he talks about the meeting. In
bold, Dr Brearey makes a specific request about notifying him and Eirian Powell if there was any
baby who deteriorates suddenly or unexpectedly or needs resuscitation. Now, do you have any
recollection, Dr Saladi, of having received this email and thought about what that might mean?
SALADI: I don't think I thought about what that might mean. I thought this is -- I cannot recollect
what my thoughts were at that stage, but we know that there was more babies unwell, more deaths at
the time so I thought it is getting more information. Information gathering.
DE LA POER: Thank you, could we take this down, please. You were involved in the care of [Child N]
when [Child N] deteriorated on 15 June?
SALADI: Mm-hm.
DE LA POER: My first question about this is: were you aware that [Child N] had deteriorated on 3
June?
SALADI: I cannot remember now and I do not know whether I was involved with the deterioration of the
baby subsequently where I was involved, whether I had, whether I had the presence of mind to --
DE LA POER: Dr Saladi, it may be my fault but can I just ask you to speak up a bit?
SALADI: I cannot remember whether I remembered about the previous episode at that time.
DE LA POER: Well, [Child N]'s deterioration on the 15th was sudden and unexpected; is that
right?
SALADI: Mm-hm.
DE LA POER: Dr Brearey had just a few days later sent an email saying that he wanted to know about
that. Did you speak to him or Eirian Powell about the sudden and
unexpected collapse of [Child N]?
SALADI: I don't remember, specifically speaking, but Dr Brearey was actually helping me in that
resuscitation. So he knew about that deterioration because we had difficulty in securing the airway
in that baby.
DE LA POER: Now, the Mother and Father of [Child N] have given evidence to the Inquiry about
speaking to you?
SALADI: (Nods)
DE LA POER: They say that you were not able to give a reason for the collapse and it seemed to them
that you didn't have any answers.
SALADI: (Nods)
DE LA POER: Is that the way that you recollect the conversation you had with them?
SALADI: I remember the consultation I had with them after the baby was discharged and they first
came and it was a very stressful consultation for me, that's why I remember, because the parents
were rightly upset and rightly angry for the baby deteriorating and needing to go to the Alder Hey
Intensive Care Unit. And I remember because my mouth was completely dry and I couldn't say -- my
words weren't coming out properly and -- but I could understand where they are coming from and the
feeling. And now I do not remember the exact words but I think they said: you have provided
substandard care and they were asked quite a few questions, they did stuff I remember, but I thought
-- I wasn't sure whether they were pointing the -- that I provided the substandard care, or me as
part of the Trust provided the substandard care. And I don't remember now but I probably would have
directed them to the PALS that -- the complaints department, and I remember worrying about that
meeting because I discussed with my Consultants. They didn't say anything about GMC but I thought
they were unhappy with the care I have provided and they -- I was discussing with my colleagues that
the parents are going to refer to GMC, what do I do? The parents said usually -- my colleagues said
usually parents don't do that, they don't lightly refer to GMC they probably will make a PALS
complaint and now we do what we can because obviously we have to accept that the care was not
adequate because the baby did end up in the intensive care and I did not have all the answers. But I
don't think I received a PALS complaint as well because I had the notes with me for the next few
weeks. So I thought they were referring -- that was the recollection I had. So does that answer what
you are
asking me?
DE LA POER: Thank you, I have got no more questions about your conversation with the Mother and Father of [Child N].
LADY JUSTICE THIRLWALL: Would you mind if I ask one?
MR DE LA POER: My Lady, of course.
LADY JUSTICE THIRLWALL: You told us what you were worried about and what you thought they might do,
but are you able to remember, because this is an episode which you do seem to have a good memory of,
can you remember what you told them about what had happened to their baby?
SALADI: In that meeting my mouth was completely dry, I was not able to speak well but I explained as
much as I could and I knew that I was not able to answer their questions well because I did not have
the answers myself but --
LADY JUSTICE THIRLWALL: So you agree --- sorry to cut across you -- because I think they said it
seemed it them that you didn't have any answers. Was that reasonable impression for them to get?
SALADI: I think so.
LADY JUSTICE THIRLWALL: Yes.
SALADI: I think so.
LADY JUSTICE THIRLWALL: You are sure about that,
I don't want to lead you into it if it is not what you mean.
SALADI: Yes, I think so.
LADY JUSTICE THIRLWALL: All right, thank you.
MR DE LA POER: Dr Saladi, I am going to move forward to the meeting that you have mentioned a
number of times now which is on 27 June of 2016. This is the Monday meeting which you speak about in
your witness statement. It's paragraph 33 if you want to turn that up on page 6. You have told us
already that that meeting caused you sleepless -- two sleepless nights before you then sent an email
on the 29th. Can you, as best as you can, just tell us what was being said at that meeting and by
whom?
SALADI: I think it was Dr Brearey who was explaining in that meeting and obviously I already knew
certain things that we had increased mortality in that -- in that period. But that was the first
time that I realised that there was one member of staff who was associated with that meeting -- with
all -- all these deaths. And the question was: what do we do next? And if I remember correctly, it's
about: can you refer a nurse or any member of staff, just because they happen to be associated, not
causally, but with the
events, okay? And that was, I was thinking of my own time when I came to UK, because I trained in
India and the UK practice was different. So I was when I first came to the UK I was going and
attending all the sick children because I wanted to know how is the things different. So to blame
somebody just because they were there I am not saying they were blaming but we were discussing at
that stage; what do we do next? That was difficult for me to swallow at that stage, even though I
didn't know what to do as well. But I knew, remembering from -- again from the description, that
they were looking at the rota. But I thought looking at the rota just to say somebody is there or
not is not a definitive way of answering the question because at that stage we had two ways of
entering the neonatal unit. One is the main entrance, which is with swipe access and the people who
have the swipe access are the neonatal doctors and nurses. And then from the back of the neonatal
unit, we had stairs to the postnatal ward, which are controlled by the digital lock. And obviously
as far as I understand the only people who know that digital lock is again the paediatric -- the
doctors and paediatric -- our neonatal nurses, not the paediatric nurses. So to say if somebody is
there definitely in the unit at that time we need to know who could have accessed the postnatal ward
as well and I know postnatal ward also is accessed by the swipe card. So that means somebody needs
to look at at least minimum the rotas of the paediatric doctors and paediatric nurses and the
doctors in the postnatal ward and the midwives in the postnatal ward and I didn't think Steve would
have easily accessed that information because we were working in two different departments. And to
definitely say that somebody is there, we need that swipe access, that only the Trust could have had
or the police could have had and that's why in the email.
DE LA POER: We will come to the email in a moment. I think you have -- so these were the thoughts
that were going through your mind on the 27th --
SALADI: Yes, yes.
DE LA POER: -- that a more detailed investigation needed to be done?
SALADI: Yes.
DE LA POER: Now, there is an email -- and I can take you to it but I hope you will be able to
remember it -- from Dr Brearey in which he sends what he describes as the consensus of the
Consultants the day after that meeting,
that Letby should be excluded from the unit. Was that the conclusion of you all at that meeting on
the 27th?
SALADI: See, after -- see in those couple of days before I sent the email we, I remember we had
quite a few meetings so I am not sure at what point that email came. But I can't see the email here.
DE LA POER: Let's bring it up. INQ0003116, page 2. It is 28 June there. You are not sent a copy of this but I
am asking you about it because --
SALADI: Yes, okay.
DE LA POER: -- he speaks about the consensus. So if you look at the third paragraph: "There has
been a watchful waiting approach since our last meeting with Ian and Alison in March. However, since
the episodes and deaths last week there was a consensus at the senior paediatricians' meeting that
we felt on the basis of ensuring safety on the NNU this member of staff should not have any further
patient contact on the NNU."
SALADI: Death of the last week.
DE LA POER: So this is the day after that meeting on the 27th and he begins the email with: "I
thought it might be helpful to put down in an email what was discussed at the senior paediatricians'
meeting yesterday lunchtime."
SALADI: This is after the senior paediatrician --
DE LA POER: Exactly, the day after. And he is saying the conclusion was of all of the Consultants
Letby ought not to have access to patients?
SALADI: I think so.
DE LA POER: Was that your view as well?
SALADI: Yes.
DE LA POER: We are now going to have a look at your email, the 29 June 2016, sent in the morning INQ0003112. We are going to go to page 3, please. You can see that email
begins there -- I know that this is an email that you have looked at closely recently, Dr Saladi, to
try to put your thoughts together. But if I just summarise what the email says, it is that you
reached the conclusion and you have set out your reasons in the email that the police were the right
people to investigate?
SALADI: Mm-hm.
DE LA POER: Is that right?
SALADI: That is correct. Police, I didn't know if there is some -- some other agency which could
help. So that question mark was there because if I can explain my thought process at this stage.
When we are providing a neonatal care, particularly in a district general hospital, we see four
groups of setbacks, okay, one is
unexpected setback, so this is a baby who is receiving a care in the neonatal unit, may be on the
ventilator, their oxygen levels comes -- goes down and the alarms go off or it could be a baby who
is feeling well until then, suddenly they stop absorbing the feeds or they might start vomiting or
the baby who is suddenly well not opens the bowels. Various what we call setbacks. These are the
common problems which we see and all the paediatricians and the neonatal nurses who work in the
neonatal unit are experienced with this, that these are the setbacks and we explain to the parents
as well, that the stay in the neonatal unit is two steps forward and a step backward because of
these unexpected setbacks, that is a common experience. So in these setbacks babies might actually
need some extra oxygen and sometimes we might need to even give some extra breaths while we clear
their airways and make them settle. So they might even need very brief respiratory support as well.
Then the next group of conditions what I would consider is unexpected setbacks leading on to cardio
respiratory collapses. Those are much less common because babies' hearts usually do not stop, as
long as they are getting oxygen they keep going, so they don't decrease. So somebody who is needing
full cardio respiratory resuscitation, it can occur in the -- at the time of birth, but after that
it is quite -- well, it is less common at least in my experience and usually they do respond and if
that is probably the situations where we discuss with regional units, particularly if we cannot
explain why they have deteriorated. And if the investigation showed a reason for the explanation,
and if that can be managed in the district hospital, they might stay with us. Or if it is something
which cannot be managed or if it is something which needs regional centres, we send them to the
regional units which might need like surgical intervention, a cardiac intervention, things like
that. Then the next step up is unexpected setbacks leading on to death. These are extremely rare in
the district general hospital. We do have deaths in the neonatal units but they are usually expected
deaths. They are expected because there is an antenatally detected abnormality which we know is not
survivable and there are some conditions like that. Or they are very extremely preterm and they know
that again they are not survivable. And usually in these situation we inform the parents, we prepare
them and so those are the deaths which normally happen in a district hospital.
Unexpected deaths are very rare in district hospital because we usually manage to stabilise them and
they are usually sent to the regional units and if they are very, very unwell they might deteriorate
and they might die in the regional unit after a few days or a decision might be done taken in the
regional centre with the discussion with the parents to withdraw the care. So that's in the district
hospital. Unexpected deaths in a district hospital are extremely rare and that's why we usually
discuss all of them with Coroner because the usual condition is -- for unexpected deaths is some
unrecognised kind of anomalies, cardiac anomaly and that's where we might ask for a Coroner's
postmortem or they might say, well, suggest to parents and if they are interested, go for hospital
postmortem so that we find out the cause. Then the next category is unexpected deaths which were
unexplained even after investigations. They are extremely rare and I think this is my opinion,
unexpected deaths which remain unexplained in a district -- in a district general hospital a
paediatrician might see only a couple in their career and I already seen one that year and during
that meeting when I am hearing that there are lots more unexpected deaths, which are
unexplained by the other colleagues as well, that is a concern. I probably did not recognise when we
were having these in the perinatal morbidity and mortality meetings because we do not know the
information of -- we discuss them usually before the pathology reports are available. So I probably
did not recognise that these remained unexplained until all that information is produced or Dr
Brearey is discussing at that stage. So that is a concern, we are having a cluster of unexpected but
unexplained deaths at that time and the worry is: could this be due to infection because we had the
taps, all the taps covered with filters. So that means something else is going on and if somebody is
saying that one person is also associated with all these deaths, that is even more worrying and the
-- sort of that's a suspicion and if we have suspicion and I thought one of the teams who can deal
with suspicion is the police because we are not good with dealing with suspicion. And that was the
reason I wrote that email and I said in the last but one paragraph, "it is unreliable information",
maybe I should have said "it is incomplete information" because of the reason I mentioned before,
that when we are suspecting we need much more
information than just looking at the rotas.
DE LA POER: Dr Saladi, you go on to say in your email -- we don't need to look at it, I am sure you
remember very well -- that you recognise the police were able to do wider enquiries such as looking
into people's lives searching this their homes, that sort of thing?
SALADI: Yes.
DE LA POER: So thank you very much --
SALADI: And I think after that we met the senior managers either that evening or the next day.
DE LA POER: We are going to have a look at that.
SALADI: Okay.
DE LA POER: We are going to have a look at that.
SALADI: Yes.
DE LA POER: I just need to ask you one question just to see if you can help us with it. Over the
page, on the screen we are just going to look at the top of it, just to see if you can help us with
one very small part of this. You say: "We have moved this particular staff member from night shifts
to day shifts and from ITU care to HDU/SCBU care." Can you just help us. The Inquiry has received a
great deal of evidence about movement from night shifts to day shifts. Who told you that Letby had
been moved from ITU to HDU/SCBU care?
SALADI: I thought most of the information was coming from Dr Brearey. But I don't know whether this
was some other team member spoke, but that was my recollection. At least that information was given,
but I cannot say who gave that information.
DE LA POER: Thank you. If we move up, please, this email thread. We will see on page 2 that Mr
Harvey, there we are, we can stop there, has sent an email to all the Consultants saying: "It has
already been discussed and action is being taken. All emails cease forthwith." What was your
reaction to receiving that email?
SALADI: I was hoping that this will generate a discussion because I know the senior the ward manager
had a different opinion about probably the deaths and particularly about Lucy Letby and maybe I
thought if you could explain these, what I was explaining to you, these unexpected and unexplained
deaths why we were giving importance, which all the Consultants had at that time, maybe they would.
But that opportunity did not arise because ... Yes, I don't know whether I -- did I answer your
question?
DE LA POER: You have, thank you. So we can take that document down. We are going to move forward to
the meeting that you have mentioned on 29 June. It was at ten past 5 and we have some notes of that
meeting. INQ0003371. This is a meeting we can see that you are identified at the top as
having attended. Also present "TC", Tony Chambers, "AK", Alison Kelly, "IH", Ian Harvey and the
initials on the far right "SPC" we understand to stand for Stephen Cross. I just want to ask you
about one thing you are recorded as saying at page 2, please. About a quarter of the way down you
use a phrase that that I think you have used with us: "Preterm babies two steps forward one step
back don't suddenly deteriorate, these babies are relatively stable sudden deteriorate and
collapse." And can you recall saying that to the Senior Executives in that meeting?
SALADI: I might have said if they have documented.
DE LA POER: I beg your pardon?
SALADI: I might have said if they have documented.
DE LA POER: Yes.
SALADI: I don't remember that.
DE LA POER: But that was something that you were thinking
at the time as you have told us?
SALADI: Yes, yes.
DE LA POER: Do you remember at this meeting whether Stephen Cross said anything about the police,
if not necessarily at this meeting but at the meetings that were taking place at this time that he
was attending?
SALADI: In that period, when we were discussing about what is an extra way -- how do we proceed, the
thing I remember senior managers were saying is: this is coming across as doctors versus nurses, so
that is why we will involve a external body, completely independent, which will have representation
from the RCPCH and they will have a nurse representation as well, probably from Royal College of
Nursing, and if they say that this is -- if they agree with what you are saying, then we will go
with the police. At least that's what I remember. That was the outcome of our discussions.
DE LA POER: My question was particularly about anything that Stephen Cross may have said about the
police and whether you had a recollection of him saying anything at all at that time about whether
the police should or shouldn't be called or --
SALADI: I think there was talk of red tape and also like the media vans will be all on our grounds
and so
there was some concern that we will be in the media spotlight at -- yes.
DE LA POER: Now, I will just read it out to you. What you say of this meeting in your witness
statement is: "However, the feeling I seem to remember from the time was that the senior management
seem to have made up their mind with the investigation they have conducted without taking our
concerns into consideration." That's what you have put in your witness statement. Can you just tell
us about why you said that in your witness statement? We can take this document down, thank you very
much.
SALADI: So when we were having this discussion, the question was we were having unexpected,
unexplained deaths and we are seeing one member of staff identified with it. How do you proceed with
it? Obviously I worked with Lucy and she appeared as a competent nurse, so I did not have any direct
worry or suspicion on her. So I thought they will gather information, they will get all of us
together, when I say all of us at least all the Consultants and the ward managers of the neonatal
unit and maybe the deputy manager, and get all of us together and share the information as to why
they are supporting her so strongly. Would they still do the same if we can put our thing forward as
well? Unfortunately that has not happened. By the time that we went there they were already talking
about, well, there were not enough Datix reports, we have looked at the -- so it -- I was thinking
that they were looking for information sharing, at least exploring our concerns. That did not happen
and that's why I thought they had already made up their mind.
DE LA POER: I think there will just be time to look at the last meeting in June, 30 June of 2016.
This is INQ0003362. It should come up on your screen. We can see you are identified as
being present as are some of the others that I have already mentioned. We can also see "DN" as the,
or what appears to be "DN" anyway as the second initial along. Do you have any recollection of
attending a meeting that Sir Duncan Nichol, the Chair of the board, attended?
SALADI: I do not recollect. I don't know. I might have met, but I don't remember now.
DE LA POER: And if we go over the page just to look at something that Dr Jayaram is recorded as
saying. At the very top he is recorded as saying: "Starting point what is safe reduce service but
staff member not addressed. Discuss going to police..."
And a word that I won't attempt to decipher: "... impact of an investigation." I will just -- can
you recollect a discussion where there was, on the one hand, being suggested that the unit was
downgraded but, on the other hand, Dr Jayaram and/or any of the other doctors present pointing out
that downgrading the unit didn't address the specific concern?
SALADI: Yes.
DE LA POER: What was the reaction as you perceived it from the senior managers as to when that
point was made?
SALADI: Well, I think that's what I was saying; that they were looking at it as doctors versus
nurses and they would get an independent input from a team, RCPCH, who are independent from us, with
representation from the nurses and if they say -- if they agree with us then they -- then they would
be going to the police. At least that is the way I understood it.
DE LA POER: Just two more parts. Page 4, please, of these notes. We can see about halfway down,
next to the word "Ravi", in terms of what was being said at that meeting: "Concern potentially
member of staff causing harm. Recurring theme." What I just wanted to ask you about, Dr Saladi, is
do you have a recollection of that being said in those
terms? So it's not just that we are worried about a member of staff, but it's that we are worried
about a member of staff causing harm, so deliberately causing harm?
SALADI: Which date was it?
DE LA POER: This is the 30th.
SALADI: The 30th. I think after I sent my email because we were discussing -- because at that stage,
we weren't -- we weren't sure what she could be doing and that is when in one of those meetings
people were talking about these rashes, "Do you remember this rash?" And then I think Ravi had done
some research and then he said, "Yes, these sort of rashes were seen in the air embolism." If it was
after that email, yes, it could have --
DE LA POER: We had moved over that email. But that email was sent that morning. So it was sent on
the morning of the 30th.
SALADI: And this is after that?
DE LA POER: Exactly.
SALADI: Yes, it would have. It goes with that then.
DE LA POER: The final thing to ask you about about this meeting if we just go over the page and this is just the note. We can see a heading "Actions": "Review nurse deep dive, exploring new model, actioning new model, planning team, comms plan, press release TV, downgrade and exclude might as well ring the police now."
LADY JUSTICE THIRLWALL: "If".
MR DE LA POER: "If", forgive me. Thank you very much indeed: "Is everyone comfortable?" And then some people are recorded apparently in response to that question. I haven't seen your name there but we can see that Dr Brearey, "Steve B": "I made my views clear, nagging after last night. We will take on observations; felt obs..." Again I am not sure of that word. It might be meeting.
LADY JUSTICE THIRLWALL: (inaudible)
MR DE LA POER: Yes, thank you, my Lady. So at the end of this meeting, were you happy about the
decision that there be a review and a nurse deep dive as opposed to the police being called?
SALADI: See, I might be clumping all the meetings together because I can't remember which day which
meeting has happened. But my recollection is the reason -- we did discuss about the police but the
reason they did not say is well, it is appearing like doctors versus nurses and we need independent
input and -- because if you are calling police, then all the media spotlight will be on us, nobody
will be coming to our labour ward or neonatal unit. So let's get an independent input and if that
shows, then we will go to the police.
DE LA POER: In terms of the concerns that you had about any risk that Letby might pose, what did
you think needed to be done while all this process was going on?
SALADI: I thought by then -- see, when we were having these meetings in those first few days, if I
remember correctly, Lucy was away on leave so she was not supposed to be coming for at least a
couple of weeks and there were quite a few meetings in those two weeks and at some stage I think the
management decided that she is not going to come into clinical work. Whether they decided or whether
we had to insist, I cannot remember. But that decision was made at that stage in those two weeks.
MR DE LA POER: My Lady, would that be a convenient moment?
LADY JUSTICE THIRLWALL: Yes. Actually just before we do, I'm sorry Ms Killingback, can you put that
document back, please. It finished 00018 and can we go to the previous page. Yes, that is the page.
Thank you.
SALADI: Sorry, Madam, I have never seen these.
LADY JUSTICE THIRLWALL: You have not seen these notes before?
SALADI: Before you sent this to me. So I have seen this report for the first time when the Inquiry
sent this.
LADY JUSTICE THIRLWALL: Yes, so that's a few months ago, isn't it?
SALADI: Yes, but I have not seen at the time of our discussions.
LADY JUSTICE THIRLWALL: No, no, I understand that. It was just there is a comment that you made or
is attributed to you about a third of the way down the page. Do you see, I think that's your name
there, isn't it, "Saladi", and you are recorded as saying: "Why review now and not before?" It may
be it speaks for itself but I wondered if you could recall why you said that at that meeting.
SALADI: "Why review now and not before?"
LADY JUSTICE THIRLWALL: You have told us about the doctors v nurses and then we'll bring the RCPCH
in and that they will decide and then we will go to the police. I just wondered if you recalled why
you said, "Why haven't you done this before?" if you did say that, and if you can't remember just
--
SALADI: I can't remember.
LADY JUSTICE THIRLWALL: All right.
SALADI: Sorry.
MR DE LA POER: My Lady, I just wonder if I might --
SALADI: I might be talking about the nursing deep dive, I don't know. I am speculating now.
LADY JUSTICE THIRLWALL: No, that's all right. You don't need to do that. Yes, sorry, Mr De La Poer.
MR DE LA POER: I don't know whether there is just one other matter that I could draw attention to on this page. Dr Saladi, about two-thirds of the way down by your name, it reads: "You are looking at us, that's what it is using 2 different..."
LADY JUSTICE THIRLWALL: Words?
MR DE LA POER: Words?
SALADI: Cards.
MR DE LA POER: Cards.
LADY JUSTICE THIRLWALL: Cards, yes.
MR DE LA POER: "... security review." Again, does that help your recollection at all about what you
were saying question when you said: "You are looking at us, that's what it is?"
SALADI: I think they were talking about they were looking at -- they were looking at who accessed
the unit with swipe cards, so I might have made some --
LADY JUSTICE THIRLWALL: I see, yes.
SALADI: So I think it might be about the swipe cards, I think.
MR DE LA POER: Thank you very much indeed. My Lady, is that a convenient moment?
LADY JUSTICE THIRLWALL: It is. Does that conclude the witness or is there more to come this afternoon?
MR DE LA POER: There is some more to come this afternoon --
LADY JUSTICE THIRLWALL: That's fine.
MR DE LA POER: -- including Mr Baker. I will have a few more questions.
LADY JUSTICE THIRLWALL: Of course.
MR DE LA POER: Then Mr Baker will be asking some questions.
LADY JUSTICE THIRLWALL: Thank you. I wasn't trying to hurry you, I was trying to work out where we were. Thank you very much, Dr Saladi. As you will have observed we are going to take a break now and we will start again at five past 2 and then there will be some more questions for you but someone will look after you over lunchtime. 5 past 2. (1.05 pm) (The luncheon adjournment) (2.05 pm)
LADY JUSTICE THIRLWALL: Yes, Mr De La Poer.
MR DE LA POER: My Lady, thank you. Dr Saladi, we are moving forward in our chronology to 13 July
2016 when there was a meeting and I am just going to ask for the notes to come up and we are just
going to look at one line within those notes, you have seen them before because they were provided
to you by the Inquiry. It is INQ0003365 and if we could move forward to page 4, please. Now, Dr Saladi, at
the bottom of this page, you will see the date Wednesday, 13 July 1 pm. You will see your name
appearing just to the right of that dateline. This is a meeting at which, as the Inquiry understands
it, senior managers presented activity and acuity data to a group of Consultants, so that's the
contents of this meeting. We can see it began with an outline from Ian Harvey just below that and
then we can see three or four lines down at 1.12, so 12 minutes into the meeting, we see your name,
"left room" and then further along the line: "distressed".
My question, Dr Saladi, is whether you can shed any light on whether you recall leaving a meeting
with Senior Executives shortly after it began in a distressed state?
SALADI: I do not remember.
DE LA POER: Thank you. We can bring that down now, thank you very much. Continuing to move forward
through the chronology, we know that you and your fellow Consultants met with the RCPCH on 1
September 2016. You deal with this in your witness statement at page 37 -- sorry, forgive me,
paragraph 37, my mistake, the page number is page 8. I want to ask you a couple of questions about
that meeting. Firstly what you say in the witness statement was that you were disappointed to learn
that they, the RCPCH, were not looking at the deaths. Can you just tell us what you meant by that
and what you understood the RCPCH was looking at?
SALADI: Yes. So when we met the Senior Executives at the end of June, I think, when we presented our
concerns and the fact that Lucy was there, at least from the point of view of rotas, their
statement, their argument is well -- I am not sure argument is right word but what they said is:
it's coming across as doctors versus nurses, so we will get an independent review which
involves doctors as well as nurses. So as far as I am concerned RCPCH was coming to look at the
deaths of the babies and we met them as a group and the first thing they said is: we are not looking
at the deaths --
DE LA POER: Sorry, no, you speak, please?
SALADI: Yes. And then they asked us about our protocols, whether we are having time for SPA that
what is supposed to happen this in a well-functioning department and we sort of answered all of
them, obviously we had some issues with our rotas and things like that, we expressed all of them.
And -- but it was very difficult to get a report of that and when we called -- I don't know, I think
I also called RCPCH, they said it is the property of the Trust and they -- it is their, in their --
I don't know the right word remit or in their gift whether they went to provide the report to us or
not. And it took quite a few months for us to get the report and when we got the report it was on a
printed sheet which the Trust said we cannot disseminate and within 24 hours or 48 hours they
actually published that report on the Trust website, which is of poor quality, when I said poor
quality, it is not the actual pdf document of the RCPCH, I don't think they would have
sent such poor quality document. It's a image of the pages which were reconverted into a pdf
document which could not be searched and I didn't know whether RCPCH realised that the Trust was
misusing their report in such a way. I don't think you have it because I don't see that in your
bundle, but I do have a copy of that in my Trust things which I don't have access any more. But what
it showed is very bad print, difficult to read, the things which are easy to read are in the bold
and they never mention in the bold that they were not investigating the deaths and they came out
with more than 20 recommendations which were all in bold. So people just go to what is in bold.
DE LA POER: Can I just take you back, please, to that meeting on 1 September because I just had one
question before we move forward in our timeline?
SALADI: Yes, yes.
DE LA POER: Thank you very much indeed, Dr Saladi. It is this: at the meeting that you had with the
RCPCH you and your colleagues said to the assessors who had come that you were worried about a nurse
on the unit potentially causing deliberate harm; is that right?
SALADI: Yes, yes.
DE LA POER: Yes. We will carry on with looking at the chronology, we will get to the point of
--
SALADI: Yes, sorry.
DE LA POER: No, no need to apologise. There was a meeting on 26 January 2017. You deal with this in
your witness statement at paragraph 55, which was an Executive and Paediatric Consultant meeting
that you describe it as, at page 10. You say that although you don't remember the exact contents of
the meeting why it was held or who led the meeting, that's your (a) you say: "I do remember the red
face of Tony Chambers, his forceful voice and him banking on the table." And you say: "It appeared
as if the senior management had completed the investigation without seeking any input from or
sharing the report of their commissioning review with the senior clinicians." Just please, if you
can, in short summary form, just give us your impression of that meeting and in particular what you
perceived to be the attitude of the senior managers towards the paediatric Consultants?
SALADI: I remember that meeting we were all sitting round the table, Mr Tony Chambers were standing
and they sort of said they have finished the investigations and banged the table like this
(indicated) and they said we
are drawing a line under it and they said what we need to do, like writing an apology letter and
things like that and obviously he was angry, red, that's the recollection of the meeting.
LADY JUSTICE THIRLWALL: Did you say you were angry or he is?
SALADI: He.
LADY JUSTICE THIRLWALL: He was angry?
SALADI: Mm-hm.
MR DE LA POER: Now, I am going to summarise the next section of events for you and perhaps you can
just listen to my summary. Is it right, and the Inquiry have seen all of these letters, that after
that meeting, there was a back and forth in terms of letters from the seven of you Consultants to Mr
Chambers and then him replying, building to a position where the paediatric Consultants said that
they wanted the Coroner to be told about their concerns?
SALADI: That is correct.
DE LA POER: Is that right?
SALADI: (Nods)
DE LA POER: It was early in that period, I think it was around the 7th or so of February, that the
paediatric Consultants were given access, all of you, to the RCPCH report?
SALADI: (Nods)
DE LA POER: You have told us -- and the word you use in your witness statement is that you had to
fight for it?
SALADI: Yes.
DE LA POER: Now, I am not going to put them up on screen but you have had an opportunity to refresh
your memory from a WhatsApp chat that you and your colleagues had at the time just before the report
was released to you and just summarise for us how you were feeling at that time, so 7 February,
about how the senior managers were treating you as a Consultant body?
SALADI: Is that after we saw the RCPCH report?
DE LA POER: Just before. It was just before and there was a message just after?
SALADI: Our communication, the relations between the senior staff and the senior managers and the
Consultants had broken down, okay, and they were not sharing the information and we had to fight for
it and in the meantime, two of my Consultant colleagues were involved in -- I don't know whether a
grievance process was already going or it started subsequently. So, and my feeling remained the
same, that they are making decisions without taking our views into consideration, particularly our
concerns that quite a few deaths remained unexplained, they are not just
unexpected but remained unexplained. I don't think they were looking at that aspect of the thing
well. That's what I thought.
DE LA POER: We know that during this period of time there was conversation about Letby returning to
the ward. What was your position at that time about whether Letby should be permitted to come back
to the ward?
SALADI: I don't think I was aware that she is going to come back to the ward but we all has -- have
decided that before Lucy can come back to the unit they need to look at the deaths and they need to
have a good explanation as to why these unexpected -- what is the reason for these unexplained
deaths. So we were not happy for her to have patient contact without explanation for these
unexplained, unexpected deaths.
DE LA POER: Was there any plan agreed between you Consultants as to what you might do if the senior
managers insisted upon Letby coming back to the ward?
SALADI: We were discussing at that stage what -- what do we do and everybody, the way whistleblower,
the way the report is sent, the way contact some media and give our concerns that this is all being
hushed up by the Trust. But I don't think we had any firm plan as to what we would be doing because
we were continuing to insist that Trust investigate the deaths properly and, yes, it is speculation
for me to say what we would have done if she has come back. But I don't think we would have just sat
down and let her come back to the unit without our concerns properly answered.
DE LA POER: In April, 12 April of 2017, you met with Simon Medland QC, as he was then?
SALADI: Mmm mm.
DE LA POER: And you deal with this at paragraph 62. There are just two aspects of that meeting that
I would like you to deal with, please. Firstly, what did you understand the purpose of that meeting
to be?
SALADI: I think my understanding is how do we present the case to the police. So he was trying --
before the meeting our understanding is he was going to help us in sort of not formulate, make it
explain probably to the police what are our concerns so that it's clear in our all minds. So I
thought it was to clarify the thoughts in such a way. Whereas when we actually met him, it
transpired that that was not the case. He was trying to -- again he was trying to prove how it
appeared as if they are looking for proof from us. And well, we thought he was
saying that there was not enough proof and the police wouldn't take it, police wouldn't spend their
time and energy on this but at least he heard all our concerns.
DE LA POER: Well, I was just going to ask you in order to complete the picture, what you say at
paragraph 62(c) is: "He was the first person in any capacity from the trust management to ask for my
side of the story and I feel some of my colleagues felt the same"?
SALADI: I agree with that.
DE LA POER: So was Mr Medland open to listening to what you all had to say?
SALADI: Exactly.
DE LA POER: Dr Saladi, there is one matter further that I just need to ask you about. It involves
us just going back slightly in our timeline because one of the areas the Inquiry is investigating is
what information was provided to the Coroner and I would just like to deal with that event now. Now,
we know from records that you gave evidence to the Inquest into the death of [Child A] on 10 October
2016?
SALADI: Mm-hm.
DE LA POER: We also know that there were some witness preparation sessions, did you participate in
any witness
preparation sessions for giving evidence?
SALADI: From the Trust's solicitors?
DE LA POER: Yes.
SALADI: Yes.
DE LA POER: Did you have any discussion with Dr Jayaram about what you might say to the Coroner
about [Child A]'s death?
SALADI: I do not remember.
DE LA POER: Now, can I make this clear. There is no evidence that the Inquiry has yet seen that you
were ever asked a direct question about generalised concerns?
SALADI: Yes.
DE LA POER: But can we just look at what you knew when you went into that witness box to give
evidence to the Coroner?
SALADI: Yes.
DE LA POER: So we will just run through very briefly what you have told us: you had attended a
meeting on 27 June earlier that year during which colleagues raised the possibility that Letby was
killing babies?
SALADI: Yes.
DE LA POER: You had written an email two days later in which you said that you thought the police
should be called?
SALADI: Yes.
DE LA POER: As you have told us you had been part of email correspondence which suggested that air
embolism may have been used as a way of killing babies?
SALADI: Yes.
DE LA POER: You attended a number of meetings with Executives at which the concerns your colleagues
had were being repeated about the fact that they thought deliberate harm may have been caused. You
were aware that Letby had been excluded as at that time due to the fact that she might be
responsible?
SALADI: (Nods)
DE LA POER: You had attended the RCPCH meeting on 1 September, so just a month or so before, at
which you and your colleagues were telling the RCPCH that you were worried that the deaths might not
be natural?
SALADI: (Nods)
DE LA POER: All of that you have told us already and of course you told us with [Child A] that as
far as your interaction with [Child A] was concerned, was that they were the healthier of the two
babies when you had dealings with them and that you had no reason to think that [Child A] was going
to die when you interacted with [Child A] and provided care. So my question, Dr Saladi is this: did
you tell the Coroner any of that?
SALADI: No.
DE LA POER: The question which follows is: why not?
SALADI: Again I think that was probably my first, maybe first or second appearance of Inquest and I
was stressed and advice we got from the solicitors was answer the questions, what is asked, don't
answer what you think was asked and keep it brief and do not speculate. So if 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. So that's why I didn't -- I didn't -- I agree I didn't.
DE LA POER: Did you think that the information that we have just run through was irrelevant to the
Coroner or did you think that it might be relevant?
SALADI: See, we were discussing with that particular child and as far as I am aware, Coroner is
aware of the deaths. I didn't need to tell them, okay.
LADY JUSTICE THIRLWALL: Why do you think that?
SALADI: Sorry?
LADY JUSTICE THIRLWALL: Why did you think the Coroner was aware of all the deaths?
SALADI: Well, because when we were having these unexpected deaths, we were referring them to the
Coroner.
LADY JUSTICE THIRLWALL: I understand.
SALADI: So there would -- he would I would expect know that there were increased deaths as well.
What was your next question?
MR DE LA POER: Well, my question was whether you thought it might be relevant information for the
Coroner to know when he makes a determination about the legal questions that he's got to answer
about the death of [Child A].
SALADI: I was thinking whether rightly or wrongly that I was answering in relation to Baby A [Child
A] my involvement, if I had any suspicion, and my answers were brief and to that point, what he
asked. It is probably in retrospect mistake for me to not share my concerns but that is because of
inexperience, I think. I did not have any experience with the Coroner's process and that is why I am
much more open now rather than just answering what you are asking, whereas at that stage, I was just
answering what is being put to me.
DE LA POER: So does it come to this: your position today is that you should have told the Coroner
that information?
SALADI: Not just that. The Coroner should have asked me.
MR DE LA POER: Dr Saladi, that concludes the questions that I have for you. My Lady, my learned friend Mr Baker Kings Counsel has Rule 10 permission to ask questions on behalf of the Families that he represents.
LADY JUSTICE THIRLWALL: Very good, Mr Baker.
MR BAKER: Dr Saladi, when you gave evidence at the Inquest, did you feel under pressure not to
reveal your concerns regarding [Child A]?
SALADI: No. I was not -- are you saying I was under pressure not to reveal? No, I was not under
pressure much.
BAKER: So you would have been entirely free to volunteer your concerns?
SALADI: I was under pressure of my own volition, not because somebody has pressurised me, because it
was new to me to give evidence like that. So I was under pressure and I was answering only what I
was asked. Does that make sense?
BAKER: You knew what the purpose of the Inquest was though, Dr Saladi, was to find out the cause of
[Child A]'s death?
SALADI: Yes.
BAKER: Did you not think that that might have been
helpful information to the Coroner that you had suspicions that someone may have murdered [Child
A]?
SALADI: Yes, I did think that way yes, it might have been -- it's probably my mistake, I didn't
consider from that point of view.
BAKER: Are you sure you weren't concerned about the consequences for you if you did reveal
that?
SALADI: No, in what way?
BAKER: Well, did you feel concerned that those who employed you might put your job at threat?
SALADI: No, no.
BAKER: I am going to ask you some questions in general about the early part of the chronology of
events, so when people first became concerned about deaths and collapses on the ward. You said in
evidence, and indeed it was said by Dr Newby, that there was a concern amongst some that there may
be a source of infection on the ward causing collapses and deaths?
SALADI: There was concern, yes.
BAKER: Yes. That concern was dealt with by investigations as to potential sources of infection,
wasn't it?
SALADI: Yes.
BAKER: Those investigations revealed no source of infection?
SALADI: There was no infection in the babies, that is correct.
BAKER: Yes, not just in the babies, in the ward either.
SALADI: Well, we were having bugs from the taps.
BAKER: But filters were put over the taps?
SALADI: I think even with the filters they were still isolating the bugs.
BAKER: But the issue when it came to the babies is that the babies were investigated for
infection?
SALADI: That is correct.
BAKER: Reliable evidence was obtained that those babies had not been infected by any contamination
from the ward?
SALADI: Yes.
BAKER: Yes. In relation to the rashes that had been seen in [Child A], B and D, you saw a rash in
[Child B] and you gave evidence that you were aware that people were contacting various specialist
teams for advice regarding the rash?
SALADI: No, for advice regarding the deterioration, not about the rash.
BAKER: I see. The discussions about the rash in the unit were: this is something that nobody could
quite explain what it was?
SALADI: I do not think at that stage I was aware of all the discussions which were going on about
the rashes.
BAKER: But you were aware that if a rash was something that you couldn't explain, but you weren't
concerned about it because it had disappeared in [Child B]?
SALADI: Yes. Well, as I said, rashes are common and we would worry if there are progressive rashes.
So we were worried as to why the baby deteriorated needing resuscitation, but I probably did not
pick up the significance of the rash which was noticed in the night which has become less prominent
by the time I saw in the morning.
BAKER: But the point is this: This was a rash, one that you saw, that you were not able to explain.
It didn't fit with anything that you had seen before?
SALADI: Well, at that stage I was thinking it is probably some sort of infection which is causing
the rash.
BAKER: But infections cause rashes that persist; they are not transient?
SALADI: Not necessarily, yes, they can be transient.
BAKER: And you were unaware of discussions on the ward regarding other people's concerns about
rashes?
SALADI: At that stage, yes.
BAKER: When it came to looking into the collapses and deaths of the children on the unit, the
concerns that you had amongst your colleagues is that these collapses were all unexpected and
unexplained?
SALADI: Unexpected, unexplained usually it is not something we have that information prospectively.
That takes as I said a detailed postmortem examination which was not available at that stage.
BAKER: But the concerns that you and your Consultant colleagues were having were as you said in
your email of June 2016, that these collapses and deaths were unexpected and unexplained?
SALADI: That is correct, yes.
BAKER: Yes. And so looking --
SALADI: That is in retrospect.
BAKER: Yes, retrospect.
SALADI: Yes.
BAKER: But the point is that looking at these collapses and deaths even retrospectively, you were
not able to find a source that explained why the children collapsed, let alone a common source?
SALADI: Yes, that is correct.
BAKER: So in the case of [Child D], who I think you were involved in, there was a suspicion that
their death
may have been caused by infection but in fact there was no clear evidence that [Child D] did have an
infection causing symptoms prior to their collapse. Do you recall that?
SALADI: I will have to see the notes, but ...
BAKER: Well, if you don't recall, it's okay. We can put that to other witnesses. But unexpected and
unexplained is important, isn't it?
SALADI: It is.
BAKER: Because --
SALADI: It is.
BAKER: -- in the context of a neonatal unit --
SALADI: It is.
BAKER: -- collapses when they occur are usually expected, but in any event can always be
explained?
SALADI: Sorry, say the second part?
BAKER: So collapses in a neonatal unit are commonly expected --
SALADI: (Nods)
BAKER: -- and usually can be explained?
SALADI: Yes, it may not always be expected, unexpected can still happen. But usually explainable.
BAKER: Yes. So it is the combination of unexpected and unexplained that is important?
SALADI: That is correct.
BAKER: Yes. Finally, I want to ask you very briefly about an interaction that you had with the
family of [Child J] in December 2015. If I just explain to you briefly the background to that
interaction. What happened was Mother and Father J complained that they had found [Child J] in the
COT with their nappy off, their stoma bag off and a towel soaked in faeces wrapped around them and
they were concerned because [Child J] had a Broviac line which was a potential source of infection
if it got dirty. Do you recall having a meeting that you attended with Family J and a nurse
regarding that incident?
SALADI: I do not recall the meeting. I might have met but I don't remember.
BAKER: At that meeting, the nurse said to Family J that they were probably just over-tired and
should go home and rest in response to their complaint. Does that refresh your memory?
SALADI: No.
BAKER: Regarding usual practice or your impression of how perhaps people should have behaved, if a
child with a Broviac line was left covered in faeces or wrapped in a faeces-soaked towel, it would
be entirely reasonable for their parents to be concerned by that, wouldn't it?
SALADI: Absolutely, yes.
BAKER: Yes. That should have led to the filling in of a Datix form, shouldn't it?
SALADI: I would agree.
BAKER: It should have led to an acceptance that their complaint was a reasonable one, not advice to
go home and have a rest?
SALADI: I would agree, yes.
MR BAKER: Yes. Thank you, my Lady, I have no further questions.
LADY JUSTICE THIRLWALL: Thank you very much indeed. I wonder if I can just ask one question. Dr
Saladi, you were asked the last question you were asked by Mr De La Poer was about what you should
have told the Coroner and he asked: is your position that you should have told the Coroner about the
other concerns? And you said: not just that, he should have asked me. The reason he should have
asked you is because?
SALADI: He knows that we will be under stress and we may not be coming forth, coming forth with the
information. I am not saying that, see he has experience, he knows that we will be under stress and
I don't know whether he will be aware of the legal
advice we will be given, so that is be brief, answer only what you are asked and don't speculate. So
that is why I am saying maybe because he is experienced and in that situation, that is a -- I am not
experienced in giving Inquests. But he is experienced in running Inquests and I would have expected
if he was aware of -- because I was when we were going to the Inquest we are not thinking of all the
things, maybe we should, but we are just thinking about what did we do, what is my involvement, did
I do anything wrong? Did I miss anything? Our mental process goes like that.
LADY JUSTICE THIRLWALL: Well, you can speak about your mental process. One of the things you
mentioned a bit earlier was that the Coroner knew all about these earlier incidents.
SALADI: Speculation, yes, because we would have at least -- I sent two, I spoke to Coroner twice --
LADY JUSTICE THIRLWALL: Yes.
SALADI: -- myself about these babies and I know my colleagues referred some of the babies to the
Coroner as well. So by the time the Inquiry came the Coroner would have the information that there
are more deaths in the unit. It is from that point I mention. I wasn't trying to be critical of
Coroner. I was just -- I don't want
to come across like that.
LADY JUSTICE THIRLWALL: No, all right. Thank you very much indeed, Dr Saladi. That concludes your
evidence. Is there something else you want to say?
SALADI: I want to say two things, madam.
LADY JUSTICE THIRLWALL: Very well.
SALADI: One is about the RCPCH evidence. I think the Trust used the RCPCH evidence in such a way
that it showed our department in a bad way initially and they used that to say that all these deaths
were due to a poorly run department and if you want I can explain why, how that is done. The second
thing is I want to apologise to all parents for not able to prevent the deaths and prevent the harm
done and it is a guilty feeling I carry and I think I will carry for the rest of the life. I am
profoundly sorry for that.
LADY JUSTICE THIRLWALL: Thank you, Dr Saladi. Mr De La Poer, do you want to ask anything arising out of the penultimate observation?
MR DE LA POER: Nothing, thank you very much indeed.
LADY JUSTICE THIRLWALL: Thank you very much. You are free to go, thank you, Dr Saladi. Now, there is one more witness for this afternoon and I am told it will be more convenient were we to start her evidence at 3 o'clock, so we will do that and then we will run through to the end of the day. Thank you. (2.42 pm) (A short break) (3.00 pm)
LADY JUSTICE THIRLWALL: Ms Langdale.
MS LANGDALE: My Lady, may I call Dr Holt.
DR SUSIE HOLT (affirmed)
LADY JUSTICE THIRLWALL: Thank you very much, Dr Holt, sit down.
MS LANGDALE: Can you give us your name and qualifications, please.
HOLT: My name Dr Susannah Holt, I am known as Susie, and my qualifications are Bachelor of Medical
Sciences and a Bachelor of Medicine and Bachelor of Surgery from the University of Nottingham.
LANGDALE: Can you tell us your role at the Countess of Chester Hospital from March 2016?
HOLT: In March 2016 I was employed as a locum Consultant and then in April 2016 I was employed as a
substantive Consultant. I was a general paediatrician with an interest in gastroenterology.
LANGDALE: You have provided for us, Dr Holt, a statement dated 4 June 2024. Do you have that with
you?
HOLT: I do, yes.
LANGDALE: Can you confirm that the contents are true and accurate, as far as you are concerned?
HOLT: They are, yes.
LANGDALE: You tell us at paragraph 4 when you first became aware that there was an issue, you
describe it as an increased number deaths on the neonatal unit. When you were interviewing, did you
have any idea about that?
HOLT: No.
LANGDALE: You tell uses it was at a meeting in April with Dr Jayaram and Dr Brearey. What did they
tell you in April 2016?
HOLT: There had been a death on the neonatal unit and it was brought up in the Consultants' meeting
the following Monday and it was then I became aware that there was some concerns about an increased
death rate on the neonatal unit. The exact details of the conversation I'm afraid I couldn't recall
now, but I was aware that there was this death and some preceding that and it was after that I asked
for more information.
LANGDALE: So there was a death preceding that meeting. In the first conversation you had, were all
neonatal deaths grouped as deaths or was there a discussion about
unexpected and unexplained deaths, distinct from other deaths?
HOLT: I couldn't -- I can't recall that kind of detail, I am sorry.
LANGDALE: But you describe it as you not aware of an increased number of deaths on the unit, so do
I take it it is more likely to have been a broader looking at deaths or you just can't remember?
HOLT: I can't remember.
LANGDALE: You tell us at paragraph 8 you can't remember being involved in any specific debriefs or
discussions, is that the whole team that you were working at the Countess of Chester in relation to
any babies?
HOLT: I wasn't involved in the resuscitation of the deaths of any of the babies and therefore I
wouldn't expect to be and wouldn't anticipate being involved in the hot debriefs that may have
followed. With regards to the Postnatal Mortality Review Tool, which was the way this which neonatal
deaths are reviewed as standard, I did attend those in accordance with my leave and other things,
but again I'm afraid to say with nine years I couldn't tell you exactly which meetings I was
involved in and which discussions.
LANGDALE: Do you know if you attended anything in relation to Babies O [Child P] and P [Child P],
the two of three triplets
who died?
HOLT: I can't remember, I'm sorry.
LANGDALE: You of course aren't there in 2015 with the earlier deaths?
HOLT: No.
LANGDALE: We asked you whether you had read or understood NHS whistleblowing policies and knew how
to raise concerns generally and you said you had a paper copy on your desk. In 2016 was that the
case?
HOLT: Yes. So I -- I don't know where it came from but I had a paper copy of the NHS whistleblowing
policy and I had read it in relation to some of these worries. In terms of what date I got it I
couldn't tell you though. I just know I had read it during that time.
LANGDALE: At some point in that year. You tell us in your statement that between you as consultants
you are discussing issues of whistleblowing and the like, but if we look at your statement, you say
at paragraph 12: "'We first wondered about calling the police. In an email sent some months before
that if I could change one thing in my life and all of this stuff things I have done, I could change
one thing in my life. I would have called the police that day." I just want to ask you what email
you are talking about there? Is it the one we know that Dr Saladi sent to colleagues about the
police and we are all -- we could all be suspects and the police should be called?
HOLT: May I just read that paragraph?
LANGDALE: Paragraph 12.
HOLT: Yes. (Pause)
LANGDALE: Do you see you refer to an email?
HOLT: Sorry. You will just need to give me a second I have got it. I will just read it.
LANGDALE: Okay.
HOLT: Thank you.
LANGDALE: While you are doing that perhaps we can have document 003112, page 3, Dr Saladi's email
on 29 June.
HOLT: I remember the email and when I received it.
LANGDALE: Is it the one that's just coming on the screen because that's in June?
HOLT: Sorry, it's ...
LANGDALE: 29 June, do you see that? If we go to page 4, please, Ms Killingback. It's not there. INQ0003112, page 3 and 4.
LADY JUSTICE THIRLWALL: We have looked at it.
MS LANGDALE: It was one from Dr Saladi. Should I read it out to you?
HOLT: It's appeared.
LANGDALE: Next page. That's page 1, so we are looking -- if we go to page 4. You see this is the
one
from him. You see that: "I believe we need help from outside agencies"?
HOLT: Yes.
LANGDALE: "We are all under suspicion. The only agency who can investigate all of us I believe is
the police." It is that one, is it?
HOLT: Yes.
LANGDALE: I just wanted to anchor the time of your paragraph 12, so it is that one in June.
HOLT: Yes, I think that is the one it relates to.
LANGDALE: Right, so if we go back to your statement now, that can go down. If we go to paragraph
12, you there -- perhaps we can have that page of your statement on the screen to help others INQ0101112, page 3. Page 3 and 4. You set out a number of observations there
and how you felt about not calling the police. It is page 3 at the bottom, that's right?
HOLT: Yes.
LANGDALE: Then if we go to page 4, we see the end the quote. So if we go to the next page, thank
you, Ms Killingback. Can you see there: "... we all read ferociously. We read the GMC guidance on
whistleblowing. We talked to our defence
union. We all read all the case reports about Beverley Allitt." So you are talking about this time,
June 2016, yes? After you have received that?
HOLT: The email was received, it's the first time I think we had put in writing about talking to the
police. The context of that interview was kind of my ramblings, I am not sure I would describe them
all to being exactly in June 16.
LANGDALE: Not the same time?
HOLT: Yes, it was more a description -- the way in which the questions were asked in that interview,
it was more of probably a bit of an emotional offload about how hard it was at that time.
LANGDALE: Yes, I understand.
HOLT: As opposed to a specific time point.
LANGDALE: So if we look at the content of it though, not tying you to June thereafter at some point
you tell us that you read GMC guidance on whistleblowing, talked to defence unions, what role could
they have for you at this point?
HOLT: So we agreed at one stage to liaise with our various defence unions and we all -- you pay your
defence union so you choose a different defence union depending on arrangements about what any
different
actions that we could take a different course of action.
LANGDALE: So did you talk to them about going to the police or phoning the police or anything like
that; you can't remember?
HOLT: I don't think it was specifically about a question. I think it was more that we were in a
situation where we had a concern about a raised number of deaths and that we had reported it and a
lot of the advice we got back was to continue to pursue within our Trust because I think their
feeling was the Trust have heard you and they are taking steps.
LANGDALE: So when you say you had reported it, reported it within the Trust to management?
HOLT: (Nods)
LANGDALE: Raised concerns with management?
HOLT: Yes.
LANGDALE: You say we had read all the case reports about Beverley Allitt. Do you remember doing
that?
HOLT: I do, yes.
LANGDALE: You say you lived in this sort of slightly dark world of just what did others do and how
did they do it. What did you mean by that?
HOLT: How did that come to the attention of the authorities and how did it get investigated? And
actually it transpired that it was through a different means, actually, the death rate was noticed
in the intensive care unit of the tertiary hospital.
LANGDALE: So you found that out at the time or you learned that subsequently?
HOLT: At and around that time that was information I found out.
LANGDALE: You say here: "I think we were wrong to put faith in the management system to make the
right decisions. Because I think, you know, reputation of course, it would cause damage." Do you
want to elaborate on what you meant by that?
HOLT: I was a brand new Consultant and I put faith that the leaders within the organisation, the
Medical Director, the Chief Executive, would know and understand how to, I don't know, process our
concerns and apply due diligence to scrutinise, you know, and look into our worries. I don't think
that is what happened and I felt one of the -- one of the senses I got was that it was protecting
their own reputation and being concerned about negative publicity for the hospital.
LANGDALE: You say at paragraph 13 that you: "... recall that we, as a group of consultant
paediatricians, spoke to the Local Negotiating Committee representative, at the time, Dr Sean
Tighe"?
HOLT: Yes.
LANGDALE: Were you involved in any discussion with him or what did you understand had been, if not
the discussion with him?
HOLT: No, I wasn't involved in the initial discussion with him. He then attended a paediatric
meeting at some point so I do remember meeting him. But again there were so many meetings there is a
bit of a blur as to what happened and in what order. But I believe I know Steve Brearey was involved
in a discussion with him.
LANGDALE: You say there were lots of meetings. Were you all on a corridor I have seen references to
a corridor, did you have offices or where were you based in the hospital?
HOLT: Yes. So we were based on the ground floor the Women's and Children's building behind a fobbed
door and there were essentially sorry -- five offices off that corridor and then our secretary's
office and a further three offices for the paediatricians off their -- off the sort of bigger
secretarial room.
LANGDALE: So plenty of chance for informal corridor conversations as well as meetings?
HOLT: Yes.
LANGDALE: Did you ever have management popping down to
see any of you there or other individuals from other departments?
HOLT: I had very little interaction with senior management in terms of Medical Director, Chief
Executive, head of nursing, very limited interactions with them during this timescale in 2016 and
through to 2017. I had a lot of interactions with my clinical lead who was Dr Jayaram and with the
sort of our business managers so the people within our division who were responsible for the
day-to-day working rota co-ordination, that kind of stuff.
LANGDALE: Who were your business managers?
HOLT: They changed a number of times over the -- over the time even I was there. But it was --
certainly I worked with -- I cannot even remember all their names, I am sorry. Emma Jane was one of
them at one stage who was our paediatric service manager. But the only interaction I had in the
offices was when Sir Duncan came to see me. I don't think he came specifically to see me but he
came, but this would have been much later on.
LANGDALE: I am going to ask you about that when you met him later?
HOLT: Okay.
LANGDALE: But as a routine you wouldn't get any visits from the board on the corridor?
HOLT: No.
LANGDALE: In terms of training, you say: "I did have training from the Trust [at paragraph 14] on
the processes used to review deaths retrospectively in adults." But it didn't cover child deaths or
processes. Can I ask you what your understanding was then about what should be done where there was
an unexpected or unexplained death of a child in the hospital?
HOLT: So I think this is a really interesting point and it's something that I have thought a lot
about since. The sudden unexplained Unexpected Death in Childhood policy is and should be applied in
the hospital as much as it would be in the community. I think perhaps there was a bias in our
thinking in that we would very rarely over the course of a career use it in hospital. The way in
which it is written I would suggest leans more towards the kind of community deaths which is more
typically where we would have met it as a learning opportunity as a trainee doctor and in all
honesty, you know, throughout your careers, sudden unexpected death in hospital is actually really,
really rare. Really rare.
LANGDALE: So I take it from that you didn't know that you should refer to safeguarding boards or
Child Death Overview Panel or anything like that at that time when there was a sudden and unexpected
death in hospital?
HOLT: So you wouldn't refer to a Child Death Overview Panel, that would be standard process is that
all deaths are reviewed in a Child Death Overview Panel that's part of the Child Death Review
process.
LANGDALE: In 2016 was that your understanding?
HOLT: Yes. Would I refer to safeguarding? So you wouldn't usually refer a child after death to
safeguarding. That wouldn't be considered standard process. You would refer a child that you were
concerned had come to harm to safeguarding, yes, wherever that had happened.
LANGDALE: Might an unexpected and unexplained death raise a question of harm, how could you
conclude that if it was unexpected and unexplained, that there wasn't harm caused?
HOLT: Sorry, say that again?
LANGDALE: You said you wouldn't unless there was harm, so you wouldn't automatically refer a death,
but a sudden and unexpected and unexplained death might be as a consequence of harm, might it, so
you can't eliminate that such a death hasn't been caused by harm,
so would you refer it?
HOLT: But you would go through the process so -- sorry, it is the terminology is a bit different. So
if you recognised something was a sudden unexpected and unexplained death there is not one referral
there is a whole process that you would go through which would involve an immediate and urgent phone
call actually to different agencies to put in motion a Joint Agency Response and that would include
police, social services, and then you would also proceed with standardised documentation. So, yes,
it is a safeguarding process but it's different to sort of a safeguarding referral, if that makes
sense.
LANGDALE: Do you know or did you know who were the designated doctors for safeguarding in the
hospital at that time?
HOLT: Yes.
LANGDALE: Who were they?
HOLT: So my mind's gone blank and I shared an office with her, so that is unforgiveable. Howie,
sorry.
LANGDALE: Dr Howie Isaac?
HOLT: Yes, was our designated doctor for safeguarding and Dr Rajiv Mittal was our designated doctor
for child death.
LANGDALE: Overview panel. Did you have any dealings with either of them?
HOLT: As I said, I shared an office with Howie Isaac for some of my first year as a Consultant and
Rajiv and Howie regularly attended Consultant meetings and had offices on the same corridor as the
general paediatricians at that time.
LANGDALE: So do I take it when you had these concerns in 2016 and talking to your fellow
Consultants, you would have been talking to do Howie Isaac, or she would have heard of it in any
event because you were sharing an office?
HOLT: Yes, I would think so. It is really difficult, isn't it, because I can't pinpoint any dates
for you, but like I say, they would attend some of our Monday meetings and they were very much part
of our wider department, so I do think they would have been aware of the concerns. I would caveat
that with I was only there for a very short period of time, from the March -- and as I said I really
didn't know anything about it until the April -- until the July when it was really very we were it
was more open because she had been moved off the unit.
LANGDALE: Do you think in conversations with either
Dr Issac or others you were conflating deaths and unexpected and unexplained deaths? In other words,
could have been talking about a higher mortality rate or deaths without being specific each time
about whether a death was unexplained and unexpected?
HOLT: We wouldn't in regular conversation be emphasising, as you are in this process, "unexplained,
unexpected". But actually I would take you back to the context of working in a district general
hospital with that level of neonatal unit, we wouldn't expect to have that number of deaths over
that period of time, so it would have raised an anomaly that we were having so many in a relatively
short period. But like I say, I was only there for the latter part of some of that, so can't attest
to the earlier conversations that may have gone on, for example around February time when I know
there was a review done, because I saw it.
LANGDALE: You saw that February mortality review?
HOLT: (Nods)
LANGDALE: When did you first see that?
HOLT: That was in the April when I was told about the concerns and as part of that, Steve and Ravi
said I could have a look at and see any of the relevant information.
LANGDALE: What did you make of that when you first looked at that?
HOLT: Hard to say. It's devastating to even think that. It's devastating when any child dies and so
it is devastating when you have a run of deaths and every single one of those babies is somebody's
loved one and I never lost sight of that and I don't think the other Consultants did either. So you
are inquisitive as to what, where, how has this happened and your first thoughts are always about
medical causes I guess because that's my training. You know, can they be explained by infection or
... and I think if I remember rightly within that report, you know, they had thought about things
like superbugs which is obviously very important to consider, and they had thought about common
medications and rare side-effects. So.
LANGDALE: Had investigated and eliminated them?
HOLT: Difficult to eliminate them but investigated ed them and then thought about ways and means of
modifying the sort of guidance going forward, the treatment plans, et cetera. If I am honest, I
don't think I really knew what to think. I was very taken aback by it all and took a bit of time
really to process it.
LANGDALE: You work in palliative care don't you?
HOLT: Yes.
LANGDALE: You, we can see from documents I am going to take you to now, were very sensitive to what
parents were being told and how they were being told things; is that fair?
HOLT: (Nods)
LANGDALE: If we go, please, Ms Killingback to 0014414, page 1 and 2. Dr Holt, what should come up,
my Lady, it is tab 5 for you, is external communication from the Countess of Chester Hospital dated
Thursday, 7 July at 2 pm. This is at a time when the unit is about to be downgraded. We see there
what is stated in paragraph 1: "Temporarily changing the admission arrangements for our neonatal
unit to focus predominantly on lower risk babies after 32 weeks." Paragraph 3: "We have seen in some
of our most poorly babies those with high dependency needs an increase in neonatal mortality rates
for 2015 and 2016 compared to previous years. In light of this we have asked for an independent
review of our neonatal service from the Royal College of Paediatrics and Child Health and the Royal
College of Nursing which is expected to be completed by the end of August."
We know before that the Consultants were sharing various emails about a draft and statistical
variations and goodness knows what, and I am not going to take you to that, Dr Gibbs was taken to
this yesterday, but you, in the middle of that, raise -- I think we were also taken to this in Dr
Gibbs' evidence at INQ0002693, page 7, the question of what will the families be told?
HOLT: Yes.
LANGDALE: We see there page 7. You say: "What will be said to families who have experienced an
infant death if they contact one of us, the unit, the Countess? Do we need to inform them by letter
separately? Where will we signpost them as this will inevitably impact on their grief? Depending on
how you interpret duty of candour I believe the Trust are obligated to inform the families." You set
the guidance out. First and foremost you say what is the right thing to do and then you talk about
the duty. So that can come down, if we may. But can you explain to us what you were worried about
with that press statement in terms of the impact on individuals who had had their babies looked
after at the Countess of Chester and worse, died at the Countess of Chester?
HOLT: I couldn't imagine how awful for any family to read in the press or hear on the radio about
mortality rates and, you know, there being a change to the designation of the unit where their baby
may potentially have been cared for before dying. I thought it would just leave them, yes, shocked,
floundering and jumping to -- well, jumping to conclusions and I thought the most appropriate and
the kindest thing to do would be to have actually spoken to the families before we put that on the
website. And spoken to them in person if at all possible.
LANGDALE: What did you think they deserved to be told before that was put on the website or should
be told?
HOLT: I think it -- I think it's really, really difficult but I think the bottom line is that people
who have accessed the NHS deserve honesty and we are allowed not to have all the answers at that
time but they deserved to know that there were some suspicions around whether the deaths were
natural and could be explained by medicine or not. I don't think we can hide information from
essentially the general public, our stakeholders.
LANGDALE: The Inquiry has heard evidence from parents that they weren't either aware it was
happening, when it did happen they didn't get the report before others and when they did get a
report, it was a redacted report. What do you say about that level of communication with grieving
parents?
HOLT: I think it was cruel and I think we should do better.
LANGDALE: The external communication refers to an independent review from the RCPCH and also the
Royal College of Nursing. As far as you were aware, working there, was anything ever obtained from
the Royal College of Nursing or requested of them?
HOLT: Do you mean with regard to the review?
LANGDALE: Yes.
HOLT: There was a senior nurse on the review panel from -- who was representing the Royal College of
Nursing because I knew of her through palliative care.
LANGDALE: Right, so who was that? Which person?
HOLT: You are going to challenge my memory today.
LANGDALE: Was it a doctor a nurse?
HOLT: No, it was a nurse.
LANGDALE: Neonatal nurse?
HOLT: Yes.
LANGDALE: Alex Mancini?
HOLT: Yes Alex Mancini, thank you.
LANGDALE: That's the reference to the Royal College of Nursing because she was on that board of
review?
HOLT: Yes, so my understanding is that she would have been approached by the Royal College of
Nursing as their representative on that panel because I know the other members were from the Royal
College of Paediatrics and Child Health.
LANGDALE: Soon after that communication from the hospital, you attended a meeting in July 2016 with
the management, I think in the boardroom. You refer to it at paragraph 35 in your statement and go
on about that later as well and you refer to a position paper that was presented. Do you remember
the meeting that I am talking about?
HOLT: Yes.
LANGDALE: Can I ask you please to have on the screen just to check, this is one of a number of the
documents that were presented then INQ0003492, page 1. While that's just being rotated, I think there were a
number of documents that were presented to you, wasn't there, in that meeting?
HOLT: Yes, but I do mainly rely on my -- the information from my interview but, yes, there were a
number -- I think there were a number presented but this is the one that I remember with the graphs
of acuity on it.
LANGDALE: That's right. So if we go on to page 2, 3, if
we could just move through that document, please, there is a number of graphs on it, description of
mortality rates. Can you tell us what you were being told in that meeting? We know -- if I can give
you the context, we know from minutes Tony Chambers, Dr ZA, Dr Gibbs, Stephen Cross, Dr Jayaram,
yourself, can you remember how many others were there?
HOLT: No, but I remember the message that we were being given which I couldn't corroborate because I
hadn't been there in the earlier part of -- well, I hadn't been there in 2010, for example, that we
were being told that the rise of acuity and busyness on the unit, that perhaps an increased number
of deaths was inevitable.
LANGDALE: There are various days between deaths presented we see here, I am not going to take you
to them. But you remember following that at the time and seeing that paper prepared I think by
Alison Kelly and Ruth Millward, you will be asked about that in due course. That can come down,
thank you. So you saw that paper?
HOLT: (Nods)
LANGDALE: You have given evidence in your statement about it. How helpful did you find that review
into the
concerns that you had as a Consultant and with your fellow Consultants about the rise of unexpected
and unexplained deaths?
HOLT: I thought it was unhelpful.
LANGDALE: Why did you think it was unhelpful?
HOLT: I am not sure what role statistics have to play in this situation. The death of each and every
baby needed to be scrutinised to understand whether these were sudden, whether they were unexpected,
and that had been part of the sort of thematic review to look at where it perhaps wasn't easy. It
feels like it should be easy to know if it is unexpected and unexplained and that's not always the
case in medicine. But I think the individual patients were what was important and the matters around
what happened to each of them rather than an arbitrary statistic like number of days between deaths.
I am not sure how that added any useful evidence.
LANGDALE: You say, if you go to paragraph 39 of your statement: "We were shown charts and graphs of
neonatal activity and acuity ..." Is that a word used frequently, "acuity", in the NHS?
HOLT: Yes.
LANGDALE: "... Acuity with the number of deaths superimposed on it. They showed how there were
busier periods in 2014 and again in 2015 but it was not a continuously increasing trend. I do not
think acuity on the ward was as a significant contributing factor. It did forgot feel like it was an
unmanageable workload. We were busy but not so much that impacted on patient safety in my opinion."
That was the evidence of fellow Registrars yesterday, Dr Neame I think said it was no different from
other hospitals. Was that your sense of the position on the ground?
HOLT: Yes, it was. I would agree with Dr Neame. I didn't have a comparison to draw to because I had
worked -- the last neonatal unit I had worked was Wirral University Teaching Hospital's which is a
different grade of unit. But certainly going to Chester and undertaking ward rounds I felt confident
that I had the time to see each of the patients, to consider where they were up to, make a plan for
their future care, feed back to the families if they were there and present and then manage any of
the sort of troubleshooting of perhaps babies who were newly delivered or on the postnatal ward. I
didn't feel like I couldn't do the work that felt necessary to keep that cohort of patients safe on
a day-to-day basis.
LANGDALE: Were you doing daily ward rounds at that time?
HOLT: We weren't -- as Consultants we weren't doing daily ward rounds at that time. We were doing --
I think we did two Consultant-led ward rounds in our hot weeks and then it was later on that we
separated the rotas and had daily ward rounds, daily Consultant-led ward rounds. The patients on the
days that we didn't do a Consultant-led ward round would still be seen by a senior paediatric
trainee and we would always touch base with them afterwards to make sure that they were happy with
plans for the day, anything untoward, both from a patience safety point of view but also from a
trainee experience point of view that you want to make sure that you are delivering good patient
care and good training.
LANGDALE: So what was your sense in the meeting? If we go your statement again at paragraph 39 you
say: "The conclusions [at that meeting], in my opinion, were reached by extrapolation rather than
evidenced." Whose conclusions, what do you mean by that?
HOLT: If I remember rightly it was Ian Harvey who presented the graphs about how busy the unit was
and it was therefore kind of concluded in the report but it was spoken through on the day I think by
Ian Harvey that you
know this was a reason to -- a way of explaining the increased death rate and I would go on to say
it's really important that we did consider all factors, so it wasn't to be instantly dismissed. It
did need thought and consideration because, you know, there are -- if that had been a contributing
factor, you would want to take steps to remediate that, that would feel like a much easier
intervention. But yes, it was the conclusion of the report but as explained to us and articulated in
that meeting by Ian Harvey.
LANGDALE: You say that at the end of the meeting you recall Tony Chambers said: so do you think we
are doing enough? Do you remember that now, can you hear him saying that now?
HOLT: Yes, I can hear him saying that.
LANGDALE: What was your response to that?
HOLT: I live in Chester, I had two of my children in the Countess of Chester Hospital and I was in
my mid-30s. So I had friends, one in particular who was pregnant at the time, and my benchmark of
good treatment is how my family and friends would want to be treated and with Lucy Letby still
delivering care on the neonatal unit because we hadn't done an investigation that I felt was
sufficient, I was really concerned, and
wouldn't have wanted that care for my friends, for my family, and therefore I didn't consider it
good enough for the general public.
LANGDALE: You said that at the meeting?
HOLT: Yes. I -- I remember giving the example of my friends and not wanting them to have care there
because it didn't feel safe with the current uninvestigated concerns.
LANGDALE: It appears that the meeting then had a discussion about using covert surveillance on the
unit or one-to-one supervision of the nurses, including Letby. Can you talk us through that
discussion, what was raised at that point in light of the concerns being expressed by the
paediatricians and you about patient safety and babies?
HOLT: So I think much like we had I have done afterwards, you know, people were throwing up ideas to
think about, well, you know, what are the potential ways we can improve the safety on the unit and
reassure people? So it was very appropriate to think of the different measures we might consider. I
think they were quite flawed and very difficult to do in the kind of timescales that we were talking
about. I have toiled over the thought of CCTV and I know it comes up later in my statement. But, you
know, fundamentally to put CCTV cameras over the cots of every single neonatal bed across the
country and make sure that they all remained working and checked and all rest of it and then to have
some quite covert potentially means of harming babies, I wasn't sure it would be good enough, even
if it could be done really quickly, both in the Countess of Chester but also in the wider neonatal
world.
LANGDALE: It appears that after that meeting, Letby was taken off clinical duties and transferred
to work at the risk department, wasn't she?
HOLT: Yes.
LANGDALE: The RCPCH report was commissioned?
HOLT: (Nods)
LANGDALE: What did you understand the RCPCH report was going to address?
HOLT: I think this is where I was very naive. I thought it would address our concerns and I thought
it would do a service review as well. I thought it would be the two things.
LANGDALE: Can I just pause there. What concerns, just summarise for me at that point in time what
your concerns were as a group of paediatricians as far as you are concerned?
HOLT: So our concerns were that we had a higher than
expected death rate in a neonatal unit, we had no -- we had some medical explanation in part for
some of the deaths but as a cohort and it really was that as a group when you looked at it all
together, we were very concerned that there was something else happening and we were then aware of
this uncomfortable association with one particular team member.
LANGDALE: With Letby, who you discussed in the meeting?
HOLT: Yes.
LANGDALE: Was that an uncomfortableness, even now I can hear it as you are answering the question
and just saying "and we thought Letby might be involved". Was that difficult to say at the time?
HOLT: Yes.
LANGDALE: Why?
HOLT: Just on a human nature, that what human wants to hurt, to me any living creature, and then
taking it down to, you know, to hurt a baby, to hurt a defenceless baby, to hurt the families, it's
abhorrent in society to think of people intentionally inflicting harm. In the caring profession, it
doesn't make any difference, actually it is that fundamental respect for human life, but we are in a
position of privilege to look after the patients that we look after. And I am so grateful to the
patients that I have looked after in my
ten years as a Consultant and I dread to think how many years as a doctor. I think we are given
trust and respect that we will do our best and it just feels even now even when the verdicts came
out, it just felt devastating to realise that someone had caused -- someone had murdered these
babies.
LANGDALE: So when you say "the RCPCH would deal with our concerns", you are in no doubt that there
were concerns about an individual and they knew that that they may be involved in harming the
babies?
HOLT: Yes.
LANGDALE: Were you interviewed with the RCPCH in a group or people or individually, can you
remember?
HOLT: I was interviewed in a group.
LANGDALE: Was it with Dr ZA, Dr V, was it that group? You probably don't know the ciphers, do
you?
HOLT: I think it was, because if I remember rightly Dr Jayaram and Dr Brearey were separate. So I
think it was that and there were only seven of us there at the time.
LANGDALE: So you were together as Consultants?
HOLT: Yes.
LANGDALE: Can you remember if you were asked directly what your concerns were and if you raised how
you have expressed them now, the concerns about how this group of
deaths could be explained, an individual, did you say an individual?
HOLT: Yes.
LANGDALE: But not by name, or you did, or by rank, did you say who it was, a nurse?
HOLT: I am really sorry I can't give you that detail with any accuracy. We did mention an individual
that we were concerned about an individual and -- but I wouldn't know whether we said she was a
nurse or whether we actually named her.
LANGDALE: When did you eventually see the RCPCH report or a version of it?
HOLT: I think it was in late January/early February 2017.
LANGDALE: Can I ask that you have a look please at INQ0009618, page 9. This is a page -- it will come up on the screen?
HOLT: Thank you.
LANGDALE: It is a page from the RCPCH report, we know there is two versions, a so-called
confidential copy and a disseminated copy. This is from the confidential and you will see findings
about an individual nurse. Did you receive a copy with this section in it? Did you read that? Take
your time to have a look at it.
HOLT: I don't think I saw this version. No.
LANGDALE: And we see on the next page, if you can just go to page 10: "Advise the Trust to follow
corporate processes in responding to allegations of misconduct by opening an investigation. Also
recommended a full and detailed independent Casenote Review is required on the deaths prioritising
those that were unexpected." So a recommendation that unexpected deaths needed interrogation and
also misconduct investigation. But you say you didn't see that?
HOLT: I --
LANGDALE: That version?
HOLT: So I don't remember seeing the page you showed me earlier entitled "The Nurse". I didn't see
that page. I was aware of I didn't know the bit about corporate processes but I did know that they
had recommended a further Casenote Review because that was the Jane Hawdon review, so I was aware of
parts of what you have shown me.
LANGDALE: We will come on to Jane Hawdon's review in a moment, if I may. Dealing with the RCPCH,
please can we have INQ0101113, page 12. That's a document you helpfully provided, Dr Holt, to the
Inquiry and it is the RCPCH in the news and it is an update that you received as a member I believe,
of a sort of press
what's going on?
HOLT: Yes.
LANGDALE: Have a look at paragraph 2. What it says about the hospital. Can you read us what it says
there and why that concerned you when you read it?
HOLT: I thought it was inaccurate.
LANGDALE: Sorry, can you tell us what it says?
HOLT: Sorry so: "The RCPCH has been referenced across the papers this morning as an invited review
of the Countess of Chester Hospital's neonatal unit which raised a string of concerns about issues
of staffing, led to a police investigation. A neonatal nurse was arrested yesterday on suspicion of
murdering eight babies and a suspicion of the attempted murder of six more." My feelings on this
were that it was --
LANGDALE: That can go down now, thank you.
HOLT: It was unfair to talk about a string of concerns regarding staffing. I think if they were
going to -- we acknowledge and accepted there were some parts of that review process that had good
and sound learning for the Countess of Chester, but I felt it presented a negative overview rather
than a balanced opinion and I thought the way in which it was written implied that they had been
instrumental in a police investigation and
that doesn't sit then and it doesn't sit now with my opinion of what that review process did.
LANGDALE: You set out -- if you can go to your statement please at paragraph 47, you say: "I
thought the RCPCH would use their neonatal experience and knowledge to discredit the 'Position
Paper' and point out some of the errors in the thinking of the Trust board members." And you
thought: "... the RCPCH would reinforce our view that the British Association of Perinatal Medicine
... staffing levels were aspirational and not adhered to by many units and therefore unlikely to be
a major contributing factor. I thought they would reaffirm that these deaths were suspicious by
nature of their gestation, timing and unknown mode of death." Is that still your view?
HOLT: Yes. I think -- I don't know how much discussion has been had before, so forgive me if I
repeat anything but the BAPM standards for nursing were a very sort of set out and actually in a
unit like ours would at times mean you have got more staff on than you need for the patients there,
which -- yes, more staff, perhaps better patient safety, but also we are in a resource limited
system and need to use resource
wisely. So it's a set of objectives that look at actually what is a safe staffing level rather than
a blanket level, I think would have been more helpful and as it says there, you know, a lot of units
around us, certainly within the region, would also not have met the BAPM staffing criteria so it
felt unfair to sort of highlight us.
LANGDALE: Did you think -- you also say at paragraph 53 the statement was factually incorrect. Did
you think it could create the wrong impression about the actual concerns and the real issue from
your perspective? Real issue that there were unexpected deaths and you were concerned that there was
an association of one person with those unexpected deaths?
HOLT: I mean, if I am honest the Royal College shouldn't have been sending out soundbites like that.
I don't think they do any more, I think it is unhelpful and I think ...
LANGDALE: We know you followed it up with a meeting, shall we take you there?
HOLT: Yes.
LANGDALE: INQ00127440001 [unavailable], yourself and Dr Brearey went to meet with a Jo Revill. We
see here a note from apology revenue he will to Russell Viner: "Dear Russell and Mike, "Emily and I
met with two doctors [this is in July 2019] from the Countess of Chester last week to talk to them
about the background to our Invited Review service and the ongoing investigation focusing on the
College's role during this period. The two doctors, Steve Brearey and Suzy Holt, were very open with
us and said they valued having the chance to come to the College to talk about their concerns." If
we go over the page, you set out your various concerns and you say: "The doctors had asked for the
police to be called in following concerns about the unexplained deaths of eight babies during 2015
and 2016. The Hospital's Medical Director decided not to do so and instead called the College to do
an Invited Review. "In terms of reference, this review began as a straightforward description of a
service review but then the Trust added a clause which asked us to look into unexplained deaths.
This is obviously not what our IR process was designed to do and would have involved different
experts, as far as I can understand." So it continues and you make reference: "Following our review
a Casenote Review was ordered and carried out by Jane Hawdon but she didn't review all
of the cases. The doctors felt that this report [that is the Hawdon report] was less comprehensive
and work the doctors had already done and there was a feeling that the reviewers wanted to focus on
BAPM standards. "In their view, the Trust used our report to try to keep the focus on the issue of
staffing levels on the ward." So it continues. Was that the Jane Hawdon report that you were
referring to there, just to check that?
HOLT: Yes.
LANGDALE: What was the feedback from that from the Royal College? You said a moment ago you
wouldn't think they would do that now, but what response did you get raising those concerns?
HOLT: Not -- I don't recall any further follow-up from the Royal College after we expressed concerns
to -- in that meeting. Interestingly, we asked then for a full unredacted copy of the report and
actually would have preferred it to have been delivered by the Royal College so that we knew it
wouldn't have been redacted and we were told that we couldn't have it.
LANGDALE: Whose property were you told it was?
HOLT: Ian Harvey's.
LANGDALE: So unless Ian Harvey gave you a full copy, you
weren't entitled. Are you a member of the Royal College?
HOLT: I am a member of the Royal College, yes.
LANGDALE: So what happens if you are a member, what do you get for that?
HOLT: It's an annual subscription with access to some events, we are expected to have membership as
part of our employment as a Consultant paediatrician. I also sit on one of the committees at the
Royal College, one of the training committees at the Royal College, but -- and I think you have to
be a member in order to sit on those as well.
LANGDALE: But you say you felt let down by their response to this and the information they provided
publicly --
HOLT: Yes.
LANGDALE: -- about their review?
HOLT: I did.
LANGDALE: You also comment in your statement about Jane Hawdon's report and the value of that
report and what was needed if she was going to have a look at the babies. What do you say about that
what was needed to do a forensic review of the babies?
HOLT: I would counter this with I am not a forensic, forensically trained. I do Child Death Reviews
a lot in
my current post and I think it is a really important part of what we do so that we make sure we
continue learning. You need to have access to all the relevant information and that is not always
easily kept in one place, there is often multiple sources of patient notes because and it will
depend on different hospitals how they record things. But you would need to make sure you had view
of medical notes, nursing notes, feed charts would be really important, medication charts if they
are not done electronically, the observation scores so heart rate, respiratory rate, things like
that?
LANGDALE: X-ray reports?
HOLT: X-ray, yes.
LANGDALE: Blood results?
HOLT: X-ray, imaging, you would want all of those things at your disposal. But I also think in such
a situation where your colleagues, albeit colleagues you don't know, are raising concerns I wouldn't
want to do a review without asking them for statements or being aware of what their concerns were. I
think you risk being blinkered and not knowing what you don't know.
LANGDALE: Moving forward, 26 January 2017. You weren't able to attend a meeting where your
colleagues were required or requested to send an apology letter but I think you signed up to an
apology letter in any event with them, didn't you?
HOLT: (Nods)
LANGDALE: Shall we go to the apology letter it is 00031870001. There we are. Tell us how you felt
about doing that?
HOLT: Devastated. I didn't feel it was appropriate. I felt I didn't feel I had a choice and I am
quite embarrassed that we ever wrote that letter and sent it. I don't know how it makes the Families
feel to -- to see that and have read that. I think it's -- I think it's awful.
LANGDALE: Did you have much discussion between yourselves at the time about the wisdom of that or
the expectation that you do that?
HOLT: Yes, we had a lot of discussion about it.
LANGDALE: It can go down now, thanks.
HOLT: We had a lot of discussion about it. And I think the consensus was that we didn't feel we had
a choice and as you can see in the text of the letter, it was an apology for how --
LANGDALE: She felt?
HOLT: -- she felt.
LANGDALE: Rather than any suggestion that she was
innocent?
HOLT: Yes.
LANGDALE: You were also aware that a further requirement of the meeting was that Dr Jayaram and Dr
Brearey were to attend mediation with Letby.
HOLT: Yes.
LANGDALE: What did you all make of that and how did you think they were coping with that
request?
HOLT: It was -- it was a pretty astonishing time. The challenge we had was that all of us feel very
passionately about our service and I say that even though I don't work there any more, we all felt
passionately about our service and wanting to be able to continue to offer a service and we were
providing an amazing service to the paediatric patients as well as the redesignated neonatal unit
and eating disorder service and training the next generation of doctors. I think we all felt that
working with our board was going to be better for the population than all of us ending up on
gardening leave, which felt like was the insinuation from that January meeting, that if we didn't
toe the line then we wouldn't be remaining in our jobs and I think it's important to remember at
this point that there was already talk of her returning to the neonatal unit and we still didn't
think sufficient
investigation had taken place. So there was a degree of thinking actually we need to also keep our
voice and not be silenced to prevent that happening.
LANGDALE: It comes very clearly across from your statement in that earlier interview you did with
Facere Melius, you were anxious, weren't you, it wasn't simply about whether you would lose your
job, you were very anxious and stressed knowing that the Trust Executives were taking steps for her
to return to clinical work?
HOLT: (Nods)
LANGDALE: Just can you expand on that, how that felt at that time knowing that that was the
projection?
HOLT: It's difficult because now we have got the -- now we have the foresight of what actually
happened it changes how perhaps you felt at the time. But there was so much swirling for us all. You
know, it's easy now that there is -- it is not easy, that's a poor choice of word. We now know she
has been tested in a court of law and found guilty, but at that time we were still dealing with
uncertainty. We were still dealing with: can this possibly be true, is that what's been happening?
How do we feel about her being returned to the unit and also trying to do your job day-to-day et
cetera?
So --
LANGDALE: Sorry.
HOLT: It is horrendous.
LANGDALE: Sorry to cut across. Who was advocating for Letby at that time? You say she may be coming
back. Amongst the nursing or management or doctors, if there were any, you know, who was advocating
for her being permitted to be there?
HOLT: I don't know, if I am honest. Certainly none of the medical Consultants that -- the seven of
us, none of us were advocating for her return. I wasn't involved in as many of the meetings with the
senior nurses on the neonatal unit.
LANGDALE: So you wouldn't know what they were saying?
HOLT: I have had second-hand information about some of the meetings but no, I wasn't involved in
those meetings directly.
LANGDALE: Okay, don't be worried that it is second-hand. What was your impression about which
nurses or senior nurses were supportive of her position as far as you were aware at that time?
HOLT: If memory serves me right the previous Nurse Manager, Eirian, had been incredibly supportive
of Lucy.
LANGDALE: Eirian Powell?
HOLT: Yes, Powell. I believe she actually retired from work that Christmas, I can't remember.
LANGDALE: She was supportive of her. Anyone else? Was Alison Kelly, as far as you were aware or
not?
HOLT: My understanding is that Alison Kelly was very supportive. My -- I didn't really speak to any
of the nurses on the neonatal unit about it, I didn't feel it was within my remit but I know many of
them were good friends with Lucy and were really traumatised and themselves torn about what to think
and how to think.
LANGDALE: Dr Gibbs gave evidence that he knew Eirian Powell supported her and was positive of her
and that caused him to -- I don't know if there was a reference to dithering but there was certainly
a reference to a pause in his thinking. You at paragraph 76 say: "You cannot have casual
conversations about these types of concerns [meaning your concerns that Letby was harming babies]
even with close family. I worried they would not believe me. It all seemed so far-fetched; like a
storyline out of a movie and not something that happens in 'real life'. I considered resigning." Was
the fact that there were other people expressing very positive views about her at that time, did
that impact upon how clearly or how sighted you were on the essential concerns?
HOLT: Yes, I mean, obviously it would because we -- the fact that we knew with certainty around the
death rate, the facts that we knew without certainty how that this come about and you had people
that you worked with and respected advocating very strongly for her and so much so that Lucy turned
up on a Christmas night out that December, that John and I had gone to represent the medical
workforce on, and, you know, the two things just seemed so hard to balance; that the nurses were so
supportive of her that they would still be inviting her to come on a social evening, I think it was
Eirian's joint retirement do. It was really, really hard to hold in mind and balance all of these
kind of conflicting and troubling different opinions.
LANGDALE: So you are at a social event with her at this time and is it all medical nursing
staff?
HOLT: It was the neonatal nurses and, like I say, just myself and John went, having discussed it --
when we became aware on the day we discussed it with the police because I come back to you are
desperately trying to continue to work with these colleagues to provide safe and excellent care and
I just -- I couldn't believe it when she turned up, I didn't think she would come and so you are
then faced with this.
LANGDALE: Just to be clear which December, which year? Was this before your apology letter?
HOLT: I think it was -- I think it was December 2016 but I might need to check that date.
LANGDALE: We know there were at least -- there was at least one tea party to reintroduce her to the
neonatal unit; do you know anything about that?
HOLT: I didn't.
LANGDALE: From what you are saying, it wouldn't surprise you there was still social interaction
with her at that point?
HOLT: (Nods)
LANGDALE: Can I ask you about a letter, please, at INQ0003095, page 1, tab 11, my Lady. 30 January 2017. A letter from the
Consultants to Mr Chambers. You sent your letter of apology at that point. You say: "Although it was
made clear that the Trust board has drawn a line under this issue ..." Just pausing there, that's a
phrase that we hear a lot "draw a line". Who's drawing a line and why?
HOLT: So --
LANGDALE: Have you got some water there, Dr Holt?
HOLT: I have some, thank you. Frog in my throat from talking too much. That is what it was reported
the words
Tony Chambers used in the January meeting that I wasn't in attendance at.
LANGDALE: " ... would be grateful for written clarification on the board's understanding of the
reason for the increased number of unexpected and unexplained deaths on the neonatal unit between
June 2015 and July 2016 and the actions that you and the board now expect us paediatricians to
take." And you say there: "Also each of us would appreciate the opportunity to read the RCPCH
Invited Review report and the report of the Casenote Review undertaken by the external
neonatologists prior to these reports being released publicly. Obviously these reports are extremely
sensitive and so we assure you that they will not be disclosed outside our Consultant paediatric
group." Did you get that report at that time, from what you have said earlier no?
HOLT: So we were told we could go and pick up a report from the -- a copy of the report from the
Exec office but it was not a full unredacted report.
LANGDALE: If we go to INQ0003117, page 1. Another letter from you all on 10 February 2017. You tell
us in your statement you sent this because you had read and considered the review reports from the
RCPCH and Dr Hawdon and had a chance to discuss them as a group. Were you all in agreement that they
didn't provide reassurance around the deaths and collapses? We see what you say here, if we go to
the next page as well, please, Ms Killingback. You concluded this letter: "It's been eight months
since we escalated our concerns to you and we do not consider any further discussion within the
Trust is in the best interests of affected families or neonatal staff. Please be assured that we as
a paediatric consultant body are making this request because patient safety is our absolute
priority. We hope a comprehensive external investigation will be in the best interests of the
bereaved families and those affected by these sad events." Do you know what response you got to
that?
HOLT: I think after this there was a verbal agreement that the Trust would have a discussion with
the police but then what actually transpired was that they were then invited -- told to go to a
meeting with a barrister.
LANGDALE: Can I just ask you to look at a couple of emails before we go to that. Just give me a
moment. If we can go, please, to INQ0003395, page 2. So what will be shown in a moment, Dr Holt, is
an email from Dr Brearey to Mr Harvey cc'ing you and fellow Consultants. I would like to remind you
of summary of a meeting and agree the summary, I don't know whether it is accurate and have a look
at paragraph 2: "... making it clear there is general dissatisfaction from the Consultant body with
the way the Trust has handled this difficult situation since it was escalated. All the
paediatricians voiced concerns at the time and all now feel their professional opinions have not
been given due regard." If we go to the next page, page 3. It concludes saying: "Nim Subhedar stated
at our meeting he too was concerned the cause of death and/or deteriorations remained unexplained in
several cases. They should undergo further detailed review". Et cetera. Then we see the response, if
we can go to page 1 of the same series, Ms Killingback, from Mr Harvey: "Given the circulation list
I felt it was important to respond especially since these notes have a particular slant and I am
wary if I didn't respond this might become the only version of the truth. "I am surprise there is no
reference to the conversation about the Coroner. I am aware that you
have each had a letter from Tony Chambers that was able to give more detail and confirm. Stephen
Cross and I had had a detailed conversation with both the Coroner and the deputy." What did you
understand was the position of the Coroner at this point and the Coroner's involvement?
HOLT: So I know that some of the cases were discussed with the Coroner at the time and I know that
the Coroner went on to request postmortems in some of the cases. My understanding was that when Ian
Harvey spoke to the Coroner that he felt he had no role to play and wouldn't consider reopening any
inquiries.
LANGDALE: Is that what you understood from Mr Harvey?
HOLT: That's what -- I don't know where I understood it from, that's what I understood at the time.
LANGDALE: Okay. So you don't know who told you that or who communicated that?
HOLT: I think there is an email alluding to it.
LANGDALE: If we look at the third paragraph, Mr Harvey in this email is at pains to say: "It might
have been stated, but it was not agreed either, that there were small changes in the acuity, I
certainly would dispute this, or that by extrapolation this couldn't play a part. I for one would
not limit myself to looking for a single cause."
So he is at pains there to set out what we see. How frustrating was that, given the position you had
all taken on that issue and your experience of other hospitals and staffing, et cetera?
HOLT: I think we were just used to hearing that response from him by this stage. We knew that they
-- and by "they" I mean Alison, Ian, Tony and Stephen had a very fixed opinion and it felt like we
were struggling to convince them of the need to think differently.
LANGDALE: Give me one moment. The meeting with Simon Medland QC, what did you understand that was
arranged for? We know it took place 12 April.
HOLT: It was -- it was a strange request of us. We thought they had agreed to discuss it with the
police and then we were told that we were going to meet with this barrister to think about how they
framed the information to give to the police or something along those lines, which I think we were
very disappointed that there was another meeting with someone other than a representative of
Cheshire Constabulary.
LANGDALE: Do you think Mr Medland, as he then was, had all of the information about your concerns
before then or do you think he came in not really understanding or knowing the level of concerns,
what was your sense of that?
HOLT: My sense of that meeting was that he came in with a similar pattern of thinking to the people
that I have already mentioned.
LANGDALE: Senior management?
HOLT: Yes. I think he came in well versed in what they thought was going on and I found the meeting
really, really difficult.
LANGDALE: The decision to involve the Child Death Overview Panel was raised in that meeting, wasn't
it?
HOLT: (Nods)
LANGDALE: With a view to what, what was the suggestion I think you thought you may have raised it
first, somebody raised it in any event?
HOLT: In his meeting in his minutes that we did see afterwards, he says he suggested it. The way I
remember that meeting kind of unfolding was we -- there was a sort of amount of discussion at the
beginning about what the meeting was for and a kind of understanding that we were perhaps at odds
even from the outset. Then we did a lot of the talking and explained why we had concerns.
LANGDALE: Which of the Consultants did most the talking about the concerns, out of interest?
HOLT: I'm sorry, I wouldn't be able to tell you.
LANGDALE: Okay.
HOLT: And then he asked a few questions and then he spoke a bit about there was a sense of disbelief
in him that we could be suggesting that these were potentially criminal acts and I think he was
trying to play it down and then when it became -- it felt like he then realised that that wasn't
going to be an outcome of the meeting so then there were a few other suggestions made, one of which
was CDOP.
LANGDALE: Child Death Overview Panel?
HOLT: The Child Death Overview Panel, sorry, yes. And another of which was that, you know, a further
internal review by somebody else.
LANGDALE: Was the purpose of the -- or the mention of the Child Death Overview Panel at that stage
to highlight that there was a representative from the police on that and that was a route to the
police or was it separately talking about the Child Death Overview Panel, as far as you were
aware?
HOLT: I think it was slightly separate but I think for me the -- it was a bit of: actually, it does
put us in front of the police, though, and that felt like -- that felt like a priority.
LANGDALE: That was in fact the way through wasn't it with Nigel Wenham and the Child Death Overview
Panel,
how eventually, not long thereafter actually, the referral to the police was achieved?
HOLT: Yes, yes.
LANGDALE: That meeting with Simon Medland was 12 April. 16 April, it looks as though you all had a
meeting with Sir Duncan Nichol, the Chair of the board. Can I ask, please, that we look at INQ00066821, please, and Dr Gibbs chooses to circulate to you all an email
summary of the actions Sir Duncan proposed taking at the end of the meeting. Were you all there at
that meeting? Can you remember or not?
HOLT: Sorry.
LANGDALE: So it may have been a number of consultants but you don't know if you were there. Did you
know Sir Duncan, would you have known him if he walked in the room now?
HOLT: Yes, I do know Sir Duncan. I had cared for one of his family members.
LANGDALE: Don't worry about that, so you would recognise him?
HOLT: Yes.
LANGDALE: So if we look at what this letter says. Sir Duncan, paragraph 3: "... repeated several
times he had come to listen
and he had understood what we were saying but it was not his role to take sides. He thought it was
highly regrettable that there had been a breakdown in the relationship between ourselves and senior
managers. "Sir Duncan urged us to try to repair these relationships for the future, especially given
the challenge of the forthcoming reorganisation of Women's and Children's Services in Cheshire and
Wirral, although he wasn't sure to what extent this would be possible with Ian Harvey, given that he
is leaving in a few months. "Actions: for communication and trust between senior managers and
paediatricians to improve specifically to involve us prior to press releases involving neonates and
when there were meetings with other bodies regarding our services." Was that because he's got the
point you were upset by the communications not engaging families or parents and also --
HOLT: I mean.
LANGDALE: -- an RCPCH review?
HOLT: Yes, it was communications as a whole. We always wondered what was said to, for example, the
Coroner, what was said to Jane Hawdon before the review. We always wondered whether people arrived
with a set bias and felt that if we had been involved in some of these setting of terms then
actually we might not have seen so much biased thinking.
LANGDALE: Number 3: "Sir Duncan offered to be our Executive Children's Champion and we should use
him in whatever way we felt appropriate and he would work with Rachel, who will remain our
Non-Executive Children's Champion." I am not sure that's the right name, but we will see when we
come to the Non-Executive Directors. But what did you understand that role of Executive Children's
Champion was about?
HOLT: It's a way of hospital boards trying to have a sense of what's going on in the many
departments that make up a hospital. What I would say is that we did meet Rachel, but it was
infrequent and certainly not helpful through this process and I don't really remember what Sir
Duncan did as our Executive Children's Champion.
LANGDALE: What about going to the police at this point? There is no reference here to whether he
has expressed a view about going to the police by16 April, that's what you were saying at this
point. Was there any -- that's what you wanted championing, was there any movement on that at this
meeting?
HOLT: Can you just remind me, what date was the meeting with the CDOP panel?
LANGDALE: Sorry, say that again?
HOLT: What date was the meeting with the CDOP panel?
LANGDALE: I can't remember now?
HOLT: I think these happened very close.
LANGDALE: This is 16 April 2018 with Sir Duncan?
HOLT: I think we had already ...
LADY JUSTICE THIRLWALL: I will look it up.
MS LANGDALE: 12 April. No, that was the meeting with Simon Medland where you discussed the CDOP
panel.
HOLT: I think we had the meeting with the CDOP panel in the diary at this point and what I would say
is we -- we were slightly exhausted with our Trust and so my focus was certainly on that next
meeting with external agencies.
LANGDALE: Did you have -- you can't even remember if you were at that meeting with Sir Duncan in
2018?
HOLT: I was because John makes notes that "I think you two" and then mentions one of the other
Consultants and me were taking notes. So I was definitely at that meeting. John gets details right.
LANGDALE: Was that the only time you met him in the work situation?
HOLT: No so I -- he -- he came down to the offices
and I happened to be on on-call one evening and I had a conversation with him then but I couldn't
tell you where in the timeline that happened. We only really had much to do with Sir Duncan in this
sort of period of 2018, though.
LANGDALE: Going back to your statement, 110, just a couple of things if I may. You went to speak to
Mr Green -- is it Mr Green or Dr Green?
HOLT: I believe it is Mr Green.
LANGDALE: I thought he was Dr Green, a pharmacist, Director of Pharmacy, who did the grievance
procedure or was investigating that. You say you went to speak to him. When was that roughly? Much
later or?
HOLT: Yes.
LANGDALE: Have a look at your statement.
HOLT: Yes, this was.
LANGDALE: Was it after you left the Trust, it looks as though --
HOLT: It was actually, yes, it was, it was at and around the time I was leaving the Trust, if I
remember rightly.
LANGDALE: That's 2020?
HOLT: Yes.
LANGDALE: So what did you say to him about that process then or about the grievance?
HOLT: I sat on one of the pharmacy groups at the Countess and so I knew Chris through that
interaction and it became apparent that there was an exchange of emails that was between Chris and
Steve that was probably steeped in kind of anger from the -- the grievance process and I was keen to
make sure that it didn't impact -- I cannot even remember what the issue was, but it didn't have an
impact on our sort of decision-making going forward. I think we had become so aware that people were
given an incorrect account of us and the concerns that we were raising and I got on very well with
Chris, I respected him, and I just wanted to ensure that he wasn't acting under false pretences. So
I had a conversation with him about the grievance process and about the concerns that we were
raising and he did seem to express surprise that he hadn't perhaps been given full disclosure of the
situation at the time.
LANGDALE: So that was long after it had been completed?
HOLT: (Nods)
LANGDALE: Did you say: we had to send a letter of apology and say what you felt about that?
HOLT: I wouldn't know the details, I'm sorry. It was a long time ago.
LANGDALE: No, I meant that you sent a letter of apology to Letby, did he know that?
HOLT: I don't know if he knew that or not.
LANGDALE: You didn't discuss her specifically, you just concerned what your concerns were as
Consultants?
HOLT: Yes, yes.
LANGDALE: What did you make of the facts, what did you hear about of the grievance process at the
time and any findings, did you know about that at the time it was going on?
HOLT: It was a really difficult time. It put a huge amount of psychological stress on the whole
Consultant body and specifically on Ravi and Steve who really struggled with it, so much so that
Steve couldn't be a part of the process. And we were really surprised and saddened when Ravi got,
again, a redacted version of the grievance that there seemed to be statements in there that were not
evidenced and we didn't recognise as being our behaviour at the time that had been upheld and was
sort of almost substantiated by this grievance procedure.
LANGDALE: Were you interviewed as part of that or not?
HOLT: No.
LANGDALE: So as you sit there, there was a grievance procedure where your conduct was questioned
and put together, but there was no investigation into Letby for
the concerns you were all raising about her and her link to unexpected deaths?
HOLT: (Nods)
LANGDALE: What do you make of that now?
HOLT: I don't think the grievance process followed the recommended procedures and I think it should
not have happened, and I feel angry with those in a position of responsibility who subjected us to
that and have never apologised for their behaviours at the time.
LANGDALE: Never apologised to you or generally?
HOLT: I think they've got a lot of apologies to make. I am not the most important person they need
to apologise to, in my humble opinion. That would be The Families.
LANGDALE: I want to ask you about one document, if I may. My Lady, I won't be much longer but there
is one document I would like to put to Dr Holt. Please, INQ00067250001. That will come up in a moment. Do you see this? So this is a
table and, as far as the Inquiry is aware, it looks as though it has been -- and I would like your
help with this -- put together by paediatric Consultants.
HOLT: (Nods)
LANGDALE: Pausing there, there is a lot of writing you all had to do about this, wasn't there? A
lot of time
must have been taken by all of you.
HOLT: Yes.
LANGDALE: You nod. That's not picked up. But how much time was this taking, setting all these
things out in different ways in different versions and letters and emails?
HOLT: Hours and hours and hours of time. We all worked significantly beyond our hours, and it was
not uncommon to find someone in the offices until very late at night because at no point did we stop
delivering care to other children and young people. So this was all done on top of Consultant roles.
LANGDALE: And correct me if I am wrong, but it looks as though on the left there is some comment
about a communication, reply by management, and your comment is on the right as a Consultant body.
It gets a little bit confusing to the left when I go through the whole document. Is that because
different people are inputting into it?
HOLT: Yes, different people inputted into it. So we circulated this, just to try and not duplicate
information so that people would add a different opinion. But, yes, try not to --
LANGDALE: You all put your own view or opinion in boxes and added it and circulated it. What was it
prepared
for?
HOLT: It was in the back and forth of letters with our management structure, essentially, trying to
highlight where we felt there were shortcomings in how the matters were dealt with and how we were
treated.
LANGDALE: It is not dated, as far as I am aware, but obviously we can see the items that you are
commenting on. But if I look at the first page, paediatrician's comments, you say here in, and you
are referring to a statement that has been made earlier: "The statement is does not correlate with
the statements and actions of the board. Ian Harvey made a public statement in February 2017 saying
this means that when we speak with parents, we can now share full and accurate information on an
individual basis. This took no account of the four sets of parents for whom there was no accurate
information regarding the cause for their babies' deaths. We cannot quantify the impact on their
grief of such misinformation." So you were identifying this, although you hadn't presumably
yourselves had contact with parents at this point, either. You could just see there was a chasm
there, a massive chasm to say the least?
HOLT: Yes.
LANGDALE: If you go to page 9 of the same document, please. The concern in the left-hand column:
"Please advise us why the medical director chose to select only some negative comments from the
reports and to omit to mention that further investigation had been recommended by an external
reviewer." And then the box on the right-hand side, third paragraph: "It was very clear in the
meeting that the Executives who spoke were trying to portray the neonatal unit as a failing and
stretched service with Consultants who were being unprofessional, making unfounded allegations
against an innocent nurse. Selections of the reports were selected to support this view. This could
be interpreted as a form of selection bias." Do you see that?
HOLT: Yes.
LANGDALE: Those reports of course, in part, continue to be stated and quoted and cited, don't
they?
HOLT: Yes.
LANGDALE: How do you feel about that in terms of how accurate that is?
HOLT: Just angry. Angry that -- angry that we were represented in that way because I don't think it
is a fair reflection on the service that we were providing then, and that I hope they continue to
provide now, and
I think -- yes, I don't think any -- I don't think anything has sort of -- it's all remained almost
as a sort of paperwork from the time, so none of it's been challenged since. But I would kind of
highlight that the most important thing out of all of this time has happened and that was getting
investigation into the children's deaths. I don't want that to get lost in this arguing between us
and the executive. I don't think those in management should remain in NHS management. I don't think
they have shown the morals, the leadership, and the compassion of managers I would want to see in an
NHS of the future.
LANGDALE: What do you think is important in terms of qualities for senior managers in the NHS?
HOLT: I think it is an incredibly hard job. I think the NHS has many and wide-ranging issues, but I
think it's really important that managers remain accountable to the most important people, and they
are our patients, and in order to be accountable you need to be able to be visible, you need to have
good processes in place, you need to employ the right people and have the right people around you.
But I think when things like this come up, you have to be inquisitive, diligent and thorough and,
yes,
I don't think they were.
LANGDALE: Finally, in terms of the culture within the hospital, how would you describe the
relationships between the doctors and managers during the period I have been taking you through?
HOLT: It's important not to label all of the managers as managers if that -- as in the same
terminology, because actually we had our service managers, which is the sort of immediate level that
we interact with more frequently, and I think we had a good relationship and a good rapport with
them. And that's true of, you know, for example, the women and children's lead I have a really good
relationship and I had back then a really good relationship with the lead obstetrician.
LANGDALE: Who was that? Dr McCormack?
HOLT: Yes, and then it became Dr Sara Brigham. The worst of our relationships was actually with the
board, with the people that we have mentioned, with Alison Kelly, Stephen Cross, Ian Harvey, Tony
Chambers.
LANGDALE: So was this more about people than roles for you or a combination? You say there were
other managers, senior managers, you got on really well with. So how would you --
HOLT: Yes, it's really difficult because there are
different pockets of people. The way in which the structures work is really complex and so, for
example, you have got a risk manager, you have got an HR manager. Individually I got on well with
many of the individuals within our institution. The sum of it, the sum of the problem, I still to
this day don't quite know what we could have done differently to have had a different outcome
because I think the layers of NHS management are part of what makes this so difficult. Whose
responsibility was it to do what at what time and whose responsibility is it to challenge when
someone in a position of senior leadership is so dismissive of an issue? And I think it is difficult
but I also know then that we had some very direct conversations with these people. So it wasn't that
things were getting lost in translation.
LANGDALE: From the doctors' or paediatricians' perspective, going to external bodies earlier
themselves was obviously a matter that you could have considered or could have done. So we have
spoken earlier about phoning the police. What would have stopped you as a group doing that at the
time, or earlier, and for those who were there before you in 2015?
HOLT: I can't answer that question. I don't know why we didn't and it is a huge regret and -- yes, I
don't know. But I am -- and I live with knowing that we have to learn from these events and that is
personally, as well as organisations and institutions. And, yes, I wish I had done something
differently back in 2016.
LANGDALE: Dr Issac, of course, Howie Isaac, and Dr Mittal will be giving evidence too but they are
safeguarders and you say you were sharing an office with one. Again, referrals via safeguarding to
local authorities, just getting out of the Trust, that was a route and an option, not canvassed at
the time between you?
HOLT: I am assuming you are thinking about LADO referral in that statement. I have been, I have been
part of situations where we have done a referral to LADO.
LANGDALE: About a member of staff or is it always parents? We do it for parents, don't we?
HOLT: No, about members of staff on more than one occasion we have done LADO referrals. This
situation is subtly different and if we'd had -- you know, if we'd had or if I'd had had significant
concern about something that I had seen or witnessed, it was the nature of the sort of
circumstantial evidence that made
that feel like a difficult step to take. In order to make a LADO referral, it is about an allegation
about a member of staff; admittedly, that they might have caused harm. There is no high bar of they
have to have caused harm. But certainly from a personal point of view, it was the overall situation,
it was the body of the number of unexplained incidents that was such a concern and there wasn't ever
one individual case where I thought: that needs referral.
LANGDALE: The actual structure of Working Together 2015 is about everybody being responsible for
child safety, child protection, child safety. So, in a sense, looking for an allegation isn't the
test, is it? The test is being concerned for children or babies and you were all obviously very
concerned about babies on the unit?
HOLT: And you are absolutely right. It is -- you know, we talk about safeguarding a lot. I regularly
am involved in safeguarding meetings. Like I say, it does tend to refer to one child. You do a
referral about a situation. But, again, I wouldn't -- I'm not sitting here completely discounting it
as a possibility. I would say, though, that if you had enough evidence to go to a LADO, then, you
know, they are not an organisation that will do an investigation. They are part of the threads that
pull together and the police
would be involved.
LANGDALE: They work with the police, though, don't they?
HOLT: Yes. Again, would they have suggested referral to the police? I can't rewrite history.
MS LANGDALE: Thank you very much, Dr Holt. Is there anything you would like to add or say that I
haven't asked you? You have been giving evidence for some time but I would hate for you to leave and
you wished you had said something else as well.
HOLT: No, thank you.
MS LANGDALE: Thank you very much.
LADY JUSTICE THIRLWALL: Dr Holt, thank you very much indeed for the care that you have taken, both at the time and in giving your evidence today. You are free to go now. Thank you. Ms Langdale, tomorrow morning at 10 o'clock.
MS LANGDALE: It's Friday tomorrow. I think.
LADY JUSTICE THIRLWALL: Oh, yes. Sorry, I will be the only one here. So Monday morning, 10 o'clock. Thank you all very much.
(4.42 pm) (The Inquiry adjourned until 10.00 am, on Monday, 7 October 2024)
LADY JUSTICE THIRLWALL: Yes, Mr De La Poer.
MR DE LA POER: My Lady, our first witness today is subject to a Crown Court order. We will be referring to her as Dr ZA.
LADY JUSTICE THIRLWALL: Very good.
MR DE LA POER: May I ask her to come forward, please.
LADY JUSTICE THIRLWALL: Yes, please, would you come forward and take the affirmation or the oath, whichever it is.
DR ZA (sworn)
LADY JUSTICE THIRLWALL: Thank you, doctor, please sit down.
MR DE LA POER: Now, Dr ZA, can you confirm for us, please, that you've provided to the Inquiry a
witness statement dated 23 May 2024.
DrZA: Yes.
DE LA POER: And are the contents of that witness statement true to the best of your knowledge and
belief?
DrZA: Yes.
DE LA POER: We are going to deal necessarily very briefly with your background. You are a medical
doctor; is that
right?
DrZA: Yes.
DE LA POER: And you are a member of the Royal College of paediatrics in child health?
DrZA: Yes.
DE LA POER: And prior to 2015, you had been a Consultant at the Countess of Chester Hospital for
some years?
DrZA: Yes.
DE LA POER: In terms of your working pattern during the period we will be focusing on, you were
working part-time; is that right?
DrZA: That's correct.
DE LA POER: Working Mondays to Wednesdays and a share of out of hours?
DrZA: Yes.
DE LA POER: And in terms of the practical consequences of that, does that mean that there were
certain meetings throughout the period that we are going to be focused on which you didn't attend
because you weren't at work?
DrZA: Yes.
DE LA POER: I'm going to consider, please, the relationships between various parties at the
Countess of Chester Hospital. Firstly, as we have heard, Dr Brearey was the neonatal lead and Dr
Jayaram was the lead for the
paediatrics service. How did you find working with both of those two?
DrZA: I'd worked with both of them for a long time, since my training as a junior doctor, and I had
a positive working relationship with both of them. I found them very approachable if I had any
issues.
DE LA POER: Now, you speak about the relationship in your witness statement between the Consultants
and the departmental manager. Could you just help us with who you meant by departmental manager?
DrZA: So at the time I think it was Jackie Blundell and Jo Moore, they were our sort of department
manager and assistant managers, so sort of the first tier of hospital management that we dealt with.
DE LA POER: And was that a positive relationship?
DrZA: Yes, we had a good working relationship with them.
DE LA POER: What was your view about the relationship between the Consultants and the junior
doctors?
DrZA: We generally got on well with our junior doctors. We were a supportive department. We
consistently got good feedback from the GMC trainee doctors survey, and the reputation of Chester
within the deanery was one that junior doctors wanted to rotate to, and certainly that was my
experience, having been
a junior doctor several times at Chester, was that it was a supportive department and that's why I
wanted to go there for my Consultant job because of the positive experience I'd had.
DE LA POER: Now, one particular junior doctor, although he wasn't very junior at the time --
DrZA: Yes.
DE LA POER: -- that we'll be hearing from later today is Dr U.
DrZA: Yes.
DE LA POER: And obviously Dr U is subject to a Crown Court order but you know who I mean by
that?
DrZA: Yes, I do.
DE LA POER: Dr U was at the final stages of his training and was at the Countess of Chester between
September 2015 and 2016; okay? He would be described as a senior middle grade?
DrZA: Yes.
DE LA POER: What was your relationship with Dr U?
DrZA: I had worked with him several times throughout both of our careers, always being slightly
senior to him. He's someone who I felt a positive working relationship with. I wasn't friends
outside of work with him but I think we had quite a friendly working relationship.
DE LA POER: We'll come back to Dr U in the course of my questions. Finally, in terms of the
relationships on the ward and in the department, what was the relationship, did you think, between
the Consultants and the nursing staff?
DrZA: I had always thought that the relationship between the Consultants and the nursing staff was
again positive and friendly. It was only around 2016 when concerns were being raised about Lucy
Letby that that relationship became strained.
DE LA POER: And we've heard from others that their perception was the strain was because the
Consultants took one view of Letby but at least some of the nurses took a different view --
DrZA: Yes.
DE LA POER: -- was that your experience?
DrZA: That was my experience.
DE LA POER: And in terms of the nurses who were taking a different view, we know that the unit
manager was Eirian Powell.
DrZA: Yes.
DE LA POER: Was she in that camp?
DrZA: Yes.
DE LA POER: Were there any other senior nurses in that
camp, by which I mean those part of the management structure?
DrZA: I'm not sure exactly what position other senior nurses had taken. They weren't very vocal
about what they thought in the way that Eirian was, and it became something that we didn't talk
about because it caused strained relationships. So I don't know what a lot of nurses' views were
because we didn't talk about it.
DE LA POER: Now -- and I've asked other Consultants about this -- Eirian Powell has, in her witness
statement, said that the Consultants would think everyone worked cohesively because everyone did
exactly what they said and didn't challenge them. Do you have any comment to make about whether that
accords with your experience or not?
DrZA: Obviously you only know what people say when you're with them, not what they say when you're
not there, but I would disagree that the nurses didn't feel able to challenge us. I think neonatal
nurses have al -- have always not been afraid to advocate for their patients, and the nurses were
quite about saying when they felt that a management plan wasn't quite what they would have liked.
They also were quite happy to ring the Consultants directly if they weren't happy with what
the trainee junior doctors were doing. So I would disagree that they didn't feel able to challenge
us.
DE LA POER: Turning now to relationships with the senior management, and here I'm talking about
those who sit as Executive Directors. What was your impression, before June of 2015, about the
senior managers' attitude towards your department?
DrZA: I didn't really have much of an impression of the senior management. We didn't really hear
from them very much in our day-to-day running. We were very much left to our own devices. If we did
try and raise issues, we never really heard anything back from them. So I don't think there was much
of a relationship.
DE LA POER: Now, one of the words that you use in your witness statement about the period 2015 to
2016 was "disinterested". Just can you help us to understand why you used that word?
DrZA: I think we were a department that generally got on with things. There were problems that were
perceived as being bigger within the Trust, so things with adult medicine and the emergency
department, and it felt that when we raised any issues that they just weren't important to the --
the overall hospital because we were a small department who were getting on with
things.
DE LA POER: Now, what -- we know that paediatrics had recently been moved into a -- the urgent care
directorate --
DrZA: Yes.
DE LA POER: -- whereas obstetrics was in the Planned Care directorate.
DrZA: Yes.
DE LA POER: Do you have a view about whether that made any difference to your department's
connection to the senior management of the hospital?
DrZA: I think it did because when we were part of a women and children's directorate, we were far
less of a small cog in a big machine, we also worked very closely with the obstetricians, so had a
lot of similar issues, and once we joined urgent care, which included the emergency department and
adult medicine, it was perceived that they had far bigger problems and issues. So we were very much
sidelined.
DE LA POER: I would just like to -- I'm going to jump slightly ahead in --
DrZA: Yes.
DE LA POER: -- our chronology but, while we're dealing with this topic of the word "disinterest"
that you used draw your attention to three events around the end of 2015 into the beginning of
2016.
DrZA: Yes.
DE LA POER: So this is in a sense in the middle of the first part of our timeline. Firstly, during
that period, did you send an email directly to Tony Chambers drawing attention to the staffing and
pressure on the paediatric department?
DrZA: Yes.
DE LA POER: And have you also -- and you were on copy at the time I believe -- seen an email sent
at about the same time by your colleague Dr Saladi?
DrZA: Yes, I've seen that email recently and I also recall receiving it at the time.
DE LA POER: And was that also saying something very similar to what --
DrZA: Yes, it was --
DE LA POER: -- you were saying?
DrZA: -- and it rung very true with my own experience of working in the department at that time.
DE LA POER: And if we just bring up a document now on the same theme at about the same time, INQ0017868, please. Now, this is a corporate directors meeting on 27 January
2016. You weren't in attendance.
DrZA: No.
DE LA POER: But if we just look down the list, we can see
about halfway down the Chair of the medical staffing committee a Consultant Anaesthetist, Mr P
Jameson, did attend that meeting, and was Mr Jameson a person who you knew or had any contact
with?
DrZA: Yes. He is -- was one of the Consultant Anaesthetists who specialised in the care of children
and did several children's lists, so we had a relatively close working relationship with him. He was
also the Chair of the medical staffing committee, which meant he looked after the interests of the
permanent medical staff so we knew him in that regard as well.
DE LA POER: So 27 January 2016, about the time that you were sending your email about the time Dr
Saladi was sending his email?
DrZA: Yes.
DE LA POER: If we move forward to page 5, please, please, three quarters of the way down the page,
there is a line ending "PJ", being a reference to Mr Jameson.
DrZA: Yes.
DE LA POER: Do you see that?
DrZA: Yes.
DE LA POER: "PJ felt the paediatric service was almost at breaking point and needed support before
it hits the point of burn out." Does that resonate with your experience at around
that time?
DrZA: Yes, it does.
DE LA POER: Obviously we're not just seeking here specifically about the neonatal unit, this is the
whole paediatric --
DrZA: This is the whole paediatric department.
DE LA POER: -- the whole paediatric department. Thank you very much, that can come down. Now, Dr
ZA, do you have a view about how the pressures that you and your colleagues were under during this
period may be relevant to the crimes that Lucy Letby committed?
DrZA: We were very busy. There weren't enough Consultants for the workloads that we were doing. We
also didn't have enough junior doctors, and that meant that we -- it was relatively common that the
Consultants would have to act down to cover vacant junior doctors' shifts, which was important to
assure the acute safety at that particular time. But that did mean that there was less time for the
non-urgent clinical tasks because everything was done to sort of a prioritise that acute safety. But
it did mean partly that Lucy could hide what she was doing within people being generally busy. It
also meant there was less time for the non-urgent acute
things like reviewing the deaths afterwards and reviewing other incidents because we were so busy
just trying to cover the acute service.
DE LA POER: Now, I'm going to move on to a topic where we are going to deal with a number of policy
matters --
DrZA: Yes.
DE LA POER: -- before we come to our timeline. But the first is safeguarding. Had you received any
safeguarding training on how you should act if you suspected a colleague was harming babies?
DrZA: No, I'd received a lot of safeguarding training throughout my career about what to do if
parents or careers were harming babies but nothing about what to do if other healthcare
professionals were.
DE LA POER: Given your experience and looking back, do you regard that as a significant gap in your
training?
DrZA: Yes.
DE LA POER: In terms of your general awareness of circumstances in which colleagues might
deliberately harm patients, were you aware of the case of Beverley Allitt?
DrZA: I was.
DE LA POER: And so you knew that insulin could be used as a deliberate way of harming patients?
DrZA: I was.
DE LA POER: And were you aware of the nurse at Stepping Hill who had also used insulin in 2011?
DrZA: I think I was aware that there was a nurse at Stepping Hill who had harmed patients but I
don't think I was aware that they had used insulin to do that.
DE LA POER: So it was within your knowledge that that kind of terrible behaviour may occur?
DrZA: Yes, it was.
DE LA POER: We'll come back to those two previous cases shortly, but we'll stay with policy,
please. You tell us in your witness statement that you consulted the Speak Up Safely policy during
2016 --
DrZA: Yes.
DE LA POER: -- is that correct?
DrZA: Yes.
DE LA POER: Just tell us, why did you consult that policy?
DrZA: We felt that we weren't being listened to when we were raising concerns about Lucy Letby, but
we'd already had behaviour that strongly implied that our jobs were at risk if we continued to raise
those concerns, so we wanted to make sure that we were exhausting the options for raising concerns
within the organisation before taking that to outside agencies such as the police.
DE LA POER: Having conducted that research to check your
position, did you establish who it was, if any one person or group of people, that you should be
speaking out safely to?
DrZA: That it was the higher management within the Trust, the Medical Director and the Chief
Executive that we should be bringing those concerns to.
DE LA POER: And across all the various meetings that you attended, did you ever make reference to
the Speak Out Safely policy or the fact that you were speaking out in accordance with it?
DrZA: I don't think I ever did. I think that my colleagues did, but I don't have a clear
recollection after this time.
DE LA POER: And so when you spoke to Executive Directors, in particular those two that you've
named, was it your view that you were speaking to them in their capacity under the Speak Out Safely
policy?
DrZA: Yes.
DE LA POER: The third policy I'd like to ask you about is the SUDiC procedure.
DrZA: Yes.
DE LA POER: Have you followed any of the Inquiry evidence about SUDiC and whether or not it applied
to the hospital environment?
DrZA: I haven't followed the evidence from the
Inquiry in any detail. I know that the wording of the SUDiC policy was very much that it did apply
to deaths in hospital, but that wasn't the practice and the culture at the time. It was only really
applied to children that died in hospital having been found collapsed outside the hospital and came
in with resuscitation ongoing. It wasn't our practice and culture to use that with children that had
died in hospital.
DE LA POER: This might be quite a difficult thing for you to put your finger on --
DrZA: Yes.
DE LA POER: -- but where was that practice and culture coming from? What was driving that?
DrZA: I think it was something that hadn't -- that it was felt that that was a very invasive
process. The SUDiC protocol involved getting the police involved, getting social care involved, and
I think the thinking was that anyone who died in hospital must have had a medical explanation rather
than an unnatural explanation because they were obviously ill enough to be in hospital. So I think
it was felt that that process was very invasive and not necessary, which obviously we now know is
not the case.
DE LA POER: I would just like it bring up the hospital's
own policy, if we can here --
DrZA: Yes.
DE LA POER: -- and just draw your attention to one very small part of it, INQ0003250, and we will go straight to page 33, please. So this is the
Safeguarding and Promoting the Welfare of Children internal Countess policy. Page 33. We can see
there: "The sudden unexpected death unexpected in 24 hours prior to death of a child under the age
of 24 months, irrespective of the place of death, at home or in the community, in the hospital
emergency department or ward." So do you agree, that appears to accord with your understanding the
wider documents?
DrZA: Yes.
DE LA POER: But that policy specific for the Countess also appears to be in direct tension with
what you tell us was the culture and practice in the hospital.
DrZA: Yes.
DE LA POER: Does that surprise you that the hospital's own policy appears to apply SUDiC across all
unexpected deaths?
DrZA: It doesn't surprise me because I've read these documents as part of preparation for coming
today, but it certainly wasn't my understanding at the time.
DE LA POER: Thank you, we can take that down. The final area of policy to ask you about is the
Datix system.
DrZA: Yes.
DE LA POER: When did you understand, in 2015/16, it was appropriate to fill in a Datix form?
DrZA: So a Datix form should be filled in for any clinical incident, which is whenever something
happens that either went wrong or could have gone wrong as sort of a near miss. There was a sort of
pick list of incidents available on the system which kind of flagged up common things that could be
reported like a drug administration error. It was common to report all deaths on the Datix system
but any clinical errors or clinical near misses should have been reported using that system.
DE LA POER: So applying to all events, if there was a concern about a clinical issue, that would
prompt a Datix form?
DrZA: Yes.
DE LA POER: But specific to deaths, even if there was no concern about a clinical issue, you would
still fill in a Datix form?
DrZA: Someone on the team would do.
DE LA POER: How about collapses that required
resuscitation so, in other words, a circumstance where a patient but for outstanding medical care
would have died?
DrZA: That wasn't our practice at the time.
DE LA POER: And, again, looking back on it, do you think it would have been helpful if that had
been the practice?
DrZA: Yes, it would have been.
DE LA POER: And just in a couple of sentences, why do you think that would have been helpful?
DrZA: I think that we had a change in the neonatal care that we provided over the timeline in
question where neonates as a group of patients have always been slightly unpredictable and done
slightly unusual things, but gradually over time the rate of these unpredictable and unusual things
changed quite dramatically. And I sort of can only liken it to the analogy of putting a frog in
boiling water versus a frog being in a pot where you slowly turn the heat up that you don't realise
at the time, because it's a gradual increase, how dramatically things are changing, whereas
something hard and fast like the Datix system may have flagged that up.
DE LA POER: We are going to move to June 2015, although only deal with it briefly. You weren't
involved, yourself, in the care of Children A, B, C or D; is that
right?
DrZA: Yes, that's correct.
DE LA POER: But did you have some awareness of the fact that there had been three deaths on the
neonatal unit in short order?
DrZA: Yes, I was.
DE LA POER: And were you aware that there was discussion about a rash?
DrZA: I can't recall whether or not I was involved in that discussion at the time.
DE LA POER: Let me just see if I can assist your recollection. INQ0025743. Now, if we scroll to the next page, but we can leave it on the
large page view, my apologies for the quality of the text, but you can see at the top it's 23 June
2015 --
DrZA: Yes.
DE LA POER: -- email from Dr Gibbs. You're included --
DrZA: Yes.
DE LA POER: -- in the circulation.
DrZA: Yes.
DE LA POER: And he's there talking about Children A, B, C and D. He's talking, as you can see in
the first paragraph, about a "strange purpuric-looking rash".
DrZA: Yes.
DE LA POER: And in particular that Dr Lambie has come to him very concerned.
DrZA: Yes.
DE LA POER: That's the email in a nutshell.
DrZA: Yes, I do recall this email now.
DE LA POER: So that was -- so is it fair to say that as at, when we come to it, August your
colleagues had shared that information with you?
DrZA: Yes.
DE LA POER: Did you have any conversations with Dr Lambie about her concerns at the time?
DrZA: I don't think so, no.
DE LA POER: And if we scroll to the next page, again leaving it on the overview page, your
colleague Dr Newby, at the bottom agreeing, with Dr Gibbs also talks about Dr Harkness, an other
another trainee doctor --
DrZA: Yes.
DE LA POER: -- coming to speak to her about the concern. So just looking at the position in June
what appears to be clear from these emails is at least two of the Registrars were concerned --
DrZA: Yes.
DE LA POER: -- concerned enough to come and speak to different Consultants separately --
DrZA: Yes.
DE LA POER: -- on the face of it, and you seven Consultants were discussing the cases between
yourselves.
DrZA: Yes, we were.
DE LA POER: So we will just take that down. So that provides us, I hope, with some context for when
we get to [Child E], which we will turn to now. 4 August of 2015 so just about six weeks --
DrZA: Yes.
DE LA POER: -- after that discussion. You tell us in your witness statement that you were present
at the time of [Child E]'s cardiac arrest.
DrZA: Yes.
DE LA POER: And your colleague Dr Harkness, so the same doctor --
DrZA: Yes.
DE LA POER: -- mentioned in that email, told you about discolouration.
DrZA: Yes.
DE LA POER: Now, did that prompt any recollection in you on 4 August about this rash and Dr
Harkness, both of which we can see was being discussed as a matter of concern just six weeks
earlier?
DrZA: No -- Dr Harkness with [Child E] had talked
about discolouration of the abdomen, which made me think of the discolouration which you see with
Necrotising Enterocolitis, or NEC. It didn't remind me of these emails, and Dr Harkness didn't
suggest the link between the rash he'd seen on the previous babies.
DE LA POER: And just to deal with it. In your witness statement you say you're not aware of the
discolouration seen by colleagues. In fact having seen that email, can you see it that you were?
DrZA: I can see that I were. It's difficult to remember the exact order in which things happened
with it being a long time ago.
DE LA POER: Well, certainly I think it is the case, Dr ZA, that it's only relatively recently that
you were given access to that email again --
DrZA: Yes.
DE LA POER: -- is that right?
DrZA: Yes.
DE LA POER: Now, what you say in your witness statement about [Child E]'s death is that it was
unusual because he deteriorated so quickly; is that right?
DrZA: That's correct.
DE LA POER: And was that something that struck you at the time?
DrZA: It's something that struck me at the time that
I was surprised at how quickly he deteriorated, but I felt that there was an appropriate medical
explanation at that time.
DE LA POER: So we will come to that in just a moment.
DrZA: Yes.
DE LA POER: But just to try and understand your thought process, we've heard from other Consultants
that this cluster of deaths was highly unusual --
DrZA: Yes.
DE LA POER: -- for the department.
DrZA: Yes.
DE LA POER: So it isn't just that [Child E]'s death stands in isolation, whatever conclusion --
DrZA: Yes.
DE LA POER: -- you might reach, it sits very much in the context of just nine weeks previously
three other --
DrZA: Yes.
DE LA POER: -- deaths. Do you think that you were sufficiently curious at that stage to look
closely at [Child E]'s death, given the earlier ones?
DrZA: I don't think I'd linked [Child E]'s death to the earlier deaths. I think I was aware that
there had been more deaths than we would expect on the unit, but I felt there was a medical
explanation for E's death at
that time.
DE LA POER: And you thought the most likely presentation fitted with NEC --
DrZA: Yes.
DE LA POER: -- as you've told us. Now, you also say this in your witness statement that at the time
you didn't realise the significance of abdominal x-ray not showing signs of NEC.
DrZA: Yes.
DE LA POER: I just wanted to understand a little bit more about that. Just the first question is
this, and I promise you, I'll give you an opportunity to say what you want to say about it, but did
you at the time look at an abdominal X-ray?
DrZA: I had looked at the abdominal x-ray, which looked relatively normal, which you do see in NEC.
So having an X-ray that shows signs of NEC confirms the diagnosis. Having a normal X-ray doesn't
exclude the diagnosis. It was reviewing E's death in hindsight I thought that if the NEC was severe
enough to cause him to die, then there should have been signs on the X-ray, but I didn't make that
connection at the time.
DE LA POER: So really just to go back to my earlier question, do you -- in terms of your level of
curiosity at that time in the context of what was happening --
DrZA: Yes.
DE LA POER: -- do you think you should have been more curious?
DrZA: Yes, I should have been.
DE LA POER: And stripping out hindsight, it's a difficult thing to do I know --
DrZA: Yes.
DE LA POER: -- but do you think at the time you should have noticed that the X-ray was normal and
that that may be -- contra-indicate NEC or in some way cause you to doubt --
DrZA: It would have made that less likely --
DE LA POER: Less likely --
DrZA: -- so I should have been more curious at the time.
DE LA POER: And had you been more curious, what investigations were available to you at the time to
take that further?
DrZA: I spoke to the Coroner and explained that I thought the cause of death was NEC, which meant
that the Coroner and I agreed that we should issue a -- I should issue a medical certificate of
cause of death with that as the explanation. Had I not had those thoughts when I discussed it with
the Coroner, then [Child E] would have had a postmortem to look for the
cause of death.
DE LA POER: In fairness to you, I just want to give the other side of it.
DrZA: Yes.
DE LA POER: What was the other side of your thought process about why you perhaps didn't want a
postmortem to take place?
DrZA: I knew that [Child E]'s parents were already devastated and didn't like the idea of a
postmortem, and I didn't want to do anything that made what was already an awful situation for them
any harder. So it was the wrong decision but it was done with the best of intentions.
DE LA POER: Because I'm sure implicit in that is that although the views of the family are
extremely important and must be dealt with as being something you should have proper regard to
--
DrZA: Yes.
DE LA POER: -- in this situation, if a postmortem was required a postmortem should take place?
DrZA: Yes.
DE LA POER: Now you filled in a form --
DrZA: (Nods).
DE LA POER: -- about [Child E]'s death, I would like just to bring that up, please, INQ0012016, just to see if you
can help us understand how this form is put together. So I think it's sometimes referred to as the
Form AB?
DrZA: Yes.
DE LA POER: I'm sure you are very familiar with. It. If we can please move to page 4, and we can
see at the top under the heading "SUDiC", "Death expected", and then there are four options to
check, "Expected", "Expected but meets exclusion criteria", "Unexpected NHS commissioning board
notification". The "Unexpected but meets exclusion criteria" box is checked. Can you just help us to
understand what that means in practical terms?
DrZA: I think that that's because I've discussed it with the Coroner and we've agreed on a cause of
death.
DE LA POER: It's difficult, but do you know what the exclusion criteria are?
DrZA: Not off the top of my head, no.
DE LA POER: No, but they sit in your mind with the fact that you had agreed with the Coroner that
the cause of death could be certified?
DrZA: Yes.
DE LA POER: Thank you very much indeed, we can take that down now. It may be that you will be asked
some questions
about interactions with [Child E]'s parents but I'm not going to ask you about those now. I'm just
going to move forward, please, to the position on the ward and in particular as between the
Consultants and whether or not, now that there had been four deaths, there was a Consultant-wide
discussion?
DrZA: There was. I can't recall exactly when but there was a quite a high level of concern that we'd
had four deaths at this stage, and very much a worry about what were we overlooking in terms of
medical care, environment, why -- why had this happened, what could we do to try and stop this
continuing to happen.
DE LA POER: In the course of those discussions, did anybody say within your hearing that there was
concern that there may have been deliberate harm caused?
DrZA: I can't recall anyone saying it at that stage.
DE LA POER: Just so that we time mark that, we are talking about the period immediately following
the death of [Child E].
DrZA: Yes.
DE LA POER: In your witness statement, you make a comment about the level of detail that Letby put
in the notes for [Child E] --
DrZA: Yes.
DE LA POER: -- and that that was something that struck you at the time. Can you just tell us,
please, what it was that caused you to notice that note and what your observations about it are?
DrZA: So I noticed that note while preparing my witness statement for the police some years later.
There was nothing kind of hard and fast, it just seemed quite a lot of information about the memory
boxes and taking pictures of E and F together, and it just seemed more detail than I would have
expected but there was nothing sort of hard and tangible, it was just as part of that overall
picture that we had of Lucy Letby at that stage.
DE LA POER: I'll just unpack that a little bit. Obviously you have huge experience of reading
medical and nursing notes --
DrZA: Yes.
DE LA POER: -- it follows from what you say that the level of detail about that note didn't strike
you at the time.
DrZA: I didn't I don't think I saw it at the time.
DE LA POER: But it, later, at a time when you knew there was a police investigation, you did see it
--
DrZA: Yes.
DE LA POER: -- and it's then that you've made the comments about it being perhaps slightly
inconsistent with what you usually see in notes.
DrZA: Yes.
DE LA POER: We're just going to stay with [Child E] here and move forward in our chronology before
coming back to [Child F]. But there was a Neonatal Mortality Meeting on 26 November 2015, which you
tell us you didn't attend because it was a non-workday for you.
DrZA: Yes.
DE LA POER: Now, although it was becoming increasingly more common for deaths to occur on the
neonatal unit they weren't -- it wasn't, as some departments will experience, a department that had
deaths occurring very often --
DrZA: Yes.
DE LA POER: -- is that fair?
DrZA: Yes.
DE LA POER: And those neonatal mortality meetings are important.
DrZA: Yes.
DE LA POER: And you shouldn't understand me to be criticising you at all for not going to work that
day --
DrZA: Yes.
DE LA POER: -- I want to look at a different side of it, which is, do you think, bearing in mind
that you were involved in [Child E]'s care and had signed the death certificate, that in fact steps
should have been taken
to ensure that you could attend the meeting about [Child E]'s death?
DrZA: Probably with hindsight, yes. But that wasn't how we practised at the time but then we did
have a lesser number of deaths at that time. I was also the first person in our department to work
less than full time, so that was a relatively new situation for the department.
DE LA POER: But it almost always might be the case that a Dr may not be working --
DrZA: Yes.
DE LA POER: -- when a meeting is scheduled --
DrZA: Yes.
DE LA POER: -- that's just -- that's just how the rota --
DrZA: Yes, they may be on annual level --
DE LA POER: Absolutely.
DrZA: -- they may be covering acute things.
DE LA POER: Absolutely. So it is not at all a question about the hours that you kept --
DrZA: Yes.
DE LA POER: -- it's more about how things were arranged to make sure the most important people
attend important meetings.
DrZA: Yes.
DE LA POER: And I think you've agreed that really it
should have been arranged so that you could attend.
DrZA: Yes.
DE LA POER: So [Child F] -- we go back to the 5 August -- and we know that a -- that [Child F] was
hypoglycemic on 5 August --
DrZA: Yes.
DE LA POER: -- a sample of blood was taken, it went to the Liverpool laboratory and it came back to
the Countess on 13 August 2015 --
DrZA: Yes.
DE LA POER: -- at a time when [Child F]'s condition was stable.
DrZA: Yes.
DE LA POER: Now, we'll just have a look, please, at the results as they appear on the notes. It's
INQ0000859, please, and we will go to page 334. I regret to say that that is a
less good quality copy than I believe the Inquiry holds. But hopefully --
DrZA: That's fine I've seen --
DE LA POER: You've seen this before --
DrZA: I've seen it before, yes.
DE LA POER: -- so I'm not asking unfair questions here. And the essential point here is that the
insulin level is high whereas the C-peptide level is low.
DrZA: Yes.
DE LA POER: And did it form part of your training that that will occur when somebody has
administered insulin externally --
DrZA: Yes.
DE LA POER: -- exogenous insulin as opposed to insulin that the body has produced --
DrZA: Yes.
DE LA POER: -- because you would expect a higher C-peptide level?
DrZA: Yes.
DE LA POER: And is this how the results will appear in the notes, presumably more legible, but this
is -- this is what will come up when you look at the electronic notes?
DrZA: Yes, yes, this is what came up on our electronic results system.
DE LA POER: And is there another significant issue when interpreting these results, namely the
glucose level?
DrZA: Yes, you need to know what the glucose level was doing at the time because the body's own
amount of insulin and other hormones is a dynamic state and very much depends on what the blood
glucose is.
DE LA POER: So I think, and you'll tell me if I'm wrong about this, if we go to 337, we can see the
glucose result. Can you see that?
DrZA: That's cerebral spinal fluid rather than blood
there.
DE LA POER: Right. Well, we can take that down for the time being. At all events, did you check the
glucose level?
DrZA: The reason the bloods were done was because the glucose level was extremely low at that point.
The bloods were taken as part of what's called a hypoglycemia screen, and that's when a baby has a
very low blood sugar, it's to look for reasons why that may have happened, and it's important that
those bloods are done at the time of the low blood sugar because of the importance of interpreting
them in the light of the sugar result.
DE LA POER: This is a hypoglycemic episode.
DrZA: Yes.
DE LA POER: Would you expect the insulin levels to be low or high?
DrZA: Low.
DE LA POER: Low. And on this result, were the insulin levels low or high?
DrZA: No, they were high.
DE LA POER: So that's a first marker that something unexpected is happening?
DrZA: Yes.
DE LA POER: And the second marker is the ratio between the
insulin and the C-peptide; is that right?
DrZA: Yes, that is correct.
DE LA POER: Now, let's just bring up your notes, which is the same INQ0000859 and page 39, please. Yes, that's the -- do you recognise that
note?
DrZA: Yes, I've seen that before.
DE LA POER: It's at half past 10 --
DrZA: Yes.
DE LA POER: -- on the morning of 13 August. We can see the SHO, Dr Lidden --
DrZA: Yes.
DE LA POER: -- starts the note. We've got the hypo screen results recorded there.
DrZA: Yes.
DE LA POER: I don't think we have the glucose recorded but that was something that you noted at the
time, was it?
DrZA: Yes, we know that those were done when the glucose was very low --
DE LA POER: Yes.
DrZA: -- I can't remember the exact reading, but it was very low at that time.
DE LA POER: And you are recorded by Dr Lidden as saying: "Insulin high, C-peptide low, unusual for
hypoglycemia as now well and sugar stable for no further ..."
What's that last --
DrZA: It's an abbreviation for "investigations". I mean, this -- this is quite a short paragraph
that sums up what was a sort of much longer discussion. We discussed how the blood results looked as
if [Child F] had been given exogenous insulin, which is an insulin as a medication given. We checked
that it wasn't prescribed. We checked that no one else on the unit at the time was on insulin,
thinking about: was it done accidentally? But the idea that someone could be doing it deliberately
just seemed so fantastical and unlikely that that couldn't possibly be what had happened. With
neonatal blood samples, because they're so small and often difficult to obtain, we do get unusual
results from time to time, and our normal practice if something is outside of what we would expect
is to repeat them. We obviously couldn't repeat the bloods at this point because [Child F] was well
with a normal glucose level, so we wouldn't be able to repeat them. At the time, I just dismissed
the idea of someone deliberately administering insulin because it just seemed so impossible, but I
deeply regret that that is how I interpreted things both for [Child E] and F's parents and for all
the babies that happened subsequently. I wish I'd interpreted these in a very different light, but
at the time it just didn't seem possible that someone could do that.
DE LA POER: Absolutely recognising that you have just accepted very candidly that you
misinterpreted those results --
DrZA: Yes.
DE LA POER: -- and did not take steps that you should have taken --
DrZA: (Nods).
DE LA POER: -- just trying to understand a little bit more about why. You've used that phrase
"impossible" more than once --
DrZA: Yes.
DE LA POER: -- what about the case of Beverley Allitt, didn't that potentially come to your mind in
any way that that is a --
DrZA: It didn't --
DE LA POER: -- real life example?
DrZA: I don't know why not. That's -- I've sort of grown up with the knowledge of Beverley Allitt
and what she did in sort of common knowledge, and then later Harold Shipman, but it just never --
never occurred to me that that would be something that happened on my ward to the patients I was
looking after.
DE LA POER: And you've raised the fact that you've had experience of results being surprising and
not according with what you think the picture should be --
DrZA: Yes.
DE LA POER: -- I hope I've characterised that correctly, presumably that's a relatively rare
occurrence?
DrZA: It has -- it's in not that rare in neonates. Because they are physically so small and their
veins are so small the taking of blood is more difficult. The giving the lab big enough samples that
they can analyse is quite difficult. So the two things that happen are either that the samples can
clot because the blood comes out quite slowly or that it can haemolyse, which means the cells break
down because of the small veins and the small needles, and the need for sort of pressure to get the
blood out. So it would be relatively rare in older children and in adults but it's something we saw
not infrequently in neonates that would have slightly unexpected readings, and we would repeat them
and they'd be okay.
DE LA POER: And had you ever seen that in relation to an insulin C-peptide --
DrZA: Never in relation to an insulin C-peptide.
DE LA POER: And so although it existed as a possibility for some results, you hadn't seen for this
sort of
result that happening?
DrZA: Yes, but this wasn't a sort of result that we had that often. They went -- they got sent off
to the lab in Liverpool, and by far and away the most common result we got back was that the sample
was insufficient for them to process, so we were more used to not getting a result because of the
technical difficulties.
DE LA POER: That was going to be my follow-up question because, again, that isn't this scenario, is
it --
DrZA: No.
DE LA POER: -- because you did get some results --
DrZA: Yes.
DE LA POER: -- with no suggestion from Liverpool that there was any reason to doubt them.
DrZA: No.
DE LA POER: Now, just to be clear about two things. Firstly, and we can look at it if you want to,
but looking at your police same you said: "I did not have anything unnatural in my mind at the
time." You've told us about a process where you discussed it with Dr Lidden, you went so far as to
check whether or not any other baby was due to receive insulin on that day, and you've described a
thought process where -- which, as you've described it, sounds like you thought
about whether there was something unnatural and dismissed that --
DrZA: Yes.
DE LA POER: -- as impossible.
DrZA: Yes.
DE LA POER: So just help us to understand, what was your true state of mind, did it cross your mind
and you rejected it?
DrZA: It crossed my mind and I rejected it.
DE LA POER: And, secondly, just in terms of whether you should have done more, in your witness
statement you say "with hindsight". I'm not suggesting that that's wrong, but do you think that you
need hindsight to know that you should have done --
DrZA: No --
DE LA POER: -- something different?
DrZA: -- I made the wrong decision.
DE LA POER: Should it have prompted a Datix form?
DrZA: It should have yes.
DE LA POER: Was it potentially serious enough that you should have contacted Dr Brearey or Dr
Jayaram?
DrZA: Yes, I probably should have done.
DE LA POER: Was it an issue for the nursing ward manager?
DrZA: Again, if I had not dismissed the thought of it being deliberate, then if I thought it was
deliberate, then absolutely it should have done.
DE LA POER: Now, you say that you weren't involved in any debrief for [Child F]. Do you know if one
took place?
DrZA: I don't think so.
DE LA POER: Given [Child F]'s course, would you have expected there to be a debrief for [Child
F]?
DrZA: No, because he'd recovered from that episode of hypoglycemia and was well enough to transfer
back to his home unit (redacted).
DE LA POER: If there had been some sort of debrief, do you think that, as they were conducted at
the time, those results might have come to the surface and there had been a discussion about
them?
DrZA: Yes, I think it would have done.
DE LA POER: Just help us to understand the practicalities. Would having a debrief in a case such as
[Child F] completely overwhelm the department if you applied that across the board or was it in fact
practical to do that?
DrZA: I think sort of referring back to what I'd said earlier about that sort of gradual increase in
acuity and strange things happening, I think at the peak of that timeline it probably would have
overwhelmed the department, but in the department as we are now and as we were before this period it
wouldn't have done. So it would have been a sensible thing to have done.
DE LA POER: And so does that go back in part to what you were saying about how much pressure the
paediatric department was under at that time as well as the additional stress caused by the increase
in the number of deaths and collapses?
DrZA: Yes.
DE LA POER: Now, you were away from the Countess of Chester between December 2015 and March 2016;
is that right?
DrZA: Yes, that's correct.
DE LA POER: It will follow from that that you were still working in 2015 at the time of the
collapses of [Child G], H and J. Were you aware of any of those collapses at the time that they
occurred?
DrZA: I can't recall.
DE LA POER: You were also working at the Countess when [Child I] repeatedly collapsed over a number
of days and then died.
DrZA: Yes.
DE LA POER: Were you aware of [Child I]'s death?
DrZA: Yes.
DE LA POER: And did [Child I]'s death bring to your mind your involvement in [Child E] or [Child
F]?
DrZA: I don't think it did. The period where I was off between December and March was a very
significant
personal stress.
LADY JUSTICE THIRLWALL: You don't need to tell us about that.
DrZA: And I think that probably affected some of what I was remembering of the previous time.
MR DE LA POER: Absolutely, and it's entirely my fault, [Child I] died in October 2015 so before you
--
DrZA: Okay.
DE LA POER: -- went away. So I don't -- and I'm not looking it pry at all --
DrZA: Yes.
DE LA POER: -- whether you going off in December affected the period before or not --
DrZA: Yes, I think I have just got confused at the timeline, but yeah --
DE LA POER: No, that's my fault.
DrZA: -- I don't recall linking them at the time, other than the feeling that we all had that things
had changed and things --
DE LA POER: Now --
DrZA: -- were not as they had been previously.
DE LA POER: -- Dr Newby, Dr Gibbs have both told us about the period after [Child I]'s death when
they were involved in a conversation with Dr Jayaram and Dr Brearey in which serious concerns were
raised.
Now, memories perhaps differ about the detail --
DrZA: Yes.
DE LA POER: -- and who was at which discussion, so I don't want to misstate the position, but were
you involved in any discussions with any of those four people following the death of [Child I], so
the period November into December?
DrZA: I think I was. I was aware that there was a definite sense of unease about what had happened
with several of my colleagues who'd been involved with more of the babies. I can't recall the exact
details of that but there was a sort of growing sense of unease and unhappiness at what had
happened.
DE LA POER: In the course of any of the conversations that you were present at, did anybody suggest
to you that they were concerned that deliberate harm may be being caused to babies on the neonatal
unit?
DrZA: I can't recall exactly when that was first mentioned, whether it was at that point or in early
2016. I do recall someone mentioning the association of Lucy Letby with the number of deaths and
collapses but that being explained by the fact that she did more shifts and she was one of the few
nurses with the intensive care qualification who wasn't a shift leader, so was more likely to be
looking after the sick babies.
DE LA POER: Do you recall who it was who drew your attention to her being in common with these
deaths?
DrZA: I think it might have been Steve Brearey but I'm not 100% sure.
DE LA POER: And do you recall whether that was before or after you had your period away from the
hospital?
DrZA: I'm not 100% sure.
DE LA POER: Just to complete the picture in relation to [Child F], we'll just bring up an email
here please INQ0005890. We're going to jump right to the end of the period that we are
looking at.
DrZA: Yes.
DE LA POER: This is 6 June 2017, so by now the police have been contacted.
DrZA: Yes.
DE LA POER: So we're right at the end, as I say, of the period that we were focusing on. This is an
email from you to Dr Brearey in which you are recalling a baby with high glucose requirements seemed
to fluctuate. You say: "Astha and I did a lot of hypoglycemic bloods and insulin level was high and
C-peptides suggested it could be exogenous insulin." Firstly, can you help us with who Astha is?
DrZA: Astha that was one of our junior doctors, but
I think I must have misremembered who it was because she wasn't involved in this particular case. At
the time of this email, I was on (redacted) leave and I just had something in the back of my mind
nagging about [Child F]'s results and the fact that at the time I'd dismissed the possibility of
deliberate harm, but now, based on what we were thinking, that didn't seem so impossible any more.
But I couldn't remember [Child F]'s details and I wasn't in the hospital to be able to look, so I
wanted to flag that to Steve.
DE LA POER: Thank you, we take that down. So there's no doubt about it, this is [Child F] that you
are --
DrZA: Yes.
DE LA POER: -- seeking to recall?
DrZA: Yes.
DE LA POER: Thank you. Finally for 2015, we've heard evidence from Dr Lambie, who left in September
2015, that she came upon a huddle of nurses who were looking at the rota together to see who had
been on when events had occurred. Were you aware of such a huddle taking place or any discussion
between the nursing about that?
DrZA: I wasn't aware of that, no.
DE LA POER: Moving forward into 2016, although it may not be 2016, you'll tell us --
DrZA: Yes.
DE LA POER: -- you tell us in your witness statement you attended a workshop when the CQC
visited.
DrZA: Yes.
DE LA POER: And was that a workshop for Consultants?
DrZA: Yes, it was.
DE LA POER: And you tell us that you sought to raise patient safety issues with the person running
it and that they suggested you speak to them at the end --
DrZA: Yes.
DE LA POER: -- and by the time the end came, they left immediately and you didn't get to say
anything more.
DrZA: Yes.
DE LA POER: What year did that take place?
DrZA: I think it took place in 2018. I know that some of my colleagues -- Dr Brearey in his witness
statement thinks that I raised something with the CQC in February 2016. I don't have any
recollection of doing that. I also was on a period of extended leave at that point and I don't think
I would have come into the hospital for a CQC meeting.
DE LA POER: Just being realistic about it, do you think you would have remembered during that
period if you'd come in for such a meeting?
DrZA: Yes, I think anything that I came in for
during that period would have to be very significant, so there's a -- I think I probably would
remember it.
DE LA POER: And also, would you have been quite an odd choice to be a spokesperson for the
Consultant body and the paediatric department, given that you were -- had been out of the loop for a
period of time by the time that meeting happened?
DrZA: Yes. I think the meetings are more sort of drop in than sort of nominated representatives. But
I don't think I would have gone to represent my colleagues in that period of time. That wasn't where
my priorities were.
DE LA POER: Thank you. [Child L] who we can deal with briefly. 9 April 2016, Dr Gibbs has
described, as I'm sure you know: "It is a collective failure by the Consultant body to interpret and
act upon [Child L]'s insulin and C-peptide ratio." Do you agree with that?
DrZA: Yes.
DE LA POER: Now, you returned to the Countess of Chester in March of 2016 --
DrZA: Yes.
DE LA POER: -- from your period of extended leave.
DrZA: I had a phased return, so I, over the next few months, gradually increased my clinical duties,
so I wasn't sort of fully back at work from March.
DE LA POER: But were you made aware of the outcome of the thematic review into neonatal
mortality?
DrZA: Yes, I was.
DE LA POER: And I think you were allocated a job under that action plan to ensure junior doctors
knew about sepsis.
DrZA: Yes.
DE LA POER: In that phased return to work period, at the latest, was that when you heard Letby's
name mentioned as being a common factor?
DrZA: Yes, that was definitely more of a concern when I came back.
DE LA POER: So you've told us it may have been before you went off --
DrZA: Yes.
DE LA POER: -- but if we bookmark it as the latest, it's that period there?
DrZA: Yes.
DE LA POER: And was it also at the latest during that period that you became aware of concerns by
your colleagues that deliberate harm may be caused?
DrZA: Yes.
DE LA POER: And was that a view which you agreed with,
disagreed with or thought might be a possibility?
DrZA: It's one that I thought might be a possibility. It was a general feeling of collective unease
at the sudden, unexpected and unexplained nature of events and the correlation with Lucy being
present, but nobody sort of knew exactly what she was doing to have a sort of positive explanation
for it. It was that sort of uncomfortable association at that point and the lack of another
plausible explanation.
DE LA POER: So you told us in relation to [Child F] that you considered the possibility of
deliberate harm and rejected it out right.
DrZA: Yes.
DE LA POER: This is different, if I've understood your answer correctly.
DrZA: Yes.
DE LA POER: So is it fair to characterise it as during that period you thought that Letby may be
harming babies?
DrZA: Yes, but I didn't have any positive evidence of that. It was more the growing association and
the lack of other explanations.
DE LA POER: Given that that was your state of mind, that a member of staff may be harming, may be
killing babies, should you have done something at that stage to ensure
that there was urgent action?
DrZA: I should have done.
DE LA POER: And why is it that you think that you didn't?
DrZA: I think partly because the concerns were coming from my colleagues who were already trying to
do things, partly because there was no definite proof, it was just a sort of growing concern and
uncomfortableness, and the fact that that would be a devastating accusation to make.
DE LA POER: In the context of safeguarding in the community, do you need to wait for definite
evidence --
DrZA: No, you don't.
DE LA POER: -- in order to act. And so, in reality, was this any different to that?
DrZA: No, it wasn't.
DE LA POER: Did you have any discussion with Dr Brearey about his meeting on 11 May with the
Executive Directors Ian Harvey and Alison Kelly?
DrZA: I can't recall.
DE LA POER: Do you recall receiving his email on 16 May in which he asked for any sudden unexpected
collapses to be drawn to his attention?
DrZA: Yes, I do recall that email.
DE LA POER: And what was your understanding at that time about what steps the senior management
were taking?
DrZA: I understood at that point that they were aware of our concerns, that they didn't feel there
was a threshold to do anything at that point but wanted to be kept appraised of the situation if
there were any more episodes.
DE LA POER: And were you yourself satisfied at that stage with that reaction from senior
management?
DrZA: I think I probably was being a bit more distant to what was happening than some of my
colleagues.
DE LA POER: So we come to the deaths of [Child O] and [Child P].
DrZA: Yes.
DE LA POER: Now, you weren't involved in their care at the time of their deaths; is that right?
DrZA: That's correct.
DE LA POER: But is it right that you came -- became aware of their deaths shortly afterwards?
DrZA: Yes, I did.
DE LA POER: And was that before or after the senior paediatrician meeting on Monday, 27 June, do
you know?
DrZA: I don't know off the top of my head, no.
DE LA POER: Was that a meeting that you attended? So the [Child O] and [Child P] died the previous
week, 23rd, 24th.
DrZA: Can I just check my statement?
DE LA POER: I don't think it's dealt with in your statement.
DrZA: Okay. I know that I did have a period of annual leave around the time of those deaths, which
is why I wasn't involved in their care. I can't recall exactly which date I returned to work.
DE LA POER: Do you recall any meeting at which, as we've heard from other witnesses, a group of
paediatricians -- senior paediatricians together with Eirian Powell met and were saying out loud
that they were concerned that Letby may be harming babies?
DrZA: Yes.
DE LA POER: So you remember --
DrZA: Yes.
DE LA POER: -- being present at such a meeting --
DrZA: Yes.
DE LA POER: -- whenever it took place?
DrZA: Yes.
DE LA POER: You know that Dr Saladi sent an email on 29 June suggesting that the police should be
involved.
DrZA: Yes.
DE LA POER: Was that a view that you agreed with or disagreed with?
DrZA: Yes, I thought the police should have been involved as well.
DE LA POER: Further up that chain, Ian Harvey gave a direction that emails should cease. Do you
recall receiving that?
DrZA: Yes.
DE LA POER: And what was your reaction to that?
DrZA: That it seemed like this was something very important and it shouldn't be something that we
should be told to stop discussing.
DE LA POER: Now, on 5 July, you were involved in carrying out a review of [Child O] and [Child P]'s
death.
DrZA: Yes.
DE LA POER: And also participating was Dr U.
DrZA: Yes.
DE LA POER: What you say in your statement is that: "I believe that we referenced the increase in
mortality and Letby's presence." And you also say: "Staffing factors and the possibility of Letby
having something to do with the deaths either by incompetence or deliberate harm was discussed."
DrZA: Yes.
DE LA POER: I'd just like you to -- in your own words, what was actually said by people at the
meeting about Letby and whether deliberate harm may have been caused?
DrZA: I think both myself and Dr Brearey stressed
the fact that we couldn't medically explain these deaths, that there was a -- the continued
association of Lucy with sudden unexpected, unexplained deaths and collapses and that that
association had gone far beyond coincidence and her working pattern, and, therefore, we thought that
she must be involved in some way, either by unconscious incompetence or by a deliberate act.
DE LA POER: And so for all of those who were at the meeting, would they have been clear that there
was a --
DrZA: Very, very clear. We were far clearer in the discussion than is in -- on the minutes of that
meeting.
DE LA POER: So not talking in code but speaking your minds.
DrZA: Yes.
DE LA POER: The meeting on 13 July, as we know, involved a presentation of information to the
Consultant body about the so-called deep dive --
DrZA: Yes.
DE LA POER: -- that had been done. I'm just going to put up on screen INQ0006458. This is really just so that you know what we are talking
about.
DrZA: (Nods).
DE LA POER: I know you've been through it. So this appears to be a PowerPoint presentation or
slideshow that has been provided to the Inquiry. Was
this the presentation that was made to you?
DrZA: No.
DE LA POER: And you've been through it and satisfied yourself of that?
DrZA: Yes.
DE LA POER: And is there any --
DrZA: Some bits of it may be the same but it wasn't the PowerPoint.
DE LA POER: Thank you, we can take that down. Is there any particular information that was put on
screen that isn't in that display that stood out for you at the time?
DrZA: Yes. There was a very clear slide projected that had a lot of patient identifiable data of
mums and babies, and it sticks very clearly in my mind (redacted).
DE LA POER: Did you say anything at the time?
DrZA: Yes, I did.
DE LA POER: What did you say?
DrZA: I asked Ian Harvey if he could remove the slide (redacted), which he did. (redacted). Dr
Harvey carried on with the presentation and didn't reference it again.
DE LA POER: Did he apologise?
DrZA: No.
DE LA POER: Now, as the Inquiry understands it, what was being said at the meeting to the
Consultant body was that the increase in deaths may be in part explained by an increase in activity
and acuity?
DrZA: Yes.
DE LA POER: Was that a conclusion, having been a Consultant on the ward, that you agreed with or
disagreed with?
DrZA: I disagreed with it.
DE LA POER: What was the central point that you Consultants made at the meeting about the data?
DrZA: There was some data about staffing levels and the deaths, but it seemed that many of the
deaths had happened on the days with better staffing levels as opposed to fewer staff. And although
we had -- we had agreed that we had been busier, the nature of the deaths weren't explained by the
increased acuity.
DE LA POER: Did the data take into account whether the deaths were expected or unexpected,
explained or unexplained?
DrZA: No, and didn't take the gestation of the babies into consideration either when a lot of the
babies who'd died were still premature babies but the less extreme prematurities where it's more
unusual for children to die.
DE LA POER: And was that a point made at the meeting?
DrZA: Yes.
DE LA POER: We know that the Trust arranged for the RCPCH to carry out an inspection. What was your
view about that as being an appropriate or inappropriate investigative step?
DrZA: I felt that it was an appropriate step. We had definite concerns about Lucy Letby. We didn't
have any sort of definite proof or anything concrete, and the idea of experienced, knowledgeable
people coming and having a look at the situation with outside viewpoints to know whether our
concerns were reasonable or not seemed an appropriate step. I think it's important to acknowledge
that, at this point, Lucy Letby was on annual leave and wasn't working, so in some ways we felt that
had taken some of the urgency out of the situation because she wasn't on the unit at that point.
DE LA POER: We understand that certain comments were made about the acceptable circumstances for
her return CCTV, and direct supervision --
DrZA: Yes.
DE LA POER: -- but we know, is this right, that she returned to a non-patient facing role?
DrZA: Yes. We discussed the facts -- the need for
there to be -- if she was supervised practice it would need to be constant supervision by someone
who knew the reason why they were supervising her because they wouldn't be able to sort of nip out
to go to the toilet or get a drink, it would have to be sort of constant supervision because the
nature of what we were concerned about.
DE LA POER: You participated in the interview on 1 September with the RCPCH.
DrZA: Yes.
DE LA POER: What was said to the reviewers about Letby, if anything?
DrZA: We were very open from the beginning of our meeting that our concern was that Lucy Letby was
doing something deliberate to harm babies.
DE LA POER: Later that month, there was a meeting with Tony Chambers on 19 September, which you
deal with in your witness statement, but it wasn't one that you went to but you do comment upon it.
Within the minute meeting -- minutes of the meeting, forgive me, it's indicated that the Consultant
body did not feel listened to?
DrZA: Yes.
DE LA POER: What was your feel about the approach of the senior managers at that period towards the
back end of
2016?
DrZA: It seemed initially like they didn't want to listen to our concerns, and then over time, as we
became more persistent, it seemed that they wanted us to be quiet and shut up about it.
DE LA POER: And are you able to identify a moment or a period in time when it changed from not
listening to "Be quiet"?
DrZA: I think the most definite be quiet moment for me was the meeting -- I think it was the 27
January, which is in my statement. Can I just check that that's the correct --
DE LA POER: It's paragraph 85 I think is the one you have in mind, the 26th?
DrZA: Yes, 26 January. I remember this meeting very clearly. We didn't receive the minutes until
some time later, and I'm not listed on there but I definitely attended this meeting. There was a
very adversarial atmosphere from the moment we first entered the room.
DE LA POER: Can I just ask you a few questions about --
DrZA: Yes.
DE LA POER: -- about just focusing on a number of aspects? Firstly, how would you describe the tone
of the senior managers, was it the same -- were they speaking with the same tone or was it
different?
DrZA: I felt very much -- all of them seemed to be speaking with the same tone and it very much
seemed like we'd been called into the headmaster's office like naughty school children.
DE LA POER: You had a summary provided to you of what the RCPCH and Dr Hawdon had said.
DrZA: Yes.
DE LA POER: As a Consultant paediatrician, are those reports that you would have expected to read
before you went into the meeting or would it be usual for it to be presented to you?
DrZA: No, I would have expected to see those reports in advance, have time to read and digest,
presumably -- I would expect there to be complex information in there that I would need time to
consider, and as being open to learning and improvement you would want to see the detail of those
reports to know exactly what was said and how we as a department could improve things.
DE LA POER: Is there any particular phrase that you recall being said in the meeting that stands
out for you?
DrZA: Yes. Tony Chambers said that he was "drawing a line" and we "weren't to cross it".
DE LA POER: And --
DrZA: Which was said in quite a threatening tone.
DE LA POER: And what did you think that might mean for
your job?
DrZA: I very much took it to mention that if we continued to carry on raising our concerns, then my
job would be at risk. I went home that night and with my husband worked out how long we could pay
our mortgage and bills for if I were to lose my job, so it certainly felt real and that that was a
genuine possibility.
DE LA POER: You mention in your witness statement being taken aside by -- and I'm quoting here "two
of the women".
DrZA: Yes.
DE LA POER: Do you know who they were?
DrZA: I don't definitely enough to say in this forum.
DE LA POER: Are you able to say whether they were Executive Directors?
DrZA: Yes, they were.
DE LA POER: And what did those two women say to you when they took you to one side?
DrZA: (redacted) they intimated that it was Dr Jayaram and Dr Brearey putting pressure on me to go
along with what they were saying, which I said that very much wasn't the case, that I had formed my
own opinions, and what I found stressful was the fact that no one was taking my considered medical
opinion seriously.
DE LA POER: And you said that in those terms to the two Executive Directors?
DrZA: Yes.
DE LA POER: We can -- we've heard a lot of evidence about the exchange of letters that then follows
--
DrZA: Yes.
DE LA POER: -- so we can deal with it relatively briefly. But having seen Dr Hawdon and the RCPCH
report, did you think the deaths and collapses had been adequately investigated?
DrZA: No, I did not.
DE LA POER: We're just going to have a snapshot of how you were feeling at the time as expressed in
an email INQ0006078. It's the email in the middle dated 17 February. You say: "I am
possibly just too jaded and distrustful now but I worry what the Coroner has been told if he has
been given our letter from the 10th and this quite clearly points out our concerns and we have to
wait for his response." Why were you describing yourself as "jaded and distrustful"?
DrZA: I think it follows on from the College review where it was apparent when we met with the
reviewers that they'd already been told of our concerns before but
had been told that they were irrational and were quite dismissive of what we were saying. I just
worried that the Coroner may be presented with our concerns in a similar fashion, but I felt that
our letter was quite straightforward and frank, and if the Coroner had that information, then that
would hopefully be sufficient.
DE LA POER: Thank you, we can take that down. I'd just like to take you to your concluding remarks
at paragraphs 110 and 111 of your witness statement. I should acknowledge on the way, you didn't
attend the meeting with Simon Medland QC, did you?
DrZA: No, (redacted).
DE LA POER: So I don't need to ask you about that. So could you just turn up, please, paragraphs
110 and 111 on page 22. Just refresh your memory from that and then just give us, please, Dr ZA,
your summary of your experience over this period as captured there.
DrZA: So I've said that when raising concerns we were initially ignored and then later actively
bullied and victimised. I genuinely believed that my job would be at risk if I continued to raise
concerns. I think there was a false narrative developing that Dr Jayaram and Dr Brearey were ring
leaders rather than that we were all professionals who'd come to the same conclusion. We decided
that we needed to continue to raise our concerns collectively as a group of seven and preferably in
writing, because then there can be less room for misrepresentation or misinterpretation. And I also
had some soul searching about what I would -- at what point would I be happy to stop raising
concerns and stop pushing, and I decided that the only point I would feel that I could sleep at
night and live with myself was that if Lucy Letby wasn't working as a nurse or as a similar
position, and that someone had a forensic look at what had happened to these babies, and I felt that
even if I lost my job I should persist until we reached this outcome.
MR DE LA POER: Dr ZA, thank you. That concludes the questions I have for you. As you know, there will be some further questions but, my Lady, I wonder if that would be a convenient moment?
LADY JUSTICE THIRLWALL: Yes, certainly. So, doctor, we are going to take a 15-minute break and we will start again just after 20 to. (11.26 am) (A short break) (11.45 am)
LADY JUSTICE THIRLWALL: I'm sorry to have kept you all waiting. Would you like to come back to the witness box, please.
MR BAKER: Thank you, Dr ZA, my name is Richard Baker, I ask questions on behalf of some of the
families, including The Families of [Child E] and F.
DrZA: Yes.
BAKER: You gave evidence about a decision that was made regarding the postmortem for [Child E].
DrZA: Yes.
BAKER: And I understood your evidence to be that the decision not to have a postmortem was driven
by the wishes of the family.
DrZA: I think it was -- I was keen to respect the wishes of the family, but I should have pushed for
a postmortem.
BAKER: Can I tell you what Mother and Father E recall --
DrZA: Yes.
BAKER: -- of the conversation? They said that when you spoke to them, obviously this is fairly soon
after [Child E]'s death --
DrZA: Yes.
BAKER: -- that you said his death was probably due to NEC --
DrZA: Yes.
BAKER: -- necrotising enterocolitis, and you said to them that a postmortem could be done and that
Mother E then asked you, "Well, what will this tell us? What more information will this give us?"
And you said that you were confident that it was NEC and that it wouldn't tell them any more. Is
that a fair summary of what the exchange would have been like?
DrZA: Probably. I don't recall it in as much detail but then it was obviously --
BAKER: It was obviously more of a significant conversation for them --
DrZA: Yes.
BAKER: Yes. I mean, the reality would probably mirror that discussion anyway, isn't it, because if
you're uncertain as to the cause of death as a doctor there has to be a postmortem?
DrZA: Yes, there has to be.
BAKER: And so it would follow that unless you said to them that, "I think this is NEC and I'm
confident it is NEC", there would have been a postmortem?
DrZA: Yes.
BAKER: As to the evidence of NEC, you recall in your witness statement at paragraph 34 Dr Harkness
telling you about a purplish discolouration.
DrZA: Yes.
BAKER: In your interview to the police you said you didn't see that yourself.
DrZA: Yes.
BAKER: Is that still your evidence?
DrZA: Yes, that is.
BAKER: So it was a transient discolouration, it had gone by the time you got there.
DrZA: Yes.
BAKER: Now, NEC causing discolouration of the abdomen that's caused by an internal septic process,
isn't it?
DrZA: Yes, and that would be permanent and not transient.
BAKER: Yes. So it isn't transient for NEC. So that's not evidence of NEC?
DrZA: Yes.
BAKER: Bleeding from the mouth, which had been noted, gastric bleeding, so upper gastrointestinal
tract bleeding out of the mouth that wouldn't happen with NEC either, would it, because it's a
problem with the intestines, so the baby bleeds from its bottom?
DrZA: Yes.
BAKER: Would the baby with NEC usually have a soft and non-tender abdomen?
DrZA: No.
BAKER: Could we look at the Datix, please. It is INQ0000194 at page 4, please. If we could scroll down to page 4, please. I'm
taking you here because the medical records are more difficult to navigate around --
DrZA: Yes.
BAKER: -- but this is a fair -- if we go on to the next page, please, sorry -- this is a fair
account of what's written in the medical records. We can see here an entry for 2 August, so the day
before the collapse.
DrZA: Yes.
BAKER: "Abdomen soft with no distension." Can you see that?
DrZA: Yes.
BAKER: And then on 3 August, there's a reference here to the pharmacist and then there's a sentence
that begins or a line that begins: "The baby was tolerating 1ml of expressed breast milk."
DrZA: Yes.
BAKER: And it says that: "Feeds could be increased if the abdomen remained soft and no increase in
nasogastric aspirates." And then there's a reference to a baby being examined at 1410 hours:
"... having good tone and movement. Handling appropriately. Had a soft abdomen which was not
distended. Bowels not open but bowel sounds present and no suspicion aspirates." So again audible
bowel sounds, no unusual aspirates, that would all speak against NEC, wouldn't it?
DrZA: It would.
BAKER: And then we come into the time of the collapse, so 2210 hours, which is a few lines below:
"ST4, who is [Dr Harkness] to review the baby as he had had a gastric bleed at approximately 2140.
He was alert pink and well profused. The baby's abdomen was soft not distended. Some bowel sounds
were heard." Now, you agreed that a bleed from the mouth would not be evidence of NEC and there is
no evidence of distension of the abdomen, there's audible bowel sounds, the abdomen is soft, and,
again, that is all speaking strongly against NEC, isn't it?
DrZA: It is.
BAKER: So in your evidence that really what changed your mind was what you saw on the X-ray, which
was also inconsistent with NEC. I mean, there are no real symptoms of NEC, are there, prior to the
collapse?
DrZA: No, I think my view was by the fact the
abdomen had looked purple and I hadn't noticed the significance of that not being there when I
examined [Child E].
BAKER: Yes. I mean, a decision about a postmortem, I don't want to labour the point --
DrZA: Yes.
BAKER: -- because I appreciate what you've said --
DrZA: Yes.
BAKER: -- but a decision about the postmortem is quite important, isn't it?
DrZA: It is.
BAKER: And making a decision that something is NEC without a reasonable basis for that avoids a
postmortem in this case and the postmortem is the opportunity to find out that there isn't NEC,
isn't there?
DrZA: Units.
BAKER: And it's also an opportunity to find evidence of other things that might have been
there.
DrZA: Yes.
BAKER: I think you do accept that a postmortem should have been done.
DrZA: Yes, I completely accept that.
BAKER: Looking then at [Child F]. The insulin results received and referred to in Dr Lidden's note
of the ward round at 10.30 of the morning of 13 August?
DrZA: Yes.
BAKER: Now, the family of [Child F] are still in the neonatal unit at this point --
DrZA: Yes.
BAKER: -- because we have a document that shows that they were transferred -- or that Baby F [Child
F] was transferred at 12.30. So during the morning ward round Mother E and F -- mother and father EF
are still there. Did you have a conversation with them about the hypoglycemia and the abnormal
results?
DrZA: I didn't. I know that Dr Lidden's entry is dated and timed at 10.30 but we had -- I recall
having a conversation about the blood results in my office, which I think was later in the day and
after they'd left. But I accept that I should have discussed that with his parents.
BAKER: So that would be very unusual, wouldn't it? I mean a note might be timed retrospectively
--
DrZA: Yes.
BAKER: -- but they're not ever timed prospectively, are they, so it's not -- it's not timed at
10.30 recording a conversation that occurs in the afternoon?
DrZA: Yes. But regardless of whether they were there or not, I should have discussed that result
with them.
BAKER: The insulin results, as the Inquiry will hear, had been telephoned through by Emma Lewis, a
Consultant clinical scientist, who made a call to the unit within nine minutes of the laboratory
receiving that result --
DrZA: (Nods).
BAKER: -- is the evidence the Inquiry will hear. How many times have you been called by a
Consultant clinical scientist about an abnormal insulin C-peptide result in your career?
DrZA: Never. I don't recall knowing that they'd been called through by Dr Lewis.
BAKER: Right. So, I mean, you -- did you not know that Dr Lidden or somebody within the team had
spoken to Dr Lewis --
DrZA: I can't recall, I'm afraid.
BAKER: Do you think it's important that whoever received the call should have communicated that to
you?
DrZA: Yes, but it was my failure to recognise the significance of those results.
BAKER: And your -- your conclusion -- well, let's look at it this way, there are two possibilities,
aren't there, the test is either right or it's wrong?
DrZA: Yes.
BAKER: Did you take any steps to explore whether the test might be wrong?
DrZA: No, I didn't.
BAKER: And so if a test is right, there are two possibilities, either somebody has given Baby F
[Child F] insulin deliberately to harm him --
DrZA: Yes.
BAKER: -- or it's a major safety failure.
DrZA: Yes.
BAKER: And so we don't have to go straight to attempted murder to realise there's a major safety
issue in a baby receiving exogenous insulin.
DrZA: Yes.
BAKER: Can you assist then with why, given those three possibilities, you didn't take any steps at
all?
DrZA: No, I don't know why. It didn't seem like a realistic possibility at the time, but that was
completely the wrong decision.
BAKER: What didn't seem like a realistic possibility?
DrZA: That it had been done as a deliberate act or an accidental act.
BAKER: But that would be the answer if the test wasn't faulty, wouldn't it?
DrZA: Yes.
BAKER: And the possibility, given that it had been produced by a laboratory, you could have
contacted the laboratory to find out whether the test was one that was
reliable or not, couldn't you?
DrZA: I could have done.
BAKER: But it doesn't need for you to think that this is attempted murder, does it, because
exogenous insulin in a baby is a serious safety issue however it gets there?
DrZA: Yes, and I should have flagged it.
BAKER: Finally, and very briefly, you were involved in the care of [Child G] as well. Do you recall
[Child G]?
DrZA: I would need reminding.
BAKER: Well, let me ask you a general question --
DrZA: Yes.
BAKER: -- and just see if you can assist me with this. [Child G] was found to have collapsed, she
was a very premature baby who had reached 37 plus six weeks of corrected gestational age --
DrZA: Yes.
BAKER: -- by the time she suffered a collapse with a serious vomit, and that was put down to
infection at the time. You assessed Baby G [Child G] on 7 September, which is a day when she
collapsed, and noted that she had a CRP, so c-reactive protein, of less than 1.
DrZA: (Nods).
BAKER: Is that consistent with sepsis?
DrZA: It wasn't. I do recall now having -- seeing that baby and having that result. Sometimes when
the bloods are taken early on in an infection the CRP hasn't risen yet, and that's what I thought at
that time because I think I reviewed her not long after that collapse.
BAKER: Well, let me just assist you. You reviewed her -- or your note is at 22.20 at night and she
had collapsed at or about 2 o'clock in the morning.
DrZA: Okay.
BAKER: The blood test and your note is timed at 1500 --
DrZA: Okay.
BAKER: -- so about 12 hours after the collapse --
DrZA: Yes.
BAKER: -- and CRP of less than 1. That's not consistent with sepsis causing a collapse, is it?
DrZA: No, it would depend on the time of when the blood test was taken rather than the time of my
note.
BAKER: Yes. I just say your note has 1500 next to the CRP and your note is timed at 2220?
DrZA: Okay.
BAKER: So a blood test 12 hours later showing a CRP of less than 1 would not be consistent with
infection?
DrZA: Yes.
MR BAKER: Okay, thank you, my Lady, I have no more questions?
LADY JUSTICE THIRLWALL: Thank you very much indeed Mr Baker. Mr Skelton.
MR SKELTON: Dr ZA, I ask questions on behalf of the other family group.
DrZA: Yes.
SKELTON: I just have two topics, one is just going back to your suspicions about Letby.
DrZA: Yes.
SKELTON: You said earlier that when you came back from leave in 2016 --
DrZA: Yes.
SKELTON: -- that there was concern amongst the Consultant group --
DrZA: Yes.
SKELTON: -- about Letby that she may have been harming children.
DrZA: Yes.
SKELTON: And I think in answer to Counsel to the Inquiry, you said that you didn't have definite
proof --
DrZA: Yes.
SKELTON: -- but there was a growing sense of
discomfort --
DrZA: Yes.
SKELTON: -- among the group. And you agreed with him that safeguarding was, in those circumstances,
the appropriate response.
DrZA: Yes.
SKELTON: Can you just explain exactly whether that would have entailed had it been triggered?
DrZA: So I don't have any experience of triggering that in a professional situation. Normally if it
was raising safeguarding concerns against parents or careers it would involve the police, medical
opinions and social care. I don't know whether social care would be relevant in the context of
raising concerns against a professional, but it would likely to be a multi-agency response with at
least the police and the hospital.
SKELTON: So your internal safeguarding team would have been informed?
DrZA: Yes.
SKELTON: And the police as an external body --
DrZA: Yes.
SKELTON: -- would have been informed from that point?
DrZA: Yes.
SKELTON: I think it's right that none of the Consultants ever called the police.
DrZA: Yes.
SKELTON: You've explored the reasons why that might have happened --
DrZA: Yes.
SKELTON: -- but do you have any reflections on what could happen in the future to enable those like
you, who, for members of public, are senior doctors taking responsibility at the highest level for
their children's lives, how you could be enabled to make that call if this ever happens again?
DrZA: I don't know because, looking back on it, it seems incredible that we didn't, but it just
didn't feel like something we could do at the time and I don't know how to change that for the
future.
SKELTON: Well, one answer might be to make it compulsory.
DrZA: Yes.
SKELTON: So if you, doctor, suspect anyone, colleague, friend, family member, anyone else is
harming a child, you must contact the police. Would that, do you think, have made it almost easier
for you as a Consultant to have broken that barrier?
DrZA: Potentially if that was a sort of obligated process because that would have given us some
protection against the internal push-back from the Trust management
if it was an obligated duty rather than a decision.
SKELTON: And looking back, do you recognise that the police were the appropriate --
DrZA: Yes, completely.
SKELTON: And they should have been called from the moment suspicions arose?
DrZA: Yes.
MR BAKER: Thank you. Thank you, my Lady.
LADY JUSTICE THIRLWALL: Thank you very much Mr Skelton. Mr De La Poer.
MR DE LA POER: My Lady I have no further questions for Dr ZA.
LADY JUSTICE THIRLWALL: Dr ZA, that brings us to the end of your evidence, thank you very much indeed for coming today and giving your evidence so frankly. Thank you very much indeed. You are free to go.
MR DE LA POER: My Lady our second witness is also subject to a protection from the Crown Court in terms of identification. That witness is Dr V.
LADY JUSTICE THIRLWALL: Thank you very much. Dr V, would you come and take the oath or affirmation.
DR V (affirmed)
LADY JUSTICE THIRLWALL: Do sit down, Dr V.
DrV: Thank you.
MR DE LA POER: Dr V, can you confirm, please, for us that you provided the Inquiry with a witness
statement dated 5 June 2024.
DrV: That's correct.
DE LA POER: And is the contents of that statement true to the best of your knowledge and
belief?
DrV: Yes.
DE LA POER: We will deal very briefly with your background. You are a qualified medical doctor; is
that right?
DrV: That's correct.
DE LA POER: I'm so sorry, Dr V --
DrV: Sorry.
DE LA POER: -- it will be me, can I just ask you to keep your voice up a little bit?
DrV: Okay. That's correct, sorry.
DE LA POER: Thank you very much indeed. That you are both a member and a fellow of the Royal
College of Paediatrics and Child Health?
DrV: Yes.
DE LA POER: And you had been a Consultant paediatrician
for a number of years prior to 2015; is that right?
DrV: That's correct, yes.
DE LA POER: I'm going to look at the relationships as you experienced them back in 2015. Was the
paediatric department a happy place to work?
DrV: Yes, it was.
DE LA POER: Were there any difficulties that you were aware of as between any of the professional
relationships?
DrV: Not that I was aware of, no.
DE LA POER: You say in your statement that from June 2016 things became strained.
DrV: (Nods).
DE LA POER: Was that as a result of the moving of Letby to a different role in the investigation
that the Trust was doing?
DrV: That's correct. It was primarily to do with us raising concerns about Letby that the nurse ward
manager and consequently probably a group of nurses felt an insult to their profession and
consequently were quite difficult.
DE LA POER: Now, before that date, so before things became difficult, I would just like you to
consider what Eirian Powell has told us. She has suggested that: "The Consultants would think the
relationship was
good because everybody did what they said and nobody challenged them." I think the word she used was
the Consultants would think it was "cohesive". What comment, if any, do you have on that
perspective?
DrV: I don't think I agree with that comment. I don't know what period Eirian was referring to but
certainly during my time leading up to that time I remember being challenged about my decisions on
many occasions, and I think that was a thing that was almost taken as granted, that the nurses were
there, they looked after the babies and were around a lot more than the doctors were, and we always
paid a lot of attention to their opinion on what should and shouldn't be done. So, no, I don't agree
with that.
DE LA POER: Now, we heard from your colleague, Dr Holt, something about the arrangement of the
offices and the corridor that offices were on. Did you use an office down the corridor?
DrV: No, my office was further -- so initially when -- I think this must have been before Dr Holt
started there was just that corridor and there was just the seven of us and we shared offices
initially. Then when the number of Consultants expanded and more areas was -- were needed there were
three offices created
beyond the -- so there's long consider door then there is a big open area where the paediatric
secretaries sit and, at the end of that, there's three rooms and mine was to the right, then there
was a middle one and of the left one, and I have been -- I couldn't tell you the exact year but I --
that we moved into that office, I'll have to go back and check (redacted).
DE LA POER: We heard from Dr Holt something about where Dr Howie Isaacs had her office. Was that in
the general area?
DrV: Yes, so that was in the general area where the -- so the -- in the -- because the corridor
offices are bigger, two Consultants share those offices. The three that I'm referring to, one of
which I am, are much smaller, so there's only one Consultant, so there's always an office shared by
two Consultants or a Consultant and another, there's a research nurse that shares one with another
Consultant. So those offices, because they're bigger -- and that's why Dr Issac shared a room with
Dr Holt for a period of time, I think.
DE LA POER: Dr Issac was community paediatrician but part of the safeguarding team.
DrV: That's right.
DE LA POER: And does that mean that throughout the period that we're going to consider, you could
have found Dr Issac fairly easily if Dr Issac was in work or did Dr Issac not use the office very
often?
DrV: As far as I remember, when she was sharing an office Dr Isaac was there frequently enough. And
whether we could have, yes, we could have. I think the main issue was how we saw that issue as
safeguarding. I do know Dr Isaac was consulted later on when we were having huge difficulties with
the management. But I think, in good faith, we started the process by going to the managers because
that seemed like the appropriate channel at the time.
DE LA POER: Just as you look back on it now, bearing in mind that Dr Issac was around, was a
paediatrician, was involved in safeguarding, do you think Dr Issac should have been involved sooner
than she was?
DrV: Yes, I think it would have been definitely worth having a discussion around it with her and
then she could have advised us what could be done or another alternative route we could take, or a
route that we could take from the start.
DE LA POER: Now, we're jumping ahead a little bit here but just focusing on the issue of Dr Issac,
were you aware of a period before June of 2016 where there were informal discussions between the
Consultant paediatricians about their concern about the neonatal
unit?
DrV: No.
DE LA POER: You weren't part of those discussions?
DrV: No.
DE LA POER: We'll come to exactly when you came to have concerns of your own and when you became
aware of others in due course. So far as safeguarding is concerned, had you ever received any
training on what to do in the event you were concerned a member of staff posed a risk to babies?
DrV: No. No. We had -- we -- there's mandatory safeguarding training that we as paediatricians need
to complete, but that's to do with children who have been harmed or there's a potential to harm
them, how to deal with the families, the children and the processes that involve social care. But
not what to do if it's a member of staff or a colleague.
DE LA POER: Do you think that's a gap in your training?
DrV: Yes.
DE LA POER: As far as the SUDiC process was concerned, what was your understanding at the time
about whether or not it applied to deaths which occurred on the neonatal unit?
DrV: So I was reading the documents that were sent through, and when you read on I couldn't tell you
exactly what page it is, it does refer to that the SUDiC process doesn't necessarily apply to
neonatal deaths, they can be dealt with within the neonatal department, and I think that was what we
were doing. So it wasn't that the neonatal deaths weren't being analysed or discussed. It was not
through a SUDiC process because the SUDiC process essentially is for children who have collapsed at
home or have been brought very sick to the hospital or to A&E, and then you start the process by
-- with the police and the social care visiting the home, which is the crime scene, which again --
I'm not taking this into account, and we can come back to that -- doesn't seem appropriate to a baby
dying on the unit because if you have had a baby die on the unit, to call the police in and social
care in and make that a crime scene, it sounds for mostly deaths that I'd had before [Child O] and P
[Child P] had been deaths that we had sadly to some degree anticipated and the discussion with the
Coroner or Coroner's officer would inform what I thought of that death, whether that was to some
degree expected and explained or not and decide on a postmortem on the basis of that. So I thought
we had a reasonable process to account for expected, but I think we didn't -- the problem is it's
unexplained and unexpected in neonates, it's how
you define, isn't it? Unexpected is you didn't expect the child to die in the previous 24 hours by
definition, which will probably apply to a lot of neonates as well, but what we expect in neonates
is they become poorly and then they gradually decline and get worse over a period of time and then
they sadly die. So to some extent there are certain complications that explain that.
DE LA POER: If I --
DrV: I don't know if I'm --
DE LA POER: If I can just stop you there if you don't mind --
DrV: Yes.
DE LA POER: -- I think what I've gathered from your answer is -- and I'll just reflect it back to
you -- that your understanding at the time was the SUDiC process did not apply to hospitals --
DrV: Yes.
DE LA POER: -- is that correct?
DrV: Yes.
DE LA POER: I'd like to ask you, please, about your understanding of Datix forms. Please, in
summary, can you tell us what circumstances you thought a Datix form was required.
DrV: So my understanding was Datix was for purposes of, for example, drug errors, any clinical
event, administrative event that you wanted to flag up and whether it would pick up if certain
incidents were being reported again and again, whether there was a theme to them that you could then
pick up and address and share learning on the basis of that. And then, like Dr ZA said, deaths were
reported just as not because they were incidents but just so they would be recognised that they had
occurred.
DE LA POER: Does it follow from your answer that, like Dr ZA, in the event that there was a sudden
unexpected and serious deterioration potentially leading to resuscitation you did not think that
that needed to be recorded?
DrV: That's correct.
DE LA POER: I'm going to come to our timeline now, please, and start in June. You tell us in your
witness statement that you were involved in the care of [Child B] on 9 June of 2015; is that
correct?
DrV: That's correct.
DE LA POER: And that you considered [Child B]'s deterioration to be unexpected --
DrV: Yes.
DE LA POER: -- is that right? And that you were called in and arrived after
[Child B] was receiving emergency treatment.
DrV: Yes.
DE LA POER: Did you see any blotchiness or rash on [Child B]?
DrV: I did. I think in my statement I have referred to -- I've said that the Registrar has
documented that the rash was much more florid and widespread, and by the time I arrived the
Registrar had intubated, they'd given a fluid bolus, done bloods and the rash was blotchy on the
right side of abdomen and arm.
DE LA POER: I believe -- if you're looking for a reference it's paragraph 34. I don't think you
need to turn it up because that is what your statement says.
DrV: Okay.
DE LA POER: What you also say is that [Child B] was, when you were there, improving and so you were
not particularly concerned.
DrV: Particularly concerned from the point of view of I think in my statement and my handwritten
notes I've put "sudden deterioration", this rash, and the treatment and then "much better", and I've
put three question marks or two question marks "cause". And then I have considered the differential
diagnosis that it could be. From what I can remember, I wouldn't go into the
details because that might identify this mother had a disorder, and we had been looking into how
that might affect the baby, and I think earlier in the day there had been some discussions with the
specialist, so there was that in the background on my mind. Infection obviously with any neonate who
deteriorates suddenly we would -- because that's probably the easiest and the quickest thing to do
and very common in babies, and then obviously things consequent to infection which can be -- which
can lead to problems with coagulation or clotting or platelet disorder, so those were the kind of
things going in my mind. But I think the reassuring thing at the time that I thought, whatever that
event had been that baby had improved.
DE LA POER: Did you take any steps to investigate why [Child B] suddenly and unexpectedly
deteriorated?
DrV: No, I did not at the time.
DE LA POER: And should you have?
DrV: I think with hindsight if I had known about Baby A [Child A] and what had happened and the
similarities in the rash between the two babies, I -- I'm not aware if there were concerns by this
time that were being discussed about rashes. But I think if I had been aware,
I probably would have taken it back to my colleagues and discussed with them what their thoughts
were.
DE LA POER: So is it the position that you knew nothing about the death of [Child A]?
DrV: No, I didn't.
DE LA POER: And does that surprise you now that the following day you are here treating [Child
B]?
DrV: Yes. See, the thing is, as we mentioned previously how busy we were, so you had one
paediatrician of the week who would know about the babies on the neonatal unit and the ward, and
then there was an on-call system, so when you're on-call you don't physically know about every baby
and every child. You would do a sort of ward round, you would be aware the sick babies and the sick
children, and then you're on-call. Now, previously, previous to this cohort that started in 2015,
the deaths would be discussed at the mortality and morbidity meetings, and I think they were so few
and far between you would probably find out about them by speaking to colleagues. And whether it was
just because it had occurred the day before that I hadn't become aware of it -- and I don't
remember, I think the first I learned the similarity of the rash between A [Child A]&B [Child B]
was when I got these statements.
DE LA POER: These statements.
DrV: Yes.
DE LA POER: Well, we'll come to that in a moment, my question was really whether looking back on
it, you're surprised. I'll just try and unpack that a little bit for you. We know that deaths on the
neonatal unit before 2015 were not common occurrences.
DrV: Yes.
DE LA POER: This is a death that had taken place just the day before.
DrV: Yes.
DE LA POER: And just --
DrV: Yes, I mean --
DE LA POER: Is it in fact surprising that nobody --
DrV: Yes, I think it is --
DE LA POER: -- told you --
DrV: -- especially with what follows after -- and I don't know whether you're going to ask me that
Dr Lambie questions that I didn't know about this and things that I did. Dr Lambie was on that
night, and I don't recall her mentioning that she was -- I know she went and found other colleagues
and discussed with them and that generated a discussion, following which there was an assumption I
was part of that discussion. But at the time, neither the nurses nor the doctor on duty said
this is really unusual, this is what happened two days before, and that might have prompted me to
discuss with colleagues.
DE LA POER: You've told us that in fact you didn't find out about the similarity between [Child A]
and [Child B]'s presentation until when you did your police witness statement or when you did the
Inquiry statements, when was it --
DrV: I think with the Inquiry statement because -- I'm not quite sure at what point, because when I
was doing the police statements I was only doing my statement. I wouldn't have known because I had
never been involved with [Child A], so I wouldn't have known. And from -- I mean, I can't remember
from eight/nine years ago whether I knew that night when I came in, and I have documented that I
have updated the parents whether I knew that they'd lost the twin. I'm really sorry but I don't
remember.
DE LA POER: Dr V, I understand that your evidence, though, is that if you had known about the
connection --
DrV: Yes.
DE LA POER: -- you would have gone to speak to your colleagues about it.
DrV: Probably, yes.
DE LA POER: Well, can I just seek to refresh your memory.
INQ0025743, and we looked at this with Dr ZA this morning. This is an email,
23 June, if we go to the page 2, please.
DrV: Okay.
DE LA POER: We can see at the top that you are one of the people that Dr Gibbs sent that email
to.
DrV: Okay.
DE LA POER: And he specifically draws attention not only to Dr Lambie who he's spoken to but to the
commonality of the "strange purpuric-looking rash". And, Dr V, my question is this, that if having
seen that email, which I'm sure you can agree now --
DrV: Yes.
DE LA POER: -- draws an association between [Child A] who you didn't treat and [Child B] who you
did --
DrV: Yes.
DE LA POER: -- was that not a prompt for you to go and speak to your colleagues to discuss it
further?
DrV: I honestly don't remember this email. I don't.
DE LA POER: Well, do you have --
DrV: In the bundle that I have I'm not copied into that email.
DE LA POER: Well, if you could just accept from me for a moment --
DrV: Yeah, fine, yeah.
DE LA POER: -- that this is the copy --
DrV: Yeah, yeah.
DE LA POER: -- that the Inquiry has --
DrV: Yeah.
DE LA POER: -- and, I mean, on the face of it you are copied in --
DrV: Yeah.
DE LA POER: -- so if it is right that you were sent that email, should you have gone to speak to
your colleagues having received that email to try and understand --
DrV: Yes.
DE LA POER: -- more about the rash?
DrV: Yes.
DE LA POER: Now, as you say, there was a neonatal -- thank you very much indeed, we can take that
down -- there was a Neonatal Mortality Meeting on 29 July, and you deal with this in your witness
statement saying: "I don't recall discussions with anyone who had attended the Neonatal Mortality
Meeting on 29 July." Obviously [Child B] who you dealt with wasn't the immediate subject matter of
that meeting. But, again, should there have been discussions between the Consultant paediatricians
to pool your knowledge, given that the connection or potential connection between those four babies
A, B, C, and D had been identified on 23 June?
DrV: Yes.
DE LA POER: And doing the best you can, what do you think the reason is for that apparent lack of
communication at the time?
DrV: I've -- I've thought long and hard about this. I think people were concerned individually and
talking to each other in smaller groups. I don't know whether it was the workload, lack of time,
that there wasn't this around the table thrashing out what was actually going on. I think the
perinatal morbidity and mortality meetings tend to be more they were joint obstetric and neonatal
meetings. They were more a learning and -- and, from that point of view, chronology of events. To
pick up trends, yes, but to bring up issues like if there was potential harm being done, I'm not
sure if they were the right forum for that. Now, whether that needed to be taken out of that
mortality and morbidity meeting and something that the Consultants should have come together
separately for --
DE LA POER: Well, this was -- and I'm here just talking about the period of June 2015 -- this was
an extraordinary time for the neonatal ward or unit, wasn't
it?
DrV: Yes.
DE LA POER: And so do you think that that required something that was tailored for this particular
situation to have a formal look at that cluster?
DrV: Yeah, I think that was done. From what I gather, these -- at least three deaths were reported
as a serious incident, but -- and -- and looked into but I wasn't aware that that had happened. So I
think that was done, so the neonatal lead did pick up that these three deaths had happened in quick
succession and there was -- I think it was reported as a serious incident and that was -- then those
deaths were analysed.
DE LA POER: I mean, if I can just stop you there, you're quite right that there was a serious
untoward meeting -- incident meeting, but really the reason I'm asking you these questions is
because your involvement was with a baby that --
DrV: Didn't --
DE LA POER: -- didn't fit the criteria for that meeting on the face of it --
DrV: Yes.
DE LA POER: -- and it's -- we can see that on 23 June the association between all four was being
discussed --
DrV: Yes.
DE LA POER: -- and you had a valuable contribution to make, didn't you?
DrV: I did, yes.
DE LA POER: [Child F], you heard me ask questions of Dr ZA about [Child F] and the insulin result.
Dr Gibbs has described it as a collective failure by the Consultants in relation to the insulin and
C-peptide result --
DrV: (Nods).
DE LA POER: -- and the fact that that wasn't acted upon. Do you agree with that?
DrV: Yes.
DE LA POER: Now, there was a Neonatal Mortality Meeting for [Child D] on 10 September 2015. Do you,
sitting there now, have any recollection of what was discussed at that meeting?
DrV: No, I'm sorry.
DE LA POER: Let's just bring up the INQ, INQ0005445. So we can see that there was another non-indictment baby discussed
in the first row. You are one of those in the top right-hand corner identified as attending this
meeting. Do you see that?
DrV: Yes.
DE LA POER: And then we can see [Child D] is mentioned towards the bottom.
DrV: Yes.
DE LA POER: And if we turn over the page, we can see in the left-hand column with text, about
halfway down: "Episode? Purpura in evening that resolved."
DrV: Yeah.
DE LA POER: And obviously we'd seen that email from the end of June where this -- that exact word
was used to describe A, B and D, and here you are at a meeting in September discussing D. I
appreciate you say that you don't have any recollection of the meeting, but just think back. You'd
seen on [Child B] purpura, was that something that it would have been relevant for you to raise at
that meeting, or is it just focused on [Child D] and, therefore, it wouldn't be appropriate to say,
"Well, that's something that I think I may have seen around the same time"?
DrV: I don't know. If I can -- I mean, yes, with hindsight, whilst we are putting the chronology of
events as we know now, it seems very relevant. But it doesn't look like it jigged my memory that way
at the time is all I can say.
DE LA POER: Just to examine that for a moment. To try and understand the approach that was being
taken by you at the time, obviously when there is a death that is a terrible incident that requires
further investigations and it has its own process, but you have told us that when there is a
collapse from which a baby recovers there isn't such formality around it?
DrV: (Nods).
DE LA POER: And that was your situation for [Child B], wasn't it?
DrV: Yes.
DE LA POER: Was it the position that at the time the Consultants in relation to anything that
didn't result in a death simply just moved on rather than keeping a mental record of it and thinking
back to it?
DrV: I think that is probably up until [Child O] and P [Child P] the only collapse that I went to.
So it was the first and the last because the later involvement that we will discuss -- and for me,
yes, it was an unexpected event. I didn't quite understand what had happened. But at the back of my
mind I wasn't aware that this was happening with other babies and with other people and I think that
probably -- that information would have been helpful that if this was known that these unusual
events were occurring to all of us -- or with all of us whilst we were on-call that might have rang
alarm bells.
DE LA POER: And whose responsibility, if anybody's, was it to make sure that when there were things
that you could all discuss to derive learning from that that discussion
should be organised?
DrV: I think the responsibility was from all of us, on all of us, yes. So I'm as much to -- I didn't
raise it on any forum either at the time.
DE LA POER: Move forward, please, to October 2015 and [Child I]. [Child I], insofar as you were
aware, suddenly and unexpectedly deteriorated in the early hours of 13 October; is that right?
DrV: That's right. I think if I can go back to my statement there was a background to her.
DE LA POER: By all means, it's from paragraph 52, page 7.
DrV: Sorry. Sorry, which bit is my statement in?
DE LA POER: It should be the very first tab that you have?
LADY JUSTICE THIRLWALL: It may be tab 2.
DrV: Yes, sorry, which page did you say?
MR DE LA POER: Page 7. Paragraph 52 is the start of where you deal with [Child I], and I've just
asked you a question focused on whether you say at paragraph 53.
DrV: Yes. I've got the wrong -- I don't know where my statement is. Is it --
DE LA POER: I don't know whether Mr Suter is able -- my Lady, if you think it appropriate, to see
if we can assist the witness.
DrV: Yeah, I think I've found it. Yeah, so I've put:
"[Child I] had recurrent episodes of abdominal distension of feed intolerance. She had raised
infection markers and had been on antibiotics. The plan was to complete 7 days of antibiotics. On 12
October she was found blue and apnoeic in her COT received resuscitation." And, yeah -- so that was
the collapse, so that was the night of the 12th, and I saw her on the ward round on the 13th.
DE LA POER: Yes.
DrV: Sorry, yes.
DE LA POER: Yes.
DrV: Yes.
DE LA POER: So I think it was at the early hours of the 13th --
DrV: Yes.
DE LA POER: -- that the collapse happened --
DrV: Yes, yes.
DE LA POER: -- and you were aware when you came on duty --
DrV: Yes.
DE LA POER: -- of that collapse, and indeed what you tell us is that there was further
deterioration later that morning.
DrV: Yes.
DE LA POER: And so, again, just reflecting, Dr V, on what
you've told us, you said that [Child B] was the only collapse you were involved with. I appreciate
that you weren't physically present for [Child I]'s first collapse, but in fact were you aware at
the time that [Child I] also was suddenly and unexpectedly deteriorating?
DrV: Yes. So I've looked into this and read back on my handwritten notes as well and, rightly or
wrongly, at the time I thought there was a reason because she had abdominal distension, and I've
written my examination findings that her abdomen was tender. If --
DE LA POER: No --
DrV: Given the -- with abdominal distension the most likely reason was the abdomen, and my
assessment that I've referred to my statement was that that was what was causing the problems which
led me to discuss her with the surgeons at Alder Hey. So I think, yes, I recognised that the
collapses were happening but I was putting them down to a medical reason, which, again with
hindsight, was not the correct judgment. But I didn't think they were unexpected collapses. I think
they were consequent to her infection. And then she was -- and I think what I didn't connect was
that that happened multiple times, she would improve in the daytime, collapse again at night, she
would go away, get better come back, and that it would happen again until the time that --
DE LA POER: So you noted, did you, that a significant number of these collapses were happening at
night?
DrV: Only now with hindsight looking at -- at the time, no.
DE LA POER: Now what you tell us having charted [Child I]'s progress over a number of days and
there were a number of collapses deteriorations, you say this: "It never crossed my mind there was
even a remote possibility of deliberate harm being inflicted on [Child I]."
DrV: Yes.
DE LA POER: And just bearing in mind that there had been the deaths in June, and we know that
[Child E] died in August, why do you think it was that that thought didn't even cross your mind?
DrV: I just couldn't think that that was a possibility. That's all I can say.
DE LA POER: Did you have any discussion with your colleagues following the death of [Child I] about
concerns that you or they had about what was happening on the neonatal unit?
DrV: No.
DE LA POER: And you heard me say to Dr ZA earlier that the Inquiry has received evidence that Dr
Newby, Dr Gibbs,
Dr Jayaram and Dr Brearey appear to have been talking around that time. You weren't involved in
those discussions?
DrV: No.
DE LA POER: And if it be right that they were concerned about what was happening on the neonatal
unit, whatever their level of suspicion, should you have been spoken to as one of the Consultant
paediatricians?
DrV: Yes.
DE LA POER: Now, there was a Neonatal Mortality Meeting on 26 November which you didn't attend.
That was in relation to [Child I]. Now, bearing in mind that you were substantially involved in
[Child I]'s care, and a number of very serious episodes, should arrangements have been made to make
sure that you were able to attend?
DrV: So just to give you a background of how these perinatal morbidity and mortality meetings are
arranged, I think I've explained somewhere in my statement, these are preset rolling half days and
the idea is that both obstetric and paediatric teams attend, so these are preset for the whole year,
like we have for (redacted) preset days when they'll be perinatal and paediatric mortality and
morbidity meetings. And, as it happens, not everyone can be present at every meeting. What we tend
to do -- because being the governance
lead for paediatrics, what I tend to do is I can move the cases around. If someone says "I want to
present X but I'm not there", either they will supervise a trainee with the case presentation and
learning or they will move it to a time that they are available. I don't know what the arrangements
with perinatal mortality and morbidity meetings were but I think making an effort that the person
who was involved then you come to -- I think Dr Gibbs was at the death -- was he, at the meeting?
DE LA POER: Yes, Dr Gibbs was at the meeting.
DrV: Yes. So, yeah -- and for the collapses that were -- so I didn't witness a collapse as such.
They were happening on nights. So if they had -- she had four collapses, then that would have been
probably four different Consultants. So I'm assuming that at least some of the Consultants who
witnessed collapses were there in addition to Dr Gibbs and whether all of us should have been there,
yes, in an ideal world but realistically it's probably, given -- I mean, there have been times when
I have been in the hospital but I haven't been able to go to the meeting because I've got something
more urgent to do. So --
DE LA POER: I think you mentioned it as a perinatal review meeting which takes place with your
obstetric
colleagues. In fact this was just a Neonatal Mortality Meeting.
DrV: Okay. Right. Okay.
DE LA POER: So you can take it from me or I can bring it on the screen --
DrV: No, that's fine, that's fine, I --
DE LA POER: So was there greater flexibility around the timing of the Neonatal Mortality
Meeting?
DrV: I don't know because my understanding was unless this -- this was arranged like this, but
they're usually called PNMMs and they are pre-decided however times a year. I know that because they
get the first pick and I get the second one when we do the -- because they have to liaise with
obstetrics, so they take priority because it's two different departments.
DE LA POER: Well, we can perhaps investigate that further with another witness. I just want to
deal, please, with one more topic under the heading of [Child I]. The Inquiry is investigating
whether it was the case that Letby was on one shift moved away from being responsible from child --
for [Child I]. Is that something that you were aware of?
DrV: No.
DE LA POER: If that happened, as somebody who was involved in the care of [Child I], should you
have been told about it?
DrV: Absolutely, yes. I think it would depend on why she was removed from the care, what the reason
had been because that decision would have been made by the nursing staff because there is a shift
leader who decides which nurse will look after which baby, and if they have made that decision I
think you would probably need to know what the reason for that decision was and, if the reason for
the decision was to give Letby some respite from looking after an intensive care baby that's a
different matter that probably the doctors didn't need to know about. If it was to do with the shift
leader's concern about harm, then I think that should have been escalated immediately to everyone.
DE LA POER: And in fact presumably not just stopping at the Consultant paediatricians but going
higher would you say?
DrV: Yes, yes absolutely. Yes.
DE LA POER: So Dr V, we're going to move forward to 2016 and the thematic review of neonatal
mortality. The meeting took place on 8 February 2016 and you were one of the attendees; is that
right?
DrV: That's right.
DE LA POER: Just help us to understand why it was that it was -- you and Dr Brearey from the
Consultant body, why -- why did you attend that --
DrV: Yes.
DE LA POER: -- given that you hadn't in fact, I don't think, been present at any of the deaths
certainly of the indictment babies?
DrV: Yes. So I remember -- well, there was an email that went round saying that an external reviewer
is coming to look at some data that we need to present to them and I need another paediatrician for
the meeting to be quorate, and that happened with a lot of other commitments where more than one
Consultant was needed or there was a certain number needed to complete a review, and we offered
depending on our availability, and it was consequent to that because I was available at that time I
said I could go, and it was mainly that more than anything else.
DE LA POER: So it was, and I'm not underestimating the complexity of people's diaries, but entirely
down to availability --
DrV: Yes.
DE LA POER: -- that you went as opposed to anyone else --
DrV: Yes.
DE LA POER: -- not because you had any special knowledge
or special skills --
DrV: Yes.
DE LA POER: -- or special pre-awareness of the issues?
DrV: No.
DE LA POER: Before you went to the meeting, did your Consultant colleagues know that you were there
effectively as -- to represent their interests on that meeting?
DrV: I think that's an assumption because the email goes out to all of us, and if somebody offers,
"Yes, I will go", then it's an assumption that that's a representation from all of us. And Dr
Brearey was going to be there as the neonatal lead so ...
DE LA POER: And did any of your colleagues approach you before the meeting took place to say,
"Look, I have this particular concern about this particular baby, could you see whether that is one
of the themes that you identify as part of your thematic review?"
DrV: No.
DE LA POER: Again, looking back on it now, bearing in mind that this is a thematic review and
different Consultants had been involved at different stages of the care, does it surprise you that
there was no prior discussion with your colleagues who couldn't be there about any particular
concerns that they may have had?
DrV: Yes.
DE LA POER: I mean, for that meeting to be truly effective, didn't there need to be that feeding in
from the Consultant body so that all of their perspectives were represented at the meeting?
DrV: Yes.
DE LA POER: We will ask Dr Brearey about it, but certainly speaking for yourself, you weren't aware
of any such --
DrV: No.
DE LA POER: And going into that meeting, did you have any awareness that any of your colleagues,
whether Dr Brearley, other Consultants or anybody else, had any concern at all that these deaths may
be unnatural?
DrV: No.
DE LA POER: Did you have any such concern yourself going into that meeting?
DrV: No.
DE LA POER: Now, in the form the Inquiry has received it, the record of that meeting on 8 February
has an appendix attached to it with staff names.
DrV: (Nods).
DE LA POER: I would just like to bring up, please INQ0003190. So this, Dr V, is a version of that appendix but it has one very
significant difference to the version that was appended to the meeting, which is that, as we can
scroll through the pages, Letby's name is identified in red whenever it appears.
DrV: Yes.
DE LA POER: Now, this document is dated 19 January, so it's about two weeks or so before -- perhaps
three weeks before the thematic review meeting on 8 February, and it was prepared, as we understand
it, by Eirian Powell. Did you ever see this version, ie the version with Letby's name in red
highlighted?
DrV: No. No, I've seen it at some point recently. I don't know whether that's part of whether it's
been sent in the Inquiry thing. But certainly at the thematic review and afterwards, I wasn't -- I
didn't clock on from that thematic review that Letby was looking after or on shift for all of these
babies.
DE LA POER: Thank you, we can take that document down. So we'll come to the record, and there are
effectively two versions of the thematic review, one which is dated 8 February and one which is 2
March when additional changes are made. But let's look at the version from the meeting that you
attended. INQ0003217. So we can see there that you are identified as one of the
attendees, the second on the list, and we don't need to review every line of this, I'm sure you are
well
familiar Dr V --
DrV: Yes.
DE LA POER: -- with the content of this document?
DrV: Yes.
DE LA POER: But if we go over the page, we'll get a flavour of what was going on, that under the
heading "Summary of Mortality Cases Discussed" we see a table where there is a diagnosis and summary
of discussion and any action points arising. Now, the second entry on that is [Child A], and we can
see most of the way, it's about five lines up from the bottom, that one of the entries about [Child
A]'s presentation is: "Sudden unexpected arrest." With. The age that was visible then.
DrV: Yes.
DE LA POER: "Twin also arrested 24 hours later." Now, that "Twin also arrested 24 hours later" is a
reference to [Child B] --
DrV: Yes.
DE LA POER: -- who you've told us you were involved with.
DrV: Yes.
DE LA POER: At that meeting, did you register the fact, and we are here about eight months later,
the fact that you were talking about the twin of a child that you had
provided care to?
DrV: No.
DE LA POER: And -- but bearing in mind you've told us that those sudden unexpected collapses, that
was the only one, although [Child I] perhaps, why do you think that seeing that there was a
reference to a twin who arrested 24 hours later that didn't prompt a recollection in you about
[Child B], the rash and all the discussion that had taken place over email as we have seen it back
in June?
DrV: All I can say to you is I, like I said to you, I do not remember that email and the email
version that I have of the rash I am not copied into it in my bundle. Coming to this, should it have
prompted me to think about it? Yes. It should have and no, it didn't. I'm sorry.
DE LA POER: And we will just move through the document. We can go to page 3. We can see for [Child
C], for example, that the discussion included that there was a PM report but no cause for
deterioration identified.
DrV: Mmm.
DE LA POER: Do you have any recollection, sitting there now, of the discussion about [Child C] and
the fact that there was no cause for the deterioration that even after a postmortem that was
identified?
DrV: No.
DE LA POER: I mean, does that, sitting there now, strike you as unusual that you would have a death
on the neonatal unit and a postmortem report, but no cause for the deterioration being known?
DrV: No. I am just thinking through because pm says "widespread hypoxic ischemic damage to the
heart" and because I have followed the transcript, I know there was a prolonged discussion whether
that hypoxic ischemic damage was before or after the collapse and I think there were varying
opinions on cause and effect, and the baby was IUGR, absent end diastolic flow. So there were
factors there to compromise the baby significantly.
DE LA POER: But be those factors as they may, the record of the discussion is --
DrV: Yes.
DE LA POER: -- no cause for deterioration identified. My question really is, is that an unusual
state of affairs?
DrV: Yes.
DE LA POER: Did it stand out to you at the time?
DrV: No.
DE LA POER: If we move forward, please, to page 5, we don't need to look. We can see that there was
a discussion about [Child I].
DrV: Mmm.
DE LA POER: Obviously you had been involved in [Child I]'s care?
DrV: Mmm.
DE LA POER: Do you have any recollection of bringing your experience of the treatment of [Child I]
to the discussion that took place or was the focus upon [Child I]'s death only?
DrV: I don't think there was a discussion around opinions. They were presented as chronology of
events as they are. I don't recall actively contributing, giving my opinion.
DE LA POER: If we go over the page, to page 6. We can -- forgive me, it's my mistake, a reference
there -- at page 7. We can see the themes that were identified.
DrV: Mmm.
DE LA POER: And one of the themes is the timing of arrests?
DrV: Yes.
DE LA POER: Now, one of the babies under discussion was [Child I] and you had seen [Child I] on a
number of consecutive mornings and known about the collapses.
DrV: (Nods).
DE LA POER: Did -- seeing that that was a theme that was identified, did you contribute that you
can recall to
the discussion saying: well, I had experience of [Child I] and now I think about it and look back
over the notes, actually that was true for [Child I]?
DrV: Yes. I think that had been an observation from the thematic review following which some
recommendations were put forward about what more we could look at, whether there had been any
deterioration in their observations prior to the time of collapse that we could look -- and so I
think Eirian went away to do some more work after that. So there was some discussion on why this
would be, whether there are any factors that we can identify what's happening and at the time what
wasn't pointed out was the staff member thing because I think that had been a big thing, which
wasn't openly discussed, at least during the time that I was there, and I think she went away and
did some work on that and if I am correct I think maybe, apart from one baby, didn't identify any
untoward signs of deterioration before collapses.
DE LA POER: So we will come back. I do -- you have just given some important evidence if I may say
about what was and wasn't discussed in your presence. I would just like to finish looking at this
document and then we will come back to that.
DrV: Okay. Sorry, yes.
DE LA POER: But it is related. If we just go over the page just so that we can understand how the
system works. If we then start at page 9, please, we will see that appendix 1. My question about
that was that appears attached to the meeting notes. Was that a chart that you all had in front of
you which you talked about in the meeting or did you not see that chart as part of the meeting?
DrV: I don't remember seeing this Level 2 report and all this. It might have been there, but I --
all I remember is the slides that we have discussed and I think there might have been some staffing
analysis slides as well, but just staffing analysis as in doctors and nurses who was on, as far as I
can remember. But I --
DE LA POER: So that brings me back. Thank you, we can take this document down. That brings me back
to the evidence that you have just given. When you were at the meeting, was there any discussion
about the fact that there appeared to be a very strong association between Letby and all of the
cases that were under discussion?
DrV: No.
DE LA POER: Was there any suggestion at all that there was
any concern about any particular staff member, even if Letby wasn't named?
DrV: No. I think the general comments were that no particular association between any medical and
nursing staff or something along those lines had been identified. So there were no themes as such to
go by that we could say, "Well, we can change this and make things better", was the understanding
that I left the meeting with.
DE LA POER: And you left the meeting. Just describe for us as best you can the circumstances of you
leaving the meeting. Was it when it was finished and everybody got up and left?
DrV: Yes. Yes, so basically my understanding was the meeting has come to an end, it probably would
have been from this time to time and it may -- I mean, I don't remember going back so many years,
but I might have had something. You know, the meeting is from 1 to 2 and at 2 o'clock I have to go
and do this. So even if not everybody has gotten up and left the room I -- my understanding is that
the meeting purpose has come to an end, so I can leave now. So I didn't leave as in the middle of
the meeting. My understanding from what I can recall is, yes, people may have still been sitting
there but the meeting presentation bit was over. I probably had another commitment I had to go to,
so I left.
DE LA POER: Just to conclude this topic, Dr V. You tell us in your witness statement that at some
point after the meeting you have had a discussion with Dr Brearey about what was and wasn't
mentioned at the meeting.
DrV: (Nods).
DE LA POER: Can you just first help us with when that discussion took place. Was it before the
deaths of [Child O] and P [Child P] or was it after?
DrV: No, that was last year.
DE LA POER: Last year, as recently as last year?
DrV: Either this year or last year because I think that had been something on my mind for a long
time. It was something that had bothered me a lot to the point that I asked him.
DE LA POER: So you sought Dr Brearey out?
DrV: Yes.
DE LA POER: And what is it that you said to him?
DrV: He was -- basically said, "Oh, we talked about it afterwards."
DE LA POER: Can I just stop you there. It will be important to hear what he said, but could you
tell us what you said to him first?
DrV: Oh, yes, okay. Sorry. So I said to him that, you know, at the thematic review what is coming
out is that one of the things that was identified was that Letby was present at all the -- all -- in
all -- on all of the shifts when these babies collapsed. But that wasn't what I took away from that
meeting. And he said, "We discussed it after, after the presentation." I said, "Well, I don't
remember that", and he said, "Well, it must have been after you left then." That was that.
MR DE LA POER: Dr V, thank you very much for the time being. My Lady, I have run slightly past 1 o'clock. Can I apologise for that. Given the witnesses that we have today, can I invite my Lady to rise for just 45 minutes over lunch to ensure that we finish at a sensible time today?
LADY JUSTICE THIRLWALL: Very well. So we will rise now and we will start again at ten to 2 please. If you could be back at ten to. (1.04 pm) (The luncheon adjournment) (1.50 pm)
LADY JUSTICE THIRLWALL: Mr De La Poer.
MR DE LA POER: My Lady, thank you. Dr V, we had reached the thematic review in February. The final
version of that document is dated 2 March of 2016 and there's an additional section included in it
about sudden and unexpected deteriorations. Do you know the section I'm speaking about?
DrV: Was it part of my bundle? If it was, then I would have looked at it, yeah.
DE LA POER: It was let's just bring it up INQ0003251. We are going to go to page 7. So although the date at the bottom
there is still 8 February, in fact we know from the very end that it was updated and there is an
additional section, you see number 1 there: "Sudden deterioration. Some of the babies suddenly and
unexpectedly deteriorated and there was no clear cause for the deterioration death identified at
postmortem." Now, that wasn't in the first version. Firstly, was that discussed at the meeting that
you attended on 8 February?
DrV: No, I don't recall.
DE LA POER: Secondly, were you consulted about this change when -- before it was made?
DrV: No, not that I can recall.
DE LA POER: And, thirdly, did you notice this change when this document was sent to you by email on
2 March?
DrV: I don't think so.
DE LA POER: [Child L], April 2016, Dr Gibbs has described this as a collective failure of the
Consultants in terms of the insulin C-peptide. Do you agree with that?
DrV: Yes.
DE LA POER: Were you aware, Dr V, that in May Ian Harvey and Alison Kelly met with Dr Brearey?
DrV: Yes.
DE LA POER: You were aware at the time?
DrV: I only am aware through the email that he sent later.
DE LA POER: On the 16th?
DrV: Yes, that was in May.
DE LA POER: Yes.
DrV: Yes.
DE LA POER: What did you understand the purpose of that meeting to be at the time?
DrV: I didn't -- if I am honest, I didn't about the meeting. It's the content of that email that Dr
Brearey had sent that he had a meeting with Ian Harvey and Alison Kelly following which it was
discussed that he and I think Eirian Powell should be informed of any collapses.
DE LA POER: Did you discuss with -- if you didn't know about the meeting at the time that it was
happening --
DrV: Yes.
DE LA POER: -- when you received that email, did you speak to Dr Brearey about, "Why were you
meeting Ian Harvey or Alison Kelly?"
DrV: No.
DE LA POER: Were you curious when you received that email why it was that Dr Brearey had met them
and why he was asking to be notified about collapses?
DrV: Yes, I think with hindsight I probably should have been more curious than I was. At the time,
the information that I processed in my mind was following that thematic review, because there hadn't
been any pattern noted, maybe going forward this was a plan that had been agreed. And, again -- for
something that will follow I can say then or I can say it now -- and maybe asked, "Well, what
happens when there is a collapse?" Because when there were we didn't have a plan, "What were we
going to do?" But I don't think that really sunk in what it meant at the time until much later.
DE LA POER: So we come to the deaths of [Child O] and [Child P]. Up until that point in our
chronology, so 23 June, did you yourself have any concerns whatsoever
about what might be happening on the neonatal unit and whether any of these deaths or collapses were
unnatural?
DrV: No. So what I did know, and I've mentioned it in my statement, was I'd overheard remarks being
made about how when Lucy was around -- around things were happening, and it was more so not being
able to quantify, well, is it because she's unlucky that she has shifts which has really sick babies
and things happen? And I know from personal experience that you can go through phases where you'll
have really bad weeks or really bad on-calls to the point that people say, "Oh, it's you", kind of a
thing. And I put it down more to that than even thinking about harm in that context.
DE LA POER: Who was it that you overheard speaking?
DrV: I think it probably would have been a few comments from Dr Jayaram, probably Dr Newby, once or
twice and saying, "Oh she's on today."
DE LA POER: If I just stop you there. Dr Newby left in February of 2016, so does it follow that you
heard Dr Newby say that before February 2016?
DrV: Yeah, yeah. So, yeah, yeah, it would have been because I haven't seen her afterwards.
DE LA POER: And having heard your colleagues draw attention to Letby before February 2016, does it
follow
that you went into the thematic review meeting on 8 February with Letby's name in your mind?
DrV: No, I didn't, because I didn't think those comments were made to the extent to implicate that
-- so somebody being there doesn't mean that they're doing something.
DE LA POER: But the point of the thematic review was to look at what might be causing not
necessarily to the point of deliberate harm, but what you are telling us is that you heard Dr Newby
draw attention to the fact that Letby appeared to be a common factor.
DrV: No, no, no. So Dr Newby -- sorry, maybe I didn't say it right -- Dr Newby mentioned after
having been on-call that, "She has been there a few times when I have gone in with sick babies." So
that was the association she had made, and that was the same association -- not implying that she
was connected to the deteriorations. So that at least wasn't my understanding.
DE LA POER: What about Dr Jayaram, when did you hear Dr Jayaram speaking about Letby being
associated --
DrV: I think again that was in passing, nothing in particular. Just saying that, you know, she's on
or she's around.
DE LA POER: I mean, this is a very serious matter, isn't
it --
DrV: Yes.
DE LA POER: -- because we're talking about babies who have died?
DrV: Yeah, yeah. But I don't remember any discussion which implicated that she was actually causing
harm.
DE LA POER: When Dr Jayaram said -- drew attention to Letby and her association, did you say to
him, "Dr Jayaram, what are you saying? Why are you -- why are you drawing attention to that?"
DrV: I think -- because I think we would normally -- that does happen to member of staffs, for
example, you know, if I had had a really bad week or I had had a run of bad weeks people would
associate that with that this particular individual is heavy footed or attracts emergencies or sick
people, which doesn't necessarily mean that they are the ones causing any problems. So I just --
whatever the comments were, they weren't that she is doing something. It was that, you know, she's
-- she's on, she's there today, or -- but just -- yeah, I didn't ask in more detail is all I can say
because I didn't connect that it could mean deliberate harm.
DE LA POER: Or even accidental harm?
DrV: Or even accidental harm, yes, yes.
DE LA POER: Do you think you should have asked more questions about why your colleagues were
choosing to speak about that in this very, very serious context?
DrV: With hindsight, yes. Yeah.
DE LA POER: Do you need hindsight to see that that is a relevant inquiry that you should be making
as a Consultant paediatrician when your colleagues are talking about it?
DrV: I think with the way those comments was -- were made at the time I couldn't tell you exactly
what was said. But I don't remember the way these -- so these were casual conversations, they
weren't serious conversations in passing. They certainly weren't discussions that we have talked
about the rashes and the connection and discussing with the juniors. None of the juniors ever spoke
with me about concerns. So with the way those comments were made, I think now that I know what I
know now I would ask more questions, but at the time it didn't seem concerning.
DE LA POER: You were involved in the care of [Child O] when [Child O] died; is that right?
DrV: Yes.
DE LA POER: You had received an email on 16 May from
Dr Brearey talking about -- drawing to his and Eirian Powell's attention any sudden unexpected
deteriorations.
DrV: (Nods).
DE LA POER: Was [Child O]'s deterioration and death sudden and unexpected, so far as you were
concerned?
DrV: Yes.
DE LA POER: And so did you contact Dr Brearey or Eirian Powell to say that you had had such a death
that you had --
DrV: Dr Brearey was there.
DE LA POER: Was there? Did you say to Dr Brearey --
DrV: No, I didn't practically say to him because he witnessed the whole situation.
DE LA POER: You tell us in your witness statement that [Child O]'s death wasn't discussed at the
evening handover on the night of the 23rd or the morning handover on the 24th, should [Child O]'s
death have been discussed at either of those handovers?
DrV: I think I've tried to explain the purpose of handovers. The night handovers -- so the night
handovers the Consultant isn't at for the night team, the half past 8 one. The 4 o'clock one
handover that very day I didn't go to it because I was busy on the unit.
The next morning -- so the handovers are generally a tool that are used for sharing information
about children and babies who are on the ward and how to manage those problems. It is not normal
practice to discuss what has happened. What we do do is we will speak to the doctors separately or
ask them to come and see us and offer support in what way we feel they might need it or signpost
them.
DE LA POER: So one reason you might have discussed the death of [Child O] is, of course, there were
still [Child P] and [Child R] in your care, and you've told us about your experience of [Child B]
and apparently not being told about the death of [Child B]'s twin, wouldn't it have been appropriate
if for no other reason so that people knew it when they spoke to the parents of [Child P] and R to
be mentioning the fact that [Child O] had died?
DrV: I think I don't recall specifically making that conversation, but I -- given that the statement
about [Child P], the night Registrar was aware of [Child O]. The Consultant -- I mean, Friday night
I would have -- Thursday night Consultant would have been aware because they were there at the
resuscitation. Friday, I was on-call myself, so I knew. So the Consultant team and the doctors team
knew what had
happened with the other twin. So there was that information from that point of view I think was
shared, even though I don't remember bringing it up, probably because Dr Gibbs was at -- on Thursday
night, and he was on, and Friday I was on-call, and the night juniors, given what Dr Mayberry had
done and said, would have probably meant that he knew about [Child O].
DE LA POER: You say that [Child P]'s deterioration was very unexpected; is that right?
DrV: Yes.
DE LA POER: And you'd seen [Child P] shortly before that collapse and he was stable and looked
reasonably well.
DrV: Yes.
DE LA POER: Now, you describe in paragraph 106 of your witness statement -- and I am drawing your
attention to it because you quote something that Letby said and so it's important that we're
accurate about this, it's page 13.
DrV: Yes.
DE LA POER: Your paragraph 106.
DrV: Yes.
DE LA POER: Just refresh your memory from that, please, and tell us what it was that you heard
Letby say.
DrV: What I have said in that paragraph, so this baby collapsed unexpectedly and we resuscitated
him, and then I think he collapsed again a little while later when we left the room for a short
period of time. After that we resuscitated him again, so nurseries are 1, 2, 3 numbered. Baby P
[Child P] was in nursery 2 and, after we had done a gas I'd spoken to the transport team and they
were on their way. I sort of walked across to Nursery 1 and I remember just standing there locking
at the clock counting minutes saying -- What have I said? Yeah -- and we'd just done a gas, which
was reasonable, and I said something along the lines of, "The transport team are on their way, they
should be here soon." So Letby was there and a few other member -- members of the nursing staff were
there, and she basically just said, "He's not leaving here alive, is he?" Which I found I think it
was more disbelief that she had actually uttered such a sentence, and I said something along the
lines of, "Don't say that, he's had a good gas and is stable." And at the time I don't think it sank
in or I actually pondered on -- for what for the next few hours on this information for some time
until I had time to reflect on what happened after that.
DE LA POER: Dr V, in all your experience of being a doctor, had you ever heard any professional
person make a comment such as that --
DrV: No.
DE LA POER: -- at such a difficult time?
DrV: No.
DE LA POER: At your paragraph 110 you speak about Letby's presentation when you went to speak to
the parents of [Child P] --
DrV: Yes.
DE LA POER: -- after [Child P] had died, and just tell us, please, in your own words, having
refreshed your memory, how did Letby appear to you then?
DrV: Yes. So this is after both of them had passed. There is a corridor that leads from the neonatal
unit through double doors into the end of what is called the Lavender Suite, that's like a quiet
zone where parents with a loss or any problems it's a contained area which is laid out in a way to
make it a bit more peaceful. So Letby and I went to speak to the parents there. I remember thinking
I don't know what I am going to say to them because I just didn't know what to say, and her
conversation was very much -- the parents were sitting on the sofas that were there. I think we were
both standing. I can't remember if I sat down later on and -- so she was sort of going on about
making memory boxes for them and said, "Do you want me to make you --
make a memory box for P the same way I did yesterday?" And it was -- it was just the way she was --
the parents were sitting there and I can't remember which one would have said, "Yes, please", so it
was like, you know, they were grateful for her making the memory box, but it was just the whole
manner in -- in which she was saying it. I just found it very inappropriate.
DE LA POER: You describe in your witness statement her as appearing "very excited and animated", is
that a fair way of capturing your experience of how she was behaving?
DrV: Yes.
DE LA POER: [Child R] was transferred to a Level 3 unit. Whose decision was that?
DrV: So at the time -- I think again this is mentioned, either somewhere in the statement or notes,
that when I'd spoken to Dr Rackham about [Child P] going across he had mentioned something along the
lines of, "We will bring R as well." So the initial plan had been that the two of them will go
together. But obviously when he arrived, Baby P [Child P] sadly arrested again and then died. After
that period, I remember we were in the room and when the final resuscitation was being carried out
somebody wheeled Baby R [Child R] next to Baby P [Child P], and I think Dad and Mum were
there as well -- I'm sorry, just one second. After we declared Baby P [Child P], Dad was crying and
he said to Dr Rackham, "Can you please take him?" And I just remember begging in my head and I just
said, "Yes, can you please take him along as well." So that was -- and Dr Rackham agreed.
DE LA POER: Perhaps this is the best way of dealing with this, I'll just remind you of what you
said in your witness statement. You said: "I just fear he [that is Child R] was going to be the next
one and there was nothing that was going to be able to stop it." Was that how you were feeling when
you were saying to --
DrV: Yeah.
DE LA POER: -- Dr Rackham --
DrV: Yeah.
DE LA POER: -- "Please take [Child R]."
DrV: Yeah.
DE LA POER: Now, I'm going to move forward in time to 27 June. Are you okay to carry on?
DrV: Yeah.
DE LA POER: And a conversation that you had with Christine Hurst, the Coroner's officer. We can see
in the notes that the conversation was timed at 10.45, and I hope you've had an opportunity to see
what Ms Hurst says about that conversation. Have you had a chance to see that?
DrV: I have.
DE LA POER: I will just remind you of it. She describes you as being naturally very upset. Does
that accord with your recollection?
DrV: Yeah. That wasn't the first time I spoke to Christina Hurst, though, because my note entry --
and I've included it in my statement -- I'll let you finish.
DE LA POER: Absolutely, we're aware that you spoke to the Coroner's officer before that, I'm just
asking about this very specific conversation on the 27th.
DrV: Yeah, but I had already spoken to her --
DE LA POER: Yes.
DrV: -- on the 24th. This wasn't my first conversation with her.
DE LA POER: No. And she says that she asked you about who was on duty at the time of the collapses.
Do you remember her asking you that?
DrV: No.
DE LA POER: And she says that your tone changed immediately, that you became a little short with
her, and said words to the effect: "What do you mean? Don't you think my colleagues
and I are distressed enough without you implying that someone may have done something?" Does that
accord with your recollection of that conversation with Ms Hurst?
DrV: No?
DE LA POER: Was anything like that discussed?
DrV: No.
DE LA POER: To complete it, Ms Hurst says that she replied to you that she was not implying
anything and it was her job to ask questions. Again, does that accord with your recollection of the
conversation --
DrV: No?
DE LA POER: -- on the 27th.
DrV: No, no, it doesn't and I've sort of gone back and thought about what Mrs Hurst has put there,
and can I add a few comments to that? One of the things is that in Mrs Hurst's statement she implies
that the first and the only time she spoke to me was on the Monday. From my note entry, and I don't
have recollection of this, it looks like I spoke to Chris, I've put "the Coroner's officer", and
then Christina Hurst, and then I've made a long note entry about the discussion we had about the
arrangements, how various things would happen. And the Monday phone call is almost a follow-up phone
call from Friday in just
confirming the arrangements about what we had spoken about on the 24th. I think if I'd had that kind
of a conversation with Mrs Hurst, about her asking me if -- who was on duty -- and again something
that's in there, the Coroner's notes as well, nothing suspicious -- it would have stuck in my mind,
because I think those -- many events from those -- that day are imprinted in my mind and I can't get
rid of them. And even if I hadn't documented them, the fact that she'd asked me such big questions I
probably would have taken it to that meeting that I went to two hours later and said, "Well, this
is" -- because I spoke about everything that had happened and how I was distressed with everything,
especially with what followed for months and months after, if I had thought that there was an
opportunity to take to someone I'm sure that wasn't information I wanted to keep to myself, I would
have -- and you're probably going to ask me why I didn't tell her about -- so I will let you ask and
then answer that.
DE LA POER: We'll come to that in just a moment. What you tell us in your statement is at the time
of this call you had grave concerns about both deaths.
DrV: Yes.
DE LA POER: So if you did have grave concerns about both those deaths you tell us, why didn't you
relay those to
Ms Hurst the Coroner's officer on the 27th?
DrV: Yes. So at that time, my concerns were my suspicions, I hadn't seen her do anything, neither
had anybody else. It was just the way these two babies had died with me spending hours and hours
going through my mind thinking: what could have gone wrong? What was it that I wasn't getting? And
then just these comments and all. So it -- so if I had mentioned something to her it would just have
been, "Well, I can't explain what has happened. I was there for both of them. Dr U was there for
both of them. And she was there for both of them." So it wasn't like she was just the common
denominator. There were other people there who had been there for two deaths as well. And I felt
that the idea of reporting it to the Coroner's officer and then the Coroner is giving them facts, I
don't know why they have died, they are unexpected and unexplained. With hindsight, I probably -- if
I was suspicious, even though I had no basis for those suspicions, I should have mentioned it. But
my only reason for not doing it at that time was I wasn't sure what to do with the doubts in my mind
that I had and I wanted to be in a -- in a more safe space with my colleagues and air my concerns
and then see what other people thought.
DE LA POER: And so having gone into the -- you then had a meeting two hours later at which it was
said out loud that your colleagues were concerned that Letby was deliberately harming babies?
DrV: (Nods).
DE LA POER: So you had an opportunity at that meeting to share your experience, including Letby's
presentation and the remark that she made about [Child P]. Having had an opportunity to hear what
your colleagues had to say, would it have been a good idea for you then to pick up the phone to Ms
Hurst after that, who you'd just been speaking to in the morning, and said, "I've had a chance to
get my thoughts together, I've spoken to my colleagues, we are worried about this"?
DrV: Yes. But at that meeting a plan was decided about further actions, and the right -- so my
colleagues knew that I'd reported to the Coroner, I'd asked for a pm because the deaths were
unexplained and unexpected, that bit they knew. I obviously hadn't discussed anything else with the
Coroners's officer. From that meeting there was a plan made on how to escalate our concerns, and my
understanding, rightly or wrongly at the time, was we're going to go down the way of escalating
this. So that is happening now.
DE LA POER: Dr V, just to understand that. I mean, did
you view yourself as having a personal duty, your duty to the Coroner to assist the Coroner with the
Coroner's investigation?
DrV: At the time I didn't think the information I had with no evidence and no facts as such would be
of any use to the Coroner, if you put it that way. I don't know. That's what I thought then. I would
probably do things very differently now.
DE LA POER: Looking back on it, do you think that that was the wrong way to think about it?
DrV: Yes.
DE LA POER: I would like to ask you about an incident on what we believe was either 28th, 29th or
30th June which you speak about in your witness statement when you encountered Letby on the
ward.
DrV: Yes.
DE LA POER: So it would be right -- you don't give a date in your statement but we know that Letby
went on who will on 1 July and in fact didn't return to the NNU after that, so have we got it right
that it was in the week that began with you speaking to the Coroner's officer and having the
paediatricians meeting?
DrV: I don't remember that. I just remember that this was another on-call. Now, exactly how long
after 27 June, I don't remember. I do remember that it
happened in the following few weeks. If the records show that she didn't come back to clinical work
after her annual leave, then it probably was that week.
DE LA POER: And was it your understanding at that time that she was allowed to continue to work but
that she would be under supervision?
DrV: Yes.
DE LA POER: And who had told you that?
DrV: I don't remember exactly but that probably was the agreement, but I -- when I saw her at first
I think I completely forgot that she was to be clinically supervised, and I just remember being
terrified that, "Oh, she's here now, what's going to happen?" And just feeling that terrible things
were going to start happening again basically. Until then another nurse intervened and said, "What
do you need? I'll get that for you." And then I suddenly remembered, "Oh, she's supervised, she
can't do any hands-on clinical work." And then we sort of managed.
DE LA POER: Just a couple more events to deal with with you, please, Dr V. The first is the meeting
on 26 January 2017. You tell us in your witness statement that you had spoken to Dr David Semple
prior to the meeting.
DrV: (Nods).
DE LA POER: What, in summary, had Dr David Semple told you about what to expect from the
meeting?
DrV: So I remember Mr Semple came down and it was the corridor offices, as we've referred to before,
and he was in one of those offices and there was a few of us around there. I couldn't tell you who
else was there but there was at least three or four of us. And he looked quite worried, and I don't
remember the exact conversation but his advice was mainly to keep quiet and saying that, you know,
"The execs don't have very good plans about you, so I would suggest that you just keep quiet in the
meeting and sit it out."
DE LA POER: And in terms of --
DrV: I may be wrong but I just vaguely remember this statement, "Heads would roll", or something
like that. I don't know if I'm -- but, yeah, he, he looked very, very worried.
DE LA POER: And again in summary, as we've heard from a number of people, we want to hear your
experience, what was the tone of the meeting that you had on the 26th with Tony Chambers and Ian
Harvey and others?
DrV: Very aggressive, very angry to the point of being scary, intimidating.
DE LA POER: Two more matters to deal with. The first is your meeting with Simon Medland Queen's
Counsel as he was. What you tell us, and I'll just quote from your statement, is that you remember
that: "He looked quite shocked at the information that we shared with him." And so just to
understand that, we know from the record that he came and introduced himself. Did you and your
colleagues then explain at some early point in the meeting that you were concerned?
DrV: Yes. So I think we each of us individually recounted our experiences. I certainly remember
recounting mine.
DE LA POER: And your perception was that he looked shocked?
DrV: Yes. So then we asked him if he had been briefed about our concerns and, from what I can
remember, he -- he hadn't been, which wasn't our impression when we went for that meeting.
DE LA POER: The final thing I would like to ask you about is your statements to the Coroner. If we
just bring up INQ0008605. This is a statement that you made to the Coroner, and if we move
to page 7, this one being about [Child O], we can see that it's signed and dated on 3 November 2016
and there is similarly a statement you made on the same day for [Child P] as well; is that
right?
DrV: Yes.
DE LA POER: Thank you we can take that down. Dr V, at that point in the sequence of events, you had
sat at meetings with your Consultant colleagues and talked about the possibility of deliberate
harm.
DrV: (Nods).
DE LA POER: You knew that that concern had been raised with the Executives, so it was being spoken
about openly with the higher management in the hospital, and no doubt you were aware that the RCPCH
were told something similar as well.
DrV: (Nods).
DE LA POER: If we look at those statements to the Coroner, you don't appear to have said anything
about any of those concerns. Why were you not telling the Coroner, whether in that statement or in
an accompanying letter when you sent it across, that as a Consultant body you were all extremely
worried that a member of staff had murdered [Child O] and [Child P]? Why didn't you tell the Coroner
that?
DrV: I don't think it was anything I was particularly trying to keep from the Coroner. I think it
probably was just my understanding of a Coroner's statement is a statement of facts that -- how
things have happened, and I didn't think -- even at that time,
and I know I added later on in my police statements, these two incidents, and I was asked later on
in the trial as well why I hadn't included them, all I can say is it wasn't a conscious remission of
facts that I was trying to keep from him. My understanding is -- was that a Coroner's statement is a
statement of facts, and whilst, yes, we had our suspicions and we were pursuing our concerns, we
didn't have as such evidence to support. However, again, with how things have happened and
unravelled over a period of time, I think it was probably not the right thing to do. I should have
included those statements. And, again, you know, I think we were pursuing a different line of
raising our concerns and felt that since we were already doing that, and my understanding at the
time -- or maybe I didn't know at the time -- but later on had also been that Coroner was aware of
our concerns. So I don't know why I didn't put them down but it wasn't something I was trying to
hide.
DE LA POER: Just to pick up on something you just said there. According to the correspondence, it's
not until February 2017 that the Coroner was being told about your concerns in terms, that's what
was being reported in the correspondence.
Just think back, when you did that statement on 3 November of 2016, was it really the case that you
thought the Coroner knows all about this?
DrV: No -- yeah, no, it wasn't, it wasn't, you're right, yeah.
DE LA POER: And obviously the function of the Coroner is to establish how that baby had come about
their death.
DrV: Yes.
DE LA POER: Do you accept that that was highly relevant information that you had to give to the
Coroner to help the Coroner determine how [Child O] and [Child P] had come about their deaths?
DrV: Yes.
MR DE LA POER: Dr V, those are all the questions that I have for you. I think that there are two further sets of questions, and I think, my Lady, Mr Skelton is to go first.
LADY JUSTICE THIRLWALL: Thank you. Mr Skelton.
MR SKELTON: Dr V, I'm going to ask you questions about [Child A] and [Child B], and I'd like you to
think very carefully about what you can recollect about the two of those children. You'll recall
just by way of background that one of them was murdered on 8 June 2015, that's [Child A], and two
days later his sister, [Child B] -- twin sister -- collapsed and you were involved in the
resuscitation, so you know who I am talking about.
DrV: Yes.
SKELTON: You, I think after [Child A]'s death, were involved with [Child B]'s care to the extent
that you were involved in getting or assisting with investigating whether there may be a
haematological cause to the death which may affect [Child B]. Do you remember that?
DrV: Yes, I remember that from the documentation which says discussion with the haematologist about
mother's condition.
SKELTON: And the reason that that was being investigated was that [Child A] had died and there was
a concern that there may be something that hadn't been identified, a condition that the mum had,
which might affect [Child B] and also cause potential risk to her. Do you remember that?
DrV: I don't remember -- remember exactly but if that's what it says in the notes, I -- I -- from
what I have read the documentation was discussion with the haematologist. I don't recall -- but,
yeah.
SKELTON: Well, let's have a look at the medical records briefly then, INQ00000698, page 25, please. I'm hoping
that's going to come on screen. Page 25. So this is the 9 June, so this is the day after [Child A]
has died, and you see initially a note by Specialist Trainee Beach?
DrV: Yes.
SKELTON: And this is to do with chasing up some haematology from a different hospital which has a
specialist investigatory unit. And we won't go into the background to the mother's condition but
suffice to say there was some concern that the mother's --
DrV: Yeah.
SKELTON: -- condition may be involved with the [Child A]'s death. Do you remember that?
DrV: I don't remember it but I can read it. It says that they have discussed with the haematologist
and they've asked for some samples from [Child A].
SKELTON: Yes.
DrV: And --
SKELTON: So this is [Child B]'s notes --
DrV: Yeah.
SKELTON: -- talking about [Child A].
DrV: Yeah, yeah.
SKELTON: And further down we can see another trainee, Davis --
DrV: Yeah.
SKELTON: -- continuing the same analysis --
DrV: Yes.
SKELTON: -- this time a message from the obstetrician --
DrV: Yeah.
SKELTON: -- that had been treating mother A --
DrV: Yeah.
SKELTON: -- and again discussing haematology and specialist assistance.
DrV: Yes.
SKELTON: And then if we go down to the bottom, you can see that you are involved, DW, which is
"discussed with", Dr V, and you give some advice about progressing things.
DrV: Yes.
SKELTON: So trying to refresh your memory as best you can, does it look like you must have known
about [Child A]'s death and the mother's potential connection with investigation of a haematological
condition?
DrV: From these notes, yes. From memory, I can't recall, I'm sorry.
SKELTON: When you -- do you remember giving evidence at the criminal trial?
DrV: Yes.
SKELTON: I'm just going to take you again by way of reminder to that because the reason I'm asking
you these questions is in answer to Mr De La Poer's questions this morning you said you couldn't
remember [Child A]'s death at the time of [Child B]'s collapse.
DrV: Yes.
SKELTON: And I want to try and get you back into the frame of mind where you may revive that
answer. But I don't want to do so without allowing you the opportunity to see what you've said
previously. So may we look at the records from the criminal trial, please, at INQ0010269. If you could go to electronic page 5 and then focus on the -- it's
quite a small print, so I'm going to try and focus on page 14, first of all, which is the bottom
left quarter, and if you could expand that quarter, please. Thank you. So just to put this in
context, Dr V, this is quite a long period of examination when you're asked about [Child B] and
you're discussing the records, which I'm going to come on to in a few minutes, about her collapse,
and at the end you start to talk about a bit of the background. So can you see just at the bottom
there you were asked --
DrV: Yes.
SKELTON: -- you were asked about the background: "So basically the evening before I'd reviewed this
Baby I [Child I] had reviewed [Child B] and we had a background history of maternal (and this is
irrelevant) and I had ..." May we now go to page 15, which is at the top right, it's a different
form of transcription, so it's the same page, page 5, just the top right quarter, which is internal
page 15. So just take a moment just to read that through, Dr V.
DrV: Yes.
SKELTON: It also says you've been made aware that [Child A], [Child B]'s brother, had passed
away.
DrV: Yes.
SKELTON: "... and obviously there was an increased alertness and anxiety about what could be done
in anticipation for [Child B] to give us some help etc, etc." So it looks like -- this is two years
ago, I think it is 25 October 2022 -- you could remember [Child A]. Does that jog your memory?
DrV: Yeah, so I think I -- probably when I have prepared this reply I haven't consulted the notes
properly, I apologise.
SKELTON: And indeed Mother A was around throughout this period, wasn't she? Do you remember she was
extremely distressed, understandably, by the death of her son?
DrV: Yes.
SKELTON: And she didn't want to leave her daughter alone. And in fact it was only at the moment
that she left her daughter that her daughter collapsed. Do you remember Mother A being around on the
unit?
DrV: I don't, I'm sorry.
SKELTON: May we just look at the notes that you have made in respect of the collapse of [Child B].
And, first of all, I think it is worth starting with Dr Lambie's notes, and if you give me one
second, it's in the -- I'll give you the reference. Dr Lambie's notes start -- it's INQ0000698, at page 26, please. Thank you. So this is a note that's written in
retrospect after [Child B]'s collapse by Dr Lambie who you will recall as being a senior Registrar
colleague.
DrV: (Nods).
SKELTON: And she has written -- I'll ask you again just to familiarise yourself with the note but
you can see: "Had acute apnea with no warning." So the baby just suddenly stopped breathing, without
warning, and she notes: "... widespread purple discolour of skin with white
patches." So that was a clinical finding that she made at the time. And without going into the
notes, what happens is that they suspect potential sepsis or possible coagulopathy, in other words a
blood disorder, and you get called, and presumably you are at home in bed, and are called in and
arrive within the hospital within about 14 minutes, I think. Do you remember that?
DrV: Yes. I don't remember it but it's from reading the notes.
SKELTON: If we go to your notes, which are a couple of pages on, on page 28, please, this is your
note, again written retrospectively, so you're arriving at 12.50 am but you're writing this a couple
of hours later or so, and one of the first things you note is the purple blotching of the body all
over with the slowing of heart rate.
DrV: (Nods).
SKELTON: And, again, you mention the purple blotching a second time in the first half of your own
notes. Do you see that?
DrV: Yes, I do. I've just said, "Baby tubed by Reg", and obviously the description I have written is
what the Reg, had seen then I go down upon my arrival
the blotchiness was on the right mid abdomen and right hand, "pink and active".
SKELTON: That's right. So it's reported to you, first of all, presumably by Dr Lambie --
DrV: Yes.
SKELTON: -- and then you go and have a look and it's still there and you note where it is.
DrV: Yeah.
SKELTON: Correct. And then your note goes on for a couple of pages, but if we go to the next page
you can see you spoke to the parents. This is at page 29.
DrV: Yeah.
SKELTON: It's going to come on the screen page 29. Can you see that there?
DrV: Yeah.
SKELTON: "Spoke to the parents. Purple discolouration almost resolved ?? Cause." And then you talk
about how the baby stabilised for the time being. So when you spoke to the parents -- and if you
don't remember this, of course say, Dr V -- do you remember mentioning the rash to them and saying,
"We don't know what's caused it"?
DrV: I don't remember that, but how I have written it there's no reason why I wouldn't have
mentioned it because there's a description of what happened, and then there was rash there, and if
the parents were present I would have discussed that, yes, the rash was much more florid. And,
again, I'm not speaking from memory, I'm just thinking what I would have said to them that I'm not
certain what's caused it.
SKELTON: Mother A has given evidence to the Inquiry orally that she remembers speaking to the
on-call Consultant who, if she's correct, would have been you because that was you that night, you
were literally called into the hospital at midnight, and being asked by that Consultant to take a
photograph of the rash. Does that jog a memory?
DrV: I'm really sorry but I can't remember. I have read Mother's transcript that the on-call
Consultant said that they weren't -- they hadn't seen anything like that before and asked if they
could take a picture, and then the nurse went off to take a photo -- to get the camera, and by the
time she came back the rash had disappeared. So we decided not to take a photograph. I'm really
sorry but I don't remember that.
SKELTON: Just focusing on your clinical thinking, your decision-making and analysis. You have a
widespread purple rash on a baby and Dr Lambie has noted as well
that it's sort of disappearing as well. It's come and it's begun, so it's resolved relatively
quickly around the same time that the child has recovered. What is your differential diagnosis for
the cause of the rash?
DrV: So the differential diagnosis at the time would have been a problem with infection, so one of
the first things that we think about is: was it some kind of infection? Is it the background related
to maternal condition? Is it to do with there's another condition which is called disseminated
intravascular coagulation. However, the rash wouldn't be expected to disappear so quickly. We had
requested some blood products, but I don't think we needed to give them. At the time, what I would
honestly say is that the idea of the rash having been caused by some type of inflicted or deliberate
harm didn't cross my mind.
SKELTON: I understand that, but what we don't see in the notes is an analysis of what it might have
actually been diagnostically?
DrV: Yes.
SKELTON: So you don't appear to have written down --
DrV: No.
SKELTON: -- what has caused the rash?? X, Y or Z, the things you've just explained.
DrV: Yes.
SKELTON: Why is that?
DrV: I think that is basically a lesson for me to write more and put a bit more detail in my
documentation when I'm writing down making sure whatever my thought processes are, are documented
properly.
SKELTON: And, of course, that is a -- it's a basic tenet of medicine, isn't it, that you note down
your thinking in response to the diagnostic science, and in fact it's reported repeatedly there's a
rash but there's no analysis at all of what the cause might be.
DrV: Yes.
SKELTON: You didn't I think also connect [Child B] to [Child A] in terms of your notes either at
any point; is that correct?
DrV: That's correct.
SKELTON: And in fact [Child A], as it happens, had shown a similar rash as he collapsed and died.
Recognising now that the significance of your own notes, it would have been helpful to have
connected those two things, and you accept that's a failing on your part?
DrV: Yes.
SKELTON: And it's also a failing of those who were involved with [Child A]'s care not to
communicate the diagnostic signs about his collapse that would have
helped you to understand [Child B].
DrV: Yes.
SKELTON: Do you understand that?
DrV: Yes.
SKELTON: In other words, you both needed to speak to each other and then would have understood the
rash had been common -- a common factor.
DrV: (Nods).
SKELTON: If you had gone through a formal process of thinking about the rash and had managed to
exclude the various diagnoses that you've just explained, so coagulopathy, sepsis and so on, and
still couldn't explain it, and also knew that [Child B] who -- [Child A] who died had had the same
rash, would you have reached the point where you suspected that there was something going on that
you needed to investigate further?
DrV: I think it was definitely probably would have been something I would have discussed with my
colleagues or maybe with the tertiary specialist to ask if there was anything I was missing in that.
I'm not sure if it would have directed my mind to deliberate harm. I'm just speaking with the
mindset I was in at the time, I think it was fixed on a pathology and that I was missing some
information about a disorder that I wasn't aware about, especially given that they were twins, so
there was a possibility that they might have the same disorder.
SKELTON: But you accept I think that the link between the two needed to have been identified at the
time --
DrV: Yes.
SKELTON: -- and indeed the link between those two and further deaths on the unit and similar rashes
in respect of those children should have been identified at the time?
DrV: Yes.
MR SKELTON: Thank you. Thank you, my Lady.
LADY JUSTICE THIRLWALL: Thank you very much, Mr Skelton.
LADY JUSTICE THIRLWALL: Mr Baker.
MR BAKER: Thank you, my Lady. Dr V, I also ask questions on behalf of some of the families. I want
to ask you some questions in particular about your interactions with Lucy Letby surrounding [Child
P]. You've given evidence already about the comment that she made during the resuscitation that he's
not getting out of here alive. You also described a meeting between you and Lucy Letby and the
parents of [Child P].
DrV: (Nods).
BAKER: You've presumably attended other meetings before where it was necessary to talk about
unhappy things?
DrV: Sorry, say the last bit again.
BAKER: You've presumably attended meetings before where it's been necessary to talk to parents
about unhappy news?
DrV: (Nods).
BAKER: What was it about Letby's behaviour on this occasion that struck you as unusual, because it
clearly was something you've since reflected upon?
DrV: As I have tried to explain before, it was the inappropriate jolliness, brightness to it, which,
as when I was being questioned at the criminal trial, was put to me as could it have been somebody
trying to make the best of a worst situation, and that's not how I perceived it, probably because
that's not how I would interact with bereaved parents. And my experience of previously doing this
with other nurses it can be done in a calm, peaceful, reassuring manner, but not in the manner that
she did.
BAKER: You presumably reflected on this meeting after the event. Did you try to look for legitimate
explanations to try and convince yourself that this was
normal behaviour by Letby?
DrV: I don't know what legitimate explanations apart from what the defence lawyers said there could
be, which -- I -- I still thought her behaviour was a bit inappropriate. That was my opinion. That
might just have been my personal opinion.
BAKER: So prior to these two incidents, your evidence is that you had no personal suspicions about
Letby?
DrV: (Nods).
BAKER: You attended a meeting -- so [Child P] died on 23 June, and you describe at paragraph 114 of
your witness statement attending a meeting where, amongst other people, Eirian Powell was
present?
DrV: Mmm.
BAKER: Can you see that section there?
DrV: Yes.
BAKER: And you say here that you became very upset and emotional at the meeting. In your own words,
why did you become upset and emotional when meeting with Eirian Powell on 27 June?
DrV: On their deaths, that they had died and I didn't know why and how.
BAKER: Did you say anything to Eirian Powell about what Letby had said to you or in your
presence?
DrV: So I said to Eirian two things, I think I said
to her about the not leaving here alive. I recounted that incident to her. And I said it wasn't just
me, there were other nurses there as well, and I also probably recounted the Lavender Suite
incidents as well.
BAKER: So is it correct to say then that the death of occurred on 23 June, prior to that point you
had no suspicions personally about Letby?
DrV: No.
BAKER: But by 27 June, so the Monday after the Thursday when [Child P] died, you were emotionally
recounting to Eirian Powell your concerns about Lucy Letby?
DrV: Yes.
MR BAKER: Thank you, my Lady, I have no more questions.
LADY JUSTICE THIRLWALL: Thank you.
MR DE LA POER: My Lady, just one short matter not by way of question, however, and that is just, Dr
V, just to let you know that we've checked with the Countess of Chester and the email that you had
dated 23 June 2015 that they hold does have your name on it and I just wanted to alert you to that
fact because it may be the Inquiry will ask you to provide a further statement to clarify that
fact.
DrV: Okay.
LADY JUSTICE THIRLWALL: Thank you very much indeed, Mr De La Poer. Can I just clarify one thing,
from my perspective, and it may be obvious from some of your answers earlier to Mr Skelton, and it
may be that I misheard you, but when you were giving your evidence earlier and you were saying that
you were unaware -- I'm talking now about Baby B [Child B] -- you were unaware the death of A, and I
think you said you were also unaware that they were twins, or is that -- have I misunderstood?
DrV: No, I think from the discussion that we've had now, I said earlier that I wasn't aware that
Baby A [Child A], the other twin, had passed and that probably has been from when I've prepared my
statement from the information that I have been given I haven't gone back to the original notes far
enough, which we did just now, to see that I actually was aware. So --
LADY JUSTICE THIRLWALL: It seems likely, doesn't it, that if --
DrV: Yes.
LADY JUSTICE THIRLWALL: -- that you would be aware because you had the other doctors and nurses
there?
DrV: Yeah, yeah.
LADY JUSTICE THIRLWALL: And the parents were
there?
DrV: Yes.
LADY JUSTICE THIRLWALL: And so I suppose that's why I wondered why you didn't make a link between
what had been seen -- what you had seen on B and what was known about A?
DrV: Yes, I'm not sure I knew about the rash on A.
LADY JUSTICE THIRLWALL: Did you ask anything about the circumstances of A's death?
DrV: I couldn't remember right now, but I -- I can't recall.
LADY JUSTICE THIRLWALL: All right. Thank you very much indeed. Now, those are all the questions
that we have for you. You are free to go.
DrV: Okay, thank you.
LADY JUSTICE THIRLWALL: I think we are going to slightly reconfigure the room, so if everyone would leave. I've been asked to stay because it causes less disruption, so I'll just stay here but if everyone would move out and then we'll come back in again. Have I got that wrong Mr De La Poer?
MR DE LA POER: My Lady absolutely hasn't, but it just occurred to me that it might be a convenient moment for us to take our break so that we have a single session all the way through. I don't know whether that was what my Lady had in mind, and that leaves us with a single block, or whether my Lady wishes it save that break until later in the --
LADY JUSTICE THIRLWALL: That's a very generous interpretation, Mr De La Poer. Let's take the break now and we'll start again at 10 past if we are ready. (2.53 pm) (A short break) (3.10 pm)
MS LANGDALE: My Lady, may I call Dr U and may the witness be sworn, thank you.
DR U (affirmed
LADY JUSTICE THIRLWALL: If we just wait a moment because there is a bit of noise at the back. Ms Langdale.
MS LANGDALE: Thank you. Dr U, you have prepared two statements for the Inquiry, the first dated 3
September and the second dated 9 August 2024. Can you confirm that the contents are true and
accurate as far as you're concerned?
DrU: Yes.
LANGDALE: Dr U, you worked, we know, at the Countess of Chester between September 2015 and
September 2016 as
a paediatric Registrar.
DrU: That's right.
LANGDALE: And you worked between September 2016 and July 2018 as a locum Consultant in diabetes and
general paediatrics at Alder Hayes hospital?
DrU: That's right.
LANGDALE: You've set out in your statement the culture and atmosphere of the neonatal unit, as far
as you're concerned, in 2015 to 2016. Can I ask you to go to paragraph 10 of your statement, please,
You were the most senior Registrar, I think, at that time, weren't you? You were the most senior
Registrar?
DrU: I think so.
LANGDALE: Do you see at paragraph 10 --
DrU: Yes.
LANGDALE: -- you set out: "There were seven Consultants who clinically managed the junior doctors,
including myself." What was your relationship with the Consultants like?
DrU: I would say it was generally friendly. It was a collaborative relationship, they supported me,
and because of my length of training and my -- my previous experience I was maybe able it relieve
them of some of the workload that the more junior Registrars couldn't.
LANGDALE: And you say junior doctors would report to the Consultant who was on the hot week, was
that a different person each week?
DrU: Yes.
LANGDALE: So how would you describe your relationship with Drs Brearey, Gibbs, Jayaram and the
like?
DrU: Generally friendly, yes.
LANGDALE: You say at paragraph 11, as far as you were: "... aware the nurses and midwives had good
working relationships, occasionally antagonism at times mainly due to communication and workload."
Was that your sense of relationships between those two groups insofar as you got on?
DrU: That's how I recall it. The workload was unpredictable, but sometimes there was a lot of work
that needed doing in a short space of time and that did cause some friction.
LANGDALE: Junior doctors and the nurses you say good working relationships on the children's ward
and between the junior doctors and nurses on the NNU. Was that your understanding or experience?
DrU: Yes.
LANGDALE: I think Eirian Powell has suggested that the Consultants -- what they said had to go or
something to
that effect, was that your experience, or do you think it was a very collaborative relationship
between doctors and nurses generally?
DrU: Generally, yes.
LANGDALE: Generally yes, collaborative. You say relationships between the labour ward midwives and
other clinicians were a bit more strained as they wanted to be autonomous practitioners. What do you
mean by that?
DrU: Labour ward midwives didn't -- they work autonomously and that sometimes meant that
collaboration, communication with the neonatal unit was maybe not as it would like or should have
been, such as babies about to deliver and it resulted in a crash call and a run to the labour ward
rather than knowing about it upfront.
LANGDALE: Rather than -- sorry, I missed that?
DrU: Rather than knowing that that baby was about to deliver in advance.
LANGDALE: Right, right. So the communication put pressure -- the lack of communication --
DrU: Sometimes.
LANGDALE: Sometimes. But overall?
DrU: Overall it worked.
LANGDALE: You say NNU felt the atmosphere was generally
happy and felt positive and no obvious problems in team working.
DrU: No.
LANGDALE: No, as in you agree that's what you think?
DrU: That's correct.
LADY JUSTICE THIRLWALL: I wonder, doctor, if you just keep your voice up a little bit. We've got
very good microphones but I think in the far distant corners it's not so easy to hear you.
DrU: Certainly.
MS LANGDALE: You say you can't recall precise timings, but in around July 2016 when Letby was
restricted to an administrative role you were aware that more questions were being asked in relation
to patient management on the NNU and that some of the nurses felt uneasy about being watched. Can
you expand upon that, what do you mean?
DrU: By July 2016, there had been the deaths that have been tried at the criminal trial and there
was a lot more focus on the neonatal unit, and certainly more of the senior neonatal unit nurses
were uneasy about the level of attention that was being cast. Whether that was because they felt
that they were being watched to see if they made mistakes or whether it was just collectively as a
group of nurses they felt
defensive, I wouldn't -- I don't know.
LANGDALE: You say there was a general feeling of unhappiness when Letby was suspended. What do you
mean suspended, do you mean moved duties in the --
DrU: Moved to the administrative role.
LANGDALE: -- non-clinical -- yeah. So when she moved to that clinical -- non-clinical role, you say
-- well, what do you say was the impact on some nurses?
DrU: They were unhappy that Letby had been singled out and moved. Whether that was due to the lack
of communication or whether that was just because they felt that somebody had been identified and
moved, I don't know.
LANGDALE: Which nurses were unhappy about that?
DrU: So I don't know their full names. One was Mina and the other, Nurse T, both of whom I --
LANGDALE: So a couple when she was moved to non-clinical roles?
DrU: Yeah. I think there were more but those are the two that I -- that stick out at the moment.
LANGDALE: Sorry, I am really struggling to hear you.
DrU: I think there were more that were unhappy but those are the two that I remember being --
LANGDALE: Why do you think there were more? Did Letby suggest that to you or do you know that for
yourself?
DrU: No, I think she may have suggested that to me but I don't recall.
LANGDALE: As far as you are aware, for your knowledge, you've got a couple of names that when she
moved to non-clinical duties you think -- felt what about that?
DrU: Sorry, I didn't hear.
LANGDALE: What did you think the couple that you've mentioned felt about her being moved to a
non-clinical role?
DrU: I don't know exactly what they were thinking but they certainly seemed sorry for her, unhappy
that she'd been moved.
LANGDALE: Again, I must ask you, is that something that you got from them or something that Letby
told you about them?
DrU: Both, I think.
LANGDALE: I'm going to ask you about your involvement with some of the babies named on the
indictment. You gave a number of statements to the police, didn't you, and I think you gave evidence
-- yes, you've given a number of statements.
DrU: That's right.
LANGDALE: In terms of [Child I], if you go to paragraph 20 of your statement, you attended a
resuscitation call, didn't you --
DrU: Yes.
LANGDALE: -- and you had to respond to an acute inventory as [Child I] had deteriorated; yes?
DrU: Yes.
LANGDALE: You tell us you don't recall if you specifically discussed this deterioration with anyone
else, and although there was a debrief much later on, you didn't go to that debrief. Why wouldn't --
why didn't you go to the debrief?
DrU: I don't know why specifically. It may have been that I was on nights at the time or just not
working at the time that the debrief took place.
LANGDALE: You do tell us at paragraph 23 that discussions did happen all of the time, in other
words even if there's a not a debrief you can have discussions amongst you as clinicians, doctors,
nurses about events on the unit presumably. You can have discussions, is that right, you would have
informal discussions even if you didn't go to a debrief?
DrU: Yes, so the people that attend the debrief may then tell others that weren't available to go or
were busy at the time, they may pass on those details, yes.
LANGDALE: Did anyone pass on to you about that debrief or discussions about Baby I [Child I]?
DrU: I'm sorry, I don't remember. I don't know.
LANGDALE: Did you have an office or a base -- we know there was a corridor with Consultants and who
they shared rooms with, did you share a room with anyone?
DrU: No.
LANGDALE: No. So how did the Registrars work you don't have an office space you just go to
work?
DrU: Yes.
LANGDALE: So are there any parts of the hospital you would gather or talk together or have a little
bit more of an informal chat?
DrU: There is an office for the junior doctors on the children's ward. There is a mess for the
junior doctors to eat their food.
LANGDALE: And who were the fellow Registrars when you were there?
DrU: There was Doctor S, Dr Upadastra, Dr Mayberry, Dr Ukoh.
LANGDALE: My Lady, at least one of those names can't be reported. And I remind people to look at the list who are reporting.
LADY JUSTICE THIRLWALL: Thank you.
MS LANGDALE: So you could sit together and have conversations if you wanted to at different times
of the day and -- just to catch up with each other?
DrU: Yes.
LANGDALE: You had started work in September, hadn't you, and so this death of [Child I] occurred
within the first month that you were there?
DrU: Yes.
LANGDALE: Yes. And we know it was a sudden and unexpected death. The Inquiry is very aware of that
detail. Did any of those Registrars or any of the other Consultants or nurses discuss with you, as
someone who had been at least in one event with Baby I [Child I], that sudden and unexpected death
and what it might mean and what needed to be done?
DrU: I don't think there was an informal discussion but it would have been discussed at the handover
meeting between the daytime team and the night team. All of the babies on either the children or --
in fact all patients on either the children's ward or the neonatal unit would be covered as part of
this handover process.
LANGDALE: Did you understand that Baby I [Child I] had died? Did you know about her death?
DrU: I'm not --
LANGDALE: I'm not talking about the night you were working, I mean generally, did you know about
her death?
DrU: I'm not sure. I don't know.
LANGDALE: Do you know if anyone discussed with you about her death and what it represented?
DrU: They may have done, but I don't remember those conversations from -- from 2015.
LANGDALE: Would you agree with me that unexpected and unexplained deaths in neonates are rare?
DrU: They are.
LANGDALE: So as a rare event, if it had been discussed with you, do you think you would have
remembered?
DrU: I may have remembered closer to the time, but I -- I don't have a memory of that discussion
now.
LANGDALE: [Child L], paragraph 25. You set out at paragraph 27 that you cared during the night
shift on 9 to 10 April for [Child L] and when you attended to [Child L], they had a low blood sugar
reading and you worked to stabilise the blood glucose in order to prevent harm from being caused.
You set that out. You also tell us you were unaware of the hypoglycaemia screen test results that
had been ordered by Dr Ukoh beforehand?
DrU: (Nods).
LANGDALE: When we look at the notes, Dr U -- and I can take you to them but you may just accept
this -- it's a page before where we see an entry to the effect: "Bloods for hypoglycaemia
investigations have been requested."
My question is when you were looking after Baby L [Child L], do you look back in the notes to see
what somebody has done before you if there's something that you don't know why it's happening or
what it means is going on?
DrU: Yes. Yes, I will have looked back through the notes, maybe only for the previous 24 hours, to
see if that explains the current situation.
LANGDALE: Well, the note -- the entry I think was at 19.20 on the 9th, so if you had looked back
you might have been expecting to see then that those screen tests results had been ordered, at least
requested?
DrU: Yes.
LANGDALE: Yes. If you had seen they had been requested, would you wonder why the person before you
had requested them?
DrU: So if the hypoglycaemia screen had been requested it was because the baby had undergone low
blood glucose.
LANGDALE: So you understood then those tests had been ordered?
DrU: Yes.
LANGDALE: But you didn't obviously have the results, they came in later?
DrU: So the hypoglycaemia screen results come back at different times because the tests are
performed at
different locations. I believe that the insulin level is a send away sample that gets sent to the
Royal in Liverpool and takes some time for the result to go back to Chester. It would be my normal
practice to look and see what results were available. I don't recall the results and if I haven't
written them down in the notes there was maybe nothing there to comment on.
LANGDALE: The results, we know, were provided later and Dr Gibbs has accepted collective failure
for the Consultants for not viewing those results, you're aware of that, aren't you, in respect of
Baby L [Child L]?
DrU: I wasn't aware of that, no.
LANGDALE: You weren't aware that the results that were sent back to the hospital test results about
the fact that manufactured synthetic insulin could be in his blood? You weren't aware of that?
DrU: No, I knew that from the criminal trial. I wasn't aware of Dr Gibbs' comments.
LANGDALE: Right. So now you are, do you take some responsibility too for not checking those records
having treated Baby L [Child L] and managed his low glucose readings, not looking later to see what
those test results were when they had been requested?
DrU: I wouldn't have expected those results to be
back within that night shift.
LANGDALE: No, sure, I meant later, a few days later. I'm not suggesting they were available to you
on the day. By 14/15 April you're still working at the hospital, having a look and thinking, "Oh, I
looked after this baby let me see what's come back"?
DrU: No, that -- normally I would only be looking for the results of the child that I was dealing
with at the time. I wouldn't go looking back retrospectively. I would have presumed that the doctor
looking after that baby on that day would be aware and checking for current results. Otherwise, you
would end up looking at the results of every child on the unit every day to see what had returned.
LANGDALE: So you would only have done it if you were looking after the child on the day that the
results came back?
DrU: Yes, you would be looking for new results. Generally, if there is a result that is unusual,
then it gets telephoned through to the neonatal unit or to the children's ward.
LANGDALE: That was an opportunity missed, wasn't it, to detect deliberate administration of insulin
to a baby, not seeing those test results at the time for Baby L [Child L]?
DrU: So -- yes.
LANGDALE: So with your knowledge of how the medical records were put together, how do you think
that might be avoided in the future? What could either the doctor in your position or anyone else
have done to prevent that?
DrU: I'm not sure what changes would work best there. It was normal practice in many of the district
general hospitals that the results went back to the Consultant named on the top of the request form,
and then that way a paper trail led back to the responsible clinician, not the junior doctors that
were rotating through shifts or sequences of shifts.
LANGDALE: Baby M [Child M], you were also involved in [Child M]'s initial deterioration, you see at
paragraph 33? You say: "I have no recollection of whether there was any discussion about the cause
of [Child M]'s initial decline that required mechanical ventilation to be commenced and/or any
discussion about an unexpected event when I started my shift on the evening of 9 April." Do you
remember that? You stated that, and you don't remember anybody discussing it with you?
DrU: It will have been covered in the handover from the day shift to the night shift. I don't
remember the details of that handover.
LANGDALE: You don't recall any discussion about anything unusual about the appearance of [Child M],
and you didn't attend any debrief. Again, is that because you didn't have significant involvement
with [Child M]?
DrU: Most likely, yes.
LANGDALE: Do you think it would be useful in any event and for learning to have had involvement in
any debrief or discussion?
DrU: Yes, I do.
LANGDALE: [Child N]. [Child N] you were involved in discussions or messaging, weren't you, with
Letby about [Child N]?
DrU: Yes.
LANGDALE: Can you tell us, first of all, your own involvement or direct involvement with [Child
N]?
DrU: On this night in particular? Or --
LANGDALE: Yes.
DrU: Okay. So on this night in particular, I was the night shift Registrar and Letby had been
looking after him on the day shift. The time differences between the two changeovers meant that
nurses and doctors changed over at different times so that there was always cover on the unit. We
had passed several messages. I think later in the night, the earlier hours of the morning and
certainly prior to the start of the next day shift, I think she asked me how he was and I had
explained that he'd been unwell over the course of the night and we'd sent some investigations off
to see if I could identify the cause of that. And then the following morning, he deteriorated
further. And the last intervention that I had to do with him was trying to intubate him and put him
on to a mechanical ventilator but I was unable to do that.
LANGDALE: And others were able to achieve that later?
DrU: Yes.
LANGDALE: Shall we go to the messages if we can? It's INQ0000569, page 2. It starts at message 17 on that page. So these are
extracts of Facebook messaging between yourself and Letby. Just before I start with that, Dr U, you
had, I think, begun in June 2016 Facebook messaging Letby, is that right, around June 2016?
DrU: Yes, I believe so.
LANGDALE: And we have a great deal of messages, if I can just say between, June 2016 and September
2016 about 1,355 messages. There's a large volume of messaging, isn't there?
DrU: Yes.
LANGDALE: Would you like to explain that?
DrU: Letby was struggling with her mental health and I think I picked up on that and I'd offered
some support, and that support, it grew, and I understand that she slept very poorly because of
worry and anxiety, and there were often messages that were passed throughout the day and sometimes
late at night, earlier in the morning.
LANGDALE: If we start around [Child N] or Baby N [Child N]., we see in fact at message 17 you say:
"Is he okay?" She gives you an answer: "Looks like pulmonary bleed on X-ray." Then: "Sorry if I was
off during intubation. Bernie ... faffing, et cetera, like things to be tidy and calm. Well, as much
as possible." It continues down the page. If we go to message 22 -- sorry, 23, message from her
telling you how Baby N [Child N] is. Then saying: "Sat having a quiet moment. Want to cry. Just mad
with so many people." You say, message 25: "Oh, Lucy poor little thing and you." And you continue to
discuss Baby N [Child N], don't you? If you go down to 27. You say: "I've never heard of epiglottis
in a baby. Odd then his CRP was less than 1. Blood obscuring my view of the chords and inflammatory
being going on. Poor you. Are you going to be okay? I'm sure he's had the best care possible and
you'll have done everything you can for him." If you go over the page, it's page 4 of the messages,
number 40. You asking her: "Are you okay? "Yes, thank you just glad he's okay. Quite impressed they
got everyone together so quickly. What do you think has caused his bleed?" And you say: "I think
there will be haemangioma or collection." And you continue. If we go further down the page, message
57. Here you say. "I called PICU. Stable overnight." Who have you called? What's happened there?
DrU: So it's common practice to phone the destination location for babies that are transferred
partly to go on the bottom of the handover sheets so the rest of the team are aware of the status of
the baby, which helps them prepare for transfer back to the unit if that's going to be required. I
will have made that
phone call when it was quieter with reduced workload overnight, just asked for an update, how's he
getting on, and then I will have shared that with the shift leader of the night shift or whichever
shift it was, and in this instance I've shared it with Letby because she will have asked me if I
knew anything more about how he was.
LANGDALE: Do you think it was appropriate to be messaging about Baby N [Child N] with her at this
time?
DrU: In hindsight, no.
LANGDALE: Why not?
DrU: Looking at the content of the messages here, I've shared too much, and from my reflections
since this has happened, it's common to give updates on how patients are without naming them,
without giving lots of clinical detail to help the recipient understand where that patient is up to.
I gave, at the time, details that I thought were helpful but I see now that that probably wasn't the
case.
LANGDALE: And how do you think Baby N [Child N]'s parents would feel about that?
DrU: I'm sure that's very upsetting.
LANGDALE: Would you have even known if they were being kept up to date at that time about their
baby?
DrU: I didn't know -- I didn't know where they were
getting their information from because I presumed that they were at Alder Hey in the intensive care
unit with the baby.
LANGDALE: But there was at least a chance that you were giving information that they may not even
have known about their own baby at that time. You wouldn't have known that, would you, one way or
the other?
DrU: No, I -- I didn't. I presumed that they'd travelled with the child.
LANGDALE: And within those messages, it fleets from information about the child to quite frivolous,
casual conversation in the way that friends do, doesn't it?
DrU: It does.
LANGDALE: Entirely inappropriate to have somebody's baby in the centre of that communication after
such a serious deterioration and now we know an attack --
DrU: Yes.
LANGDALE: -- an attempt murder. Can we go, please, to your statement on [Child O] and [Child P]
starting at paragraph 37. You tell us you have: "... quite a good recollection of the events as it
was a very traumatic experience for all of us on the NNU." The Inquiry has received written and oral
evidence from a number of people about Baby O [Child O] and Baby P [Child P] and it
was traumatic, wasn't it?
DrU: Yes.
LANGDALE: Unexpected, unexplained, devastating. Do you agree?
DrU: Yes.
LANGDALE: You also say at paragraph 40. "I agree with Dr Brearey's statement that [Child O] as well
as [Child P] were born in excellent condition of good weight and there were no obvious concerns for
either of them." Do you agree?
DrU: Yes.
LANGDALE: These were well stable triplets, weren't they?
DrU: They were.
LANGDALE: You were part of the delivery team.
DrU: Yes.
LANGDALE: One Registrar per baby, all set up to welcome them into the world.
DrU: Yes.
LANGDALE: You say at paragraph 48: "We were all very traumatised by [Child O]'s unexpected and
unexplained death." You then say: "We could not attribute it to a non-medical cause and had not
observed anything suspicious." You couldn't give it a medical cause either, could you, it was
unexplained, unexpected and you didn't know what had happened?
DrU: That's correct.
LANGDALE: Surely anything unexplained, unexpected and you didn't know what had happened falls in
the category of suspicious "We don't know. This shouldn't have happened. Until we know more this is
suspicious."
DrU: Yes, I agree. The problem with trying to attribute a cause at the time of the death is
problematic because not all of the investigations have been returned. If this was an overwhelming
infection that result isn't going to be available for another 36 to 48 hours.
LANGDALE: It may take longer, not 46 to 48 hours for a real forensic scrutiny?
DrU: Yes.
LANGDALE: And that's what's required, isn't it, unexpected, unexplained detailed forensic scrutiny
is required to see what's happened. Do you agree?
DrU: Yes.
LANGDALE: Did you know the process to be followed or what should happen after an unexpected and
unexplained death?
DrU: Yes, I'm -- I'm aware of the sudden death
protocols. The -- and I'm unsure as to how much of that was carried out at this time.
LANGDALE: Were you aware then what the protocols were, back in -- taking yourself back some time
ago now to 2016?
DrU: I'm not sure. I'm sure that they were part of the induction or had been -- that I had looked at
them previously. I don't recall whether I was able to recite them or able to pull them to mind at
the time.
LANGDALE: Did you and your colleagues, your medical colleagues, have discussions about what should
be done? It is clear everyone was devastated, but practically, what should be done?
DrU: Baby O [Child O] died late in the afternoon, just into the early evening and I think a large
number of the people that had stayed to help with the resuscitation had stayed beyond the end of
their shifts, and the process of taking samples, making the extended case notes were done by those
that were remaining for the rest of the day.
LANGDALE: But I'm thinking more about the process of where the deaths should be referred to. Who
should be examining the death? What needs to be considered?
DrU: Well --
LANGDALE: Do you know?
DrU: Yes, it would have been referred to the Coroner.
LANGDALE: You say at paragraph 49: "There was a lot of discussion amongst the doctors at handover
following [Child O]'s death as there were still two siblings who were alive and we wanted to ensure
that we considered how best to manage them. This was a medically unexplained event but there were no
concerns about mismanagement or suspicions that someone was to blame as far as I was aware." How can
you say there were no concerns about mismanagement or suspicions when no one knew how the death had
arisen? Until that has been investigated, you can't assert there were no concerns, can you?
DrU: I think what I'm meaning in that paragraph is that there was no event attributable to that --
that decline. It wasn't that a tube had been displaced or pushed too far, it wasn't that an
incorrect medication had been administered as far as recorded on the prescription chart or recorded
in the notes. I'm not sure that any of us would have considered a deliberate act.
LANGDALE: Why not?
DrU: Because I don't think any -- any of the doctors or nurses on that neonatal unit had thought
that
there may be somebody causing harm to babies. The -- the professionalism and the good practice
demonstrated by all members of the team on that unit didn't raise any suspicions. Certainly, as far
as I was concerned, I hadn't seen anything that had worried me. I hadn't seen anything that I had
gone back and had a second look and thought "Oh, what was that?" I hadn't observed anything.
LANGDALE: Dr Lambie told us last week that by September 2015 she had observed a group of nurses in
a huddle conducting an exercise where they were looking for a name or information that might link
someone to events on the unit that had been unexpected, caused concern and suspicion, otherwise they
wouldn't have been doing that exercise. That was in September 2015. Did you ever understand that
people were putting together information to see who might be present at these unexpected and
unexplained events, not just deaths, unexpected and unexplained events be they death or
deteriorations, when did you understand that kind of information was being collated?
DrU: I think that was later in 2016. I don't recall the exact month but it was in the middle to
latter half of 2016.
LANGDALE: After Baby O [Child O]'s death or before?
DrU: I'm not sure.
LANGDALE: We know that Dr Brearey had sent an email to fellow Consultants saying that he would like
to know or be informed about any deteriorations that had happened, and Baby N [Child N] fell into --
taking into account after that email had been sent. Did you know about that email from Dr Brearey
wanting to know about deteriorations or unexpected events?
DrU: To the other Consultants?
LANGDALE: Yes.
DrU: No, I don't think I was aware of that email.
LANGDALE: But you did talk to the other Consultants, you're a collaborative group, were you not
aware informally that Dr Brearey was keen to know about unexpected deteriorations or anything
suspicious?
DrU: Not as a result of that email.
LANGDALE: What was it as a result of then?
DrU: I beg your pardon?
LANGDALE: What was it -- you say not as a result of an email, what did you hear that from?
DrU: There was a discussion with the junior doctors in the office on the paediatric ward, the middle
to latter half of 2016, where I believe it was Dr Jayaram and Dr Brearey mentioned to us -- I think
it was at the end of an afternoon handover -- that the deteriorations,
the -- the neonatal unit was -- I'm sorry, I'm struggling to find the right words -- he had
suggested that the neonatal unit was having a bad run, that there were more events occurring on the
neonatal unit than had been in previous years and we were I think during that handover asked just to
keep our eyes open.
LANGDALE: Keep your eyes open, what for?
DrU: Well, I suspect for things -- for things that may be the cause of the deteriorations.
LANGDALE: We know the email Dr Brearey sent was May 2016. Is this conversation around that time --
you sent it to Consultants, but is this a conversation with you around that time?
DrU: It was around that time, May or June I suspect.
LANGDALE: So by the time of Baby O [Child O]'s death, you are aware of that conversation.
DrU: Yes.
LANGDALE: And Baby O [Child O]'s death comes out of the blue.
DrU: Yes.
LANGDALE: Baby P [Child P]. What was your involvement with Baby P [Child P]?
DrU: On the Friday morning that Baby P [Child P] deteriorated, I was conducting the ward round on
the children's ward. I had been told not to go to the
neonatal unit that day because of the events of the previous afternoon.
LANGDALE: Pausing there. Why, because you'd endured the death the previous day and shouldn't go
back again or what -- why?
DrU: Yes.
LANGDALE: So that was a protective way of managing doctors or nurses, was it, if they'd been
exposed to something traumatic before?
DrU: Yes.
LANGDALE: So who gave you that instruction or suggested that you shouldn't go back?
DrU: That will have been done at the morning handover because both wards were handed over at the
same time. It was most likely the Consultant of the week. I think that was Doctor V that week.
LANGDALE: Again, my Lady.
LADY JUSTICE THIRLWALL: So that name is not to be reported.
MS LANGDALE: So on that next day, you were told not to go there but did you end up going there?
DrU: I did.
LANGDALE: Right. How did that come about?
DrU: I was contacted using the bleep system to -- I was bleeped and a message was passed that I
should go
to the neonatal unit.
LANGDALE: And what was the scene on your arrival?
DrU: So Baby P [Child P] was in the far right-hand side of Nursery 2 and there were a lot of people
in that room, doctors and nurses, and Baby P [Child P] was clearly unwell from the monitoring system
and just how he looked. I had a very, very quick handover about what had happened but it was clear
that he was at the point of needing to be resuscitated.
LANGDALE: Did you think at the time, "How is this happening again?" You'd said earlier you were all
conscious, two siblings, and here you are walking into that scene?
DrU: At that time my priority was to resuscitate the baby. I -- and I got on with the tasks needed
to get him mechanically ventilated and then starting to put more venous lines in so that more drugs
could be administered.
LANGDALE: And after the intensity of the scene, did you then think, "How can we be here again?"
DrU: So the rest of that day, the intensity only dropped slightly. He got a little bit better and
then declined again, then got a little bit better and declined. I stayed predominantly at the side
the cot dealing with breathing, circulation, volume replacement, and I -- I didn't have the big
picture. I had a summary of what had happened prior to me arriving there. I didn't know what had
happened, I don't think, overnight. And I -- I spent I think the rest of the day in that room. There
were some discussions because many of the Consultants came through and joined during the day and I
-- I understood that they were discussing with the transport team and what should be done next.
LANGDALE: Baby O [Child O], P, and R's parents knew that they needed to get Baby R [Child R] out of
the Countess of Chester to keep him safe. They didn't know medically what had happened or how, but
they knew Baby R [Child R] was not safe there. Did you as a doctor think something's happening, he's
not safe here after what had happened to O and then P?
DrU: I was glad that Baby R [Child R] was transferred. I don't think I had put together the string
of events of O [Child O] and P [Child P]. I was still looking for a medical cause for their
deterioration. But I was glad that Baby R [Child R] moved.
LANGDALE: We know, going back to messages from Letby to you -- if we go back to 0000569, page 5, a
message -- 94 and 95, you message her at 94: "Chaos this morning and triplets this afternoon. What a
day." And she says at 95:
"The triplets delivered. Wow. How did you manage to finish early and actually leave the building?"
So she's asking you, isn't she, about triplets there. And if we go over the page, page 7 of the
message, message number 125: "What gestation are the trips? Are you on NNU tomorrow?" And you
respond at 126: "33 plus 5." Again, somebody asking you about the babies at that point in her
messaging. Did you understand why she would be asking that or think that was an unusual thing to be
asking you about?
DrU: That message I presumed was getting ready for returning to work.
LANGDALE: Sorry, say that again?
DrU: I -- I thought that that message was getting ready for returning to work. I believe she'd been
on holiday prior to that.
LANGDALE: Right. And presumably the fact that triplets were going to be born at the hospital was a
big source of excitement. It's very rare, isn't it?
DrU: It's unusual.
LANGDALE: How many sets of triplets have you known --
how many have you been involved in the delivery of?
DrU: Three, I think.
LANGDALE: So if we go to the message over the page at 216, so page 9, 216. It looks as though --
and this is the 23 June, so page 9 of the sheet, message 216, you say here: "I'm glad you could talk
to me and hope I helped." She says: "That's okay. Didn't want you collapsing mid resus. Good to talk
it through." "I think the debrief was good [this is you]. We didn't come up with anything missed or
delayed. Maybe it is better to do it straight away rather than wait." What are you discussing, what
debrief here?
DrU: So I -- I think there that there will have been a discussion at the end of the resuscitation so
that everybody had the opportunity to say what they'd seen, what maybe hadn't been noticed by others
at the time and to then pick up any of the points of information that may be helpful.
LANGDALE: So you're discussing at this point a sudden and unexpected death of Baby O [Child O]
between you in the messaging?
DrU: We did, yes.
LANGDALE: If we go over the page, so page 11, message
323, this is the start of the next day, you -- you say there was thought about you not going back to
be allocated to the sibling. It appears that Letby was. She was back on, wasn't she, with P?
DrU: Yes.
LANGDALE: She says: "I've got my student again but might see if she can work with someone else as I
don't feel I'm in the frame of mind to support her. Loads of paperwork to finish off." And she has
made reference to Baby P [Child P] as: "Stop feeds, is large asps." Meaning aspirations
presumably?
DrU: Yes.
LANGDALE: And you say: "Large asps. I wonder if they have all been exposed to a bug that B Pen and
Gen didn't account for. Are you okay?" She says: "I will be watching them both like a hawk." If we
go further down at 324, message 324, she is messaging about [Child P]: "Just going to dress him take
footprints. Hope you're okay." Further down, at 330/331 she says: "I made a fool of myself whilst
there. I asked them to be quick for you." And so it continues. If we go over the page, at 457, this
by then is 25 June, we see at 22.46 Letby saying to you: "Do I need to be worried about what Dr
Gibbs was asking?" You say: "No, he was asking to make sure normal procedures were being carried
out." What was going on there? We can see -- we can by all means have a look at that exchange,
what's she worrying about?
DrU: I don't know exactly what she was worrying about. But the -- I think, having looked after the
two babies on consecutive days, she was concerned that she would be thought to be responsible for
the deaths and, as I didn't know of the number of preceding deaths, I didn't -- it was a reassuring,
no, I don't -- I hadn't observed anything that had gone wrong in the resuscitation of O or P.
LANGDALE: You were a Registrar, albeit one of the most experienced ones, at the resuscitation. How
could you possibly say, no, nothing to worry about? You didn't know what this death represented. You
couldn't know.
DrU: No, it was -- it was a reassuring no because I -- again, I was aware of her mental health
problems and the amount of anxiety that she had.
LANGDALE: Well, she was worried, wasn't she, if people are asking questions about it?
DrU: In hindsight, yes, obviously.
LANGDALE: And at the time you mistook that for, what?
DrU: Anxiety.
LANGDALE: If you look at page 14, at message 471, you are reassuring her: "If anyone knows how hard
you have worked over the last three days it's me. If anybody says anything to you about not being
good enough or performing adequately give my details. I can provide a statement." She says:
"Sincerely I hope I won't ever be needing a statement, but thank you." And you then say, message
473: "You will know that the coch nice mortality rate is a bit higher than the network average.
Makes people, consultants look at trends and patterns. That may have been why Dr G came to ask." It
wasn't about mortality rates, was it, it was about unexpected deaths? And were you aware that Letby
had only been moved
to day shifts -- comes back from holiday -- and that's where you knew she had come back from
holiday, and that's when Baby O [Child O] died, the day she came back.
DrU: I don't -- I don't think I was aware that it was day shifts only.
LANGDALE: You didn't know she'd moved to day shifts?
DrU: I'm not -- no, I don't think so. It may have been mentioned in passing but it wasn't something
that -- that I remembered.
LANGDALE: She did talk to you about moving to day shifts, didn't she? If we go to page 19, message
681, you see there: "Eirian has just phoned telling me not to come in tonight and do days instead.
Asked if there was a problem. She said no just trying to protect me a bit. We can have a chat about
it tomorrow but now I'm worried." You say: "Please don't worry." She says: "I can't do this job if
it's going to be like this. My head is a mess. Why is she ringing at this time? There must be a
problem." And you continue to say: "You did nothing wrong at all. We all work
tirelessly." Message 691: "We did everything possible. I don't see how anyone can question that E
has always been very supportive." And from this point onwards, of course, she was going -- just to
finish with messages -- she had to undertake or was undertaking a number of processes, wasn't she,
she went on to have a grievance process, and you continued to message her during that time?
DrU: Yes.
LANGDALE: If we go to message on page 27, 1028, 6 July, you say: "You need to keep this to
yourself. The meeting this afternoon looked at everything with [Child O] and P [Child P] from birth
onwards, reviewed everything, the room, beds medical views and actions. We looked at all
documentation, medicine. If you have any doubt about how good you are at your job stop now,
documentation was perfect. Everyone commented about the appropriateness of your request for review
following the vomits." What meeting were you referring to there?
DrU: This was a meeting on the neonatal unit looking at these two deaths. And it was a review -- it
was a review of the written medical notes and of the typed nursing notes and whatever other
information was available at the time, and we looked from birth through to death for both babies.
LANGDALE: Was this one where Dr Brearey, Powell, Williams, Griffiths you, Dr ZA and Hayley Cooper
were present, a mortality review, or was it something different?
DrU: It may have been something different. I -- I recall it as a meeting in an office on the
neonatal unit.
LANGDALE: You say at 6 July there when you say -- when you send the message, "This meeting this
afternoon", was that the day -- well, actually it's -- what time is that message? Five to 1, so to
could it have happened on 5 July?
DrU: Yes.
LANGDALE: Right. If we go -- we can leave the message for a moment -- to that mortality meeting
that occurred on 5 July -- mortality review -- it's INQ0005121. So that's page 1, 2. If we go to page 3. We see the people you
said you were likely to be with doctors Brearey, Williams, Powell, Griffiths, Dr ZA. Dr ZA -- and
there's one for P as well. There are two babies, everything is being looked at, as you have said. Dr
ZA gave evidence this morning to say that
Letby's presence was referred to in this meeting of 5 July and Letby having something to do with the
deaths, her continued association, and things had gone beyond a coincidence and she might have been
involved in some way either deliberately or through incompetence. Do you remember that Letby was
mentioned in this meeting as Dr ZA told us this morning?
DrU: I think I was only present for the beginning of that meeting, so for the bits where the cases
were discussed, because I was present for both of them. I -- I think I left and then the
conversation continued afterwards.
LANGDALE: Why do you think it continued after you left?
DrU: I -- I presume they wanted to discuss what they were considering.
LANGDALE: Dr ZA said anyone at the meeting was very clear about this association, but your evidence
is that conversation or part of the discussion didn't happen when you were there?
DrU: I don't think it did. I'm sure that I was just there to give evidence for the -- not evidence,
information about the resuscitations.
LANGDALE: At this point, it seems everyone has to accept they were discussing or thinking about it,
but you say you still weren't at this point thinking that Letby had
an association with the deaths or deteriorations.
DrU: So I -- I think if I'd left earlier in that meeting I may not have been aware of that bit of
the discussion about specific concerns.
LANGDALE: If you left that meeting early, it doesn't change the fact that all of your colleagues --
your medical colleagues had those concerns at this point. Do you agree?
DrU: Yes.
LANGDALE: So how is it you're the only one who says you had no concerns at this point? Were you not
speaking to any of them?
DrU: Yes, I mean we -- we spoke all of the time. I'm not sure that we discussed specific members of
staff. I'm not sure that we discussed specific babies to that extent.
LANGDALE: Why did you say in that messaging I took you to earlier "You need to keep this to
yourself" to Letby.
DrU: I wasn't sure whether the nursing team knew that there was review into the deaths, and I didn't
-- I think the unit was still very upset about the deaths of Baby O [Child O] and Baby P [Child P]
and I didn't want it to be gossipped about.
LANGDALE: If they had wanted Letby at the meeting or the mortality review she would have been
invited, wouldn't
she?
DrU: Yes.
LANGDALE: So why was it for you to pass on information about that meeting to her?
DrU: She'd appeared very upset after the deaths of both Baby O [Child O] and Baby P [Child P].
LANGDALE: Everyone was upset.
DrU: They were, they were. And as the nurse looking after the two babies she told me that she was --
she was upset by it, and I was -- I went -- I gave her information to reassure her that her part in
the resuscitation process had been very good. I -- I don't think I actually discussed the
resuscitation with her or the discussion about it. I just said that her notes were very clearly
written.
LANGDALE: If we go back to the messages, so again INQ0000569, page 28, at 1071, please, you say: "I've since had an email from
SB [that's Stephen Brearey] which makes me understand what's going on. I'll forward it to you, you
might find it interesting." And you forward an email that you've received to her email address,
don't you? And if we go to it we can see that email at INQ0001445, page 1. So you're sent this from Dr Brearey: "I think it's quite
likely both will go to an Inquest and you're likely to be asked to give a statement. Can I suggest
you prepare it now when everything is fresh in your mind. It can include things we discussed
yesterday that might not be in the notes, particularly around [Child P]'s initial arrest and who put
IOs in and where and what went through them." What can you remember was discussed that wasn't in the
notes at the meeting of 5 July?
DrU: My recollection of that meeting on 5 July was about the resuscitations for the two babies. I'm
-- clearly there was other -- other items discussed. I'm not -- I don't think I was aware of those.
LANGDALE: Well, were the other items the concern of Letby's association with the deaths again?
DrU: They may well have been, yes.
LANGDALE: So does that mean Dr Brearey had raised those concerns with you?
DrU: I don't recall them being raised as a specific concern about a specific member of staff at that
time.
LANGDALE: If we were to go back to the notes, we know that Letby says to you -- I can perhaps read
them out rather than going back on to the screen -- she says on 6 July:
"Why is it going to Inquest?" You say: "Unexplained cause times 2." She says: "It's a bit of a worry
if it's going that far." And then she asks: "Do you think I will be involved?" And you say:
"Probably not. Your documentation most likely will be used in place of a statement. The questions
will be about management and procedures." She says: "I don't know what to say. Feels like a bit of a
blow considering everyone's hard work." Why did you send that email to her?
DrU: Why did I forward that email?
LANGDALE: Yes.
DrU: It was because of the -- the worry about these two babies, they were unexpected deaths, and she
had been -- or gave me the impression that she was very upset by them and was doing a lot of --
there was a lot of conversation about these two babies and I was basically trying to give her some
insight into what was going on.
LANGDALE: That there was going to be an Inquest?
DrU: Potentially, yes.
LANGDALE: Why was it for you to tell her that?
DrU: It wasn't. Again, in hindsight that was an error on my part.
LANGDALE: And you say to her: "This email has to stay between us, is that okay?" So you knew you
shouldn't be sending it to her otherwise why would you say that?
DrU: I shouldn't have sent it.
LANGDALE: And you knew that at the time, because you say -- you say that.
DrU: I think at the time I -- I sent it in order to help reassure her that the process was being
followed, but I didn't send it as a way of bypassing normal routes. I did it as a reassurance that
the process was being followed.
LANGDALE: She was also -- she went on to be worried about her RCPCH interview, didn't she?
DrU: Yes.
LANGDALE: And if we go to the messages, 0000569, page 33, message 1234: "Karen has just come. The
panel want to see me ASAP. Waiting for a time slot. The rep isn't available so Karen coming with
me." 1234, do we have that? Yes.
Letby asks you: "Do you think there's a problem?" You say: "No, I don't think there's a problem."
You say: "They will probably want to talk about what you remember. Be calm it is in the a review of
you." She says -- you see what she says there: "On the verge of a massive meltdown." You say:
"Remember the debrief with Olivier. I want you to go through in your mind when you meet the
reviewers deal with it in the same way. There are no trick questions. You didn't do anything wrong
and you are still the best NNU nurse I have ever worked with." She says she's: "A bit concerned
about going without a rep but Karen says has to be today." And then if we go overleaf, so it's page
34, so it is page 34. She has the meeting, we see messages going backwards and forwards. Message
1274, page 34, she says: "The two members were nice. They didn't ask much about the babies it was
more about the unit as a whole. In brief it looks as though there's the potential for this to go
further over a long period of time. H thinks we need it look at taking out a grievance case." So we
know she does take out a grievance, and she messages you about that as well. And you're broadly
supportive of her taking a grievance; is that right?
DrU: Yes. The --
LANGDALE: Did you ever think these are your Consultant colleagues, doctors Brearey, Dr Jayaram, who
are really worried about her role and what she has been doing and you support her to take out a
grievance in whatever way you can, texting or messaging, did you never stand back and think, "My
doctor colleagues are really worried about this?"
DrU: No. What had happened, I'd become part of that support process, largely mental health and
anxiety, and a lot of the time the messages were supportive in nature, whilst I was doing other
things, and I was providing a conversation on the phone, but I wasn't --
LANGDALE: Can we deal with that -- sorry, Dr U, finish if you like.
DrU: Carry on.
LANGDALE: Can we just remove the word "anxiety" and in your reflection would you accept a guilt
about being challenged about what she had done having meetings and reviews?
DrU: In hindsight, yes.
LANGDALE: There's reference to her saying she was panicking at some points.
DrU: Yes.
LANGDALE: Yes? So rather than using the word "how it felt at the time", what do you think now when
you look at it?
DrU: Now it does look as those these were moments of panic about the events that had taken place and
her role in them.
LANGDALE: And getting information about -- from you about babies, how they might have died, how
they were?
DrU: That -- from -- from what felt like being a supportive gesture, that now feels like a massive
mistake. It's something that I've considered on a daily basis for the last six to eight years. The
amount of reflection that I've done over this is significant.
LANGDALE: You supported her, didn't you, at the time in December 2016 to get some observational
experience at Alder Hey as well?
DrU: Yes.
LANGDALE: We've got emails in relation to that. But you had a conversation I think, first of all,
with the senior retired now surgeon a Mr Lamont about it; is that right?
DrU: Yes.
LANGDALE: And you sent an email, if we go to INQ01078440001. See there at the bottom: "Dear colleagues Mr Lamont has
recommended I email you to enquire about the possibility of arranging some theatre observation time
for a neonatal intensive care unit practitioner. Lucy Letby is a band 5 staff nurse with an interest
in NICU nursing of post-operative babies. In order to facilitate her personal development, she would
like to have the opportunity to observe some theatre sessions. Mr Lamont feels that there is no
problem from a surgical perspective." We see the clinical lead above in the email responding --
clinical lead for training, I should say: "As long as she has the clearance to work within the trust
coming theatre won't be a problem. Will Lucy be visiting on an ad hoc basis or is there a specific
date that you would like her to come. I am assuming you are co-ordinating with Mr Lamont." If you go
to, please, INQ0107841. So 0107841, there's further discussion here between whether an
honorary contract is required or not. I think it should be -- at the bottom the page is the first
one, I think. You've asked prior to that: "Does she need to complete an honorary pro forma?"
And we see at the bottom the page from recruitment: "Yes, this is correct. I am sending your email
to the recruitment team is there now processing the honorary pro formas. Will the person in question
be observing only?" Comes back to you: "Yes. A neonatal intensive care unit nurse. She is using the
theatre observation to build up part of her PDP. It will just be observation in theatre, most likely
two to three days Jan/Feb 2017." "She would not need an honorary contract. We can issue her with a
letter of access. I will contact the Countess of Chester." I think you say in your statement it was
Karen Reece you thought from the Countess of Chester who approved their end --
DrU: Yes.
LANGDALE: -- or gave information about DBS checks; yeah?
DrU: Yes.
LANGDALE: We can ask her about that. You then send another email, INQ0107842, page 2 -- 0002. I don't think that's the right one. That's it: "Lucy is having a little trouble being released from Chester to attend Alder Hey for the observation." This is May 2017: "Would you mind extending the letter of authority through to December for me?" That's May 2017. And then if we go to INQ01078321, we see 9 December 2016 the letter of authority: "Because it is an observational visit she must be supervised at all times. No direct patient contact is permitted during your visit." You do not say in your --
LADY JUSTICE THIRLWALL: We just got that one actually.
MS LANGDALE: Sorry. Thank you, my Lady. Have a look at that. Just that page is fine. So the
conditions are set, supervise, "no direct patient contact is permitted" because she's gone through
this route. You don't say, do you, in any of your emails, and presumably not to Mr Lamont either,
that she is not occupying any patient-facing role at that time at the Countess of Chester, that she
can't be with babies on the unit? You don't set that out in this request at all, do you, the
situation at the Countess of Chester?
DrU: I didn't. And the -- she was still having patient contact at that time. My understanding was
that she was conducting the clinical audits in the obstetric
or gynaecology outpatient department and had been to somewhere else within the Countess to cover an
audit of -- of a service.
LANGDALE: Is that office-based? When you say patient contact, is it contact with patience in an
office or --
DrU: No, so this was in the clinic rooms --
LANGDALE: Right.
DrU: -- and from that, I assumed that the move that she had to the admin role had been for
retraining and for then deciding what other interventions were required alongside a masters module
that she was reading for.
LANGDALE: When the police went to her home, they found -- if we can go to INQ0100851, page 2-3. So 0100851, page 2 to 3. Next page, 2 to 3, please, not
that. 2 to 3 we see there, signed by you -- if we go for 2 first, please. If we can just -- sorry,
Ms Killingback, go back to page 2, the first page of this two-page document, we see here a list of
what she has done, and I understand it is undated but signed by you, so can you tell us how that was
put together presumably for her by you?
DrU: This was put together because she required documents to add in for her revalidation and the
number of times that she had attended Alder Hey I summarised,
and she used that document for revalidation or to assist with the revalidation.
LANGDALE: Were you having discussions with Karen Reece or Eirian Powell or anyone from the Countess
of Chester at this time about plans for Letby or her aspirations for her career or anything like
that?
DrU: No, I didn't. The -- the request came for the clinical observation and I was told that it had
been approved by whoever was managing Letby at the Countess of Chester at the time. I, again in
hindsight, was remiss not to complete the loop and check that that was correct. But my assumption
here was that in offering a letter of access, with contact with the Countess of Chester, that had
all been signed off as appropriate, and if it wasn't appropriate, the HR or the nursing management
team from the Countess would have said "No".
LANGDALE: A matter you raise on a different point, in your second statement, you refer to a comment
reported to you by Letby in which she said a Consultant had referred to her as a baby killer, and
you wanted to clarify an elaborate on that. Can you tell us about that now?
DrU: Yes. So this was recounted to me and this was information second to third hand.
LANGDALE: From Letby?
DrU: She told me --
LANGDALE: Right.
DrU: -- what she had been told which had been overheard by somebody else.
LANGDALE: Right.
DrU: That --
LANGDALE: Do you know who the somebody else was who was supposed to have told her that?
DrU: No, and even if I'd had the name I don't think I would have known who that was.
LANGDALE: Was it a nurse -- another nurse?
DrU: I believe it was a doctor.
LANGDALE: No, not -- not a nurse who said it -- sorry, said the comment. Do you think it was a
nurse who told Letby somebody had said that about her?
DrU: Yes.
LANGDALE: Yes. So what nurse told Letby a doctor had said something like that?
DrU: I don't know. I don't think I was ever told that.
LANGDALE: Okay. So she told you someone had referred to her as a baby killer, what did she say?
DrU: So I don't think she was referred to as a baby killer. I think the message that was passed to
me was there's a baby killer on the unit.
LANGDALE: Right. So Letby said to you that somebody had said there was a baby killer on the
unit?
DrU: Yes.
LANGDALE: Did you know who was supposed to have said that?
DrU: I don't think I did. It -- from further discussions -- and, again, I didn't know the name of
the doctor -- I understood it to have been an obstetrician.
LANGDALE: And you say: "At some later point in time, although I can't recall when, the comment was
attributed to Letby. I know this as I was told that the consultant obstetrician had to write an
apology letter to Letby." So you knew there was a link with her with that remark?
DrU: Yes. So I think after that initial comment, at some point it was refined to be directed towards
Letby, and I don't know who or where that took place, but I do know that an apology letter was
written later on. I don't know the contents of that letter.
LANGDALE: And, again, she was the conduit for the information to you, was she?
DrU: Yes.
LANGDALE: So finally from me, Dr U, do you have anything to add or say or reflect upon in the light
of the
evidence that you have given?
DrU: Yes. I -- I have reflected on this daily since -- well, certainly since my first police
interviews in January 2018, and I think I've become more aware that I wasn't aware of the full
clinical picture, and I provided support by being misled and maybe manipulated, and for that I'm --
I'm really sorry that things have come to end as they have. I have a lot of regrets about how that
period of time took place.
MS LANGDALE: My Lady, Mr Skelton has a few questions. I know there's a statement of evidence we are due to prepared in as well. I don't know if a break is necessary for Dr U, I see the time, or whether we should be pressing on for I imagine 15 minutes in total with the statement read as well, but --
LADY JUSTICE THIRLWALL: Dr U, you are all right for another 15 minutes or so?
DrU: Of course.
LADY JUSTICE THIRLWALL: Thank you, then we can finish off today. Mr Skelton.
MR SKELTON: Dr U, can I just recap on your background without trespassing into confidential
information. During the period that the babies were harmed at the Countess of Chester you were the
senior Registrar.
DrU: That's correct.
SKELTON: And from September 2016 you were a locum Consultant with a specialism in part in diabetes
and also in general paediatrics?
DrU: That's correct.
SKELTON: And you are now a (redacted) Consultant (redacted)?
DrU: Yes.
SKELTON: Can I ask you first about [Child L]. It may be helpful to look at the medical notes in
this regard just to anchor your answers in the contemporaneous records INQ0001169, please. Do you remember [Child L]?
DrU: I don't recall the position of the child within the nursery and I don't recall the events that
took place, but I may have more recollection after looking at the notes.
SKELTON: Thank you. Let's look at those, then. May we go to page 13 first. This is just to refresh
your memory.
DrU: Yes.
SKELTON: This is a note by you on 10 April 2016, half past midnight, and if you take a moment
there, you can
see that there's -- one of the first notes that you make is about blood glucose and the need for
glucose to be administered.
DrU: That's right, yes.
SKELTON: A fairly common problem with neonates.
DrU: It -- it can be, yes.
SKELTON: Prior to that, but I won't take you to the notes, there had been a period in which [Child
L] was suffering from hypoglycaemia, for obvious reasons, and you're in fact a continuation of the
care that has been given in response to that.
DrU: Yes.
SKELTON: Father L and M, because there were two babies from the same family, don't recall being
told about the hypoglycaemia and its significance. Can you explain why that might have been the
case?
DrU: Yes. So this was half past midnight and on a night shift at the Countess there will have been
me and a more junior doctor and it is -- I don't recall who the junior doctor was that night, but
it's quite likely that they were a foundation doctor or a GP trainee without a lot of paediatric
experience, which meant that I was dealing with the calculations, the practical procedures and all
of the management of the glucose on my own. The junior doctor will have been dealing with requests
for reviews either from the postnatal ward, labour ward, children's ward or A&E, and in that way
I was protected to get on with looking after Baby L [Child L], and the management of Baby L [Child
L]'s glucose worked, and I carried on managing it. I didn't go up to the postnatal able ward and
leave the neonatal unit and this baby in particular without me supporting them to wake up Baby L
[Child L]'s mother and father if he was there to tell them.
SKELTON: Just pausing there?
DrU: Can I sorry -- can I --
SKELTON: Please go ahead.
DrU: At the time it was common practice for information about babies to be given to the parents on
the morning ward round and they were encouraged to come down for the ward round so that they could
be updated. That's what I presumed would happen the next morning.
SKELTON: So at some point they should have been told this?
DrU: Yes.
SKELTON: And if they weren't told that that may have been a mistake?
DrU: Yes.
SKELTON: And in fact I think you had to scrub in to do a long line for this child, didn't you?
DrU: That's right.
SKELTON: Which was -- took you off your otherwise onerous tasks with other children presumably?
DrU: Well, they weren't onerous tasks. They took me away from being able to leave immediately to
respond to something. So for the period of time that it took to site this long line, I will have
been supported by the junior doctor who was working with me, and if anything had been -- if I'd been
needed for anything clearly I would have abandoned the long line and gone to help. But, yes, it does
take me out of circulation for a period of time, half an hour or so.
SKELTON: The previous day -- if we go to page 12 just above that, please, just if you could just
highlight the bottom half. Is that a note by Dr Jayaram?
DrU: Yes.
SKELTON: And is he in that note ordering blood investigations? Is it bloods for -- is it
hypoglycaemia or is that another word there?
DrU: I think it says, "Bloods for hypoglycaemia investigations sent."
SKELTON: So do you think that's the blood result -- the blood testing that's being initiated that
comes back five days later?
DrU: Yes.
SKELTON: Thank you. Can we then turn to what happens in the subsequent period of time. You I think
were on duty subsequently. Is that right, you were on -- I've taken you to the 10 April, but you
were also on on 14 April, if we go to page 19, in the morning. That's you I think there, isn't it,
at the bottom, your notes?
DrU: Yes.
SKELTON: Your handwriting?
DrU: Yes, it is.
SKELTON: So you are there on the 14th, and if we continue on -- I think you're also there on the
15th; is that right?
DrU: No, the information at the top there is the remainder of --
SKELTON: Sorry, I'll take you to the page just for clarification. Page 22, further down. That's you
there on a cranial ultrasound.
DrU: That's right.
SKELTON: Just pausing there, can you remember what that was for?
DrU: No, but I don't recall the baby's gestation or birth weight because they may have played a role
in the need for a cranial ultrasound.
SKELTON: So at this remove you can't remember the specific reason that you might have asked for
that but it could be to do with just checking on the health of the baby's skull and brain?
DrU: So the cranial ultrasound is to look for evidence of bleeding within the fluid compartments
within the brain and it's to look for those and to look for evidence of other bleeds or other
lesions within the brain.
SKELTON: What might have prompted that request? If you look at the page, there doesn't seem to be
much of an indication of a reason?
DrU: I'm just looking at the top of that page.
SKELTON: Yes.
DrU: And the plan says cranial ultrasound.
SKELTON: In response to what? Is it suspected infection?
DrU: No, I wouldn't have thought infection would be the planned -- would be the plan for a cranial
ultrasound, but I'm assuming that the baby has been jaundiced or there is a concern that blood has
been lost somewhere, and the ultrasound is to check that there hasn't been a bleed into the fluid
compartments of the brain.
SKELTON: So you were on shift on the 14th in the morning, and we've seen a note that I've taken you
to at 9.20 in the morning, and then the next note in this child's records by you is at 4 pm the next
day. Would you have been doing two day shifts in the hospital throughout that period of time?
DrU: Yes.
SKELTON: If we go back to the page 21, which is above your -- which is earlier in the day on the
15th, you will see that a doctor, name unknown, is making a note about [Child L]'s blood results.
Can you see that, it's slightly off the usual run of narrative on the right-hand side in the
middle?
DrU: Yes.
SKELTON: If you were on duty as the senior Registrar on the 15th would you have looked at [Child
L]'s notes for that day? I appreciate you said to Ms Langdale you don't have the time and don't
necessarily have the need to look back for days and days of every child you look at, but would you
look at the day's medical records to see what's going on?
DrU: No, I suspect because I've just written that short note about a cranial ultrasound I've gone in
performed the scan as required, reviewed the images and then written the procedure in the notes. I
would have -- as this is a morning ward round, any abnormal
results would usually then be discussed with the Consultant whose week -- who is the neonatal hot
week. I think for that cranial ultrasound there were not many of us that could perform the
procedure, so I've gone in and done the scan and written the notes down.
SKELTON: So trying to understand how these results would have been recorded and interpreted,
they've been picked up, have they, on the ward round in the morning first thing at 9.30?
DrU: It looks like it as they're entered in the ward round notes, yes.
SKELTON: Can you at this removed assist in who was the Consultant who might have been on that ward
round from what you can see from this page?
DrU: No, I don't recall who was the Consultant for the week of the 15th.
SKELTON: But there always is a Consultant on that ward round?
DrU: No, there is always a Consultant responsible for the hot week for that week, and then the ward
round is done, and at the time, on a Thursday, there would be a Consultant ward round and also one
of the weekend days, so a Saturday or a Sunday, and they would alternate with the Registrar.
SKELTON: So it looks likes what's happened is that
whoever this is a junior doctor, not a Consultant, has written down the blood results but there
hasn't been any interpretation of them and their significance at all at the time.
DrU: That's correct, yes.
SKELTON: In terms of the responsibility for that absence, Dr Jayaram organised the -- or asked for
the blood results. They come in at a time when presumably he is not here, he certainly doesn't
reappear in the notes around this time. Whose responsibility is it to receive and think about the
results when they come in?
DrU: I'm sure every hospital has a slightly different system and, as I explained earlier, it's often
the case that the result goes back to the Consultant whose week it was because they were responsible
for the care of the babies that week. Unusually, abnormal results are normally phoned through from
the lab direct to the neonatal unit so that the team looking after the baby at that time is aware of
them. Obviously that may not be the case for an insulin level that's five days old but, again, if
it's an unusual result, many laboratories will phone it through. As for what happened to the results
subsequent to the hot week of that Consultant, I don't know. I had presumed that because they're all
on an electronic
system I would presume that they go back to the Consultant to have a checklist for, but I don't know
how the Consultants organised their results management.
SKELTON: From your perspective, (redacted) these are obviously abnormal reluctance and they appear
to indicate exogenous insulin having been administered either deliberately or inadvertently?
DrU: Yes. So these are not results that you would see in the patients that I deal with because this
is a result of too much insulin rather than not being able to make enough. But, yes, they are
abnormal results and I would have expected that they had flagged some sort of warning or alert.
SKELTON: And in a baby with hypoglycaemia?
DrU: Yes, on the -- on the night in question if those results had been available, they would have
been very helpful. But, as I said earlier, insulin is a sample that gets I believe sent away to
Liverpool and then comes back days later.
SKELTON: So there will be evidence later in the week from the scientists. I think there was a phone
call from the lab to the scientists in your hospital and then an attempt to call the ward --
DrU: Sorry, I didn't hear.
SKELTON: And then an attempt to call the ward but no record of a telephone call. But at some point,
whoever has made this note has received them probably by electronics means or by paper copy --
DrU: Yes.
SKELTON: -- the day after I think they were in fact received at the hospital, so they were received
on the 14th and they appear in the notes on the 15th. No one appears to have looked at them. Had you
noticed that, bearing in mind that you were aware of the child's hypoglycaemia, would you have
recognised this was something that required immediate follow-up?
DrU: I'm just trying to look for a blood glucose reading at the time that those results are written
down and --
SKELTON: Well, the child has been treated for hypoglycaemia at the time?
DrU: No, I -- absolutely. But, the -- if the -- the length of action -- once the source of the
insulin is removed the baby's blood glucose will return down to normal as I think happened in this
case and the calculations for how much extra glucose is required are then dialled back because the
baby doesn't need all the supplemental glucose. I agree that that result is -- that the insulin
level is unusually high.
SKELTON: The clinical condition may have resolved, but the problem that may have contributed to
that condition, namely insulin that shouldn't have been administered, needs investigation, doesn't
it?
DrU: Yes.
SKELTON: Because there's only really one of two possibilities: deliberate or mistaken?
DrU: Yes.
SKELTON: Either of which is unacceptable?
DrU: Yes.
SKELTON: May I just turn briefly to some of the other children, [Child M]. You were asked about
this [Child a] little by Ms Langdale and I don't want to touch on it in any detail of course bearing
in mind the time. In your statement you say that you don't, this is paragraph 34 if you want to
refer to it, you didn't observe any clinical signs which made you suspect a non-medical cause for
that child's collapse. Could you just explain what you mean by that?
DrU: So a non-medical cause would be a deliberate act or an act done in error, that had caused those
signs and symptoms and I hadn't witnessed any of those.
SKELTON: But you are alert to the possibility that there may be no evidence of such an act --
DrU: Yes.
SKELTON: -- clinically?
DrU: Yes.
SKELTON: And of course insulin administration or air administration is precisely that kind of
action?
DrU: Yes.
SKELTON: If you had been aware the unusual rash recalled but not recorded by Dr Jayaram, might that
have affected your interpretation of the cause of this child's collapse bearing in mind [Child B]'s
collapse some time previously with the same -- with a similarly unusual rash?
DrU: There was discussion about babies with rashes and we I don't think had been able to come up
with a clear reason for why those rashes were occurring and that continued through to the time that
I finished at the Countess.
SKELTON: And it took Dr Jayaram I think to begin to suspect it may have been administration of air
and did the research that he will explain no doubt when he comes to give evidence. But none of the
rest of you suspected that, is that correct?
DrU: That's correct.
SKELTON: At any time?
DrU: It's not anything that I have ever, ever considered would be done. Administration of air is not
something -- you work to prevent that at all costs.
SKELTON: Briefly on [Child Q] and I only ask this because this isn't something dealt with in any
detail in your statement or at all in any depth. You were involved with [Child Q]'s care.
DrU: Yes.
SKELTON: And there are a number of notes, I won't take you through them, but is there anything that
you can assist with when it comes to explaining [Child Q]'s deterioration? What was the cause of it
insofar as you were concerned as one of the treating doctors?
DrU: So the cause of it was unclear. It -- it looked as though he was in discomfort and the signs
that were being reported to me, the observations that had been written down suggested something to
do with his gastrointestinal tract and with that in mind, I carried out some blood investigations
and a blood gas I believe and then an X-ray of his abdomen. And it was that X-ray that looked
unusual and I then contacted the surgical team at Alder Hey who looked at the X-ray because they
could see it from -- they could see the same image from where they were and then they organised his
or they requested his transfer to Alder Hey.
SKELTON: Did you ever get a satisfactory explanation for [Child Q]'s repeated desaturations?
DrU: I don't think there was an explanation at the time, but with an abnormal abdominal X-ray that
would potentially cause those desaturations.
SKELTON: Could you be specific about what the X-ray showed which would be the underlying cause for
that?
DrU: Yes, and I -- I can't remember the exact wording of it and it would be much easier with the
picture, but I believe that there was some bowel that had moved to a position that it didn't
normally occupy and --
SKELTON: Which could be caused by harm or some other cause?
DrU: Yes.
SKELTON: Ms Langdale asked you about the messages that you had with Lucy Letby and you have
expressed a degree of contrition and embarrassment, understandably, about that. Can I just ask you
about messaging generally. These messages that the Inquiry has received are on a platform called
Facebook Messenger. Is that on your personal phone or is it on a professional phone?
DrU: That will have been on a personal phone.
SKELTON: Did you have a work phone?
DrU: No.
SKELTON: Were you -- were there other platforms, WhatsApp, et cetera, that you were using for
ordinary professional interactions about patients?
DrU: So there was no bespoke platform for communicating, but WhatsApp was used.
SKELTON: Were there particular groups that would be you and the Consultants, you and your fellow
Registrars, you and the nursing team or was there just a -- how did it work in practice?
DrU: There were often groups set up so that if there was a gap on the SHO rota or on the Registrar
rota a message could be sent to the appropriate group and say, "Can anybody cover" the gap that's
come up at short notice. That, that sort of messaging is -- is common.
SKELTON: And was WhatsApp the way in which you would have been contacted if you were out and about
in the hospital and you needed to be recalled urgently to the ward?
DrU: No. So an urgent recall to the ward would be through the bleep system. There was a baton bleep
that was passed from person to person, so that it was always, always held by somebody.
SKELTON: So is it right then that just in terms of WhatsApp there is a dividing line between your
professional WhatsApp interactions, which may be about
patients within a professional group, and your personal interactions which will be about your own
personal life and et cetera ordinarily?
DrU: Yes.
SKELTON: But what has happened on Facebook Messenger is those two things have become blurred?
DrU: Yes.
SKELTON: And you recognise I think that that's inappropriate?
DrU: Yes, I do.
SKELTON: Because you are discussing patients' names and conditions with a member of staff in a
personal capacity?
DrU: Yes.
SKELTON: Are you aware that for at least some of the parents, and I am thinking in particular of
Father N, that's particularly difficult to have seen occur in this case; that their child was the
subject of private messaging outside of the ordinary professional communications?
DrU: Yes, I -- I can understand that and the purpose of the messages at the time was to give clear
information that would help in the care of that baby on a subsequent shift. That was the intention,
nothing else.
SKELTON: Well, it looks to some extent also like you are just talking about what you are doing at
work and there isn't always a clinical imperative to the messages, is that fair?
DrU: I think sometimes the -- what's going on. Yes, that was the case.
SKELTON: Well, you talk for example about cuddling certain babies and things like that which
clearly isn't a medical process?
DrU: No.
SKELTON: Is there anything you would like to say to the parents whose babies appear on your private
messages with Lucy Letby?
DrU: Yes. Again, I have reflected on that for the last six-plus years. I fully accept that that's
not the way that the information should have been managed, but there was no malice intended in it.
It was done to share information that would be helpful on a subsequent day, nothing more.
MR SKELTON: Thank you, doctor. Thank you, my Lady.
LADY JUSTICE THIRLWALL: Thank you, Mr Skelton.
MS LANGDALE: My Lady, I have no further questions for Dr U.
LADY JUSTICE THIRLWALL: Thank you very much. Dr U, you are free to go. If you'll just stay there for the moment. Do you want to take the next statement now or do it tomorrow?
MS LANGDALE: Yes, I was going to ask Ms Bennett if she would read the next witness evidence from Ms Saunders.
LADY JUSTICE THIRLWALL: Thank you very much, Ms Bennett. MS BENNETT: My Lady, this is a statement that the Inquiry has received from Erica Saunders, Director of Corporate Affairs at Alder Hey Children's Hospital.
LADY JUSTICE THIRLWALL: Thank you. MS BENNETT: "I Erica Saunders will say as follows: "I am employed as Director of Corporate Affairs at Alder Hey Children's Hospital Foundation Trust. This is a board level executive position which covers responsibility for the Trust's corporate governance, regulatory risk and legal matters. Under this remit, I am the Trust executive lead for Public Inquiries as well as a range of other sensitive confidential matters that may arise from the broad aspects of my role. "Alder Hey Children's NHS Foundation Trust is a specialist paediatric centre providing all aspects of healthcare to over 450,000 children and young people each year. The Trust employs a workforce of 4,500 staff who work across our community and hospital sites and as a teaching and training hospital we provide education and training to around 900 medical and dental students and over 1,000 nursing and allied health professional students each year. "It is known that Lucy Letby attended the Trust in order to undertake observational visits during the period January to April 2017. The visits were facilitated and arranged by Dr U who at that time was a locum Consultant in diabetes and general paediatrics at the Trust. This appeared to be the result of a personal connection arising from a professional relationship which developed when he and Letby worked together at the Countess of Chester Hospital. To that extent the request to visit Alder Hey was not made directly to the Trust by Letby herself. "The initial request made by Dr U with regard to the visits was addressed to colleagues in the theatres management team and education team on 7 December 2016 by email referencing a prior conversation with Mr Graham Lamont, a senior paediatric surgeon and then Clinical Director. The email identifies Letby as 'a Band 5 nurse with an interest in NICU nursing of post-operative babies and states that the purpose of the visits was in order to facilitate her personal development.' "On 8 December Dr U was informed that if Letby had clearance to attend the Trust the visits could be accommodated. Dr U responded to enquire as to the checks Letby required in order to attend, ie a DBS check. Dr U later e-mailed members of the HR team to enquire as to whether Letby would require a honorary pro forma. He provided Letby's email address to enable direct communication and stated, 'If you need a in-house signatory to confirm please send the pro forma to me.'" Following questions from a recruitment officer as to the nature of the activities she would be undertaking, Dr U was informed on 9 December that Letby would require a letter of access rather than a honorary contract. Further, they would contact the Countess of Chester Hospital to: "Ask them to confirm Lucy's pre-employment checks. Once they have confirmed I will let you know if we need it apply for any outstanding checks ie a DBS." A pro forma was received from the Countess of Chester confirming the pre-employment checks undertaken by them on Letby's appointment including a DBS. The letter of access was issued to Letby and Dr U separately on 9 December and contained the following condition: "The observational visit will be for the period 1 January 2017 until 28 February 2017. During this time, you must be supervised at all times. No direct patient contact is permitted during your visit." Dr U also sought an opportunity for Letby to observe at ENT list. On 9 February Dr U e-mailed the recruitment officer with a request to extend the letter of access until May 2017 as Letby was "unable to get across to Alder Hey but is now able to do so". The letter was re-issued on the same day to the end of May in accordance with this request. On 3 May 2017 Dr U sent a further email stating: "Lucy is having a little trouble being released from Chester to attend Alder Hey for the observation. Would you mind extending the letter of authority through to December for me?" This was actioned on 4 May. The request by Dr U on Letby's behalf was informal in nature. The observational visits proposed did not fall under the scope of the Trust's formal work experience policy thus this was not applied. The Trust frequently receives requests for colleagues from many other organisations to visit our services as can be seen from the exhibits. The appropriate steps were taken to ensure both Dr U and Letby understood the conditions that applied to the visits. So far as the Trust has been able to ascertain, ie via documentary evidence, Letby attended a diabetes multi-disciplinary team meeting on 2 March 2017 at which her presence was minuted. In addition, it is understood that she may have attended an outpatient clinic with Dr U during March and a roadshow related to insulin pumps on 22 April. The visits were sponsored by Dr U, as can be seen by the email correspondence, and to that extent he was the responsible officer. Media reports following Letby's conviction last August that management at the Countess of Chester "wanted to find Letby a placement at Alder Hey". The Trust has no record of any approach from anyone at the Countess of Chester. Moreover, as described, the nature of the contact was ad hoc observational visits, not a placement or work experience. Trust senior management was unaware of the arrangements being made to visits by Dr U. Therefore, no enquires were made to the Countess of Chester regarding Letby's role, background or qualifications. Checks were made at the appropriate level, given the nature of the request as explained. The Trust took steps to establish the facts in relation to visits following Letby's arrest in 2018 and again following the verdicts in the criminal case. All written records have been checked where they exist. And that concludes the statement, my Lady.
LADY JUSTICE THIRLWALL: Thank you very much indeed, Ms Bennett. So we will adjourn now until 10 o'clock tomorrow morning. Thank you all.
(5.08 pm) (The Inquiry adjourned until 10.00 am, on Tuesday, 8 October 2024)
LADY JUSTICE THIRLWALL: Ms Langdale.
MS LANGDALE: Good morning, my Lady, may I call Dr McCormack and can he be sworn.
LADY JUSTICE THIRLWALL: Yes, certainly. Who is going to -- ah, there you are. Thank you, Mrs McQueen.
DR JIM McCORMACK (affirmed)
LADY JUSTICE THIRLWALL: Thank you, Dr McCormack, Ms Langdale will be asking the questions.
MS LANGDALE: Dr McCormack, can you give us your qualifications, please.
McCORMACK: I qualified in medicine from Queen's University, Belfast in 1982. I did a further
postgraduate degree in MD at Queen's University in 1997 and I became a member of the Royal College
of Obstetricians and Gynecologists in 1987 and was conferred fellow of the Royal College of
Obstetricians in 1999.
LANGDALE: Dr McCormack, you provided a statement to the Inquiry dated 7 June 2024. Can you confirm
whether the statement is true and accurate as far as you are concerned?
McCORMACK: Indeed it is true and accurate. Do you think
I could speak to the mothers before we carry on?
LADY JUSTICE THIRLWALL: Yes, of course.
MS LANGDALE: Yes, you may.
McCORMACK: I just wanted to say I read all of their mothers' and family transcripts and found it
very moving and compelling to hear them all tell their experiences. I wanted to start my evidence
today by expressing my sincere sympathy to them all for their terrible loss and suffering, and
commend the enormous strength and resilience they've shown in coping with the unimaginable events
following. Thank you very much.
LANGDALE: Dr McCormack, we sent you indeed some of the transcripts of evidence and I will return to
those in a while, if I may. When I am asking you questions the link seems pretty good now and the
signal --
McCORMACK: Yes.
LANGDALE: -- but if it drops and you can't hear me raise your hand and I will do the same for you;
okay?
McCORMACK: I will.
LANGDALE: I will also do the same if I think -- and I don't want to overspeak when we're not in the
same room -- if I think I need to move on to something else. So it's questions as well as gestures
to look out for if you would. In your statement at paragraph 12, you refer as
well to having been an associate Medical Director at some point. You tell us further up, I should
say, by 2015 you'd had 23 years Consultant clinical experience in obstetrics and gynaecology, but
you also say at important professional responsibilities at one point you were an associate Medical
Director. Can you tell us when that was?
McCORMACK: I've forgotten the exact year but with introduction of the new Consultant contract and I
was employed as an Assistant Medical Director for approximately six months to interact with all the
Consultant staff, make them familiar with the actual contract and ensure they understood what was
involved before they considered moving to the new contract. Once the contract had been introduced,
then my tenure in that post stopped.
LANGDALE: Was that something you were interested in as a role? What were the expectations of that
even as a short-term role?
McCORMACK: I -- I think I may have showed some knowledge of the different attributes of the new
contract at that time and they have may felt it was -- I was a good person to select and do that
job.
LANGDALE: You were the ...?
McCORMACK: A good person --
LANGDALE: Good person.
McCORMACK: -- to select with that knowledge to do that job or undertake that job.
LANGDALE: You tell us the responsibilities at paragraph 16, chair of the women and children's
governance board, firstly.
McCORMACK: Yes.
LANGDALE: And also lead obstetrician for perinatal mortality morbidity meetings?
McCORMACK: Indeed.
LANGDALE: Can we look at one of those meetings, just to see what they look like. The perinatal
morbidity and mortality meetings, and the INQ reference number is 0003294/1. So 0003294, page 1.
This is what we see, and indeed on page 2 we see a reference to [Child A]. Can you tell us what the
purpose of the meetings were and who was invited? And if we go back to page 1, if we look at the
date, in fact the date of the meeting is 24 June 2015, so I assume the period of assessment is March
to June 2015?
McCORMACK: Will I give you some context to the perinatal meetings and their organisation?
LANGDALE: Yes, what was the -- what was the aim and who attended?
McCORMACK: Okay. Well, the meetings were organised in advance because we chose days where there was
no clinical activity to allow members of staff to attend. So each year there were 12 days in the
calendar year that clinics were stopped and I would have chosen four of those days for the use for
perinatal mortality meetings. So they were chosen in advance and then confirmed with Dr Brearey that
they suited for him and then allocated those days. At each of the meetings, secondly, my Registrar
was allocated to secure the most recent of the still births to be presented and he would have
prepared a complete PowerPoint presentation for those with all the events, and the same with the
paediatric Registrar. At that time -- at that time I was also inviting the pathology Consultants
from Alder Hey hospital and they would have been invited about three weeks prior to the meeting, if
there happened to be a pathology presentation for those particular deaths. Following the meeting --
these were prepared by Dr Brearey and myself. You haven't got any of the ones that I prepared for
the stillbirths, but all the reports you have, with the exception I think of three, are from the
perinatal meetings and these are his summary of the events that took place.
These summaries are very brief, they were meant to be brief, they are meant to be an aide memoire
for staff to look at and be able to recall exactly what was happening, because don't forget the
perinatal mortality meetings were to review for learning, and the environment was one of expected
entirely natural deaths. And, in addition to that document that you put up, Dr Brearey would also
have sent a letter or a note to all the members of staff with the three or four or five learning
points from the meeting. And the purpose of the meeting was entirely a learning environment. And the
last point I would make about it is that within the hospital we had an intranet and we had an
S-drive for the Women's and Children's directorate so all this material for learning, the summary
items, the concerns about learning, the presentations from each of the two doctors at a particular
meeting would all have been put on the intranet because not all staff that were involved may not
have been able to attend because obviously they may be covering the neonatal unit or the labour
ward.
LANGDALE: The meeting record -- just pausing there, Dr McCormack, the meeting record doesn't record
who did attend it, but you're telling us, you and Dr Brearey could invite people and routinely did
invite people?
McCORMACK: All the available -- it was a compulsory attendance for anybody who wasn't actually
working or on annual leave, so any of the junior staff Consultants would attend. On average we would
have had an attendance of, I don't know, 15/20 people.
LANGDALE: And that's anybody who had been involved in the care of the baby, was that the
expectation?
McCORMACK: No, it was meant to be all the junior staff that were available and all the Consultant
staff available because it was a -- very much a learning exercise environment --
LANGDALE: If we look at Baby A [Child A] --
McCORMACK: -- and a very open and transparent discussion of events.
LANGDALE: Let's just look at what it says about Baby A [Child A] then if we go back to page 2. If
it's a learning environment, we see here it says "awaiting pm". There's not a lot you could learn at
that point, could you, without knowing forensically --
McCORMACK: No --
LANGDALE: -- about that death?
McCORMACK: -- and that's absolutely correct in that particular scenario. But the letter that would
have gone out would have enumerated the 3, 4, or 5, 6 learning points from that particular meeting,
and
Dr Brearey would have sent that out to all the other Consultants and to all the junior staff.
LADY JUSTICE THIRLWALL: Would he have done that before or after the meeting?
McCORMACK: It was done after the meeting, my Lady.
MS LANGDALE: That can come down now, thank you, Ms Killingback. Were you aware the way that event
is described at the meeting with the line in situ that that was a sudden and unexpected death of a
stable baby?
McCORMACK: Like it's nine years ago now, and I -- I can't particularly recollect the exact
discussions, but that would -- I am certain would have been something that Dr Brearey would have
highlighted and the junior doctor who was presenting the case would have highlighted at the meeting.
LANGDALE: Because we know that after Baby A [Child A]'s death, members of the medical and clinical
staff were shocked, upset. One of the younger doctors took some time off. It was an unexpected death
of a neonate. That's a rare event, isn't it? An unexpected and unexplained death.
McCORMACK: Yes, certainly on talking to the other paediatricians that -- I think that would be the
case. I'm not sure whether that's just bridging into the neonatology expertise as opposed to me
being an obstetrician.
LANGDALE: Can we go to paragraph 33, please, of your statement if you have it with you.
McCORMACK: I have.
LANGDALE: You say that, in your experience at the hospital, the relationship between the obstetric
team and the NNU has always been very good and that was unchanged in 2015 and 2016, and there would
have been daily clinical care discussions which would usually have occurred as necessary between the
obstetric Consultant who was managing the labour ward and the equivalent Consultant on-call for the
NNU. You've highlighted communication between you and Dr Brearey, which I take was very good from
what you're saying?
McCORMACK: Yes, and that refers to the actual on-call Consultant obstetrician on the labour ward,
and if he had concern about any of the patients on the labour ward he would have been able to have
direct conversation whoever was the neonatal Consultant on-call. But the working relationship that
obstetrics had with the neonatal unit I would have described as excellent, and this was something --
I have been a Consultant for 23 years now, we all knew each other well and we would have worked well
in certain situations, for instance you
had a witness, the teamworking, if you were on the labour ward and there happened to be a collapsed
baby and the team came in to -- to resuscitate, or for that matter an elective section, and -- and I
had no concerns about the working relationship between ourselves and them.
LANGDALE: Can you tell me a bit about the layout of the Consultant offices and the administration,
the opportunity for what I would call corridor conversations or informal conversations when you're
passing each other?
McCORMACK: We were very fortunate because our building really was all very close to each other. So
the neonatal unit was next to the labour ward, and our offices were very close to that building. The
ground floor had all the neonatal offices and the top floor had all the obstetric offices. And it
wasn't unusual for me to walk downstairs and speak to John Gibbs or one of the others about a
particular issue I was concerned. Our relationship for discussing things was very good.
LANGDALE: So things that were worrying them they could share with you and vice versa, and did?
McCORMACK: I would agree with that.
LANGDALE: That's how concerns were raised informally. More formally, at paragraph 51, you comment
on the
previous structure with a separate Women's and Children's division might have allowed more focused
discussions of the issues at that management board level. So can you expand on that, why do you
think it would have been better retrospectively to have a different structure? Set that out.
McCORMACK: Well, I'm not convinced that it would have been because the structure that we had in 2015
had been changed in 2010, it was a structure that we were very familiar with and --
LANGDALE: Was that driven by cost or anything else, why was it changed, do you know?
McCORMACK: I think it was changed for financial reasons. We used to have a separate director --
directorate for Women's and Children's, which includes neonates, paeds and gynaecology, and with our
own directorate manager, Clinical Director, et cetera, and they changed that and integrated the
departments to then two directorates then to Planned Care and Urgent Care. And -- but we'd been
working in that environment then for four years by the time it was 2015, and I think that I thought
that even within the environment we got we still had good contact with the paediatricians, and we
had good links still with senior management in the --
in Planned Care. Our divisional Medical Director in Planned Care in fact was a gynaecologist, and
our Head of Midwifery sat on the QSPEC board as well. So I don't have concerns about -- about --
about -- about those changes. Obviously if you said to me now and we were going to redo it by choice
I think we would choose to have neonates within -- within our own directorate but --
LANGDALE: As it was before the financial motivated changes?
McCORMACK: Sorry, Ms Langdale?
LANGDALE: You'd have it as it was the prior structure if --
McCORMACK: Yes, yes, I think we would. And I -- I don't know whether it has changed to that now. I
imagine it has. But the point I was making was when you asked would it have made any difference with
very like-minded individuals surrounding you, and I think the only example I can give you in
relation to that would be, for instance, the governance board. Now, the governance board at the time
in 2015 had very like-minded individuals around the table. We had the lead in obstetrics, we had the
lead gyaeny, we had the Head of Midwifery we had the lead paediatrician we had the lead nurse in
paediatrics, and so that was an environment that I thought would have allowed appropriate
discussion. But, you know, I -- I was conscious that wasn't the case, because --
LANGDALE: Did you have discussion on that lead governance board about sudden and unexpected deaths
on the neonatal unit and whether someone might be causing them?
McCORMACK: No, definitely not. And that's exactly what I was just going to say was that if -- if --
in my preparation for my evidence and looking at all the other evidence like it is clear that Dr
Brearey and Dr Jayaram, you know, were relentlessly pursuing directly to Senior Executives their
concern about harm to babies and possible causes of the deaths. Well, I never saw that at the
governance board, so --
LANGDALE: Let me ask you about the women and children's care governance board for now, if I
may.
McCORMACK: Yes.
LANGDALE: And you tell us at 52 -- paragraph 52: "It did include staff from obstetrics, paediatrics
neonatology and gynaecology within the board." A few questions I may of some of the meetings. If we
could go to INQ0004235, first of all, at page 2, box 7. While we're finding that, Dr
McCormack, I'm
certainly not going to ask you about the details of a particular case this far away and one that
doesn't impact on the Inquiry. What I want to ask you about is the rationale behind it. So at
paragraph 7, reference to a stillbirth: "Waiting to find out how it will be taken forward in
relation to an investigation. OSR completed and it highlighted issues with care provider
decision-making. An ethos of transparency external reviewer to analyse this case as no one in the
Trust outside of the division with expertise to review the case." So what was the basis in principle
for taking cases to external investigation, and was that simply something that fell within the
obstetric team to investigate?
McCORMACK: I -- I can't recollect what that --
LANGDALE: That can come down, now thanks.
McCORMACK: -- particular stillbirth was and what the issue was in relation to expertise, and it
would be very unusual for us to do that. There was a climate -- an increasing climate for stillbirth
reviews and stillbirth learning meetings to include an external reviewer, and that was one of the
reasons why we considered the two different reviews with an external attending to it. But, for our
own purposes, the only external person
that we ever regularly had at our perinatal meetings would have been the pathologist, which was --
which was a very valuable input to our meetings --
LANGDALE: Indeed. Let --
McCORMACK: -- and, and we only properly started that not more than two or three years before 2015.
LANGDALE: Can I ask you then to contrast in the same document -- sorry, Ms Killingback, if we can
have it back at page 3, so 0004235 for Baby A [Child A]. We see here reference to documentation
excellent, multi-disciplinary working was excellent, clear reviews, precise managements, excellent
escalation from midwifery to medical staff when there were concerns, no issues with any element of
care, will be subject to neonatal review and will be discussed at perinatal mortality review
meeting. No mention there of external or pathology or the invitation for someone elsewhere to
investigate at that point.
McCORMACK: No.
LANGDALE: Can you explain the difference in approach for the committee, understand that in
principle?
McCORMACK: Because this, this was part of the risk management review of the deaths, so when a
neonatal death occurred, and I may not be completely clear with
the neonatal structure, and you can confirm that with one of the neonatologists, but a Datix would
have been issued, and the Datix was just a paper record of -- a computer record of a concern about
risk, and one of the risk team then would have sent that to Dr Brearey who was the lead in clinical
risk, and he would have prepared for the purposes of the risk team an SBAR. And in cases where there
was concern about the obstetric management he would ask us to do an OSR. And this is the OSR report
which I think I did on [Child A]. And could I point out, in my statement, I'm not sure what page it
is, it's on item 69 where I said I hadn't done an SR, I apologise, and in fact when I started to
lock through evidence I realised the only one I did was [Child A]. So this is a summary of me
sitting with the notes to look through the obstetric notes for the benefit -- for the benefit of the
paediatricians to know were there any serious risks that could have had an effect on the neonatal
care afterwards. But this --
LANGDALE: So when you -- sorry, Dr McCormack, can I just focus on what it says: "No issues with any
element of care provided." Were you commenting on antenatal care? Because it was not within your
remit, was it, to comment on anything post delivery if you were not present for that care or didn't
know what happened in that care?
McCORMACK: Well, I -- I wouldn't -- I wouldn't comment on any. So once the baby is born, then all
the care is the care of the paediatricians and neonatologists. So any report you would have of an
obstetrician would stop at the delivery. So that review that you see and read there under
"Obstetrics Secondary Review Actions" is just referring to the care that Mother A had during her
pregnancy and looking to see was there any issues with that care that could have been relevant for
the outcome post-natally?
LANGDALE: Was a neonatologist present at the meeting? It can go down now, thank you.
McCORMACK: No, not the all.
LANGDALE: Why not? Sorry, pausing there, why not? You've got a situation where you know that the
antenatal care has been excellent, you say, and this baby has died and it's an unexpected and
unexplained death.
McCORMACK: Well, this -- this -- this isn't actually -- this was no -- I tell a lie. The -- the --
the SBAR would have had the risk manager added and would also have had the Head of Midwifery. So the
three of us sat down and then discussed the case, and then I would have prepared the -- the report
that you've just read.
But the report was directed to midwifery care and obstetric care up to the point the baby had safely
delivered. And after that time -- so I wouldn't have commented on it being unexpected, I wouldn't
have commented on it being a neonatal death at all, and --
LANGDALE: Would you have asked about it as a matter of professional curiosity? You've looked after
this patient, she has had her babies, would you just ask and say, "What do you think happened there
then?" You've got an informal arrangement --
McCORMACK: I might have been part of a discussion at one of the perinatal meetings, there's no doubt
about that, and I chaired it and would engage different people to make comments. But in respect of
the -- of my request to review the case, the case would only be reviewed entirely relating to
clinical matters in obstetrics, and the Head of Midwifery at that particular -- was looking at
issues relating entirely to midwifery care, as she will tell you in due course, I'm sure.
LANGDALE: I'm sure that was the process. I am asking now about the excellent communication that
existed between the groups and informal conversations, and you said concerns in the perinatal
mortality morbidity meeting may have been raised. What concerns were said? You said earlier to me
that Dr Brearey would have said
unexpected and unexplained. What was being said -- leaving aside the structure and the governance
and the process, what was he saying to you?
McCORMACK: Well, for me to reflect now what was actually discussed, and I haven't got a record of
it, it's extremely difficult, quite honestly.
LANGDALE: Sometimes we have a sense, though, don't we? We have a moment where we remember something
really significant was told to us or we were worried or professionally curious enough to go back
again and say, "What was that about?"
McCORMACK: Well, I -- I am certain -- I would think that the key features in each of the cases would
have been discussed at the perinatal meeting, and the nature that it was unexpected, sudden, failure
to respond to resuscitation, all the things that we have read in various reports from the
paediatricians would have been -- would have been discussed at the perinatal meeting. And, like,
it's very difficult to think back but I don't think at any case -- in any of those cases there was a
feeling or a concern that these deaths had been caused by intentional harm.
LANGDALE: I will go to that later, if I may. I just want to deal with concerns so unexpected
unexplained, do you know when a rash was discussed with you? Was
that -- who raised that? When was that raised with you? That's a feature -- as you say we've all
read about that and --
McCORMACK: That -- that wouldn't have been discussed with me at any stage.
LANGDALE: Right. So at no stage that. What about -- you mentioned --
McCORMACK: Being quite frank, Ms Langdale, I wouldn't have had a serious conversation with the
paediatricians in relation to those features.
LANGDALE: No, I'm just asking whether their concerns were shared with you. I'm not suggesting you
sat down with a paediatrician --
McCORMACK: I'm certain -- I'm certain that with the peculiarity of the rash and the rareness of it
and them unable to explain it and even at a senior level unable to explain it I'm sure it was
mentioned at the meeting.
LANGDALE: Right. And equally we know Dr Gibbs, as far as Baby C [Child C] was concerned, was
curious and had never seen in a natural disease process after the resuscitation for the heart to
effectively start again. Did he share that concern with you?
McCORMACK: No, he didn't. But I -- I obviously have seen that on the evidence that's been given.
LANGDALE: Yes.
McCORMACK: And I -- I didn't actually consider the cause of death in relation to Baby C [Child C]
because of the -- how ill Baby C [Child C] was during her pregnancy.
LANGDALE: I will go to Baby C [Child C] later, if I may. Let me stay with neonatal minutes Women
and Children's Care Governance Board.
McCORMACK: Okay.
LANGDALE: Can we go, please, to 0004249. This is the minutes of the Women and Children's Care Group
for 22 October, page 2, and we see under "Neonatal" 47 -- 47 incidents reported. Do you see at the
top of the page?
McCORMACK: Could you make it -- yes, thank you.
LANGDALE: Not, it's number 47. "Neonatal", here we go.
McCORMACK: 47 incidents reported. Yeah.
LANGDALE: That's not the section I want, sorry. Yes, it is. 47 incidents reported. Two moderate
harm incidents relate to neonates that sadly died --
McCORMACK: Yes.
LANGDALE: -- and the five top categories are said to relate to seven babies with feeding problems.
Is moderate harm an appropriate category for a baby death, do you think?
McCORMACK: No, definitely not --
LANGDALE: Just continue for a moment, Dr McCormack. The categorisation of baby death appears
through the
documents to have been interpreted differently. So we know for Baby D [Child D] it records the risk
grading as actual harm none, no harm caused. So there doesn't seem to be consistency. Was there
consistency and do you think the categories were always described appropriately?
McCORMACK: No, I don't at all and -- and that was allocated by the risk team. Not by any of the
medical staff. I think there was several boxes on the Datix form that had to be completed and those
-- those -- that terminology has resulted from ticking whichever box they have ticked --
LANGDALE: So it's not a medical person necessarily?
McCORMACK: -- and on reflection it's entirely inappropriate.
LANGDALE: So it sounds like that's a matter for the risk team, is it, if they're ticking the boxes,
you don't think medical team?
McCORMACK: No, none of the medical team have produced that. This report is from the risk team, their
quarterly trend analysis, and they will have ticked the box on that Datix report "Moderate harm".
And if you look at, for instance, the Datix report that you showed -- that you've got in the pile
from C or A you will see those boxes where they can tick those to
describe which -- what description they want to use for it.
LANGDALE: So it sounds like you'd agree there should be a clearer process to accurately categorise
deaths within this system and it may well have been helpful, wouldn't it, to have an unexpected and
unexplained death category, for example? That can be taken down?
McCORMACK: I think there actually is one.
LANGDALE: You think that's --
McCORMACK: I'd have to -- I'd have to look at the Datix, but I think there is an opportunity to tick
that box as well. You -- like, you can confirm that with the risk team when you're talking.
LANGDALE: If we can go to a meeting, January 2016, INQ0004293, page 2. We see at box 7, "[Child D] Case Review": "Need
clarification on approved abbreviations. DP will check what are classed as the approved
abbreviations." There appears there to have been a concern that abbreviations were adopted without
standard uniform application. Do you know what that was about and do you think there should have
been a standard application?
McCORMACK: Well, that -- that was a review undertaken by Dr Brigham. And in fact when I was looking
at that case
recently that was a locum on that night, and the locum used abbreviations that were not accepted
practice. And that was the comment Dr Brigham made in her OSR report. So they -- they were -- staff
were highlighted that. But that particular night it was a locum doctor on.
LANGDALE: We'll come to the Brigham report in a moment -- that can go down, thank you -- but there
was a lot of review of notes and record-keeping and learning in that sense within the Brigham
review, wasn't there, but not anything addressing causation of deaths or what they might represent,
nothing of that type?
McCORMACK: I think that's correct, and that still falls back to the fact that in -- in Dr Brigham's
review it was an antenatal and midwifery review. Again, it wasn't reviewing the -- the clinical care
or clinical outcome of the babies after they were delivered because that would have been the remit
of the neonatologists. So that particular report entirely was to address were we missing something
antenatally or was there something antenatally that could have contributed to the deaths, and that
was the purpose of the review.
LANGDALE: And we know -- I was going to come to that later but you're dealing with it now, Dr
McCormack, thank you -- the learning from that was very much directed to antenatal care or, in the
case of Baby D [Child D], record-keeping. It was not examining forensically, or in any sense
attempting to, the causation of deaths in the babies on the indictment that were included in that
review.
McCORMACK: I would have --
LANGDALE: It was really an obstetric review -- it was an obstetric review, wasn't it?
McCORMACK: It was a what?
LANGDALE: It was an obstetric review really, not a neonatal --
McCORMACK: It was an obstetric review. But you -- you -- you talk there about the learning. Like,
there was very significant learning from that particular report. There were two essential: one
intrapartum death and one neonatal death from hypoxia during their -- all from misinterpretation of
a CTG. And you can see in Dr Brigham's learning thing two or three pages are to try and address that
particular element of care. And I'm just highlighting that the review was to address obstetric
issues. And there were bigger obstetric issues relating to that particular report. But you're
perfectly right, the report doesn't address any issues relating to the cause of death with the
neonates.
LANGDALE: And we see the fact that it was called an obstetric and neonatology review appears to
have created a sense of false reassurance that some of those neonatal deaths were considered or
scrutinised in the sense of understanding the cause of death, and they were not, that was not the
purpose of that review.
McCORMACK: I'm not sure I would agree with that. Right from the onset, the purpose of our review
would be to look to make sure that our care didn't impact on any of the neonatal deaths. And -- and
the review that we would have done would have been entirely confined to obstetric care and midwifery
care for that reason.
LANGDALE: So it looked at whether obstetric care could cause the death but nothing in neonatal care
or pursuant to the delivery of the babies?
McCORMACK: Absolutely, because we hadn't got the expertise to comment or review relating to neonatal
care.
LANGDALE: Going back to your statement, Dr McCormack, paragraph 54. You raise the Datix management
form that was raised in respect of Baby C [Child C]. And if we can go to that document, it is INQ0003229. It begins on page 1. And if we go to page 2, we see your name. And
we see at page 3 the SI panel meeting. Can you just tell me, the ticks, does that
represent who goes to these serious incident reviews?
McCORMACK: Well, the serious incident panel is a specific panel and it includes usually the Nursing
Director and Medical Director, and I assume those other people. So at that particular one I
interpreted when I read and looked at that document that only three people were at that particular
-- and I know in fact from other evidence that Mr Harvey actually wasn't present at that meeting.
LANGDALE: And the meeting looks as though it's 2 July. It's just a point to clarify. You say in
your statement the SI meeting on 2 August, you mean this one presumably, 2 July? Or was there
another meeting, as far as you were concerned? I haven't seen anything to suggest there was, Dr
McCormack. I just want to clarify at paragraph 55 you say --
McCORMACK: Yes, I think that's an error because I'm talking about the panel relating to when [Child
C] was discussed, and there only was one serious incident panel, and I think Baby C [Child C] was
discussed at that meeting. So my apologies for that, that is -- I think that is --
LANGDALE: And did you have any input into that?
McCORMACK: No. That's decided by the risk team, so under review of the SBARs going back from Dr
Brearey and from Jo Davies -- Dr Davies did that report for the OSR. So
those two reports would have gone back to the risk team, they make a decision that, look, this needs
further review, and it will be assigned then to -- to have a serious incident panel. I think in this
case, because of the time frame for the three deaths, I -- I think that the -- they -- they've
reviewed all three at the same time.
LANGDALE: Dr McCormack, I don't need to take you to it -- the document can come down -- but we know
at that serious incident panel the name of the investigating officer Debbie Peacock: "Report on
STEIS. No." And there's comments: "Awaiting pm but likely acute bowel distension sepsis." So no
report on STEIS. Did you understand what should be reported through the STEIS system? What was the
--
McCORMACK: I couldn't tell you right now but there was a list of events that should be reported
through STEIS.
LANGDALE: You looked after Mother C in her pregnancy and she described the antenatal care that you
provided very positively, and we know that you had a meeting with Mother C after the death of Baby C
[Child C], and you have attached -- and we see your notes of that meeting and what was said. You
were able in the meeting with Mother C, weren't you, to explain and discuss how it was that the baby
was preterm delivery and had severe intrauterine growth restriction. You were able to discuss that
with her, the antenatal issues and the birth at 30 weeks. But you were not able to discuss death,
were you, or to understand the death at that point; is that right?
McCORMACK: Yes, that -- that's absolutely correct. The reason that I saw Mother C back for her
review was specifically to review the pregnancy. It had been a very difficult pregnancy and it would
be not frequently that we see a baby with growth restriction from 18 weeks, and it was important for
me to see her back because it was highly likely she was going to have the same problem next time.
And, secondly, I knew the cause of the growth restriction because of the placental biopsy and
examination of the placenta, and that condition really causes a very abnormal change in the placenta
which results in the placenta not working well. And --
LANGDALE: You --
McCORMACK: -- and I wanted to discuss that with her. And in mums that do have that there are other
blood tests that --
LANGDALE: Don't worry, I'm not going to ask you about those -- I'm not going to ask you about
those, thanks, Dr McCormack, it's what you were discussing. You tell us in your statement you
weren't aware of the circumstances in which [Child C] died until evidence was presented at the
criminal trial.
McCORMACK: My apologies for that. I -- I -- I didn't realise what the circumstances you were asking.
I thought you were asking the circumstances relating to how the perpetrator had caused the death. I
obviously was aware of the collapse, the failure to resuscitate, and I had been present at the
perinatal meeting when it was discussed. So when -- when I read that circumstances I was thinking in
my mind that, you know, in relation to whatever mode of -- method had been used to actually kill
Baby C [Child C], and that's when I answered that that's what I was saying. I obviously was aware of
the sequence of events after delivery because as we've discussed in relation to perinatal meetings.
LANGDALE: So who told you what about Baby C [Child C], which Consultants or doctors discussed his
death with you? I mean, you're meeting Mother C, you're discussing future pregnancies, presumably as
a matter of -- professionally, even if it's not your expertise, neonatology, you want to understand
as much you can
about that death before you speak with her?
McCORMACK: Well, I wouldn't per se have addressed the issue of the actual death. I -- I -- and I
can't be certain, but I may have discussed that death with John Gibbs before I spoke with Mother C.,
but from what I was going to say it wasn't actually strictly necessary.
LANGDALE: So Dr Gibbs tells us that that was an unexpected and unexplained death. So he has told
you that as well, presumably, if you're talking to him before you speak to Mother C.
McCORMACK: Yes, he -- well, I think that would have been pretty clear when we -- when we discussed
it at the perinatal meeting. I don't remember -- I don't recollect a specific discussion with John
Gibbs, and I wouldn't have had -- I wouldn't have needed to discuss any element of the neonatal care
with what -- with what I was going to discuss with Mother C. My brief was a very clear brief on what
elements I needed to go back over with Mother C and -- and make sure she understood why Baby C
[Child C] was -- was -- was restricted, that it was likely to happen again and our plans for her
future pregnancy.
LANGDALE: If -- if --
McCORMACK: I -- I honestly wouldn't have addressed with
her issues relating to the neonatal death. I just wouldn't have discussed that, and still don't
discuss that with --
LANGDALE: Even if you knew about it -- my question, Dr McCormack, for you and other doctors is if
there are concerns that it's an unexpected and unexplained death and you don't know, you just don't
know --
McCORMACK: Yes.
LANGDALE: -- wouldn't you share with the parent that you don't know, who may then say, "Well, how
are you investigating? How are we going to find out? I want to know"? Is that a conversation or do
you just not say much about the bits you don't know?
McCORMACK: Well, it's not the bits you don't know, it's the bits that you don't really have an
expertise in. So the neonatal team would be responsible for that degree of discussion. And I
certainly would have empathised with Mother C in relation to Baby C [Child C], but I wouldn't have
addressed cause of death, possible cause of death with her at that meeting, I wouldn't have -- it
wouldn't be considered to be an area that an obstetrician would discuss. And -- and being absolutely
open and honest with you, I never ever considered that this death could have been from deliberate
and --
LANGDALE: At this point -- at this point when it's unexpected and unexplained -- I understand
you're not as ans obstetrician able to say this is what happened, but don't we defer to other
experts -- I might say to someone "Well, I'm not the commercial lawyer you need to go and find one"
-- that when someone's asking you about something or you realise it overlaps with the area you're
talking about you defer to another expertise or discuss who they might get the answers from.
McCORMACK: And I think that would be very valuable, and I'm absolutely certain that the
paediatricians would have done that and would have discussed that with the network and shared the
concerns about the different things. But I -- I have to -- I have to say that that discussion and
that professional discussion I wouldn't have undertaken it with Mother C because it was --
LANGDALE: Would you have undertaken it with Dr Gibbs and say, "Well, who are you going to find out
then? What pathology -- are you going to make sure you speak to a pathologist", clinical
pathological interaction?
McCORMACK: Well, the difficulty with mother -- sorry -- sorry --
LANGDALE: With Dr Gibbs. If you wouldn't have said it to Mother C, would you have said it to Dr
Gibbs, "Who are you going to get to investigate the death?" Just look at the -- to see what's being
done around finding
out, or did you think that was not a matter for you?
McCORMACK: Well, it -- it -- it was a matter for our learning and, and I -- I can't actually
remember but I think it was George Kokai that did the pathology report who would have been most
likely at the perinatal meeting. And I think there would have been less of that discussion because,
certainly from my perspective when I saw the post-mortem result and the immaturity of baby's lungs,
like, I presumed that this was a death entirely consistent with prematurity. And I knew that this
baby was very sick. I knew that it had abnormal doppler. I knew there was no (inaudible). I knew
that the growth of the baby was very abnormal, it was small, and that is a baby for me that when I
saw that post-mortem I would have said to myself, "Right, well, that's typical with my experience
with that sort of mother -- with that sort of outcome."
LANGDALE: It's a requirement, isn't it, not to apply general principle looking at patients whether
they're babies, whether they're the elderly? You could say old people die but they don't always die
unexpectedly or in an inexplicable fashion, do they? The fact as a group they're vulnerable to death
doesn't mean we say they're old, they've died. You need to examine the cause of deaths particularly
if they are unexpected and
unexplained, don't you, whatever the age of the prematurity or the age?
McCORMACK: I --
LANGDALE: You're not the only one to express that view, Dr McCormack, but I'm challenging the view
if you're a premature baby you are more likely to die, therefore I'm not going to scrutinise when
there's a death of a stable baby that wasn't actually very sick -- premature but not very sick.
McCORMACK: And I accept what you say. I'm only saying that in -- in Baby C [Child C]'s case there
was a post-mortem report that actually had a cause of death. So -- and I know there's some debate
about the interpretation of it, but to look at it, it's not as if the pathologist is saying this is
unexplained --
LANGDALE: I was challenging your -- sorry, pausing there, Dr McCormack, we'll deal with that later
-- I was challenging your assertion because the baby was premature. But you agree with me that's a
generalisation and there is a need to be more specific?
McCORMACK: Yes.
LANGDALE: In terms of Mother C, finally, she was having regular appointments with you at the time
the announcement was made that the RCPCH were going to be
coming involved, and there was an investigation into deaths at the hospital. We've seen the
communications, you may have been aware of it at the time how the hospital announced they were going
to downgrade and that there was going to be an investigation. And Mother C remembers discussing that
with you in her subsequent pregnancy and saying how let down she felt to read about that RCPCH
investigation in the paper, and you said to her that the Consultants had been told all the patients
had been informed about the RCPCH investigation, those parents who would have been affected, whose
babies had died in the period that the press announcement was referring to. Can you remember her
raising that with you in the subsequent pregnancy and you saying you thought that she and indeed
others who were impacted upon would have known about this?
McCORMACK: Well, my only recollection of any discussion about the RCPCH report would have been when
I was at the board meeting on 30 June. And I -- I do remember as part of that meeting them
discussing communications and press releases, and it was only to that extent, and I certainly would
have expected there to be an adequate communication with mum, and certainly it's very -- very
unreasonable to find that she discovered it in the press. But I don't actually recollect that
conversation with --
LANGDALE: It sounds like you thought it, so you may well have said it.
McCORMACK: Indeed.
LANGDALE: So she's right about that, that's something you were concerned about you were at that
meeting, the communication strategy meeting --
McCORMACK: Yes.
LANGDALE: -- and it was obvious they should know, isn't it, all those parents that were affected
and should have known before, arguably, if there were concerns still about the deaths?
McCORMACK: Absolutely. Absolutely. There should have been full warning of what was expected so that
they could prepare for that information.
LANGDALE: You were also providing antenatal care, weren't you, for the mother of O, P and R
triplets? And Mother O, P and R says that at every scan you would express disbelief she was still
pregnant and successfully carrying the boys as close to term as possible. Does that resonate with
you, this is a naturally conceived triplets not as rare for you as the rest of us but still pretty
rare I'm assuming?
McCORMACK: Indeed, and I would have seen Mother O, P and
R very frequently in the pregnancy. There's no way to assess that the babies are growing normally
without regular scans, so I would have had very frequent scans with her where I would have had the
opportunity to discuss issues with her or address any concerns she had. And there always will have
been a risk of her going into premature labour, but we would have considered 34 weeks as term with a
triplet pregnancy, so once it got to that stage, then she would have been delivered by the fact she
was 34 weeks, which is the time we would have considered appropriate for ending the pregnancy with a
triplet pregnancy.
LANGDALE: Mother O, P and R says you were a huge part of her pregnancy, she put all her trust in
you and she felt like you looked after her very well in that antenatal period.
McCORMACK: Well, it's that bond that occurs I think. When you're seeing mothers we -- we are -- we
are in a very special place and build up upon over the weeks you are looking after a mother, so I
would -- I would entirely agree with that.
LANGDALE: You were involved in November 2015 in that Brigham review we've referred to stillbirth
and neonatal deaths, and that's November 2015. A question from Mother O, P and R's perspective and
our perspective is
this: did at any point you think it was sensible to suggest care at another hospital, Liverpool
Women's Hospital and to have delivery there, or did you ever question whether the Countess was the
right place for her or them to have their children?
McCORMACK: Well, I think probably the opposite. I think I -- I -- I would have said to the mother
frequently I thought it was unlikely that she was going to deliver in Chester, because for her to
deliver in Chester we needed three baby cots, and at that time, in 2015 -- pardon me -- we were
having great difficulties managing our high risk pregnancies and often had to move them to another
hospital. So I wouldn't have been concerned with her delivering in Chester. My only concern was I
would only know a day before or the morning before whether or not there was three available cots
there.
LANGDALE: So the questions --
McCORMACK: I say --
LANGDALE: So why not encourage her to be elsewhere? That's the point, if you were concerned about
the services, why not say "Don't" -- from the outset, "Don't have them here, go to Liverpool Women's
Hospital"?
McCORMACK: Well, I think it may well be the same case in another unit. So Liverpool Women's could be
completely
full, and I -- I would have said to her that I couldn't have said to her which unit she would go to.
Like to get three cots available for a triplet pregnancy it might be difficult.
LANGDALE: The review that was conducted in 2015. We can go to INQ0003222, page 1, review of neonatal deaths and stillbirths. Page 1 and 2 is
the summary, Dr Sarah Brigham's summary. Go to page 2. Results, 18 cases identified. We know that
within this review babies A, C, D and E were included, Baby I [Child I] wasn't, even though the date
of death preceded it. I think we've agreed it largely focused on antenatal care obstetrics and not
certainly investigations that needed to be conducted for the deaths I've referred to. But did the
fact --
McCORMACK: -- focused on midwifery and antenatal care.
LANGDALE: Yes. But the fact that it was even being done at all, did that worry you that this needed
to be done at all? It can be taken down now, thank you.
McCORMACK: Well, the reason that we under -- we undertook the review was because we were aware of
the increasing deaths. I think -- in the previous years I think we had nine or eight stillbirths
and, at that stage, we had 12 stillbirths. The expected stillbirth rate at 2015 was about four per
thousand, so we should have had 12. And the same for paediatrics, we should have had six. So we
decided that we would review -- and you will remember I mentioned the need for an external assessor
at reviews and so we thought it would be entirely appropriate to undertake it. But just to give you
some idea with the clinical variation of the stillbirths, that --
LANGDALE: Don't worry, sorry, Dr McCormack, I need to move you on there, if I may, I don't need to
know about that variation, but can I take you to paragraph 69 of your statement. You say: "I did
attend discussions with doctors on the NNU in respect of the deaths of the babies named on the
indictment after their deaths. I would have been present when some of these deaths were discussed
jointly with the Neonatal Team at the PNM. If requested, some of the deaths were also reviewed at
Obstetrics Secondary Review by the Clinical Lead but I was not involved with those discussions."
McCORMACK: That is the correction I made earlier to you --
LANGDALE: Yes.
McCORMACK: -- that I've said there I was not involved in
these discussions, but clearly when I went to look at the evidence to prepare my review I did the
OSR on -- on Mother A, so I was involved in relation to that.
LANGDALE: And, really, Dr McCormack, it comes to this, although the paediatricians in detail are
being asked questions here about what they did or didn't know, there is a sense that other people
around them are removing themselves from conversations that they have had or documentation that they
have seen. But you agree with me, you did attend discussions about their concerns, you knew that
they were worried about the deaths and that they were unexpected, unexplained and some of the
clinical features?
McCORMACK: That's correct. But I would have to say that at any of the meetings -- the perinatal
meetings that I attended or engaged in any discussion the understanding was that this was a natural
death and -- and it -- it -- it wouldn't have been -- it wouldn't have really been considered by --
by me that the risk was -- that the deaths were being caused by -- by harm.
LANGDALE: Dr Lambie told us that in September 2015 she observed a group of nurses in the neonatal
unit trying to work something out, she wasn't sure what they were working out, but she said it was
clear it was potentially linking someone to causing deliberate harm
to babies because there had been a number of unexpected and unexplained events and they had started
to think the unthinkable, a group of nurses.
McCORMACK: Yes.
LANGDALE: September 2015. You're doing your review -- or the Head of Midwifery is, November 2015.
Are you hearing conversations or discussions about the "unthinkable" as people have described
it?
McCORMACK: I don't think -- well, I think there may well be a time period where people start to
think is there another reason for this and is this from intentional harm. And the -- the earliest
time, I think, for us probably would have been the triplet pregnancy where we delivered a babe at 34
weeks, three babies in excellent condition, and you will know from the papers the survival rates at
this gestation should approach above 95%. So that -- that was -- was certainly a consideration at
that stage.
LANGDALE: So you -- never mind everyone else, you were saying that you certainly thought about that
after the triplet deaths.
McCORMACK: Well, we certainly considered at -- at that time that -- that, look, this is a very
strange happening now. I think the discussion in the neonatal
unit may well have been confined entirely to the neonatal unit. I'm not devoiding myself from
thinking of the situation. But I -- I know that in discussions I had with paediatricians there --
there wasn't a discussion and -- and -- and a discussion to say to us, "Look, we are concerned here
this must be intentional." That was not something I heard at -- in any interaction with the paeds.
What I did think after the triplets that this was certainly something very strange.
LANGDALE: You are recorded as saying there that you think the discussion may well have been
confined entirely to the neonatal unit. These are colleagues that you have conversations with. Are
you saying Dr Brearey, Consultants aren't talking to you about concerns that someone else is
involved, deliberately causing harm, their suspicions about this?
McCORMACK: Well, I -- I can't talk for Dr Brearey.
LANGDALE: No, I'm talking -- asking you -- I'm not asking you to talk for him -- that he hasn't
said that to you?
McCORMACK: Well, you know, I -- I sat with him right through whatever number of governance board
meetings, and the paediatric team had an opportunity to highlight their concerns at that stage and
-- and that wasn't the case. Anybody who was at that governance board meeting still understood that
it was likely that these deaths were -- were from natural causes.
LANGDALE: Let me ask you about paragraph 74 please in your statement: "Requests for postmortem
examination were usually made in all deaths but only undertaken with maternal consent ..." But you
were only involved with stillbirths as an obstetrician.
McCORMACK: That -- that's correct. With the Alder Hey Inquiry and the difficulties with the organ
issues at that time it completely changed our ability to undertake post-mortems that had been sent
for examinations, and they weren't undertaking without explicit consent from mum. And we were
fortunate in relation to a stillbirth that nearly all of our placentas went for examination but the
mum had to decide and consent to having the pathological examination of their baby for either a
neonatal death or a stillbirth.
LANGDALE: Did you understand that was necessary from a neonatal death that you needed mother's
consent or not at that time?
McCORMACK: Yes, you definitely needed consent. They had to complete a consent form for organ
examination and for
keeping specimens for teaching. And it was -- it was a very extensive document that mum had to read
it and sign.
LANGDALE: So if a mum said she didn't want one, there would be no circumstances where you would say
that should happen or not?
McCORMACK: Well, I think you would have to -- from my perspective in -- in -- with relation to
stillbirths, it may well be that a scan has shown very serious abnormalities and it's clear that
these are present with the baby and that a post-mortem may not be necessary. But if there was strong
concern of an issue you would try and encourage the mother to consider it, but it was -- it was a
difficult conversation quite honestly. They'd just lost the baby and suddenly you were -- you were
in a position where you were discussing very serious things with them. So it -- in general it was a
fairly immediate thing for mum. They knew straight away, "Yes, I want that, I want more
information", or "Oh, I didn't want that to happen." So there wasn't a big persuasion thing, the
mums themselves knew, in my experience, fairly immediately, and -- and -- and that's usually what
happened.
LANGDALE: Paragraph 83 you refer to Dr Brearey
undertaking a multi-disciplinary review, the thematic review of neonatal mortality, dated February
2016. There's a subsequent one in March. When did you see that, do you know?
McCORMACK: The thematic review?
LANGDALE: Yes.
McCORMACK: The thematic review I didn't see it until June 16.
LANGDALE: Right. So we asked you whether it had been -- at paragraph 82 you answer this I think --
whether it was the intention that the neonatal unit would complete their own review or they would be
combined. There was some suggestion that they might be combined, the Head of Midwifery review and Dr
Brearey's review, but that didn't happen, did it? His --
McCORMACK: I don't -- I don't think there was ever an intention because I don't think there was a
discussion prior to either that, "Look, you do this and we do that." We looked at the stillbirths
and the neonatal deaths, and they reviewed the years of the neonatal deaths. So the two reports are
entirely separate and I think properly supplementary.
LANGDALE: In terms -- you referred earlier to the obstetric review and the learning from it, can we go to INQ0015135, and we see a Lorraine Millward emails many people. Page 1, 2 and then 3 we see the content of the email.
LADY JUSTICE THIRLWALL: We haven't got it yet.
McCORMACK: I think that she was one of our risk staff and --
MS LANGDALE: She was. And it's 0015 -- here we are go to page 3, if we may, Ms Killingback.
McCORMACK: And although the report was received in Women's and Children in December, I think some of
the learning hadn't been completed until the end of March because I~think we changed the -- just let
me find it.
LANGDALE: If you look at the email here -- it's there: "We must ensure a Datix is completed for all
neonatal deaths or stillbirths." That went to a lot of people, didn't it, that email?
McCORMACK: Yes, because I think one of the stillbirths hadn't been Datixed and it was sent to remind
them of the importance of a Datix in relation to a death.
LANGDALE: And what was your understanding of the importance of the Datix? What information -- that
can go down now, thank you -- what should it incorporate?
McCORMACK: When you complete it?
LANGDALE: Yes. The nurses complete it, do they, or doctors or both, who should complete a
Datix?
McCORMACK: Both -- well, both would complete it and -- and you really produce a small synopsis of
the event and -- and the risk staff then -- depending on where it came from then obtain more
detailed SBAR assessment of exactly what that involved.
LANGDALE: Dr Brearey's thematic review, February 2016, appeared at the Women and Children's Care
Governance Board. If we can find, please, INQ0003212, page 5. Page 5, please. Thank you. You're chair of this board, I
think, then and we see there the thematic review is referred to higher than expected mortality rate.
Cases have been reviewed at NNIRG. Perinatal mortality review and action plans have been made: "An
obstetric thematic review did not identify any common themes or identifiers that might be
responsible for the rise in mortality in 2015." Your review wasn't even attempting to look at
whether any person or individual could be involved in deliberately causing deaths, was it?
McCORMACK: No, not at all. Both of these reviews were on the basis of a natural death, and the
investigations were based on that. I don't think there was any, these -- these -- these aren't --
aren't, for want of
a better word, a "forensic" review of everything surrounding the death.
LANGDALE: So your evidence is that there was an assumption even behind the thematic review that
these were natural deaths just looking for any learning -- clinical learning or generally, it wasn't
even a question whether forensic scrutiny or suspicion of someone was being factored into the
analysis?
McCORMACK: Well, I'm not sure about that because Dr Brearey modified his report after three weeks
and he did add in some features that would have suggested that it was odd, in other words he did
mention that there were sudden deteriorations, and he also mentioned that six out of the nine deaths
had occurred at an odd time between 12 midnight and 4 am, and it would be slightly unusual to have
your deaths confined -- confined to that time period. But -- so he has included those but hasn't
gone as far as saying in the report, to my knowledge on reading it, that it was caused by
intentional harm. And this -- this report was undertaken on 8 February, so ...
LANGDALE: The time, deaths occurring in the night, you've just picked that up, so was that
something -- that can go down, thank you -- was that something, looking at that review, that did
jump out at you as
being unusual or unexpected?
McCORMACK: Well, I think it did. And he had got it as one of his -- top of his -- top of the little
list, sudden deaths and -- and the time period, and I think that was -- they would have been two
factors I think he was highlighting, and certainly on reading it, I was reading as, well, that is a
bit odd.
LANGDALE: You went to two meetings I think -- I think the Inquiry understands they both happened on
30 June -- one with the paediatricians in the morning and one with management later, and you deal
with these at paragraph 110 of your statement. It was a meeting you were invited to attend at 7.30
on 30 June.
McCORMACK: Yes, these two meetings -- there was two meetings. One was at the request of the
paediatricians in early morning and the other one was to join them at a board meeting on 30 June. I
think the paediatric meeting was -- occurred in response to the deaths of the two triplets.
LANGDALE: Pausing there. The unit and everyone was in shock about that, reeling and devastated,
weren't they, nobody expected that, and you say yourself at that point you were thinking someone
could be responsible?
McCORMACK: Correct. Though, the paediatricians we met them one morning early, so the Baby P [Child
P] died on the 24th
and the meeting with the execs was on the 30th, so I assume this meeting was early on the Monday,
the 27th, or early on Tuesday morning, but it was at half 7 in the morning.
LANGDALE: Leave aside the date that may be contentious, but we've all have got the point, you're at
this meeting, all of you together, and what happens at the meeting -- what do you say that causes
some response?
McCORMACK: Well, we -- we had no idea -- well, it was very unusual for the paeds to ask to meet at 7
in the morning. It was very well attended by obstetricians. There was three paediatricians there, Dr
Gibbs, Dr Jayaram and Dr Brearey, and some senior neonatal staff of which one was Eirian Powell. And
Dr Brearey I think quite early on, the meeting was not long, it couldn't have been anymore than
15/20 minutes but he said there was great concern -- or the there is concern that a nurse was
causing intentional harm to babies on the unit. And, like, my remark, it seems I could have
expressed myself better and maybe said, "Is this intentional harm causing deaths?" But I did say
that, "Are you saying that a nurse on the unit is a murderer?" And he replied, "Yes." And like we
were absolutely shocked at this stage, and everybody was taken aback from in an obstetric point of
view -- obviously the paediatricians were aware of this for some time -- and the meeting really
finished very quickly. They also mentioned two other things at the meeting, one, that they were
considering downgrading the unit and, two, that they were thinking about external review. And they
asked us -- they had a planned meeting with the executive team on the 30th June and would some of
the obstetricians like to attend. And the meeting finished. And we were at the back of the room and
the paediatricians and nursing staff were at the front and, as we left, they filed out first and we
filed out afterwards. I had no idea of the impact on what I'd said to Eirian Powell. I didn't
witness any interaction with her and Dr Brearey. And I -- on the way through and out to my clinic I
had no contact with anyone. And the first time I knew that there had been any concern with what I
had said was when Ian Harvey rang to ask me to apologise seven months later.
LANGDALE: Pausing there --
McCORMACK: So --
LANGDALE: -- let's go back a bit, first of all. So you say you said -- are you saying a member of
staff is a murderer or something like that? What were your exact
words?
McCORMACK: Well, from what --
LANGDALE: -- as far as you can remember?
McCORMACK: -- I remember saying I think I said, "Are you saying a member of staff is a murderer on
the unit?"
LANGDALE: So you say -- you're saying, "There's a murderer on the unit", and you say, "We were all
surprised with when Dr Brearey said it." You've already told us you were thinking after these deaths
of O [Child O] and P [Child P] and all that had gone before something had happened, someone is
causing harm. That was in your own mind, wasn't it, it can't have been a complete surprise when Dr
Brearey said it to you?
McCORMACK: Well, don't forget that was only -- that was only two/three days before.
LANGDALE: Yeah, but it was in your mind, these perfectly health triplets, two of them had died
unexpectedly and everyone was devastated you didn't know why.
McCORMACK: Yes, but I hadn't discussed it with anybody else and I hadn't actually heard the
paediatricians standing up or coming across and saying to me, "We also think that. There is great
concern on the unit." So it still was a surprise to me to be confronted with the paediatric team,
the three senior paediatricians saying, "Look, we have" -- they didn't say "grave concerns",
they said "there was concern". So --
LANGDALE: Eirian Powell will give her evidence about this meeting but, as far as you're concerned
you didn't see Eirian Powell you said in the meeting, you didn't see her talking to Dr Brearey, you
didn't appear -- you didn't have any feedback about that comment when you were in the meeting from
anyone; is that the position?
McCORMACK: Correct. Absolutely correct.
LANGDALE: Right. So no one says anything at the time and then months later you get a telephone call
from Mr Harvey, so do pick up and tell us again in your own words.
McCORMACK: Well, I got a call from Mr Harvey, could I come over to his office, and I wasn't
expecting anything. He would have rang me and odd time to facilitate a Level 2 report from a
department, and I was expecting something like that. I walked into his office, sat down with him and
he said to me, "You are going to have to make an apology to Lucy Letby." Now, I didn't even know who
Lucy Letby was at that meeting of the paediatricians. One, Steve Brearey didn't say the name of the
person nor whether it was male or female, but I didn't know who she was, and he passed me the report
for -- no, he didn't. I asked to see the report because he said it had been
documented in the report that I'd called Lucy Letby a murderer. And I said, "That's not the case.
It's definitely not the case." I qualified what Dr Brearey had said and asked him, "Are you saying
that a nurse on the -- on the unit is a murderer?"
LANGDALE: So you did say a nurse rather than a member of staff or you can't remember which? Before
-- I'm not sure these --
McCORMACK: I said a nurse. But he said a nurse.
LANGDALE: Right, he said a nurse.
McCORMACK: Steve Brearey said, "We are concerned that a nurse is intentionally harming babies on the
unit." So I said in response to that, "Are you saying a nurse is a murderer on the unit?" And it had
been disclosed in the HR report from Annette Weatherley that I had called -- it had moved then to
say I had called her a murderer. I didn't call her a murderer. I didn't know who she was. And I said
this to Ian Harvey. I said, "Look Ian, I'm very -- this -- this -- this isn't right. You know,
that's down in an official document now. I've got a HR document with that in it and I'm a bit
unhappy about that."
LANGDALE: Were you sent that at the time -- the Inquiry's got the grievance procedure documents and
the findings -- were you sent what Annette Weatherley said to you at the time or have you had that
subsequently through this Inquiry process?
McCORMACK: I have only had that through the Inquiry process, but I did get --
LANGDALE: Right. So at the time you just listened to Mr Harvey telling you what --
McCORMACK: No, I didn't. I asked him, "Could I see the report?" And he produced the report and I
read the section that he was talking about and gave it back to him. So I read a small paragraph
where the bit said, "Jim McCormack had called her a murderer." So -- and I said, "Well, look, I'm a
bit unhappy with that. I shouldn't really have to apologise." And --
LANGDALE: So you weren't allowed to take the report out, you were just shown the paragraph that
referred to you by Mr Harvey in his office?
McCORMACK: Correct. Correct. I didn't see the report until you provided it recently.
LANGDALE: And that was the same page that you saw about where you were supposed to have said
something in what way you said it; yes?
McCORMACK: Correct.
LANGDALE: So if we go to INQ0012076, page 1, we see your
apology letter dated 8 March.
McCORMACK: Yes.
LANGDALE: You say "I appreciate" -- to Lucy: "I appreciate you have had a very difficult and
stressful time during the course of the investigations into issues relating to the neonatal unit. I
have been reported to have made an inappropriate comment during meetings with the Consultants and
senior nursing staff when discussing events related to the neonatal unit issue. I wanted to
apologise if this caused you any distress." And you explain there: "I am only aware recently that
first name is Lucy and I have specifically avoided knowing your identity or name to try and afford
you some anonymity when you returned to work in the neonatal unit. I have made no specific
derogatory references personally about yourself."
McCORMACK: Correct.
LANGDALE: At the time, did you think you should have to be sending that letter?
McCORMACK: No, I didn't. Not at all. I didn't send the -- and I was surprised that she accepted it
when I -- when I was writing the letter because I was really saying nothing. I didn't actually
apologise for calling
her a murderer. So I was surprised that she didn't come back and say, "I want Mr McCormack to
actually say." So my letter that I wrote I was very careful in what I said that it didn't actually
say that because I didn't actually do it, and so I was -- I was -- I was surprised that in fact she
had accepted the apology and -- and took it exactly as it was.
LANGDALE: Did Mr Harvey -- that can come down -- think it was a reasonable thing that you had to
do? Did he say that to you or what was your sense of what he felt about it?
McCORMACK: Well, I think he was in the position because he -- I can't remember what -- I -- I think
... Do you know in my statement where it's discussed?
LANGDALE: It's only if you remembered anything in addition --
McCORMACK: But, I -- he -- he certainly was because he said to me that -- and I can't remember the
words in the statement but he said to me that the chairman wants -- needs an apology from all those
involved to address the issue and that I hadn't choice because the paediatricians had already
replied. And he said to me, "Look, do you want to go and add your name to the paediatricians?" So
I'm sitting down, when I'd finished with
Ian Harvey, I toddled over and Ravi Jayaram was in his office and so I went in and he smiled at me
expecting me to come in because he knew I probably would come in and always thought I would be
pulled up on that remark. And he showed me what their letter was and I said, "Well, look, thanks for
that I -- I don't think" -- and I wasn't really working on the unit and I didn't want to be included
in that group, and so I said, "I'll make a separate letter." And so I prepared the separate letter,
met Ian Harvey and said -- and he was actually quite helpful about some comments and saying, "Don't
say that." And that was the final letter that I sent -- that I gave to Ian Harvey.
LANGDALE: So in that process you found Ian helpful -- Ian -- Mr Ian Harvey helpful to you and you
thought he was doing it at the direction the Chair of the board or you thought it was necessary in
any -- in any event?
McCORMACK: Definitely he said to me that it was Tony Chambers had insisted that an apology letter
was written. He -- he I don't think -- he was helpful to me in the text of the letter. That's what
he was helpful to me with.
LANGDALE: So he was helpful with the text but he said Tony Chambers required that of you?
McCORMACK: Tony Chambers required that an apology be -- be provided.
LANGDALE: Did you have a conversation with Mr Chambers about that?
McCORMACK: No. No, the only thing I asked -- because I was then in a position when he said that four
paediatricians had apologised I thought, "Well, I'm not really going to be in a position I can get
out of this it's already been documented in the HR report." And I thought it wasn't going to be
something that I was going to be unable to avoid.
LANGDALE: Standing back, and you're retired now Dr McCormack, what do you make of that HR process
that you ended up writing that letter, and the paediatricians had as well, to someone who's now
convicted of murders --
McCORMACK: Well, I think it's extremely disappointing, extremely disappointing, and I said to Ian
Harvey at the time -- and I actually specifically asked Ian that, you know, of all the departments
in the hospital to be producing the report and -- and not to have confirmed from a person, "Is that
what you said?" Or, "Are there any truths to it?" I -- I couldn't understand it. And I asked Ian
could he go back and address that with the HR team because there seemed to be something amiss with
me that an investigation had a remark to that extent resulting in what was happening I hadn't got an
opportunity to -- to discuss the situation and the sequence with which the remark was made.
LANGDALE: Dr McCormack, I have only got two or three more questions, are you all right to continue?
Is that all right with, my Lady? The time -- I notice the time.
McCORMACK: Yes, I'm all right.
LADY JUSTICE THIRLWALL: Yes, thank you very much, Dr McCormack. Yes, please do continue.
MS LANGDALE: Another meeting, please, at INQ0003362, page 1, it starts at page 1. This is a meeting on 30 June that you
tell us you attended, Dr McCormack, with there Dr Jayaram, Mr Chambers, Mr Harvey, Dr Brearey and Ms
Fogarty, and it's understood that the handwritten notes are made by Mr Cross.
McCORMACK: Correct.
LANGDALE: And this is a meeting where a downgrade of the unit is discussed and also RCPCH review.
You make the point in your statement, Mr McCormack that you didn't have the chance to review the
minutes or approve them. You saw these notes I think -- was it the first time when we sent them or
had you seen them before?
McCORMACK: No, the first time I saw them was when you
sent them, and -- look, I think -- I think they're fairly representative. They're only notes,
obviously. Nobody's reviewed them and said -- I was only making the point that they're Stephen
Cross's notes without someone looking at them and changing them. And my impression was that they --
they -- on my recollection that they fairly represent what was discussed at the meeting. That's what
I thought when I read them. And, you know, I had somewhat prepared after the -- after the meeting
with the paeds that were going to this executive team -- because it was a very senior team, there
were six of the Executives there, and I thought it would be an opportunity to discuss the issues and
--
LANGDALE: It's interesting you say that, Dr McCormack, because six of the Executives and, of
course, seven paediatricians -- as an Inquiry we see many letters signed by seven paediatricians. In
your experience, how rare is it to have that number of people committed to the same intention or
documents and writing around an issue, does that happen very often, in your experience?
McCORMACK: Well, you know, I -- I -- at that time I'd stopped most of my senior roles so I wasn't at
big board meetings and big meetings, so in the past I might have sat round the board with those.
But for everybody in the room there, there was eight Consultants and seven senior members of the
exec -- six senior members the executive team, plus the chairman of the board. So it was a -- it was
a fairly serious meeting.
LANGDALE: If we go to page 4, you are discussing the RCPCH instruction or potential instruction and
you -- look next to your name Jim McCormack: "Do they know about nurse concern?"
McCORMACK: Which page is that?
LANGDALE: Can you see that?
LADY JUSTICE THIRLWALL: It's on page 4.
MS LANGDALE: Page 4. It's on the screen at the bottom, in the last few --
McCORMACK: Can you make it a bit bigger?
LANGDALE: You see the handwriting? Here we are. "Do they know about ..."
McCORMACK: Yes, I do, yeah --
LANGDALE: So you're raising --
McCORMACK: -- and I remember asking this because I wasn't really that supportive of them doing the
external review because of what Ravi and Steve had said about their concern about harm, and I
thought that we -- even though I -- it was only very recently I'd thought of it, I thought that this
wasn't going to address the intentional harm. The expertise of the Royal College of Physicians I
understood, having had previous obstetric reviews, it was all about manpower and about your
guidelines and about how you address risk. It -- it wasn't going, I didn't think, to give us
information that was going to help us address the issue of intentional harm, and that's why I asked
them: "Do they know about the nurse concern?" And he said quite clearly, "Yes, the issues have been
highlighted and including the nurse issue."
LANGDALE: And then you say -- carry on with what you say then. See the --
McCORMACK: I then said at that stage I don't think it's fair to ask the college to do a forensic --
I didn't use the word "forensic", I think he -- Stephen Cross has put that in. But I would have said
I don't think it's fair to ask the college to do this review and I meant that in relation to the
nurse issue, because I couldn't see how they could address that in another review. And I knew from
the two reviews we'd done, albeit they can be criticised for various things, that there was
certainly no concern in relation to natural deaths with the two reviews, and I couldn't see the
college being able to address that. And I specifically had in mind that this
was something that was in the realms of the police would be able to do a better investigation, and
that's what I was -- that's what I was saying at that stage.
LADY JUSTICE THIRLWALL: Sorry, Dr McCormack, just to be clear, so what appears beneath the yellow,
that's all what you were saying?
McCORMACK: That's all what I was saying, yes.
LADY JUSTICE THIRLWALL: Thank you.
MS LANGDALE: And if we go to page 5 at the top of it, that's presumably SPC, Stephen Cross:
"Outline and police action."
McCORMACK: Yes.
LANGDALE: Can you remember what Mr Cross said about that, about police?
McCORMACK: That was the -- that was the surprising thing because -- and everybody spoke forcefully
at the meeting, like Steve and Ravi spoke forcefully about their issues, and Stephen Cross made it
absolutely clear that it would be the end of the unit, there would be black and white tape up
everywhere and gave a very unwelcome tone to the suggestion that the police should be involved?
LANGDALE: When you say black and white tape everywhere, what did you mean by --
McCORMACK: Sorry, blue and white.
LANGDALE: Blue and white?
McCORMACK: Yes. You know they way you get the blue and white tape. His -- his quotation, not mine,
blue and white tape round the wards. And in fact to stand up for the police, their investigation
when they suddenly arrived they were very accommodating, you wouldn't have known they were there,
and entirely unobtrusive.
LANGDALE: But he was saying blue and white tape everywhere, what, that it would be disruptive to
the unit, close the unit, be a problem, what was the inference did you take from whatever he was
saying?
McCORMACK: I took that it would become a crime scene and that there would be blue and white tape all
around and that it would be the end of the unit. Like, those were the -- his remarks, and it wasn't
so much the content of the remarks but for us to be talking about the need for a police
investigation and contact the police to address a specific issue it didn't seem a very supportive
remark to address that particular issue of intentional harm, because that had been brought up by
both Ravi -- sorry, by both Dr Jayaram and Dr Brearey and, at that time, no one, except myself, had
said, "Look, this is something that the Royal College of physicians will not address and it's
something that is a police expertise."
LANGDALE: And then you say:
"Women around the country are not stupid, choice ..." And then what did you say after that?
McCORMACK: Well, that was in relation to the unintended consequences. I'm not -- my recollection of
exactly what it was -- but I was saying that, look, police, no police you know if -- if you're
talking now, women are very educated as regarding their pregnancies and they will choose their unit
depending as they -- as they see, and if there's increasing deaths with no intervention they will
move to another unit. If the police are brought in and they've concerns of that they'll also move to
another unit. It had no bearing on the need that we required, in my opinion, at that stage if the
two Consultant paediatricians had grave concern and I think this is the first time at the meeting
that they actually openly declared it that I was aware of, and I just thought that it looked very
like, in my interpretation, that the only resolution at that time was police to address that issue.
LANGDALE: That can go down now, please. Then can we go to 0014605, page 31. While we are finding
that, Mr McCormack, whilst that was the only time you say you heard them openly say that in those
terms, and you say earlier that day you used the term "murderer", that's not to say they weren't
raising concerns for some time that someone would be deliberately -- could be deliberately
harming.
McCORMACK: I would agree with that.
LANGDALE: Because it's very easy, isn't it, to say the concerns weren't expressed loudly or clearly
enough in the terms that you raised in the meeting on the 30th, but the concerns were still there,
weren't they, and still evidenced by the sudden and unexpected deaths repeatedly that were
occurring, and deteriorations?
McCORMACK: Yes, and -- and we've discussed that a couple of times.
LANGDALE: Yes. If we go to this page, this is your interview with the RCPCH I think because it says
at the top "Three midwives, Jim and Sarah." And it looks, and it's just for clarification for the
record: "Detailed second report. All cases have been OSR. Went through all the cases together
looking at them." It looks like you're talking about the Head of Midwifery or someone is that
Brigham review that you'd gone through, stillbirths and neonatal deaths, yes, that told them that
that review had been conducted?
McCORMACK: Yes, I think so.
LANGDALE: You don't have much recollection of it. Do
you know if somebody interrogated that a little bit further, as I have today, about what it
represented and did and did not do?
McCORMACK: My recollection of the meeting was it wasn't really -- there wasn't any persistent
questioning or confirmation in relation to anything that was said, but if you hadn't sent me that
copy of the written text, I would have no recollection whatsoever of what was discussed.
LANGDALE: So not memorable at all, from your perspective, in terms of trying to find out what was
happening with --
McCORMACK: No, and that would reflect what I said previously about the nature of a college review.
They weren't there to investigate deaths. They were there to undertake a review.
LANGDALE: Looking at the governance structure that was in place at the hospital at the time, Dr
McCormack, how do you say concerns about a staff member should have been reported and addressed
through the governance structure that you had there? The document can come down, thank you.
McCORMACK: Well, I did discuss that slightly earlier with you in relation to the members of staff at
the governance board. The governance board had senior
obstetric, gyaeny, paediatric staff, and when there was an issue on the board, the particular staff
that that related to and their expertise related to would have clearly discussed that, and that's
what I was saying to you in relation to the governance board and the paediatric. At no stage did --
was any concerns shared directly at the board. Now, I don't know why that was, but, you know, it may
well have been that he considered this the incident so sensitive in relation to the staff involved
that that wasn't a discussion. You'll have to enquire why that was. But certainly I got the -- I got
the impression -- and don't forget, everybody at the board had no knowledge still of the talk of
intentional harm and concern in that regard. So the only people coming to the meeting who would have
access to that information were the head of -- the nursing head of paediatrics, the lead, Dr
Jayaram, or I think once Dr Brearey came. And, as you said previously, they were beavering
industriously elsewhere to ensure that the Senior Executives understood there was an issue with
intentional harm. But that wasn't the nature of their conversations at the governance board.
LANGDALE: Were you aware of the case of Beverley Allitt at that time?
McCORMACK: Oh, absolutely. I was 23 years a Consultant. And, you know, that -- that would have been
something that all of us at that time would have been -- would have been shocked about.
LANGDALE: So as those cases were repeating themselves, Baby A [Child A], Baby C [Child C], Baby D
[Child D], E, I and then the deaths of the triplets, O, P, never mind the deteriorations in between,
and there were a number, were you thinking for yourself, whatever they said "We could have somebody
here intentionally harming or killing these babies?" Irrespective of what they -- how they
articulated their concerns to you, just the numbers and the patients that you'd seen who were --
McCORMACK: And, again, we've discussed that previously in relation to at what stage you arrive and
consider, look, this does look to be something very abnormal, and should we be considering
intentional harm? And I assume there must be a threshold by which -- by which that -- that actually
happens. And I have to be honest with you and say I didn't reach that threshold until June 16 with
-- with, as I have discussed, the triplets and then the subsequent visit of the paeds and then the
subsequent visit with the board, and, you know --
LANGDALE: Do you think you should have reached that earlier -- do you think you should have reached
that earlier looking back and listening to what people were saying?
McCORMACK: But I -- I think -- you know, I used to do perinatal meetings and there was a chain of
events in labour ward and you would have discussed it, and it was very easy when you look back and
you say, "Well, why didn't we make that decision?" And -- and I think the same is very valid of
this. Like, if you think of there has only been four deaths as a result of Beverley Allitt, and
we've 7,500 deliveries a year since that time, and I think that the -- the realisation of
intentional harm is something I think very, very difficult to grasp. And, you know, I still -- when
I heard -- read John Gibbs's statement and he was ashamed of his -- that they hadn't -- I think any
of the clinicians involved have a feeling of shame that in some way that they couldn't actually have
prevented that.
LANGDALE: You tell us in reflections that medical examiners and their introduction would assist
with this and provide independent scrutiny of deaths not referred to the Coroner, is that your view,
that the --
McCORMACK: I -- I have no experience of medical examiners. They've only actually been brought in now
in the last -- I think they were only appointed '23/'24 but
my suggestion was that this is an office within your own hospital that has expertise about deaths
and would easily facilitate this type of discussion. In other words, you could go confidentially and
talk to someone and it would give you the ability then to -- to source the place or Coroners or
whatever it was, and I just thought that it's a role I would have thought should be emphasised
greatly. And -- and even as far as education, if you talk about Beverley Allitt and then Chua, and
then Norris, and all these guys, you know I have never seen in my 23 years an educational meeting
where someone comes in and just reminds us of these things. And, like, Chua was, what, he sentenced
the same year and still we're not aware of that. And from the medical examiners they have that great
ability now I think maybe as part of an education to raise it, even though I've mentioned extremely
rare, and that would be a role I think could easily be highlighted.
LANGDALE: You also say: "I think it is necessary to have established links with the police and
Trust Executives to permit discussion at any time to assess the need for police involvement or
investigation." Do you think being at that meeting there just
wasn't enough awareness of how to contact the police?
McCORMACK: I don't think there was enough awareness to contact the police. I'm not sure whether it
was self-belief that this isn't happening or -- or what exactly it was, and you'll get the
opportunity to ask them. But my point was -- and I have to apologise, I hadn't realised there was a
memorandum of understanding already in some existence of contact the police (inaudible) and I hadn't
actually realised, because I've nothing to do with the child death overview reviews, I hadn't
exactly realised there was contactable police there as well. But I did think that for this sort of
scenario, where one of the senior execs to be able to speak to a senior police officer in confidence
and say, "Look, we have a genuine concern here in the hospital. Our two paediatricians have grave
concern of intentional harm. There is no evidence whatsoever to support that. Look, can I have a
chat with you?" And I thought that could have been -- like, even after a meeting I had in a board on
30 June, I thought that was a discussion that should have been available at that time without
leaving it to much, much later.
MS LANGDALE: Thank you, those are all my questions. Thank you, Dr McCormack.
McCORMACK: Thank you.
MS LANGDALE: Does my Lady have any questions?
LADY JUSTICE THIRLWALL: I have no questions, thank you very much. No questions from anyone else. Dr
McCormack, thank you very much indeed and for sitting a bit later, that concludes your evidence and
you are free to switch off.
McCORMACK: Thank you very much, my Lady.
MS LANGDALE: My Lady, can we resume at 12.05.
LADY JUSTICE THIRLWALL: Yes, so we will adjourn until five past 12. (11.47 am) (A short break) (12.06 pm)
LADY JUSTICE THIRLWALL: Mr De La Poer.
MR DE LA POER: My Lady, thank you, our next witness is Dr McGuigan and I wonder if you might step forward, please.
LADY JUSTICE THIRLWALL: Dr McGuigan, would you like to come up to the desk, please.
DR MICHAEL MCGUIGAN (affirmed)
Thank you, Dr McGuigan, please sit down.
MR DE LA POER: Please could you give us your full name.
McGUIGAN: It's Michael Patrick McGuigan.
DE LA POER: And, Dr McGuigan, can you confirm, please, that you provided the Inquiry with a
statement dated 30 May 2024?
McGUIGAN: That's correct.
DE LA POER: And are the contents of that statement true to the best of your knowledge and
belief?
McGUIGAN: They are.
DE LA POER: Did you qualify as a doctor in 2002?
McGUIGAN: Yes.
DE LA POER: And you became a member of the RCPCH in 2005; is that correct?
McGUIGAN: That's correct.
DE LA POER: Since 2004, have you worked exclusively in paediatrics and neonatology?
McGUIGAN: That's correct.
DE LA POER: Did you become a Consultant in paediatrics in 2012?
McGUIGAN: Correct.
DE LA POER: And did you initially work as a Consultant in Crewe in paediatrics and neonates?
McGUIGAN: That's correct.
DE LA POER: In June of 2016, did you apply from a job at the Countess of Chester?
McGUIGAN: Yes.
DE LA POER: And did that job begin on 9 January 2017?
McGUIGAN: It did.
DE LA POER: Finally, just to complete the overview of your career, in December 2018, did you become
the clinical lead for the paediatric department at the Countess of Chester?
McGUIGAN: I did.
DE LA POER: And was that in effect taking over from Dr Jayaram?
McGUIGAN: Yes.
DE LA POER: And did you continue in that position until December 2023?
McGUIGAN: Yes. Yes.
DE LA POER: So we're going to begin the substance of my questions, Dr McGuigan, by just dealing
with your understanding of ordinary medical practice in paediatrics before you arrived at the
Countess of Chester. Firstly, what was your understanding of the purpose of debriefs?
McGUIGAN: Debriefs were often conducted after there had been either a difficult resuscitation or an
unexpected -- or resuscitations that had ended in a death there would usually be a hot debrief, as
in
immediately -- as soon as possible in the half hour/hour or so after the event, a meeting of the
doctors, nursing staff who were involved in the resuscitation, and sometimes a cold debrief a few
days later to discuss sort of after the events. The purposes of those debriefs, in my mind at that
time, were two-fold. The first was to support the staff who had been involved. For example, a staff
member may leave a resuscitation thinking because I didn't do this at this time this is why the
patient died, an opportunity for people to raise concerns and potentially correct things that needed
correcting for people. So immediate staff support. And then also giving staff an opportunity to
share any immediate feedback or learning from the process of the resuscitation, perhaps a piece of
equipment wasn't as handy as it could have been or something else would have been helpful, you know,
whether there's any immediate learning from the resuscitation that's taken place.
DE LA POER: At the start of your explanation for debriefs, you said -- and here we're talking about
before you got to the Countess -- that these debriefs would occur when there was a death but also
when there was a collapse leading to resuscitation which didn't ultimately and happily end in death.
Was that uniformly the case at
Crewe or did it depend upon the person who was leading the resuscitation effort, or were there some
other factors that governed whether a debrief would take place?
McGUIGAN: Yes, I don't there was any policy on it, so it was always a decision by the person leading
the team based on the severity of the resuscitation. Certainly if there was a cardiac arrest as part
of the resuscitation I think it would be usual for some kind of debrief to take place afterwards.
DE LA POER: And when you got to the Countess of Chester, did you find that in those early months
their approach to debriefs was the same as you had experienced at Crewe or was there a
difference?
McGUIGAN: Yes, I don't think I ever particularly remembered when I was rotating round as a junior
doctor different hospitals having a different approach to debriefs or having any formal policy about
debriefs. I think practice was probably fairly similar from place to place. I don't remember if
there are any debriefs in those first few months, but I don't remember the practice being different
to where I'd worked previously.
DE LA POER: When you were in Crewe, did the hospital you were working at use the Datix system?
McGUIGAN: They did.
DE LA POER: And before you got to the Countess, what was your understanding about the circumstances
in which a Datix form should be created?
McGUIGAN: I think my understanding was that a Datix form was usually being completed when an
incident happened where there could be learning so, for example, if a mistake had been made, if a
drug error had been made. I don't remember it being routine to Datix, for example, that there had
been a collapse or even necessarily that every death would be Datixed at the time. It's really hard
thinking back, you know, because it is quite a long time ago, but that would be my recollection was
that -- and that's changed a lot in the years since but my recollection at the time was it wouldn't
be routine necessarily to Datix a death or a sudden collapse in the way that it would be now.
DE LA POER: When you got to the Countess of Chester in those early months, did you find that the
approach of the paediatric department was the same as that which you had previously experienced in
relation to Datix or were there differences?
McGUIGAN: I think there were inevitable differences because of the situation that they were in, that
they were investigating a number of unexplained deaths and
collapses and, therefore, the expectation in how we would respond particularly if there was an
unexpected event on the neonatal unit was different by that point.
DE LA POER: So you think the policy that you were met by had been influenced by the events of the
previous months?
McGUIGAN: Yes.
DE LA POER: You mentioned that the procedure has changed since the circumstances you experienced at
Crewe. Is it now your understanding that Datixes would always be created in relation to a sudden
unexpected collapse that does not end in death but for which there is no immediate or obvious
explanation?
McGUIGAN: Our practice now would be any significant deterioration in a patient's condition that led
to them needing intensive level care of support would be Datixed, and that would be on our
children's unit as well, so any child, even if there were no concerns about the care, who needed to
go to intensive care at Alder Hey we would Datix that and we would review all those incidents.
DE LA POER: And do you regard that as an improvement to the system or is it overly burdensome and
impractical?
McGUIGAN: I think it's an improvement to the system. The problem sometimes can be that if you --
people might
not necessarily perceive there was a problem with the care but once there's opportunity to review
the care in more detail in the cold light of day that there might be useful learning that comes out
of that, so I think it's a good change of practice, and I think it reflected a big change in general
in how we've approached these things over the last few years. We didn't have HSSIB investigating
neonatal deaths and brain injuries at that time. I don't think we had the perinatal mortality tool
at that time, or it had been recently introduced, so there's been a lot of changes in how we
approach child death particularly in neonates over the last few years.
DE LA POER: The sudden unexpected death in infancy and childhood protocol, and here I'm speaking
about something the Inquiry has heard quite a lot about, namely the convening of a Joint Agency
Response or a multi-agency reaction where local authority and police will be involved very quickly,
so that SUDiC process, when you were at Crewe, did you follow that SUDiC process in relation to
sudden unexpected deaths on the neonatal unit?
McGUIGAN: I've thought a lot about this in preparing for my evidence. I can't think of an example
anywhere that I've worked where there's been a sudden unexpected death
of an inpatient that's led to a Joint Agency Response.
DE LA POER: And so that we understand the geography of where you've worked, has that largely been
confined to the north-west or is this -- has your career spanned more areas than that?
McGUIGAN: That was in London and Bristol as a junior doctor, SHO level, and in the north-west since
middle grade Registrar level.
DE LA POER: And we know that Working Together was published or republished in 2015, and that's the
version that we have been looking at closely. Your career since 2015, has that been confined to the
north-west or --
McGUIGAN: Yes.
DE LA POER: It has been?
McGUIGAN: Yes. Yes. And when I thought about it preparing for this evidence, I remember attending
training as a Registrar -- a full day of training in managing sudden unexpected death in childhood
and it being made clear in that training that if you had an unexpected unexplained death in hospital
that the same rules would apply in terms of activating a Joint Agency Response. But I think it
probably reflects that sudden unexpected -- well, certainly sudden unexplained death in hospital
patients is not a common event, so it's probably not something that would be activated very often.
But I can't recall a time when that has been activated in that situation.
DE LA POER: And, finally in terms of your experience, before you got to the Countess of Chester,
had you ever previously encountered a situation in which there was concern raised about a particular
staff member, whether doing harm deliberately or inadvertently, so where there was a concern about
an individual, I'm not asking you to name them, but had you encountered that before you got to the
Countess of Chester?
McGUIGAN: No, I can't recall any -- any.
DE LA POER: So this question is very much a hypothetical in those circumstances. If there was
concern about a particular individual, what is your view about whether or not, whether anonymously
or by name, that -- a standard governance meeting should be discussing that issue? I can put that in
a different way, if you like, that is the standard governance structure equipped for discussing a
concern like that about a particular person or should there be a separate route by which that person
is discussed and the risk is managed?
McGUIGAN: I think my answer to that would be that within a governance meeting there's lots of people
with
different roles. There might be an audit lead there, there might be -- you know, there might be a
variety of people there and that a sensitive investigation like that might not be appropriate to be
discussed within a governance meeting setting and might be discussed separately. If that happened
and I was leading that governance meeting, I certainly would be thinking about whether in some way
it needs to be acknowledged that this process was going on. But I would be mindful of -- of having a
fair process for the individual concerned and the confidentiality issues with that against the need
for that to be -- have the oversight of the governance committee.
DE LA POER: So are you perhaps, and you tell me, envisaging a hybrid situation where the detail of
it isn't discussed at the governance meeting but the fact that such an investigation is taking place
might be mentioned and minuted so that at the governance level, whichever tier that is of the
hospital, a track can be kept of the fact that that is occurring?
McGUIGAN: Yes, and I guess it depends on what the level of concern is. You know, I'm trying to think
back whether it's hypothetical or not, there must be circumstances where there's concerns about how
a staff
member is performing in some way. But, yes, I -- I can't see that it would be usual practice for
that to come through a governance board meeting.
DE LA POER: So does it follow from that that if you don't think that that is the appropriate route,
that it is extremely important that there is a clearly designated route by which those concerns can
be investigated, monitored and progressed?
McGUIGAN: Yes.
DE LA POER: And looking back to your time at Crewe, were you aware of any such route existing at
Crewe?
McGUIGAN: No, I think -- I suspect there may have been a route but -- and I suspect -- you know, I
was a relatively junior Consultant at the time -- that if I'd spoken to people in more senior
positions that there would be a route for progressing that but I wasn't familiar with it.
DE LA POER: So we're just going to move chronology logically through your experience of the
Countess of Chester and in fact events begin for you before you arrive in January of 2017. You
applied in June of 2016; is that right?
McGUIGAN: Correct.
DE LA POER: And the Inquiry has received evidence that there was a press release by the Countess of
Chester in
early July of 2016 about the downgrading of the unit and, given that that was a place that you
wished to work, did you become aware of that press release?
McGUIGAN: Yes, my memory is that it was made between the job being advertised and my application
being completed.
DE LA POER: And was it drawn to your attention by those that you had applied to, ie the Countess
said, "You should be aware of this", or did you just see it in the press or --
McGUIGAN: Not by the Countess but because there was a change in designation of the unit that was
communicated around all the local hospitals so that we were aware of that. So I knew it through --
through the Neonatal Network rather than directly from Chester. After I'd applied for the job, Dr
Jayaram then contacted me to say, "There's been developments here and I think you need to come and
speak to us before you come to your interview to understand a bits more what's happening."
DE LA POER: So we'll come to that now. You describe this as a pre-visit --
McGUIGAN: Yes.
DE LA POER: -- where you met with Dr Jayaram, and was that at the Countess?
McGUIGAN: It would have been, yes.
DE LA POER: And was that meeting such that you just went straight into a room and talked to Dr
Jayaram or did you gather any feel for the unit as you walked through?
McGUIGAN: Yes, so --
DE LA POER: How much information did you gain from that first meeting outside of what Dr Jayaram
told you?
McGUIGAN: Yes, so the usual process of applying for a Consultant -- substantive Consultant job would
be that you would meet a number of members of the organisation. One of the nursing leads took me on
a tour of the estate and the paediatric and neonatal units, so I spoke to a number of different
people as part of my pre-interview visits. But in particular Dr Jayaram had asked me to make an
appointment to speak to him because he wanted to give more information on what was happening with
the neonatal unit.
DE LA POER: What was your impression outside of what Dr Jayaram told you in August or July of 2016
of what sort of place it was to work and how it was functioning and how people's morale
appeared?
McGUIGAN: Yes, the people I met were nice. They seemed to have good relationships with each other. I
knew some of the people who worked there who liked the teams that they worked with. Lots of our
junior doctors will have come from Crewe who've rotated from Chester in
a previous and said good things about it and that it was a God place to work. So I -- yeah, I had a
good impression of the department, which was partly the reason I decided to continue with my
application there.
DE LA POER: Did anyone other than Dr Jayaram tell you about events of the recent months or anything
about why the unit had been downgraded?
McGUIGAN: Gosh, I don't remember. I don't remember.
DE LA POER: Tell us, please, what Dr Jayaram told you in that pre-visit meeting with him.
McGUIGAN: I can't remember what I said in my statement. I don't remember --
DE LA POER: Paragraph 8 if you wish to remind yourself.
McGUIGAN: Yeah, what I've said there -- what I remember is that is those facts that there had been a
spike in mortality, that there had been a Royal College review commissioned, that they'd downgraded
their status of the unit while investigations were taking place, and presumably with an intention of
dealing with those issues and getting back up to Level 2 status again.
DE LA POER: And, as you've told us, you continued with your application following that
pre-visit.
McGUIGAN: (Nods).
DE LA POER: Is that because you were comfortable with what you were told?
McGUIGAN: Yes, that's right. Yes.
DE LA POER: Now, we're going to come in a moment to what you were told when you were appointed and
turned up for your first few weeks of work. But what I would like to just deal with first had,
please, is your impression at the very earliest stage of your arrival in January of 2017, because I
think it wasn't immediately that you were told about more detail of the concerns; is that right?
McGUIGAN: I think it was in the first week that I started that Dr Jayaram came to speak to me to
give me more detail about what the concerns were and where they were up to at that point.
DE LA POER: Well, doing the best you can to disentangle things in terms of when you did and didn't
know things --
McGUIGAN: Yes.
DE LA POER: -- before you were told about those very serious matters, what was your impression of
the department that you walked into fresh?
McGUIGAN: It felt very similar to where I'd come from in Crewe. Like I said, the junior doctors
rotate around and my understanding of Chester was it was a unit that had a good reputation, that it
was good for training, the trainees liked going there, it was a popular place
to work, that the trainees who went there felt supported by the team they worked with, and it was a
good unit to work in, and that's, you know, what I found when I started and started working on the
wards and going to handovers.
DE LA POER: And so does it follow if that that you didn't detect from your interactions with
various people before you were told more about the concerns that there was any dysfunctioning within
any of the relationships?
McGUIGAN: No, I -- I would have met Mr Chambers and Mr Harvey as part of my pre-interview visits. As
far as I remember, Mr Harvey was on the appointments panel for my interview. You know, a
conversation, 20 minutes, they seemed like nice people and, you know, I -- I had a good impression
of the place I was coming to work in.
DE LA POER: Did either of them tell you anything about what was -- what you now know was going on
in the background at the time that you met them?
McGUIGAN: I don't remember what we discussed.
DE LA POER: If you just think -- think back, do you think it would have stood out in your
recollection, as it has for Dr Jayaram, that you were given some information about the challenges
the hospital was facing at that time?
McGUIGAN: I don't remember. Mr Harvey we met in the coffee area of the education centre with all the
candidates that were interviewing that day, so certainly I don't think we would have discussed
anything like that. Mr Chambers I met on his own. My memory of talking to him was talking about
where things were likely to go with paediatrics and health in that part of the world over the next
few years, thoughts about how Chester and Arrowe might work more closely together, and I don't
remember discussing the neonatal issue with him.
DE LA POER: Knowing what you do now, do you think that was something he should have talked to you
about even in the oblique terms that Dr Jayaram had?
McGUIGAN: I don't know. I obviously walked into a very difficult position -- situation that I didn't
appreciate I was walking into. It was also an evolving situation. There was lots of confidential
issues in there. I think I can understand why I was only given limited information at that point. I
think I would have liked to have understood the difficulty of the relationship between the
paediatric Consultants and the execs at that point, but I think that had deteriorated a lot more
between July/August and then when I started in January.
DE LA POER: What you tell us in your statement was that
you observed good relationships between the clinicians and managers at the ward level --
McGUIGAN: Yes.
DE LA POER: -- in the department, and that you found the Consultants to be supportive of each
other.
McGUIGAN: Yes.
DE LA POER: You also say that what you discovered upon arrival was that outside of the department
those relationships were strained.
McGUIGAN: Yes. So there's various levels of management, but -- that their relationships with the
higher level management, ie the executive level management, was very strained at that point.
DE LA POER: And was that something simply that you were told or, as perhaps we shall see, was that
something you observed for yourself as events unfolded?
McGUIGAN: I don't remember. I think -- I think it probably became clear to me at that meeting at the
end of January I attended in the third week of working at the Countess of Chester.
DE LA POER: And you said that it was very different to your experience at Crewe in terms of that
interaction between those outside the department at managerial level and the department.
McGUIGAN: I guess I hadn't really had time to settle in
and -- and see what the normal relationships would be like. My experience at Crewe was very good in
that both the Chief Executive and the Medical Director had invited me to meet them in my first two
or three months in the post and welcomed me and got to know me a little bit. I obviously arrived
here and by the third week we had this very difficult meeting. So I walked into a very difficult
situation.
DE LA POER: Again, we're going to look at the detail of this, but just dealing with your summary of
the position. At your paragraph 61 -- you don't need it turn it up unless you want to -- you observe
that the Consultants could have given up. Was it your perception over the course of those early
months that the Consultants' concerns could have resulted in them simply stopping raising
problems?
McGUIGAN: They certainly could have done, but I never saw any intention that they were going to stop
until they were satisfied that the issues they were concerned about had been addressed.
DE LA POER: In terms of the quality of the care on the neonatal unit that you observed -- again,
you deal with this in your witness statement -- but just describe for us in your own words what you
thought of that?
McGUIGAN: Yes. So what I was able to witness working
there was working on the neonatal unit seeing the policies and practices they had in place, seeing
the expertise of the nurses who were looking after the patients talking to me about what was
happening with the patients, hearing the other Consultants talking about patients at handovers and
how they were managing the patients. And, as far as I could see, the care was excellent quality. I
agreed with the clinical decisions that my Consultant colleagues were making on the patients, and I
didn't -- I felt like I was working in a place where the doctors and nurses knew what they were
doing and providing a good level of care.
DE LA POER: Just dealing with the governance arrangements and matters of management and the
divisions. Again, this is something you deal with in your witness statement, we can turn it up if
needed, but what was your view, having walked in to the situation that you did, about the divisional
structure that the hospital was operating, in other words the fact that paediatrics was in Urgent
Care whereas obstetrics was in Planned Care?
McGUIGAN: Yes. I don't think you see that as much when you are not in a clinical lead role within a
department. But certainly I was quite surprised at the way it was divided. And clearly we've heard
from Dr McCormack this morning, the paediatricians' and the obstetricians' offices are very close,
the neonatal labour ward was close. So there was lots of interaction between the two. But it did
concern me that the governance structure and the divisional structures were -- were so separate --
DE LA POER: And --
McGUIGAN: -- and I hadn't seen that anywhere else I had worked.
DE LA POER: Was it under your clinical lead position that the divisional structure changed to what
it is now or did what change before you took over that role?
McGUIGAN: Yes. So over the year after I started probably in 2018, there was a decision to bring
women and children's back together as a single directorate within one division. So we were in the
Planned Care division, which included all the surgical services, women and children's became a
separate directorate with its own directorate management within that division, and then in the last
year we have separated out and become our own women and children's division separate from any of the
other divisions in the Trust.
LADY JUSTICE THIRLWALL: I'm sorry, Mr De La Poer, does that mean you have a seat at the board
table, as it were?
McGUIGAN: Yes, so that means that the women and children's division is run by a triumvirate of
nursing manager, which is the Director of Midwifery, the Medical Manager, which is the Clinical
Director for the division, and a divisional manager and that those three people then speak directly
to the execs as their immediate managers above them.
LADY JUSTICE THIRLWALL: Thank you.
MR DE LA POER: And is that a change for the better?
McGUIGAN: Yes, very -- it very much feels that way. And I think it's easy in any organisation for
which predominantly deals with adults, you know, often is starting its morning with 30 patients in
A&E corridors, lots of busy wards and trying to keep operating lists going, it's potentially
very easy for the needs of the smaller patients to be lost within that, and certainly I think that
being in a separate women and children's division again just gives the -- it just gives a bigger
voice and easier to make sure that that voice is heard.
DE LA POER: You say in your witness statement that the governance support in place at the time,
meaning when you arrived: "... struck me as minimal and insufficient." Please could you just tell us
what you mean by
that?
McGUIGAN: Yes, that was perhaps from listening to the people that I was working with, you know, who
perhaps had those risk lead roles at that time and if a significant incident occurs and you want to
have an investigation it takes a lot of time to do that investigation. Somebody needs to prepare the
timeline, to get the statements, to bring all the information together. Often these things can be
30, 40, 50 pages long, and it takes a lot of time, and without the personnel to be able to do that,
you can't have that rigorous analysis of the events, and from what I understood, the amount of
support they had from people to do that at governance level wasn't there. And I think we've heard
from other people that, and this is what I was aware, that sort of the Consultants were basically
finding time to do that outside of their normal working hours to try and process -- and so many
significant events had happened in such a short space of time -- trying to process that.
DE LA POER: So where was there a lack? Was it in the paediatric department or was it in the risk
department supporting --
McGUIGAN: Yes, so my understanding was particularly the risk -- midwife risk nurses who would
support with that
process were lacking. I think as well within job plans, you know, Dr Brearley was the neonatal lead
but also took the responsibility for the neonatal risk. The plan had been, and what ultimately came
when the Consultant after me was appointed, was that a second Consultant took on, you know, a PA a
week to be the neonatal risk lead and took that role separate from the neonatal lead. So that led us
to a place where we had -- and ultimately we've got more midwife nursing risk support from the risk
team, but also more time within the Consultant job plans to have the time to look at neonatal risk
and assess it properly.
LADY JUSTICE THIRLWALL: So when you talk about a job plan, that's a sort of -- is it how many hours
you spend on what?
McGUIGAN: Yes. So a job plan, yes, would be how many hours have you got in a week to work.
LADY JUSTICE THIRLWALL: Yes.
McGUIGAN: And what do you spend that time doing. If your time is full of clinics and clinical work,
but you also need time to do other things like being a clinical lead role or working in neonatal
risk, for example.
LADY JUSTICE THIRLWALL: Thank you.
MR DE LA POER: So now, is this right, there are two people effectively doing the job that Dr
Brearey was doing during this period?
McGUIGAN: Yes. Yes. They don't spend their full time doing that, you know, but sort of two people
doing -- or the work has been split between two people with one taking a lead perhaps on service
development and neonatal standards and that sort of thing and one taking a lead on term admissions,
incidents, Datixes, reviewing all of those things to make sure that that's being managed correctly.
DE LA POER: Finally, before we come to what you were told when you arrived and what then
transpired, you say that: "Management within the division at the time also struck me as lean."
Again, can you just tell us what you mean by that?
McGUIGAN: Yes. What I mean is that there weren't many managers within the directorate, and managers
have an important role in getting things done correctly. And then when we faced challenges, that's
when you particularly see that. The challenge they were facing in 2015/2016 was a spike in neonatal
deaths and trying to understand what was causing that. In 2020 it was Covid. In 2021 it was our
transition to a new electronic patient record. And each time when the situation is stressed when you
lack that management
support you particularly feel it. There's been a general sort of expectation in terms of managers,
so all units now are expected to have a director of midwifery, which we didn't have before, so
that's a senior, you know, midwife who is the nursing lead for our division. We had a Matron for
paediatric nursing but we now also have above her a lead nurse for paediatric and neonatal nursing.
And, again, I see a huge difference in -- you know, the Matron trying to do that whole job by
herself was just overwhelmed, they didn't have the time to do all the things that needed doing with
in terms of whether that might be service development or responding to incidents and risks, and both
the Director of Midwifery and the Head of Paediatric Nursing would have significant roles in the
risk and governance management within the department.
DE LA POER: And just so that we understand which of the people that we are very familiar with
you're talking about, when you refer to the Matron, are you talking about the role that Ann Murphy
was doing at the time?
McGUIGAN: Yes. So we still have a Matron, which is the role Ann Murphy was doing at the time, but
above her we now have a Head of Paediatric and Neonatal Nursing who has a more senior role.
DE LA POER: So we come now to the point in your first week when you are told more about what the
problems had been.
McGUIGAN: Yes.
DE LA POER: Just in your own words, what information were you given and by whom?
McGUIGAN: Yes. So my memory is that in that first week Dr Jayaram wanted to speak to me and explain
the situation in that not only had there been a spike in neonatal deaths, but a number of the deaths
were unexplained and unexpected, that there were a number of features of those deaths which had
raised concern, for example this pattern of recurrent mottling and rashes on the skin which they'd
not seen before and that there -- that he'd come across some evidence that that potentially might be
linked with air embolisms. My memory of how he explained it to me was that they had come to
recognise that the unexplained collapses and deaths were all occurring when one member of staff was
on shift and that that member of staff had been moved from working days and night shifts to only
working on day shifts, at which point the collapses at night had stopped, and they'd only been
happening during the daytime and, therefore, they'd reached a concern that between the unexpected
nature and the recurrence of this individual associated with them that there might be
somebody deliberately causing patient harm. It was then explained to me that the way the Trust had
decided to approach it is they wanted to make sure that there wasn't any systemic problems in how
the neonatal department was practising before, you know -- I think his words might have even been,
"Make sure there's no problems in our own backyard" before sort of looking at that and, therefore,
they'd commissioned the Royal College review, and that had led on to an external Casenote Review and
that the reports from those two were due back imminently to then sort of work out how we would
proceed next with this concern that somebody might have been deliberately harming patients and that
that person had been moved out of clinical practice while those investigations were taking place.
DE LA POER: Now, you were interviewed by Facere Melius, the organisation, and what you told them
was that you had been a Consultant in Crewe and you couldn't remember a single baby who had suddenly
and unexpectedly deteriorated and died, do you recall saying that to them?
McGUIGAN: Yes. And in 2017 I think I put that in my email as well. I -- I thought that what they
were -- what Ravi was describing to me in that meeting that first week was very unusual and I could
think of babies becoming sick maybe sort of having a sudden collapse, having some resuscitation
which they responded to, continuing to deteriorate, perhaps transferring out to a Level 3 unit,
continuing to deteriorate and dying. But I couldn't think of a time where a baby had suddenly
collapsed and died out of the blue. And they were describing this happening on a repeated frequent
basis over that year period of time. So it struck me as very unusual what was being described to me.
DE LA POER: The phrase you use in your witness statement "extremely concerning". Does that
represent your state of mind at that time?
McGUIGAN: Very much so, yes.
DE LA POER: Having had this described to you, one professional to another, did you think this
doesn't sound like a problem, or did you think that the Consultants might be thinking along the
right lines?
McGUIGAN: Yes. Certainly, you know, with full awareness of what had happened in Stockport, full
awareness of Beverley Allitt, that combination of repeated sudden unexpected unexplained collapses
and deaths associated with one member of staff being on duty certainly I was immediately concerned
that that needed to be appropriately investigated to ensure that somebody wasn't deliberately
harming patients, and perhaps was on
the understanding that those investigations were in progress through the Casenote Review and the
Royal College review.
DE LA POER: What was your view, in that first conversation when all this information was given to
you, about whether the RCPCH were an appropriate body to be investigating in these
circumstances?
McGUIGAN: Yes, I think it was a lot to take in to be honest. I don't think I got as far as thinking
through the Terms of Reference and how they had gone about that.
DE LA POER: Was there any discussion between you and Dr Jayaram in that first conversation about
whether the police should be involved?
McGUIGAN: I don't remember.
DE LA POER: In that first conversation, did you consider that what you were being told was a
safeguarding issue or did you think about it in different terms?
McGUIGAN: I think in the way that I'm usually thinking about safeguarding issues it -- it felt
different and clearly it was a safeguarding issue. I probably was thinking patient safety rather
than safeguarding.
DE LA POER: Had you had any safeguarding training about how you might raise concern about a
colleague if you thought they might be causing deliberate harm?
McGUIGAN: I've certainly had a lot of safeguarding
training as a paediatric trainee and as a paediatric Consultant. A lot of that would have been
relevant to that specifically, you know, as a paediatric Consultant that's about being prepared to
think the unthinkable, being prepared to investigate something according to protocols. You know, for
example, a baby presenting with a bruise, even if everything else seems in order, that we would
still go through the process of investigating that according to protocols because you have to be
prepared to think the unthinkable and you can't judge people just by the way they come across to
you. You need -- it's based on making sure things are investigated appropriately. I can't remember
if I had any specific safeguarding training on if I was concerned a member of staff might be harming
patients. I don't remember. If -- if I had, it was perhaps in relation to thinking about perhaps
sexual abuse. I think there had been a paediatrician at that point in the media who had been
convicted of sexual abuse on patients at work. So I must -- I'm sure -- it's hard to recall what
training I had had but certainly I think a lot of the generic training we'd had about safeguarding
was very applicable to the situation. But I don't know if I would have been fully clear on the best
way to raise
concerns in that situation.
DE LA POER: I mean, looking back on it now, with the benefit of hindsight, you acknowledge that the
principles are equally applicable but your thought was patient safety, not safeguarding, do you
think it would have been better to think about it as a safeguarding issue and do you think that's
how people should think about this sort of issue should it ever arise in the future in those terms,
that this is a safeguarding issue?
McGUIGAN: Yes. I think when people were making their decisions about how to manage and investigate
the situation that they are thinking through all of those, there's lots of things they take into
account. And in some ways patient safety and safeguarding are the same thing, you're trying to
protect children from -- from harm. I guess patient safety we're often thinking about non-deliberate
harm rather than deliberate harm. Yes, I -- yes, I don't know if safeguarding was the word that came
to mind.
DE LA POER: I suppose one advantage about thinking of it in that way is that there are trained
safeguarders within the hospital who you can immediately go and tell who are outside all of the
management structures and whose single remit when you raise that with them is to pursue it
relentlessly.
McGUIGAN: Yes, and I think, you know, if there had been an allegation that somebody had, you know,
slapped a child or, you know, touched a child inappropriately or anything like that that would be
the obvious path to go down. But I can see why perhaps it wasn't the obvious path to go down when
people were considering how to investigate this case.
DE LA POER: So you have had your initial briefing in situ from Dr Jayaram?
McGUIGAN: Yes.
DE LA POER: Was there any more discussion that you had with any of your other colleagues before
that meeting on 26 January to better understand the situation that you had walked into?
McGUIGAN: I don't remember. The gap between that conversation, you know, settling into a new place,
you know, and all those things and the meeting that happened later that month was so short, I don't
remember if I had many more conversations in the meantime.
DE LA POER: There came a point when you and your Consultant colleagues were invited to a meeting
which we now know took place on 26 January of 2017.
McGUIGAN: Yes.
DE LA POER: Why did you go to that meeting?
McGUIGAN: That's a good question. I believe an email came round saying can we try and find a time
when as many of the paediatricians are available, Consultants are available as possible and,
therefore, I was included in that email when people were asking about availability, and then I was
invited to the meeting. My understanding from having to spoken to Dr Jayaram is that we were waiting
for these reports to come back and, therefore, this meeting would be a chance to discuss those
reports. So as a Consultant within the department it seemed appropriate to be invited and go along
to hear the outcome of the reports on the department.
DE LA POER: Now, as best as you can recollect, what was the terms of the invite that you received
to that meeting?
McGUIGAN: Yes. As best as I can recall, and my earliest written recollections of -- from two years
later when I was giving a statement to the police, but the best that I can recall is that the
invitation was unusual in that it wasn't saying, you know, "We want to share these reports with
you." It was that you were invited to this meeting. My memory was that there were words along the
lines of it's not a disciplinary matter at this point and you
don't need to bring Union representation or something like that. That just gave me a flavour that
this was not quite the meeting I was expecting.
DE LA POER: Now, for transparency, Dr McGuigan, I showed you an email this morning and I will just
tell everybody what the reference is. I do not want it brought up on screen. That's simply because
it hasn't been appropriately redacted, not because there is anything sinister about it. INQ0057567
[unavailable]. That's for everybody else so that they know what you have seen. That's an email that
you were a recipient of which started with Ian Harvey asking for dates for the meeting; is that
right?
McGUIGAN: Yes, that's right.
DE LA POER: Having had a chance to refresh your memory this morning about that, is that the email
that you are referring to mentioning, "Not disciplinary, don't bring Union reps"?
McGUIGAN: I don't think that's the email. I think that's an email that's gone via the paediatric
secretaries to liaise with the Consultants about a convenient time for the meeting. My memory is a
separate email inviting us to the meeting with a confirmed venue and time.
DE LA POER: Have you been able to find the email that you
received?
McGUIGAN: No. I -- my email address is an NHS email address and there was quite limited storage, and
I presume at some point it's ended up lost and sort of rather than archived. I looked hard for it in
2019, but I wasn't able to find it at that point.
DE LA POER: Just so that everybody understands, the Inquiry hasn't yet identified that but you've
given us your recollection of what was in it. You've told us that you were expecting that at the
meeting there would be some discussion about the reports that were pending. In your experience, if
you were to go to a meeting to discuss a report, would you expect to see the report ahead of the
meeting so that you could read it or would you expect that you would simply receive a copy or be
told about it for the first time in the meeting?
McGUIGAN: Yes, I think the NHS isn't famous for efficient meetings, but, yes, I would expect that
the report would be sent out before the meeting, people can read the report and then come to the
meeting to discuss it together.
DE LA POER: And did that happen in this case?
McGUIGAN: No.
DE LA POER: Were you party to any pre-meeting discussion between the Consultants about the approach
that was going to be taken in the meeting or with any other person who was giving information about
what the meeting might contain?
McGUIGAN: I don't remember a pre-meeting. I remember that because we needed to walk over that most
of us walked over together and that in the corridor on the way over that there was a discussion that
there was a feeling that the execs were after somebody's scalp and that the plan would be that the
Consultants wouldn't be speaking up within that meeting for fear that if they spoke up they might be
scapegoated in some way and, therefore, we were going to listen to hear what was being said and that
we would then come back and speak together before rather than anybody raising questions within the
meeting.
DE LA POER: The Inquiry has received evidence that a person by the name of Dr David Semple may have
given some information ahead of the meeting. Were you aware of that at the time?
McGUIGAN: No.
MR DE LA POER: So -- my Lady, I'm conscious of the time and I'm also conscious that this is an important part of Dr McGuigan's evidence which perhaps best be heard as apiece. I wonder if now would be a convenient moment just to rise and we will come back after lunch to deal with this.
LADY JUSTICE THIRLWALL: Very well. Dr McGuigan, we are going to rise for a break and would you be
back please ready to start at 2 o'clock.
McGUIGAN: Thank you.
LADY JUSTICE THIRLWALL: Thank you. (12.58 pm) (The luncheon adjournment) (2.00 pm)
LADY JUSTICE THIRLWALL: Mr De La Poer.
MR DE LA POER: My Lady, thank you. Dr McGuigan, we had got to the point in your narrative that you
were entering a meeting that had been convened on 26 January 2017. And what sort of room did that
meeting take place in?
McGUIGAN: I think it was the boardroom, so a room with a long narrow table and everybody sat round
the table.
DE LA POER: And was everybody dispersed throughout the room or was it doctors on one side, managers
on the other, how was it arranged?
McGUIGAN: I was at one end of the long table, Tony Chambers was at the opposite end of that table. A
lot of the managers were clustered seated near him, a lot of the paediatricians were clustered
seated near
to me, but I think at least one the nursing managers was sat on my side the table.
DE LA POER: And what was the atmosphere as you walked in and everybody took their seats?
McGUIGAN: I don't know if I remember that now.
DE LA POER: You begin your narrative of this meeting by saying that Ian Harvey provided a summary.
Can you just give us a flavour, please, of what Ian Harvey was talking about?
McGUIGAN: So he was giving a summary of the Royal College of Paediatrics Invited Review, which he
explained contained 22 recommendations about improvements that could be made to neonatal services
and the results of the -- the Hawdon review, the external Casenote Review, which he told us hadn't
identified any evidence suggested foul play and that, you know, concluded that the deaths were
natural causes. Can I take the last bit back? I can't remember -- I don't think he said he concluded
the deaths were natural causes, but the feedback from the Hawdon report was that there was -- there
was nothing concerning that had been revealed from that external Casenote Review.
DE LA POER: The way you put it in your statement and you do caveat it by saying, "I don't remember
his exact words", was:
"The interpretation was there was no evidence that babies had been deliberately harmed."
McGUIGAN: Yes.
DE LA POER: Does that capture it?
McGUIGAN: Yes.
DE LA POER: And again doing the best you can, was that delivered in a measured tone from a seated
position --
McGUIGAN: Yes, yes.
DE LA POER: -- or -- nothing that stood out about the style of that presentation to you?
McGUIGAN: No.
DE LA POER: You tell us that the next event was that a statement by Letby was read out. Was that
given any introduction by anybody?
McGUIGAN: I think it might have been written by Letby's parents, if my recollection is correct.
There was some degree of introduction that there had been a grievance procedure and that this letter
would summarise, from Lucy Letby's experiences, the suffering that she'd experienced over the
preceding months while she'd been under investigation.
DE LA POER: You say in your witness statement of that document the statement was relatively long
and very emotive.
McGUIGAN: (Nods).
DE LA POER: I would like to bring up a document on screen to see if you recognise the statement
that was read out, just to help the Inquiry understand exactly what happened at this meeting INQ0012080. Just ignore the highlights on it, that's the form in which we've
received it, and take a moment just to familiarise yourself with the content of it. (Pause). It goes
on over the page. I mean, you'll have noted that it appears to be addressed -- forgive me, if we
could go back -- it appears to be addressed to the doctors, at least inferentially, the highlighted
section at the bottom that: "Analysis tables relating to the mortality rates had columns amended by
your team."
McGUIGAN: (Nods). Yes.
DE LA POER: If you don't know, you don't know, Dr McGuigan, but does this document ring any bells
for you in terms of prompt your memory in terms of what was read out at the meeting?
McGUIGAN: I've not seen this document before. But, yes, that -- that's similar to what I recall was
it was an explanation of what Lucy Letby had experienced, what she'd found upsetting and how she
felt that -- well, presumably the result of her grievance, why she felt
that she had been treated badly.
DE LA POER: And so if not that document itself, then a document of a similar tone?
McGUIGAN: Yes.
DE LA POER: Thank you, we can take that down. After the statement or letter was read out, did Tony
Chambers speak?
McGUIGAN: He did.
DE LA POER: And you deal with this at paragraphs 18-20 of your witness statement if you want to
turn it up, but it may be that you have a recollection sitting there of what he said. So do you want
to just walk us through as best you can remember what he said and how he said it.
McGUIGAN: Yes, when I prepared my statement I looked back at the written statements I'd made in the
past, the earliest of which was 2019, which was obviously a lot closer to events than it is now. I
recognise that different people have reported different recollections of what was said in that
meeting. I think from my perspective, you know, there's meetings since then that I've been asked
about from a year later that I don't remember much about the meetings, but this one was very
striking. I'd just arrived in the hospital, you know, I'm three weeks into
the job and I've gone to this -- this rather remarkable meeting, so the events still stand out to
me. My recollection of what Tony Chambers said was that the conclusion of the process was that the
reports had been received, they'd identified that there were areas of neonatal care that needed to
be addressed, that they'd not -- that the external Casenote Review hadn't found anything of concern,
and that while the Consultants weren't wrong to raise concerns that the way it had been carried out
was inappropriate and that he had met with Lucy Letby and her parents, had apologised to them, that
Lucy Letby would be returning to work on the neonatal unit and the Consultants would be expected to
apologise to her before that happened, that they would be accepting the recommendations of the Royal
College review and that that would be published on the Trust website in the next few weeks.
DE LA POER: And in what tone and from what position in the room did Tony Chambers say that?
McGUIGAN: So my recollection is that he was seated at the other end of the boardroom table from
where me and the -- what I remember the other paediatricians were sat at that end of the table as
well.
DE LA POER: And the tone?
McGUIGAN: The tone was -- my memory of the tone was that
it was a measured tone, that it was serious, stern but not angry or shouting is my recollection.
DE LA POER: And have you had an opportunity to consider the typed record of that meeting?
McGUIGAN: Yes. I -- in 2018, we, in communications with the exec, said we'd never seen minutes of
that meeting. I first saw minutes of that meeting I think in May 2019, so about two years afterwards
when I was interviewed by the police.
DE LA POER: So we're just going to bring those records up, INQ0003523, and we'll turn to page 2, please. Firstly, having considered those
nearer the time, do you regard this typed record as broadly reflecting what was said at the
meeting?
McGUIGAN: They're fairly brief, aren't they? In some parts, yes, in terms of who spoke and the board
-- I didn't recognise some of the things that Dr Jayaram is reported to have said and I disagreed
with the recollection of some of the things Mr Chambers said.
DE LA POER: Well, let's just look at the latter first. In the middle of this page on page 2, at the
end of the largest paragraph in the centre: "It is recorded he [that is Tony Chambers] said 'Let's
be clear that we need to draw a line on the past and it is about how we go forward in the
future."
McGUIGAN: (Nods).
DE LA POER: Is that a fair and accurate summary of what Tony Chambers said, as far as your
recollection is concerned?
McGUIGAN: No, that -- that differs from my recollection.
DE LA POER: You used the word "distortion" in your witness statement; is that a fair way of
describing it?
McGUIGAN: Yes, the word "line" is in there, but the phrasing has changed a lot from what I recall
him saying, and that sounds quite reasonable to say you need to draw a line in the past and think
about how we go in the future, but that's not at all what I remember him saying.
DE LA POER: Well, tell us best you can what you remember him saying.
McGUIGAN: So my memory is that he -- that he said, "I'm drawing a line under this", and then looked
up at us and said, "Do not cross that line."
DE LA POER: And in what tone did he say that latter part?
McGUIGAN: In quite a severe, stern tone.
DE LA POER: Others have recalled that the table was thumped or struck at some point during Tony
Chambers's address to the Consultants, is that a recollection that you have?
McGUIGAN: I don't remember that.
DE LA POER: Now, over the particulars of claim I think is the part that you don't recognise in
terms of Dr Jayaram. That first sentence: "Dr Jayaram stated that consideration would have to be
given to any poor Consultant performance." Do you recall him saying that?
McGUIGAN: I -- I don't remember him saying anything along those lines. The only thing I really
remember him saying was, "Can we see the report", because it had been made clear at that point the
Trust were making the decisions on these reports and that the paediatricians wouldn't be allowed to
see them and that the first sight we would have of the Royal College report would be when it was
published on the Trust website.
DE LA POER: And as somebody who had no investment in what had happened before, what did you make of
the suggestion that the Royal College report would be published on the website apparently containing
criticisms of the paediatric department before any of the Consultants had seen it?
McGUIGAN: Well, I really wanted to know and what I wished I'd asked in that meeting was, is that
report in front of you to say there are serious failings on the neonatal unit and these explain why
you have had so many deaths on the neonatal unit, or does that report say
there's -- overall the care looks okay but there's probably some things you could improve and here's
some recommendations? But, you know, I wasn't given the chance to read the -- well, ultimately we
did get to see the report before it was released, but ...
DE LA POER: But would you expect a report that contains comments upon the running of a department
to be published for the world to see before the people it's commenting upon have had a chance to
read it?
McGUIGAN: I think this is why the meeting is so shocking, that a report has been received on the
neonatal unit and that I'm going to read it when it's published on the Trust website despite being a
Consultant in that department. I would expect -- I would expect not just to read it but that the
people with expertise in the neonates in the hospital would be expected to help the Trust to
understand the content of that report before they made decisions about based on it.
DE LA POER: Thank you, we can take that document down. And so coming out of this meeting, once it
had finished, what was your impression of how the situation was being managed by the Executive
Directors?
McGUIGAN: Yeah, I came out of the meeting very shocked,
expecting that I was going into a meeting where it was going to really get the answers to what the
paediatricians had been wanting to be investigated over the last year, and came away with a feeling
that there had been a Royal College review that had made recommendations but, from what I heard,
hadn't really identified significant failings on the neonatal unit that explained the spike in
mortality in a unit that prior to that had a good reputation, had a low mortality rate and in many
ways was quite advanced in some of the aspects of patient safety and care that they had in place,
and that -- and just felt that an external Casenote Review wasn't the level of investigation that
was needed to be able to exclude somebody harming children. So I left thinking that there's no
answers there and this hasn't been investigated in the way that it needs to be investigated.
DE LA POER: What did you make of the expectation that the Consultants would apologise and how that
had been handled?
McGUIGAN: Well, it was hard because the Consultants' concerns were that somebody may have been
harming patients, that they had good reasons to be suspicious that somebody may have been harming
patients, and that the person who had fallen under suspicion hadn't really -- there hadn't been an
investigation sufficient to clear that allegation and, therefore, the idea that they would be
expected to apologise to her was ridiculous really to apologise whilst still actively concerned that
it hadn't been investigated.
DE LA POER: Now, there was a meeting on 27 March which you didn't attend. But did you send an email
in advance of that meeting setting out what your views were?
McGUIGAN: That's right. There was -- on 27 March, Dr Brearey and Dr Jayaram were meeting with Tony
Chambers and Ian Harvey as part of ongoing discussions that the paediatric Consultants were
concerned about the level of investigation that had happened. Before they were meeting with the
execs, the Consultants were meeting together to have one final discussion about what views they
wanted Dr Jayaram and Dr Brearey to say on their behalf at that meeting. I would normally have been
at that meeting but there was a gap on the junior doctor rota the night before, so I stepped in to
cover the night shift. So reflecting over that day I decided that I wanted to send an email with my
thoughts so that they could be heard within that Consultant meeting the following day and,
therefore, potentially reflected on to Tony Chambers and Ian Harvey.
DE LA POER: Just by way of a short digression before we get to that email, you were effectively
acting down to cover the junior doctor rota. We've heard a bit about that. Was that something that
happened not infrequently?
McGUIGAN: Yes, there was sort -- there were times when it was better and there was times when it was
worse, it depended on exactly what staffing we had on our current Registrar rota. Registrars come
from the deanery and they rotate every six months, so you might have gaps sometimes, not gaps other
times. If somebody goes off on long-term sick it is not very easy to get cover in. And there weren't
and continue not to be very easy access to paediatric locums at that level to be able to cover the
gaps. So it wasn't infrequent that a Consultant had to act down to cover a Registrar gap to ensure
that care remained safe in the Trust.
DE LA POER: Let's have a look at the email you sent INQ0101093. And if you want to turn up your witness statement, because you
devote a substantial portion of your witness statement just to talking about your reasoning. It
starts at paragraph 27, and I'm not inviting you to read it out loud, but let's just have a look at
the email and you can talk us through what was in your mind and why you framed it as you did. Over
the
page, please. So we can see your email at the top, and so just talk us through it and why you
included what you did.
McGUIGAN: Yes. So, firstly, what had been happening on the neonatal unit for that period was very
unusual. There was a high number of deaths and collapses. They were a number that were unexplained,
unexpected and, you know, it needed an answer of what was going on, whether that was poor care or
whether that was an infection that was spreading in the unit or whatever it was it needed an answer.
I'd read by that point the Royal College review, and while there were recommendations on there I
didn't see anything that really explained the high number of deaths that we had seen over that
period. And points that had been drawn out and highlighted, you know, including in the media at that
point, about shortages of staff, shortages of nurses weren't substantially different from other
units -- the staffing wasn't different to other units I had worked in substantially. Some of the --
some of the staffing levels that were being discussed were potentially aspirational targets that a
lot of units were looking to sort of whether they could get there over time but weren't at the
moment. So I didn't see any significant differences
in the staffing levels that explained the -- the mortality. And I was -- I'd arrived from another
hospital. I'd moved -- I'd started work as a Consultant and I felt I was working with people who
were good at their jobs, who had good processes in place, you know, competent nurses, competent
doctors. I didn't feel I'd seen an explanation for these unusual unexplained unexpected events, and
there was this nagging worry that there was one individual who always was there when these were
happening. And, therefore, I felt it hadn't been -- I felt it hadn't been investigated properly.
DE LA POER: And that is the very thing that you begin with: "My opinion is that this can never be
investigated properly without a police-led investigation." You go on to indicate that you don't
think the Coroner is an appropriate alternative to that or an adequate alternative to that.
McGUIGAN: Yes.
DE LA POER: Is that fundamentally because of the time that that process would take?
McGUIGAN: Yes, that was the other approach that was being considered was that a number of these
deaths still need to go there through the Coroner's process and that would be an opportunity to
raise concerns and potentially a way to lead to other investigations. But that if you waited for
that, by the time you got there you've left even more time without investigations and more time for
memories to lapse and for sort of the investigation to become harder.
DE LA POER: You've already told us about your opinion about the RCPCH service review.
McGUIGAN: Yes.
DE LA POER: Your penultimate paragraph, something you've told us already, but this is you saying it
at the time: "In five years at an equally busy Level 2 unit in Crewe I can't remember a single
unexplained collapse and I think the events you have described to me are extremely unusual."
McGUIGAN: (Nods).
DE LA POER: And then, finally, this: "Ultimately you suspect a crime has been committed and I think
there is an obligation to report this to the police whether or not your managers agree." Now,
"obligation", a very powerful word. Presumably you gave considerable thought to how you were going
to frame this for the Consultants because there was going to be no back and forth about what your
opinion was. Why did you choose the word "obligation"?
McGUIGAN: Well, the other discussion that had been happening over those preceding weeks was about
whistle-blowing and whether what the Consultants were considering doing, which was speaking to the
police, even though the Trust was saying that this shouldn't go to the police, whether that would be
considered whistle-blowing. And what I'm saying there is, you know, I don't think this is
whistle-blowing -- I haven't said that word -- I don't think this is whistle-blowing, I think this
is you suspect a crime has been committed and you need to inform the police.
DE LA POER: And might have -- get lost in that natural construction but it's need, that was your
view at the time?
McGUIGAN: Yes.
DE LA POER: You've mentioned about the potential disadvantages of just leaving it to the coronial
process in terms of delay. Did you, at that time, in March, have concern about the delay that had
already been caused and what was it that you thought that delay would affect?
McGUIGAN: So I -- I've mentioned already that sort of as time passes it gets more difficult to
remember events, so the more time that passed the more difficult it was for people to recall what
exactly had happened.
We've heard that in one Thursday, Friday, Saturday in June 2016 two babies unexpectedly collapsed
and died and a third unexpectedly collapsed in a three-day period, and over the following week lots
of discussions happened about whether this should go to the police or not. If a police investigation
had been launched at that point, you know, those post-mortems potentially hadn't been carried out
yet, there might have been more detailed toxicology, infusion bags might still be around that could
be -- you know, there was all sorts of potential opportunities, even at that point, to investigate
more thoroughly that were missed by a delay in police investigation.
DE LA POER: Two days -- thank you, we can take that down -- in fact I think it was three days, my
mistake, after that email, two days after the meeting that you couldn't attend, you tell us in your
witness statement that you received contact from a person called Tracy Bullock. Firstly, who was
Tracy Bullock to you?
McGUIGAN: Tracy Bullock was the Chief Executive at Leighton Hospital in Crewe where I'd worked for
the previous five years as a Consultant.
DE LA POER: And was she one of the people that you told us about that you had met and had got to
know you a little bit when you were working as a Consultant?
McGUIGAN: Yes. Yes, somebody I knew well from working there and had a friendly relationship with.
DE LA POER: And the contact in the first instance, according to your witness statement, was that
you received a request to contact her by telephone.
McGUIGAN: Yes, that's correct.
DE LA POER: And what initially did you think that conversation might be about?
McGUIGAN: I had no idea. I really wasn't expecting it was going to be about events at Chester. I
really didn't know. My secretary contacted me, we arranged a time, and she called me I think the
following day or two days later.
DE LA POER: And when you spoke to Ms Bullock what did she say to you?
McGUIGAN: What she said to me was that as a Chief Executive working close to Chester Chief
Executives spoke to each other about situations they were facing and she'd become aware of the
situation in Chester and that she hadn't clicked that I had moved on from Crewe and was now working
in Chester but that an email from me had been read out in a meeting in the last few days, and she
wanted to contact me really to give me a bit of friendly advice and warning about the situation I
was potentially finding myself in. Essentially what she was saying is that her understanding of the
situation was that there were problems on the neonatal unit, that the Consultant paediatricians were
refusing to accept that there were problems in the standard of care on the neonatal unit and instead
they were pursuing this other line of inquiry, that there were two particular -- I think she used
the word "ringleaders" or certainly two particular leaders of that and things were likely to end
very badly for those two, and she was concerned that my reputation potentially could be dragged down
along with them if I wasn't very careful in how I was conducting myself.
DE LA POER: Let's see if we can just unpack a little bit of that. The email of yours that had been
read out, did you infer that's your email of 26 March?
McGUIGAN: Yes.
DE LA POER: And the meeting, therefore, must have been the meeting on the 27th --
McGUIGAN: Yes.
DE LA POER: -- that you couldn't attend. Had you been aware until that point that your email was
read out at that meeting? Had anybody told you that they read out?
McGUIGAN: Yes, I think Dr Brearey had told me that sort of at that meeting he'd said, "Look, here's
an email from a Consultant who's just joined our department
working in a similar hospital down the road and these are his thoughts about the situation here."
DE LA POER: And so who --
McGUIGAN: Sorry, I was going to say also my understanding that the outcome of that meeting had been
that Tony Chambers had agreed that there would be an approach to the police.
DE LA POER: So that's something that was fed back to you by one of your Consultant colleagues?
McGUIGAN: Presumably by one of my Consultant colleagues, yes.
DE LA POER: After the meeting. Who had you understood was present at that meeting on the 27th?
Obviously the Consultants were all invited.
McGUIGAN: No, it was only -- I think it was only Dr Brearey and Dr Jayaram representing the
Consultants for that meeting.
DE LA POER: So why -- why might you have attended, you were giving your apologies effectively?
McGUIGAN: So there was a meeting at 11 am where the paediatric Consultants were joining together to
talk about the situation and what they wanted Ravi and Steve it say on our behalf --
DE LA POER: And then --
McGUIGAN: -- and then a meeting at 5.00 pm was Ravi and
Steve meeting with the execs.
DE LA POER: I understand. And so that meeting at 5.00 pm, Dr Jayaram and Dr Brearey, and who did
you understand that they met?
McGUIGAN: Tony Chambers and Ian Harvey. I'm not sure who else.
DE LA POER: And did Ms Bullock tell you who she'd got her information from and who was it who
thought there might be ringleaders and that it might end badly for them and that you're --
McGUIGAN: My understanding was that her information was from Tony Chambers as a friend and local
fellow Chief Executive.
DE LA POER: Chief exec to chief exec?
McGUIGAN: Yes.
DE LA POER: And what was your reaction to being provided with this information by Ms Bullock?
McGUIGAN: I -- I think at this point I was already treading very carefully and thinking very
carefully through my actions. So I was grateful for the warning in a way but I was already, you
know, very aware that I was in a difficult situation. I kept the conversation to myself and just
reflected on it, really. But it was really -- it was only later months really that I realised it
helped to
understand the thinking at that time, that certainly Tony Chambers appeared to be seeing it that the
paediatricians were looking for a better excuse than saying your department is not doing very well
and were refusing to accept that there was a problem in their department.
DE LA POER: And did Ms Bullock indicate to you who the two ringleaders were supposed to be?
McGUIGAN: No. But I think it was obvious that it would be Dr Brearey and Dr Jayaram.
DE LA POER: And were they acting as ringleaders, as far as you were concerned?
McGUIGAN: No, not at all. No. And I think you've heard that from other people here that the concerns
that were being expressed were the concerns of the whole paediatric Consultant body.
DE LA POER: Just a few more matters to deal with by way of your overall reflections. You say in
your statement that you are struck looking back at how difficult it was for the entire Consultant
body of seven paediatricians to have their voice heard in an organisation.
McGUIGAN: (Nods).
DE LA POER: Would you like just to tell us why you wrote that and what it was about the situation
that you now see looking back?
McGUIGAN: I think in the NHS we're aware there's a lot of people who work -- some of them are in
more powerful positions -- or power and some less positions of power. There's lots of people who are
in NHS organisations might have concerns and be trying to speak up and the Freedom to Speak Up
process is trying to make sure that when people have concerns that they are able to have their voice
heard. You'd have thought that it would be relatively easy for a Consultant to speak up within an
organisation because they're people who have a relative amount of power within an organisation.
You'd have thought that when all of the Consultants within a particular specialty are trying to say
something that that would be relatively easy to have that voice heard, but that's not how it
appeared to me looking back at the experience that happened over that period.
DE LA POER: And from your perspective, are you able to identify why you think that was?
McGUIGAN: No. And I think coming in, having not been a part of it, it was very difficult to
understand the timelines and what had happened at different points, and there's a lot that I would
like to understand from this Inquiry myself.
DE LA POER: Turning to your concluding remarks and just
some observations that you make there generally. You identify the role of the children's champion as
been an important one. Just tell us about the children's champion when that came about and why that
might be generally an appropriate role?
McGUIGAN: Yes, the children's champion was a recommendation from the Royal College report. I don't
think I'd heard of a children's champion before I read that report, I think it was a relatively new
recommendation by the Royal College. The idea of a children's champion was somebody sitting on the
board who took a particular role in championing children's issues when they were being discussed at
board level. I'm not sure what we got in place the first year or so was quite right, but sort of
once we got to a position where we got it right, we had a non-executive director who took a lead in
thinking about children's -- within the hospital. And when I was clinical lead, she would contact me
on a regular basis. I was free to speak to her at any time if there was anything I felt that I was
stuck on that I needed to sort of get some escalation on. If I'd not spoken to her for a while she
would contact me and say, "Can I catch up with you? And let's just touch base on what's happening
with paediatric services." Or she if came across something
at a board meeting that thought it would be helpful to get my opinion on, she would contact me. I
think those roles have moved on now so that now it's a mandatory expectation that all units will
have a neonatal safety champion and a maternity safety champion, and that the lady who took on that
children's champion role ultimately took on all those roles, and we now have both a non-executive
and an executive who has those champion roles within sort of patient safety and children's and
neonates and maternity. And I think in an organisation where it's a big organisation, there's lots
of things happening, there's lots of people involved, you know, that -- that link between the execs,
non-execs and the paediatricians and neonatologists I think is very helpful.
DE LA POER: Data. You comment upon the relative usefulness of data and in particular how data when
it is of a historical character is perhaps less useful to day-to-day care than real-time data. Do
you see a role for real-time data in terms of day-to-day paediatric care and improving your
service?
McGUIGAN: Like I said in my statement, I think because the numbers are small often changes are just
the natural variation and statistical distribution. So I don't know if I do, and the time it takes
often to get the data
back it's probably missed the opportunities to intervene would be my opinion.
DE LA POER: But when things start to go wrong, so not necessarily business as usual but where
things start to go wrong, might data in real time have a role to play there?
McGUIGAN: Yes, I think in general data is really helpful and there would be lots of data we would
want to look at in a neonatal unit to help understand that the care we're providing is good, not
just mortality rates but all sorts of outcomes which we get now benchmarked against some of the
units.
DE LA POER: And, finally, just an insight that you had into the CCTV question, should it be on
neonatal wards?
McGUIGAN: Yes.
DE LA POER: You present both sides of the argument for it. But I don't know that we've heard this
necessarily from any other person, certainly not very many other people. The way in which CCTV might
be presented as a good thing, do you want to just help us with that?
McGUIGAN: Yes, I think you probably heard already the sort of concerns the staff have of having CCTV
cameras on them all the time, the privacy concerns in a unit where women would be breast feeding and
these types of things, and expressing, and how you balance that. But often on the -- most of the
time on the children's ward, certainly in the district general hospital, most of the time any small
children in hospital their parent or one of their family members will be with them at all times. And
the neonatal is quite different to that because the babies are in for such a long time it's quite
common that most babies there will be quite frequent times where they're just on the unit being
looked on the staff without their parents there, and I think that's quite difficult for parents. We
try and make our unit as welcoming as possible. We now have beds next to the cot spaces so the
parents can stay. They're open 24/7 access. We have a siblings' room so that if there's a toddler
sibling it doesn't obstruct the parent in spending time on the neonatal unit. But the idea of video
links has been quite popular, regardless of the safety thing, that being able to check in and look
at your baby at any point while they're on the neonatal unit seems a good thing, and I would have
thought a thing that most parents would welcome.
MR DE LA POER: Dr McGuigan, thank you for answering my questions. My Lady, those are all the questions that I have for Dr McGuigan and there aren't any Rule 10 questions?
LADY JUSTICE THIRLWALL: Thank you very much.
Indeed, Dr McGuigan. Thank you very much indeed for coming to give us your evidence, it has been
very helpful and you are free to go.
McGUIGAN: Thank you.
MR DE LA POER: My Lady, with your leave I will now hand over to Ms Browne.
LADY JUSTICE THIRLWALL: Very well. Can the witness be sworn.
DR PAUL JAMESON (sworn)
LADY JUSTICE THIRLWALL: Do sit down, Dr Jameson.
MS BROWN: Could you please state your full name.
JAMESON: Dr Paul Morpeth Jameson.
BROWN: And you've provided a statement to the Inquiry dated 31 May 2024. Is that true to the best
of your knowledge and belief?
JAMESON: Yes, it is.
BROWN: Dr Jameson, you graduated from the University of Liverpool Medical School in 1986 and are a
fellow of the Royal College of Anaesthetists. You have a clinical fellowship in paediatric critical
care from the University of Toronto and you were appointed as a Consultant anaesthetist at the
Countess of Chester in 1996; is that correct?
JAMESON: That's correct.
BROWN: And what is your current role, Dr Jameson?
JAMESON: I'm a Consultant anaesthetist at the Countess of Chester Hospital.
BROWN: Thank you. Turning to your role on the Medical Staff Committee at the Countess of Chester,
you were chair of the Medical Staff Committee from approximately 2011 to 2019, and I think it's
correct that that's an elected and unpaid post?
JAMESON: That's correct.
BROWN: And who is it that elects -- who elects the chair of the Medical Staff Committee?
JAMESON: So you put yourself forward or you're nominated and seconded, and then there's an election
for that post by the -- all members -- all permanent members of the medical staff within the
Countess of Chester Hospital.
BROWN: And I think it's the case that, certainly since your appointment as a Consultant in 1996,
there has been a Medical Staff Committee at the hospital.
JAMESON: That's correct.
BROWN: Turning to the purpose and role of the committee, you address this in your statement and it
is at paragraph 15, and you say it's threefold. It represents the interests of medical staff, it
provides
a forum where mutual concerns can be discussed between colleagues and the MSC enables communication
between medical staff and the Trust management.
JAMESON: Yes.
BROWN: If I can just turn to what's tab 6, my Lady, in your bundle and it is INQ0098143. These are the terms of reference for the Medical Staff Committee.
They're not dated, Dr Jameson, but we know from other documents that they were in fact drafted by Mr
Butcher the ophthalmic surgeon who was the secretary to the Medical Staff Committee from
approximately 2010 to 2020, and they were drafted in 2017. Do you recall approving these Terms of
Reference?
JAMESON: Yes.
BROWN: And is it fair to say that although they were formalised in 2017, and I think based on a BMA
document, they reflected what had already been the case, they weren't a -- they weren't a departure
from what the Medical Staff Committee had --
JAMESON: No, that's correct.
BROWN: And just going to this document, then. We see there under the heading "Membership" that the
membership consists of all Consultant medical staff, all permanent staff and associate specialist
doctors and appropriate representation of junior doctors is determined by the committee. What did
that mean in practice, representation of the junior doctors?
JAMESON: We asked for junior doctors to -- for a representative of the junior doctors. In fairness,
I don't think we ever had any junior doctors attend.
BROWN: Thank you. And then going down, we see standing invitations are normally issued to the Chief
Executive. So for most of the period we'll be talking about that was Tony Chambers, the Chairman of
the Trust board, so Sir Duncan Nichol and any Clinical Director, and then we see beneath that the
words: "The Chief Executive, Chairman of the Trust board and Medical Director [of course, Ian
Harvey] may be asked to retire from the meeting of the discussion of items where it is felt their
presence would not be appropriate." So it seems there, Dr Jameson, it was engaged that there might
be occasion on which those individuals might attend but equally there might be an occasion where
they would be asked to leave the meeting?
JAMESON: That's correct.
BROWN: And prior to the events we're looking at, 2016 onwards, were there any instances that you
can recall where as a matter of course the Chairman, the chief exec or the Medical Director would
attend these meetings?
JAMESON: The Medical Director would fairly regularly attend.
BROWN: So that's Mr Harvey?
JAMESON: Yes, often because he would want to address the Medical Staff Committee about particular
issues. I don't remember Mr Chambers attending any of our meetings.
BROWN: Thank you. And looking at meetings, just going down towards the bottom of that document, we
see the committee should meet on an average of once every six weeks but as a minimum four times a
year. And then if we can go over the page, to page 2, we see there the chairman -- at the top of the
page: "The chairman must arrange an extraordinary meeting if more than four members request it in
writing." And then below that in the centre of the page: "The chairman of the committee is to be the
spokesperson for medical staff in the Trust." And would you agree with that characterisation of your
role as chairman and as spokesperson?
JAMESON: Correct.
BROWN: Turning back to your statement, Dr Jameson, you expand a little on the role in paragraph 20
of your statement and you say that, in addition to the role of spokesperson, you saw your role as
one of interfacing
with the senior management regarding the wishes of the Medical Staff Committee. And later on you
define "senior management" as being the Chair -- being the Medical Director, the chief exec and the
Chair of the hospital board.
JAMESON: Correct.
BROWN: And if we could just go to, my Lady, tab 7 in your bundle that's INQ0017868. This is the corporate directors group and it's a meeting on 27
January, and we will see there that it was attended by, amongst others, Mr Chambers, Mr Harvey, Mrs
Kelly, Mrs Hodkinson and your name appears in the centre of the page, chair of the medical staffing
committee Mr Jameson. And if we go over to page 5 of that document, we see there that an example of
you acting in your role as spokesperson. What was being discussed was the paediatrics business case.
And if we go to the bottom of the page we can see that what was being discussed was a business case
to appoint two Consultants. And we see about 10 lines up from the bottom your initials: "PJ felt the
paediatric service was almost at breaking point and needed support before it hits the point of
burnout." So we see you there, would you accept, acting as
a spokesperson for your paediatric colleagues and quite forcefully supporting their business
case?
JAMESON: Yes, that's right. Do you want me to expand on that?
BROWN: No, it's just to make the point --
JAMESON: Thank you.
BROWN: -- that was the role you took within those sort of meetings.
JAMESON: Yes.
BROWN: Yes. Sorry, Mr Jameson, if there is something you think is pertinent to say regarding that
that goes to the event that we are looking at.
JAMESON: The only point I would make is that because I worked fairly regularly and closely with the
paediatricians in my role as being one of the paediatric anaesthetists at the Countess of Chester
Hospital, so I was regularly on the ward, I think I had quite a clear understanding of their
workload dealing with the sick and injured child and their dedication to that service, and so really
felt they needed help and support in the expansion of their department.
BROWN: Thank you very much. And going back then to paragraph 21 of your statement, you say there
that: "Historically the Chair of the Medical Staff Committee had a place on the Hospital Board and
that was ... the case with the previous management structure ..." When did that change? When did the
Medical Staff Committee no longer have a place on the board?
JAMESON: From memory, I can't remember exactly when but it must have been after that meeting that
you've shown the minutes there?
BROWN: I think that wasn't a board meeting that was -- that was a meeting which you were invited
to.
JAMESON: Right. Historically, I'd always been invited to the -- to the hospital board meeting. Then
I think probably around 2015/16, I noticed I wasn't being invited, so I asked the -- the Chief
Executive's secretary if she could send me the date of the next meeting and I turned up to the next
meeting and then was asked to leave that meeting because it was felt that the Chair of the Medical
Staff Committee didn't have a role on that meeting. And from then on I didn't attend hospital board
meetings as I was uninvited.
BROWN: And did you raise an objection to that, that you were no longer able to attend those
meetings?
JAMESON: So, I brought it up with Mr Harvey, the Medical Director, and his explanation was that it
was felt that the medical staff were like any other staff
group and, therefore, shouldn't have a place on the hospital board ahead of any other staff group,
and that was the thinking and reasoning behind it.
BROWN: And it was -- did you understand that to be Mr Harvey's position or as his own personal view
or something that had been decided on collectively?
JAMESON: I think he was transmitting a collective view, as far as I was aware.
BROWN: And did you feel that that decision represented a change where staff views were not given so
much importance?
JAMESON: It made it very difficult to be chair of the Medical Staff Committee because it took away
that interface I had with the senior management teams, I didn't know them as well, I didn't speak to
them regularly in that environment, I didn't know what was going on within those management and,
therefore, the role almost became impossible because my only interface with senior medical staff was
through the meetings with the Medical Director. So I was aware I would get his -- his view that was
to be transmitted to me and so I felt it was an issue.
BROWN: And just looking at the timing of this, was there any event that you understood provoked the
decision to not allow you to attend board meetings?
JAMESON: No. I think it was just a restructuring of their management structure within the hospital.
I think maybe they felt they were needed to be a leaner management board to make decision-making and
communication easier. But I never got a clear explanation about why it occurred. I didn't know if it
was a national directive, a regional directive or just a local directive.
BROWN: And I think you said date, the best you could do, was that approximately 2015?
JAMESON: Around that time, just because you sent me the minutes of that previous meeting that you
brought up, and I think that was one of the last meetings I'd have been at.
BROWN: Well, that was a meeting, the one we've just looked at, the corporate directors group, that
was 27 January 2016.
JAMESON: Well, it must have been around 2016 then.
BROWN: If I could just turn to the topic of safeguarding now, Dr Jameson and you address this in
paragraph 63 of your statement, and you say there that you've undergone regular safeguarding
training throughout. Does that relate to regular safeguarding training throughout your time at the
hospital?
JAMESON: Yes, because of my role as a paediatric
anaesthetist I have to undergo Level 3 safeguarding training and keep that up to date. So I have
done throughout my career.
BROWN: And -- so presumably you would be familiar with the Working Together to safeguard children
guidance?
JAMESON: So I'm familiar with it but it's a while since I've undergone that training because it's
three-yearly.
BROWN: I'm not going to go through it in detail but just in terms of the key principle that
safeguarding children is everyone's responsibility and that each professional and organisation
should play their full part, you would be familiar with that as a principle?
JAMESON: Absolutely.
BROWN: And at paragraph 64 you say there in relation to that: "... if any person, either a member
of staff or anybody involved in harming a child or baby in hospital ... I would know to inform the
safeguarding officer and that this [would] be clearly documented as per safeguarding training." And,
Dr Jameson, just to check, that would be your understanding now but was that your understanding in
the period from 2015 onwards as well?
JAMESON: Yes, it would.
BROWN: And were you aware of who the designated doctor for safeguarding was in 2015 to 2017?
JAMESON: I would have been at the time because it would have been -- we sort of had a safeguarding
intranet page, so if I had a safeguarding issue my first port of call would be the -- if it was a
paediatric patient would be the paediatric team on-call and then they would highlight it through
their safeguarding process.
BROWN: And what level of concern would trigger reporting to a safeguarding officer?
JAMESON: So from my point of view as an anaesthetist, it might be that we might see some physical
harm to a child that we would then highlight, or within a history we might highlight it, and within
the -- the admission notes of every patient there is -- the Trust does have a safeguarding box, so
the admitting team should have considered safeguarding.
BROWN: And in fact the designated doctor for safeguarding at the time was Dr Mittal. Does that ring
a bell?
JAMESON: It does, yes.
BROWN: And if we can go back now to paragraph 22 of your statement. You say in there -- that paragraph that you were first approached or you believe you were first approached by the paediatricians around the end of January/early February 2017. If we could just go to look at that date, first of all to tab 2, and the document number is INQ0012995, page 1.
LADY JUSTICE THIRLWALL: Ms Brown just while that's being looked up, may I just check that the transcript is still working for everyone. Plenty of nods around the room. I think it's just mine. I can manage, I just wanted to make sure we weren't all in the same position.
MS BROWN: And this is an interview or the copy of a record of an interview that you gave in July
2020 to Facere Melius, and you say in the middle of the page: "I was approached I think -- it was
sort of February/March of '17 by a number of the paediatricians who were basically in crisis. They
-- and that was the first I heard really anything about the neonatal concerns. There had been the
odd sort of rumour within the hospital." Just stopping there. What was the rumour that you had heard
prior to them approaching you?
JAMESON: So I think all I'd heard -- at that point, I may have heard that a member of staff was --
had been excluded from the neonatal unit but no more than that.
BROWN: Did the rumour extend to why that member of staff had been removed from the unit?
JAMESON: No.
BROWN: But presumably that would be something, if it was a rumour, that would be the subject of a
conversation if someone was being removed. Was there speculation?
JAMESON: To my memory, no. I mean, the neonatal unit was very much a very small part of the hospital
and unless you were directly involved in the neonatal unit, you probably wouldn't know what was
going on. So in all honesty, I cannot remember hearing the specifics about -- or remembering that
rumour this far away from it, but obviously remembering that Dr Jayaram contacted me February --
January, February, March 2017.
BROWN: And prior to that, prior to the contact from the paediatricians, were you aware already of
the increased mortality rates?
JAMESON: No.
BROWN: Dr Tighe can't remember precisely but he thinks he might recollect speaking to you in early
2016, some informal discussions about mortality rates. Is that a conversation that you can
recall?
JAMESON: I can't remember. I know that we did discuss it in 2017 because the paediatricians had
approached me because of their concerns regarding grievance procedures that were being brought
against them.
BROWN: Just going back to the document there. You say you were approached by a number of
paediatricians. Who were the paediatricians that first approached you?
JAMESON: I was first approached by Dr Jayaram and then Dr Jayaram asked if I could meet within -- in
his office, and I spoke, from memory, with Dr Jayaram and Dr Brearey.
BROWN: And if we see as well in that paragraph, the passage we're looking at, you say that they
were feeling bullied and harassed and what they were trying to do was raise patient safety.
JAMESON: Correct.
BROWN: And if we could go over to page 2, just trying to date this. Your evidence is that, doing
the best you can, it was approximately February. I just want to see if it may have been slightly
earlier. We see there towards the bottom paragraph: "They came to me when the Royal College of
Paediatrics Child Health report came in and they were -- you know, they were only allowed access it
to a brief period of time and then when they were given a redacted report." Now, we know that they
were -- Dr Brearey and Dr Jayaram were allowed access to it for a brief period in November. Does
that help you at all? It's a slightly confusing --
JAMESON: Yes, no, I think they came to me actually very specifically after -- in -- after their
meeting that was discussed slightly earlier about being asked to write a letter of apology, and
that's when they first came to me in my role as the chair of the medical staff. But at that point,
they did -- then gave me a narrative saying that earlier they had been -- these were the issues that
they were -- they were, in their words, probably battling with and they brought up the fact that
they'd only been asked -- allowed to see briefly a redacted Royal College report earlier.
BROWN: So the redacted report was in February, and in terms of asking to write a letter of apology,
that would bring it closer to December. We're going to look at a document that talks about the
letter of apology. But -- so at the very -- the end of 2015, beginning of 2016, would that be?
JAMESON: No, that was much later than that that I first heard of. It was certainly 2017.
BROWN: Sorry, 2017, sorry, my error. But it was between January -- between December and
February?
JAMESON: Probably, yes, to the best of my recollection.
BROWN: And, Dr Jameson, was an explanation offered to you as to why they had waited until January,
February 2017 to come to you? We know, of course, their concerns arose much earlier.
JAMESON: I feel at that point their concerns were that Lucy Letby had been removed from the unit and
then there was a suggestion at that point that they were to apologise to her and that she was to be
allowed back on the unit. And from their point of view, I think when they were pressing for a full
investigation that they felt that Ms Letby was excluded from the unit patients weren't at risk, but
I think they were very fearful at that point that she might be reintroduced to the ward and what on
earth could they do and, therefore, they looked for the support of the Medical Staff Committee.
BROWN: And if we can look at paragraph 24 of your statement, you list then what their concerns
were, which I think you've highlighted, but they were concerned about the increased morbidity and
mortality of the neonatal unit, so the number of deaths and collapses on the neonatal unit, they
were frustrated about how this was being handled by the senior management and, going down, serious
concerns regarding patient safety and that these were concerns of the whole department.
JAMESON: Exactly.
BROWN: So at that stage, at the latest February 2017, there were specific concerns about the rates
of babies
dying that had been communicated to you that that was from all of the department, and you were
aware, at this stage, that the issue related to a particular nurse; is that correct?
JAMESON: Correct.
BROWN: And they were communicating as well that they were frustrated by the response of senior
management?
JAMESON: I think they were not only frustrated, I think they were quite fearful about their jobs and
so their frustration was -- and fear was huge.
BROWN: And, Dr Jameson, in your role as spokesman who has then been approached by the
paediatricians, why did you not go to Ian Harvey or Tony Chambers at that point on their behalf and
say, "This matter must be reported to the police"?
JAMESON: I did go to Ian Harvey and the first thing I expressed to him was that this was a whole
department that I knew, respected. I knew they were not only thought of as good paediatricians and
it was a strong department but because of some of the work I'd done with the -- regionally with
paediatrics I knew it was a very well-respected department regionally, and that their concerns
should be really treated with the utmost importance.
BROWN: And you say in your statement that you
championed their cause by saying that they should be listened to. But did you say specifically to Mr
Harvey or any other senior executive that the police should be approached at this point and that you
as a spokesman were making that point to him?
JAMESON: I think I used the words that this was a safeguarding issue and that, you know, if the
paediatricians are asking to go to the police, then the senior managers should go to police?
BROWN: And just looking at safeguarding, we know that at this stage whilst Letby was off the ward
there weren't any restrictions on her registration at this stage. We've looked at the fact that the
paediatricians were coming to you with serious issues of patient safety. When you heard of their
concerns, did you enquire as to whether they had informed the safeguarding officer?
JAMESON: I have no memory of doing that. But they were very clear to me that they were pursuing all
avenues.
BROWN: Sorry, who was saying they were pursuing all avenues?
JAMESON: This was -- this would be Dr Jayaram and Dr Brearey, and they were very clearly stating to
me that they wanted to go to the police but had been told that they should not at present.
BROWN: And what did you do actively to support them by going to the police, did you consider going
to the police yourself?
JAMESON: I felt that I should very clearly go to the senior execs and say is all due process being
followed? Because the details of actually what had gone on, I knew very little of the actual details
other than knowing that I knew and trusted the opinion of my paediatric colleagues.
BROWN: And did you consider that you needed to make a safeguarding report?
JAMESON: I didn't. I probably regret not doing that but I felt that because this was 2017, and I'd
been told that due process and investigation was being followed, I regret that.
BROWN: And if we can go to paragraph 34 of your statement where you set out the actions you took.
You say that you recall meeting with the Medical Director Mr Ian Harvey and you felt your role was
to stress that the paediatric department were highly regarded, and you say: "I had at least one or
maybe two meetings with Mr Ian Harvey within his office. These were non-minuted meetings ..."
Why did you not take minutes of these meetings, given the severity of the matters that were being
discussed?
JAMESON: I suppose that our meetings had always been relatively informal meetings within his office
and what I was trying to do was make it clear to him that I had faith and belief in my paediatric
colleagues and the points they were making, and I was hopeful that that would -- would stimulate him
to reconsider the process that he and his team were going through.
BROWN: You say there that Mr Harvey: "... made it clear to me that these issues were not a matter
for the Medical Staff Committee to get involved [in] ..." What was your response to that?
JAMESON: I -- at the time I felt that the way we could help support the paediatricians was just to
reassure them and make it clear that in effect we -- we had their back, that if they were threatened
with losing their jobs that we would -- as a Medical Staff Committee we would support them.
BROWN: Did you not consider this was a meeting that you should minute a clear statement by you on
their behalf that the police should be contacted and if the executive didn't do that that was
something you wanted
minuted?
JAMESON: In retrospect I should have done that.
BROWN: And you say at paragraph 37 that: "... Mr Harvey did not want any external involvement by
other members of the Medical Staff Committee ... he very clearly stated the matter was in hand."
What reassurance did he give you that the matter was in hand?
JAMESON: He just very clearly stated that there was a full investigation going on. He didn't mention
to me the Royal College reports but he made it clear that he was in charge of governance and that
this was not something for the Medical Staff Committee to get involved with.
BROWN: And did you think he was right about that or did you think it was a matter for the Medical
Staff Committee?
JAMESON: I think we should have been more vocal in stating that the police should have been called
earlier.
BROWN: And you then say that you also met -- so these are meetings with Mr Harvey, but you also met
with Sir Duncan Nichol. And what took place in those meetings and when did they occur?
JAMESON: So they occurred in the months after when I'd
first become aware, and at that point I think the police had been called, so it was round the time
that the police were involved.
BROWN: So February, when the paediatricians first approach you, the police weren't contacted for a
few months after that. Given the police in these months were not being contacted, did you consider
going to Sir Duncan Nichol when Mr Harvey was clearly not taking action at that point to contact the
police?
JAMESON: I think I spoke with Sir Duncan Nichol and explained that I had concerns and that my
concerns were one and the same as the paediatricians and that he was fully informed of that.
BROWN: So that's quite significant, Dr Jameson. Your recollection, is it, that you went to Sir
Duncan Nichol before the police had been contacted to say that in your role you felt the police
should be contacted?
JAMESON: I'm not certain of the exact timings when Sir Duncan Nicol and I started a dialogue. It was
around about the time that the police were called, so I couldn't honestly say when -- when I had
that first meeting.
BROWN: But do you recollect or not saying to Duncan Nichol the police need to be called in this
matter?
JAMESON: No, I don't recollect saying that to him.
BROWN: And going down to paragraph 41, you say there: "Primarily my meetings were just to try and
support them to act as a sounding board ... [and] to try and facilitate meetings with ... Duncan
Nichol ..." Do you feel on reflection, Dr Jameson, that in fact the Medical Staff Committee should
have done something more than being acting as a sounding board?
JAMESON: So what I'm referring to there is a period of time after the police had been called and
when we were trying to support the paediatricians while they were navigating gauge this very
difficult time when the relationships between the senior managers and themselves had totally broken
down.
BROWN: And you address then the very specific issue that you've mentioned before, the fact that the
paediatricians were only permitted to review a redacted report, and you say your response to that
was one of disbelief. Can you just expand on that briefly?
JAMESON: Yes. My feeling is that the experts in the running of the neonatal unit were the
paediatricians and that if a report had been asked for it should have been shared with them
immediately in an open, transparent, inclusive way, where team working is at the heart of running a
safe unit. And I -- I genuinely could not
believe what I learnt of this in early 2017 that they wouldn't have been sharing that report from
its -- from its very first time it was available so that they could learn from it.
BROWN: And you say there: "I think he stated to me [that's referring to Mr Harvey] that ... it was
handled appropriately though this meeting was not minuted ... [it] is only my memory of the
meeting." When Mr Harvey gave these responses that it was handled appropriately, what -- what
response did you make to that, given your disbelief at what had been going on?
JAMESON: I think at that point my relationships with Mr Harvey were the communication was quite
short and brusque. I don't think he was really interested in my view as chair of the Medical Staff
Committee, so it was -- it was as simple as that.
BROWN: And if I could turn now to the general management style of the Trust, which is something you
address at paragraph 45 in your statements, and you say that: "My observations regarding the
management style of Mr Tony Chambers and Mr Ian Harvey, is that there was certainly a marked change
in the management style
compared to the previous Chief Executive ... Medical Director ..." How would you characterise the
management style of Tony Chambers and how did it differ?
JAMESON: The previous Chief Executive and Medical Director were very opening and welcoming of -- of
medical opinion and being questioned. Certainly I felt that I almost didn't have a relationship with
Mr Chambers after I had been asked to leave a sort of management board meeting. And my meetings with
Ian Harvey, though we had them regularly, were always quite superficial.
BROWN: And if I could turn you to -- my Lady, it's tab 3 in your bundle and document INQ0103247. This is the statement of Jeremy Butcher. He's the ophthalmic
surgeon who is the secretary to the Medical Staff Committee, and if we could turn to page 2 and
paragraph 11. He says there: "Paul Jameson, the chair of the MSC, told me that he no longer sat on
the board of the trust. He also told me that Tony Chambers had said that he considered the
Consultants as no more important than any other staff group such as porters." Is that something you
recall saying?
JAMESON: I can't recall wording it in such a specific
way, but certainly Mr Harvey had said it to me that one of the reasons that we weren't -- we weren't
-- the chair of the Medical Staff Committee wasn't required on the board because we were just like
any other staff group and no more important.
BROWN: And just following that theme, if we could turn now to INQ0012995 and page 5 of that document. This again is the interview you had in
2020 about events, and you say, looking towards three quarters of the way done that page: "Certainly
the impression I got about Tony Chambers is very clearly that senior medical staff were not that
high up on his priority in running the Trust." Can I just stop there. Is that -- where you say
senior medical staff, are you referring specifically to the paediatricians or are you referring to
Consultants more generally?
JAMESON: I think Consultants more generally.
BROWN: "... and he sort of ..." And you go on: "... and he sort of openly made that clear and he
wanted -- you know, his view, maybe rightly or wrongly, you know, senior medical staff are just like
any other medical staff." Again, is there anything you can say to expand upon that view in terms of
how Tony Chambers viewed senior medical staff?
JAMESON: Not specifically, other than saying that when I felt he didn't value the chair of the
medical staff within involvement with the board but also, as we've heard earlier, the conversation
with the paediatricians when they were very clearly told what to do.
BROWN: And what are you basing your opinion upon there, Dr Jameson?
JAMESON: My own personal view.
BROWN: And your own personal experiences?
JAMESON: Yes.
BROWN: And any experience in particular?
JAMESON: No, other than the -- that -- that issue where I did turn up at a board meeting where I
expected to have a place and then be politely but firmly ushered out of the room.
BROWN: And going back to your statement -- that document can come down now, thank you -- at
paragraph 48. You say: "When I discussed the paediatricians concern with Mr Ian Harvey, he certainly
gave me the impression that he felt they were a difficult department to interact with." How did he
give that impression and what was it
that he was saying to you?
JAMESON: I don't think he said anything directly but it was just his overall body language and he
made it clear he didn't want to discuss their issues with me.
BROWN: Thank you. If we could just look now at a few of the minutes of the Medical Staff Committee,
so if we could go first to tab 8, which is, my Lady, tab 8 in your bundle, and that is INQ0004451. This is the Medical Staff Committee meeting on 1 November 2017, so
about nine months after you first -- the paediatricians came to you. And we see that you were
sitting as the chair, Mr Butcher the secretary, and there were six others present. That seems like a
small number. Was that characteristic of the meetings, the numbers that would turn up at a
meeting?
JAMESON: Unfortunately it was, it wouldn't be quorate at that number, and there was a disengagement
with the Medical Staff Committee over this period of time.
BROWN: Was that related in any way to the fact that the Medical Staff Committee didn't have a seat
on the board, in your view?
JAMESON: I couldn't answer that.
BROWN: Going over to page 2 of that document, you say there the -- at the top of the page:
"The committee understands that the police investigation to premature baby deaths is ongoing." And
you told the committee that: "... would continue to offer our support to our paediatrician
colleagues." And that was the stance of the committee at that stage?
JAMESON: Correct.
BROWN: And going over, tab 9 in the bundle, my Lady, and document INQ0004485. This is a meeting, so seven months later, in June 2018. Larger
numbers here. You sitting at the chair, Mr Butcher the secretary, and approximately 31 others. And
if we go over to page 3, we see there under "Any Other Business" that you told the committee that
the paediatricians were feeling marginalised, stressed and isolated, and that there may -- that they
may "have an extraordinary MSC meeting to demonstrate support for our colleagues". And you urged
good attendance. If we can go then to -- it's one tab on in the bundle, INQ0083556, this is a chain of emails where you were discussing that meeting.
And if we can go to page 3 of that email chain, which is the first in time, you wrote to
Detective Inspector Hughes, you introduced your, and you say in that email that the paediatricians
have approached you as the chair to ask if you can call an extraordinary meeting, and you go on to
say: "The meeting will not discuss the issues related to the investigation. It will be limited to
the breakdown in Trust, communication and relationship between paediatric medical staff and senior
management and their concerns." Just pausing there. Was that how you saw the issue there, a
breakdown in communication and relationships?
JAMESON: At that point it was because the investigation was now ongoing but it had moved on to that
breakdown in trust between one group of Consultant staff and the senior managers.
BROWN: And you wanted essentially the police to say whether they felt it was appropriate to have
that meeting. And I think we can see if we go to page 2 of that document, which is the email in
response, that Mr Detective Inspector Hughes responds and said that he is aware of the breakdown in
relationship between doctors -- some of the doctors within your organisation of the Trust and that
he is happy for the meeting to continue. And he says with some foresight: "I'm quite sure that at
the conclusion of this investigation a public Inquiry could well be commissioned and I am certain
most of these concerns will be raised in that format." And then if we can go on to page 1, we see,
just to follow the trail, that you forwarded that email to Sir Duncan Nichol and made clear that the
police were happy for the MSC to call an extraordinary, meeting and you add your view that you also
feel that a public Inquiry is inevitable. And if we can go -- and this is -- we are almost at the
end of the documents now, Dr Jameson -- to the minutes of that extraordinary meeting, which is INQ0098147 and tab 11 of the bundle. There are actually two meetings that are
referred to there, there's a pre-meeting on 11 September 2018 and that was attended by Sir Duncan
Nichol, Dr Gilby, so that's the new Medical Director, Mr Harvey having retired by now, yourself and
Mr Butcher. Why was there felt to be a need for a pre-meeting?
JAMESON: At the time, because there was such -- this huge breakdown in trust between a group of
Consultants and the senior managers, that one of our -- one of the concerns of the Medical Staff
Committee -- because I didn't really hear about the issues on the neonatal unit until 2017, one of
my concerns was could there be
other departments where there was a similar breakdown in trust between -- and, therefore, we needed
to explore this. Also we felt that there would be highly likely that from the secondary meeting that
the Medical Staff Committee might ask for a vote of no confidence in Mr Chambers.
BROWN: And we'll come -- that didn't happen in fact, we'll come to that, but that was -- so was the
risk of vote of no confidence that you felt -- you, therefore, felt the need to have the
pre-meeting, were you alerting Sir Duncan Nicol and Dr Gilby to that vote at that point?
JAMESON: Yes.
BROWN: And we see then -- sorry, you also say there that the minutes will not be circulated by
email to ensure confidentiality. What was the particular confidentiality issue that you were
concerned about?
JAMESON: I think we were very much concerned at this point about The Families of the bereaved that
-- you know, it was -- we were still all the medical staff -- and I did want to say earlier that
contact with the present medical staff -- that all the medical staff in the Countess of Chester were
very much aware of the -- the absolute pain and loss that all these families had gone through, and
so we felt it was important that, you
know, the court case hadn't gone ahead but we were discussing -- you know, hugely delicate and
upsetting for the family and we didn't want that The Families to be hurt any more than they'd
already been hurt.
BROWN: Thank you. And we see there then it goes on to the minutes of the meeting of 19 September,
and we see huge numbers attending. I think if one counts it up it is over 100. And turning over the
page to page 2 of that document, you gave a statement on the purpose of that meeting emphasising the
confidentiality and read out a statement from Detective Inspector Hughes stating that there should
be no discussion about anything that would prejudice the investigation. And you made the point about
the minutes that you would review them for accuracy but they wouldn't be circulated, or I think they
would be accessible for those who attended. And you told the committee then that you'd invited Sir
Duncan Nichol, Dr Susan Gilby to the meeting. Mr Butcher's views were he felt their presence might
inhibit discussion. Was that something you agreed with?
JAMESON: No, I didn't. I felt at this point that Dr Susan Gilby was new to the Trust and new as a
Medical
Director, and I knew her view on the way this had been handled previously was very different from
the previous Medical Director's and --
BROWN: What -- just expand on what you mean by that, very different?
JAMESON: Well, within a week of her being appointed, she was very clear that she couldn't believe
that the paediatricians hadn't been treated in a more trusted and collaborative and open,
transparent way.
BROWN: And we see there in the middle of the page Sir Duncan Nichol told the committee he was there
to listen, and he told the committee that Tony Chambers had decided to stand aside as CEO, and that
Susan Gilby would be acting CEO. Was that the first time you and -- not only you but all those 101
doctors attending, was that the first time they were informed that Tony Chambers had decided to
stand down?
JAMESON: Yes.
BROWN: Were you aware of it prior to this meeting?
JAMESON: I think I might have been made aware of it, I don't know, half an hour before the meeting.
BROWN: And what happened then was there was a presentation by Dr Gibbs, and in that presentation
some slides were shown, and these minutes in fact reproduce what was on those slides, and he sets
out the -- Dr Gibbs set out the history. Did he talk -- can you recall, did he talk through the
events or how did that take place in practice?
JAMESON: I cannot specifically remember his presentation but it was very much a narrative timeline
of the events.
BROWN: And we see that reflected in fact in the notes here, which in turn reflect the PowerPoint
slides. He talks -- I'm just going to pick out one or two -- June 2015 the serious incident meeting
held after the three deaths. Going down then, July 2016, the Consultant paediatrician demanding
action from the police. That's following the death of [Child O] and [Child P]. Then September 2016,
the RCPCH review. And then coming right down after various other events to meeting with a QC and
then contacting the Child Death Overview Panel. And in May 2017 the Deputy Chief Constable informing
the Chief Executive, who at that point would have been Tony Chambers, that the police investigation
would take place, and that history was set out to you?
JAMESON: Yes.
BROWN: And were you already well aware of this history at this point?
JAMESON: No. That was really the first time in detail that I understood the timeline.
BROWN: And then we see the concerns set out. And then just very briefly, the lack of action of
patient regarding serious patient safety concerns, only two paediatricians had -- briefly saw the
redacted RCPCH report. Did you understand that to be Brearey and Jayaram? Dr Brearey and Dr
Jayaram.
JAMESON: Correct.
BROWN: And then the fact that the executive decided deaths and collapses were explicable but the
paediatricians disagreed, was that expanded upon in the meeting?
JAMESON: I think later in the meeting, when other paediatricians presented, there was more
information. But I was the same as almost everybody else in that meeting, it was utter disbelief
that this had occurred.
MS BROWN: My Lady, I'm conscious of the time, I have probably about another five minutes. I don't know if you permit to carry on to the end.
LADY JUSTICE THIRLWALL: Yes. Dr Jameson, are you all right to continue for another five
minutes?
JAMESON: Yes, thank you.
LADY JUSTICE THIRLWALL: Thank you. Let's do that.
MS BROWN: So just dealing then -- the other
concerns. At the end of that they also -- there's reference to repeated misleading statements
concerns regarding what has been said to parents. That was another concern that was discussed, was
it?
JAMESON: That was the first time that I'd heard of that, though in my -- one of my meetings with Mr
Harvey he was very clear that the Medical Staff Committee shouldn't get involved was because he was
in discussions with families and, therefore, there was a patient confidentiality and sensitivity
that would be around the discussions I had between February and May of 2017.
BROWN: And as far as you can recall, Dr Jameson, these concerns, which we're obviously just viewing
as a list here, was there a lot of discussion of these amongst the 101 doctors that were present or
did Dr Gibbs in effect run through a list, insofar as you can recall?
JAMESON: At the time there was quiet shock displayed by the whole meeting, but we were very clearly
going to allow all the paediatricians to say what they felt was important?
BROWN: And I think if we go over the page, to page 4, we'll see that some notes have been made, a
summary of what the paediatricians said. So we have -- and I'm just going to pick out a very brief
line from each of
those -- Dr Saladi referred to the fact that the Consultants were concerned about deaths being
unexpected and unexplained, and that these were not then investigated appropriately by the
Executives. Dr ZA talked about the relationship with the executive board had broken down to the
extent that current patient safety was jeopardised. And Dr ZA also had concerns that there was
victimisation of two Consultants. Can you assist -- one assumes that is Dr Brearey and Dr Jayaram,
are you able to assist if that's who was being referred to?
JAMESON: Yes.
BROWN: And, again, a reference there to concerns that the grieving families had been misled over
the cause of their child's death. Dr Jayaram spoke as well. He was attempting to obtain some minutes
of board meetings. He refers to board documents that could not be specified in this forum. Do you
know what he was referring to then?
JAMESON: No, I don't.
BROWN: And he -- also going over the page, this is page 6 -- suggested things said in the Speak Out
Safely forum had been used against the paediatricians. Were you involved Dr Jameson in the Speak Out
Safely?
JAMESON: No, I wasn't.
BROWN: Dr Brearey then spoke. He was concerned about press statements being inaccurate or
misleading, and he picks out in particular a comment by Mr Harvey -- this is halfway down --
comments by Mr Harvey that there were only two infants for whom the cause of death was uncertain,
and Dr Brearey said that was inaccurate. And Dr Brearey also referred to a May 2018 interview with
the Chester Chronicle where Tony Chambers is reported to have said: "There were just a few niggles
that our clinicians said, 'Look, we have got 90% the answers but there are still bits that we need
to in a sense be clear we have not missed anything'." And Dr Brearey felt that didn't reflect
accurately the paediatricians' concerns. And then, finally, Dr Holt, and this maybe gives us some
idea of what had been intended by the meeting and what in fact occurred. She highlighted the purpose
of the meeting had changed in the light of the events. Was the purpose of the meeting, Dr Jameson,
to have a vote of no confidence on Tony Chambers?
JAMESON: The purpose of the meeting was to clearly allow the paediatricians to voice their concerns
and the
way they had been treated, and then following on from that if the Medical Staff Committee had felt
that this complete breakdown in trust between one whole department and Consultant group would
suggest we have a vote of no confidence in the Chief Executive, then we would have taken that
forward, if that had been the view of the Medical Staff Committee.
BROWN: And that would explain in part the numbers of those attending at this meeting.
JAMESON: Absolutely.
BROWN: Then going on, there was a discussion, as one might expect, following the paediatricians.
And just so that I'm correct in this, the minutes would imply each paediatrician took the floor for
a moment and set out their particular concerns; is that correct?
JAMESON: Yes.
BROWN: And we see on page 8, "RJ", so that's a reference, one assumes to, Dr Jayaram: "... said
that he had been told at the beginning of the process that the idea of intentional harm would be a
convenient possibility." What did you understand he was referring to there?
JAMESON: I think you would have to ask Dr Jayaram, so I don't know what he's referring to there.
BROWN: And then the conclusion there, we see at the
bottom, you say that: "The main aim of the meeting was to facilitate the paediatricians ...
expressions of their experience." And that you -- consideration for a further extraordinary meeting.
Was there a further extraordinary meeting?
JAMESON: No, we didn't have a further extraordinary meeting after that. But the other conclusion
that I said on the page before when we specifically asked whether any other departments felt
bullied, marginalised, threatened or treated in the same way as paediatrics it was important that we
raise that question in this forum.
BROWN: And as a result of that, you didn't feel the need to go forward to another extraordinary
meeting to look at another department?
JAMESON: Yeah, yes.
BROWN: And just on page 9, then, the final page of these minutes, you thank -- well, first of all
Sir Duncan Nichol thanks Susan Gilby and you, and said the non-executive directors would look at the
culture of speaking out. Then you thanked colleagues for attending in such numbers and you said the
previous senior management had not wanted the meeting to happen. What's that a reference to and
who's that
a reference to by senior management?
JAMESON: That was in reference to the meetings I had with Mr Harvey where he very clearly stated
that he felt the -- this issue was not one at that time that was to be discussed by the Medical
Staff Committee as in when I was having the discussions with him in early 2017.
BROWN: And just with that, so 2017, when the matters came to you as chair of the Medical Staff
Committee, this meeting 2018, was it the opposition of Mr Harvey to this meeting that meant that the
forum that the MSC created for discussion of this meeting wasn't used it appears until September
2018?
JAMESON: I think we didn't use it before that point because there was the period of time where we
were waiting for the police involvement. And after the police involvement, there was a hope that
there could be a reconciliation in that we hoped that the senior managers would understand that the
paediatricians were the ones who were speaking out and needed to be supportive, and certainly that's
what Sir Duncan was trying to -- trying to take forward, but that failed really at every turn.
BROWN: And there is just one final matter on the documents. You've been shown I think a letter
dated 1 December that was sent by Ms Weatherley to Letby, and I think your evidence is that that
wasn't a document you saw at the time.
JAMESON: Correct.
BROWN: And this relates to the grievance, and in that letter -- so although you clearly didn't see
the letter but what Ms Weatherley concluded was that the -- Letby's removal from the unit was
orchestrated by the Consultants with no hard evidence to support this action, their behaviours and
comments fell short of what was expected by the Trust. Was that a conclusion that you were aware of
at any time?
JAMESON: No.
BROWN: And also in that letter, Ms Weatherley talks about the fact that apologies would be required
from named Consultants who had made unsubstantiated comments and refers specifically to Mr
McCormack, Dr Brearley Dr Jayaram and Dr V. The question there is, were you aware of the comments
these doctors had made which prompted the recommendation for an apology?
JAMESON: No.
BROWN: And, finally, Dr Jameson, if I could just return to your statement for your reflections that
you set out at paragraph 71, you say: "It is my view, on reflection, that as soon as the
paediatricians raised any concerns regarding the increased mortality within the neonatal unit by any
member of the department, that these should have been immediately passed on to the Local Authority
Designated Officer and the police". Dr Jameson, whose responsibility do you consider it was to
contact the local authority and specifically to contact the police?
JAMESON: I think the paediatricians informed senior management of their concerns and, therefore,
senior management, probably jointly with the paediatricians. In a -- in a healthy Trust one would
hope that that trust and respect for both would mean that they would both draw that conclusion. It's
easy with retrospect to say that, but fundamentally at one and the same time they should have been
going to the local authority and police.
BROWN: And when you were aware of the patient safety concerns that had reached you, and the
concerns that the management weren't reacting to respond to that, did you feel on reflection that
that was also part of your responsibility to go to the police?
JAMESON: I felt at the time because Lucy Letby was excluded from the unit and, therefore, the unit
wasn't at risk. But, in retrospect, I think like all those
involved, I wished I'd been more forceful in saying to the senior management that, "You must go to
the police."
MS BROWN: Thank you very much, Dr Jameson. There are no Rule 10 questions, my Lady.
LADY JUSTICE THIRLWALL: Thank you, Ms Brown. Dr Jameson, thank you very much indeed. Often a
barrister says five minutes they mean 15. I suspect you probably guessed that.
JAMESON: Yes.
LADY JUSTICE THIRLWALL: So thank you for being patient with that, and you're free to go. So we will take a break until five past 4. (3.48 pm) (A short break) (4.05 pm)
LADY JUSTICE THIRLWALL: Ms Langdale.
MS LANGDALE: My Lady, may I call Dr Tighe.
LADY JUSTICE THIRLWALL: If you would like to come and take the affirmation.
DR SEAN TIGHE (affirmed)
MS LANGDALE: Dr Tighe, you have provided the Inquiry with two statements, the first dated 18 June
2024 and a short statement of clarification 4 September 2024.
Can you confirm the contents of true and accurate, as far as you are concerned?
TIGHE: Yes.
LANGDALE: You were a Consultant anaesthetist at the Countess of Chester Hospital from August 1993
to April 2021; is that right?
TIGHE: Correct.
LANGDALE: You're retired now.
TIGHE: Yes.
LANGDALE: And you were, while you were at the Countess of Chester, chair of the BMA local
negotiating committee; is that right?
TIGHE: Yes.
LANGDALE: Can you tell us what that roll entailed and what more about the BMA?
TIGHE: Yes. Well, the BMA is the main Union of -- representative Union of all doctors and I was an
elected chair of that and, as such, was the Union representative for the doctors employed by the
Trust, and my role was mainly in negotiating terms and conditions with the executive dealing with
complaints and concerns of colleagues with regard to application of those terms and conditions and
in disputes with management. In that role, I enjoyed an excellent relationship with the executive
through quarterly meetings that we had, called the Local Negotiating Committee Meetings, and we
generally came to very satisfactory mutually advantageous decisions.
LANGDALE: When you say -- through the period 2015 to 2016 and 2017, were you having those LNC
meetings then with the Executives?
TIGHE: Yes, we would have had around that time.
LANGDALE: And so when you say you enjoyed excellent relationships, can you tell us which executive
officers you enjoyed such relationships with?
TIGHE: Sorry, I'm having difficulty hearing you.
LANGDALE: Which executive officers did you enjoy such good relationships with in 2015 to 2016?
TIGHE: Okay, so the Medical Director.
LANGDALE: Was that Mr Harvey?
TIGHE: Ian Harvey, the Chief Executive -- several Chief Executives in fact over my 10-year tenure,
and the representatives of the Human Resources department. Also on the committee was Dr Jameson, the
chair of the Medical Staff Committee, who you just heard from, and there was always a BMA
representative from -- employed by the British Medical Association in attendance as well.
LANGDALE: You tell us in your first statement, Dr Tighe, about an informal meeting with Mr Harvey,
the Medical
Director, in his office in early January 2017 where he asked or requested that you attend a meeting
on 26 January between the CEO, himself, other board directors, senior nurses and the paediatricians
as a witness. Can you tell us about that conversation and what Mr Harvey was asking you?
TIGHE: The informal conversation --
LANGDALE: Yes.
TIGHE: -- before the meeting?
LANGDALE: Yes.
TIGHE: Yes, he asked me to come and see him and -- to discuss me attending as a witness to a meeting
that was to take place between the paediatricians and the Medical Director and himself. And this was
really the first time that I'd heard any detail at all about the problems on the neonatal unit. The
Medical Director appraised me of his view of the current situation, assured me that he had
undertaken an independent analysis that had not -- that had not registered any firm evidence that
harm was being done and that it was much more likely to be a statistical aberration or related to
poor clinical performance. He told me that, as a result of the concerns expressed by the Consultant
paediatricians, two independent reports had been commissioned by the Trust
and he handed me one of them to read. I can't remember whether he actually let me take that away or
not but I assume he must have --
LANGDALE: Was it redacted?
TIGHE: -- because I refer to it later. Very significantly redacted. I mean, about 50% of it was
blacked out. And I did not see the Jane Hawdon report but he told me that that had not raised any
concerns. And, therefore, the purpose of the meeting was in order to consider the reinstatement of
Ms Letby back on to the unit as she -- he also told me that she had been removed from -- from a
clinical role for some months by that time and had raised a grievance procedure which had been
upheld, and the result of that was that she was -- they were hoping that she would be reinstated,
and that all I had to do was literally sit there and be a witness. I think he was actually doing
that in order to be seen to be protecting in some way the interests of the paediatricians. An
independent party, if you like, to observe the proceedings.
LANGDALE: So to be helpful for the paediatricians. Was the request from Mr Harvey that you should
be there to be helpful and supportive of them or when you say protecting?
TIGHE: I can't remember exactly what it was but I got
the impression that I was there as an independent observer.
LANGDALE: You say in that paragraph 5 he gave you: "... a detailed explanation about the concerns
expressed by the paediatricians, including a description of his personal analysis of a series of
unexpected deaths on the NNU ..." Did you understand that Mr Harvey had done a personal analysis of
the unexpected deaths?
TIGHE: That was my impression, yes.
LANGDALE: What did he say to you about that, his own analysis? I see what you say about the RCPCH
and Jane Hawdon's but about his own analysis?
TIGHE: Well, I couldn't really -- I didn't really say anything about it. I had no -- nothing to go
on. He wasn't actually showing me the data.
LANGDALE: But you understood that he'd done something himself to reassure him --
TIGHE: I understood that he'd done something himself, he was the Medical Director, and with the very
limited or zero knowledge I had at the time I had to take his word for this.
LANGDALE: You say here: "The MD also raised concerns about the professional behaviour of some of
the paediatricians ..." What were those concerns about their professional behaviour that he raised
in that first meeting with you?
TIGHE: There was also an issue over alleged -- alleged negative remarks that Ms Letby had accused
some of the Consultant paediatricians of making and that if those allegations were to be upheld
those would be considered professional misconduct. It has to be said, however, that the
paediatricians vigorously denied every making --
LANGDALE: I'll go it that in a moment. Sorry, to interrupt, Dr Tighe, but just dealing --
TIGHE: But that's what it was about. And also it was also that one of the -- some of the relatives
had threatened to refer some or one of the paediatricians to the General Medical Council.
LANGDALE: So that was my next question, was it Mr Harvey, because that's his evidence to the
Inquiry, that it was Letby and her father who'd raised the possibility of reporting the Consultants
to the GMC; is that what he was saying to you or that he was --
TIGHE: No, I got the impression that it was one of the parents -- the parents of the -- of the
children that had threatened GMC action. I wasn't aware that Ms Letby or her father had threatened
to do so, although I might be not remembering that correctly. It might
well have been the other way round, as you say. I don't know. But all I remember was there was the
-- the potential for GMC referral was mentioned and that frightened me on behalf of my paediatric
colleagues, because the potential -- the actual GMC referral is an absolutely disastrous thing to
happen to any clinician because you are guilty until proved innocent in effect, and they would be
automatically suspended from clinical practice until the GMC had made their decision. So it's a
very, very major thing to happen and, as my evidence shows, a lot of my actions subsequently were to
prevent that happening.
LANGDALE: At what cost would you say you would prevent that happening?
TIGHE: By encouraging my paediatric colleagues to do the right thing but to also be seen as
co-operative and understanding of the executive point of view.
LANGDALE: If we go to the meeting itself, the reference is INQ0003523 and it starts at page 1. This is the meeting that you bore witness
to. Did you say anything in the meeting?
TIGHE: I have seen this, yes.
LANGDALE: Did you say anything in the meeting --
TIGHE: No, nothing.
LANGDALE: -- when you were there?
TIGHE: Only afterwards when I spoke to the paediatricians informally.
LANGDALE: We see at the beginning: "Mr Harvey reported that running in parallel to the above
reviews was the HR process relating to the grievance." What did you understand or did he say about
the grievance process, can you remember?
TIGHE: Well, it was the first time I'd heard that -- no -- that there was a grievance. Mr Harvey
might have mentioned it in the informal meeting in his office beforehand that a grievance -- no, he
had mentioned it, there was a grievance procedure had been enacted and as a result that grievance
procedure had concluded that she was to come back to work.
LANGDALE: And if you see at page 2, paragraph 3, it's recorded Mrs Rees read out Lucy's statement
to the meeting. Do you remember that, a statement being read out?
TIGHE: Yes, I do.
LANGDALE: What did you make of that in this meeting?
TIGHE: Well, I thought it was completely inappropriate. We had been told that the meeting was to
explore the reports -- the contents of the reports and
to explore the possibility of Ms Letby returning to work, not to hear a 20-minute melodramatic
dissertation from Ms Letby herself.
LANGDALE: We know -- I think it's -- that can -- it's been on the screen earlier -- we know that
there was reference in that letter to suggestions of various names that she had been called. Do you
remember that?
TIGHE: Yes.
LANGDALE: And what did the Consultants say in response to that?
TIGHE: Well, they completely denied that they had said anything derogatory.
LANGDALE: Can you remember which one said anything specifically or not really, they just all said
they hadn't?
TIGHE: I think it was Dr Jayaram, and they followed that up and also to say, "Can we please have
details of exactly what these derogatory remarks were?" And that was no comment was made.
LANGDALE: In the statement -- and, again, I don't need to call it up -- but the statement that was
read out said: "Members of your team have been heard to publicly make comments such as angel of
death, murderer on the unit, cold and calculated." So that's what was said to the Consultants.
TIGHE: That I think is what Ms Letby was referring to.
LANGDALE: Yes.
TIGHE: But the way it was presented to us was that it was directly the Consultants that had said
that not members of their team. The Consultants recognised that members of their team may possibly
have said that.
LANGDALE: What do you think the tone of that meeting was? How would you describe it?
TIGHE: Well, it was -- it was pretty shocking really. The -- first of all, it was extremely
one-sided. The paediatricians hardly had any opportunity to say anything, and in fact hardly did say
anything. The tone started off with the Medical Director being fairly placatory but just describing
factually his -- his own and the board's interpretation of the two reports, concluding that there
were no concerns, other than perhaps organisational issues and staffing issues, and it was followed
up by the Chief Executive, whose tone was dictatorial, somewhat regimental, demanding that the board
had made their decision, that this was final, and that the paediatricians were to draw a line under
the whole thing, and were to accept Miss Letby back to work and were to apologise to her for the
derogatory remarks
that they had -- that had been alleged they had made.
LANGDALE: Given that was the tone, did you think to speak up about this at the time in the meeting
or say anything --
TIGHE: No --
LANGDALE: -- and if not, why not?
TIGHE: -- I didn't think this was my role. I was being specifically asked to sit there and be a
witness and say nothing.
LANGDALE: In the earlier meeting that you'd had with Mr Harvey or --
TIGHE: Yes, yes.
LANGDALE: Did the paediatricians expect you to be there?
TIGHE: I expected some paediatricians to be there I didn't expect all of them -- I think all of them
all of the Consultant paediatricians were there. I'm not sure. But I knew they were going to be some
paediatricians there. That was the whole point of the meeting.
LADY JUSTICE THIRLWALL: But did they know you were going to be there?
TIGHE: I'm not sure. Ma'am, I'm not sure.
MS LANGDALE: At the top of the page on the screen, we see Mr Chambers stated that: "The Speak Out
Safely process had been
professionally managed, he noted emotions were running high at the time. Things have been said and
done that were below the values and standards of the Trust. He added that an action would be
developed from the outcome of the grievance". What did you understand to be the Speak Out Safely
process and did you know if that had been used or not?
TIGHE: Sorry, could you repeat that question again I'm having terrible trouble hearing you because
of the echo in here.
LANGDALE: There is an echo. Me too.
TIGHE: And I've got bad hearing.
LANGDALE: Mr Chambers stated that the Speak Out Safely process had been professionally managed. Do
you know what he meant by that and do you know if that process had been used?
TIGHE: No, I don't know what he meant by that. I think he was referring to freedom to speak out, the
policy that the government were pushing at the time and following previous Inquiries. But it was --
I got -- it was almost a passing remark.
LANGDALE: You tell us in paragraph 12 of your statement, if you would like it go to it, you -- the
document can come down now, thank you, Ms Killingback -- you met with Dr Jayaram on the morning of
29 January 2017 in his
office. What did you discuss with him then? The meeting, of course, had been on the 26th, what was
your conversation with him about?
TIGHE: Right. I think actually this was probably a typo or error here. I think it's probably the
27th, the morning after, which was a Friday --
LANGDALE: Right.
TIGHE: -- the 29th was a Sunday. I doubt I -- he or I would be there unless we were on-call
together.
LANGDALE: So it was the Friday looking at your subsequent letter.
TIGHE: So the content of the meeting, yes. Well, I was -- after the -- after the actual meeting on
the 26th I met, after, in the corridor with Dr Jayaram and Dr Brearey to express my surprise and
shock as to what we had both just witnessed and my deep concern for them and the position they were
in and this particular conflict with the Trust, and this request to apologise for something that
they firmly confirm that they had nothing -- that they had firmly denied, and so I had said to them,
"Look, there's nothing to be lost by making a reserved apology for perceived hurt and it is not
going to do any harm and you -- and it still leaves you complete freedom to proceed in any direction
you want to go." But I said, "As your Union representative, I'm extremely disturbed by the -- by the
pressure you are being put under", and by the -- what I saw as a direct threats to them that if they
didn't do as they were told by the Chief Executive there were going to be consequences. I think he
even said, "There will be consequences." I thought this was completely inappropriate and realised
that my position as a witness was no longer as such. I was now their Union representative because
there was potential that their jobs were at stake. And that's very much where my role was in
defending their terms and conditions and defending them should there be any threat to their
employment as a result of what I thought they were doing, which was very much the right thing. So I
had had that meeting with them. But I said, you know, "If it's a matter of -- the other issue here
is that the Trust want to let Ms Letby back to work. What do you think about that?" And they said
"Under no circumstances. That is completely impossible. That is our bottom line and we cannot have
that." So I said, "Well, I'll help. I will do whatever I can to make sure that happens." So I said,
"To take the heat off, let's think about writing this apology so we can proceed with the more
important issues." So I then --
LANGDALE: Sorry, just to --
TIGHE: -- met with Ravi the following morning. Sorry.
LANGDALE: I was just going to say you met him that following morning, but can I just ask you about
what you said about the threats. Dr ZA -- there is a cipher list if you want to see who that is, I
can't give you the name of that doctor -- in her written evidence says she remembers someone saying:
"Senior management in the Trust were keen for someone to stick their head above the parapet and get
blamed and they could get their head knocked off." And she referred to the fact it may have been you
saying that. You don't remember saying that --
TIGHE: Yes.
LANGDALE: -- but this threat of the GMC, did you discuss that with the doctors?
TIGHE: No, I didn't. Not -- well, I did discuss it the following morning with Dr Jayaram. I did
raise that issue that I was aware that there were threats of GMC referral and that I was very
concerned about that.
LANGDALE: So you did on the 27th discuss that threat of referral and you said a moment ago that was
the worst thing that you -- when you were describing being
reported to the GMC you said that's just the worse thing, you wanted to avoid that if you could.
TIGHE: Yes, yes. It would be -- when, in my view, my Consultant colleagues had done absolutely
nothing wrong and in fact quite the opposite, were proceeding in an extraordinarily professional and
courageous manner I thought that would be disastrous because the GMC only has one way of doing
things and that is suspicion and that's it. You know, there's nothing -- that's what happens.
Overnight you are suspended and then of course the paediatricians would have no ability to proceed
with their case.
LANGDALE: You then went home that weekend and I understand from your evidence read the RCPCH
report, did you? Or you tell us. What did you look at?
TIGHE: Yes, well, I then -- I was very disturbed by a) the meeting itself, b) the subsequent meeting
with Dr Jayaram in his office where he went into further detail and don't forget I knew very little
about this until Dr Jayaram sat me down and told me what had been going on. So I then went home and
did some research and, yes, my research was extremely disturbing and I wrote the letter that you
have that you no doubt are about to
refer to.
LANGDALE: I am. Let me put that on the screen so you can tell us. INQ0003489, page 1 and 2. That's your letter of 29 January 2017. Please tell
us what you are setting out there at paragraph 2.
TIGHE: So I start off by saying, you know, you've got to recognise that the Trust are doing
something, they have come to a conclusion, the board has come to a conclusion. But that if you think
they are wrong having now read the reports -- which of course they hadn't seen, they hadn't seen the
case report at all and they hadn't seen the unredacted report -- and having seen that and considered
them as impartially as you can, you cannot draw a line under this because there is by definition a
significant risk that serious crimes have been committed and therefore could be committed again if
not in this Trust then in another. There was talk of Ms Letby being moved to Alder Hey so I was
actually concerned that if that were to occur we still had a major responsibility to prevent that
happening. So -- but I gave them the alternative on paragraph 3, which is: however, if after reading
the reports you agree the Trust has done everything they possibly can then of course you can take
the accused person back and draw a line under as you have been asked.
LANGDALE: You say in paragraph 1: "I have done some background reading and there are disturbing
similarities with the Beverley Allitt case and others." So you were aware of that case.
TIGHE: I was aware of that case, yes. I read it up and there were others in the United States of
professional staff murdering patients, murdering their own patients.
LANGDALE: If we go to page 2 of this letter, you set out there assurance for all the deaths or as
many as possible, at 2, have been subjected to detailed forensic pathology and toxicology, including
all remaining infusions, blood samples, et cetera, and you set out what's needed to allay concerns.
At paragraph 262 you believe a full forensic examination must take place: "This has not been
adequately carried out and this can probably only be done properly by the Coroner and the police."
Yes?
TIGHE: Yes. I was concerned that although I wasn't aware of the full details, I was highly
suspicious that
the Royal College report had not been properly briefed about the concerns of the paediatricians, had
been briefed by the Trust executive and therefore there was a biased briefing, if you like, and that
was my only explanation as to why they had not addressed the issue that we were all -- we were all
so concerned about. All that was in the college, redacted college report that I saw was criticism of
-- of the neonatal unit, organisational aspects. But it turns out that they did look into those
issues and it was in part of the redacted part, but at that time we hadn't seen it. So my concern --
and similarly with the Casenote Review for the pathologist, I was concerned that she had not been
properly briefed either.
LANGDALE: Is this Dr Hawdon?
TIGHE: The Hawdon Report.
LANGDALE: She's not a pathologist but that review?
TIGHE: So I was -- I was thinking to myself how, both in the interests of Ms Letby and anybody and
the -- and the Trust the only way out of this was to have a detailed forensic investigation and a
detailed forensic investigation includes detailed toxicology. I note that the Shipman Inquiry
recommended, one of the recommendations -- I think it was 263 or something -- recommended that full
toxicology is carried
out on every autopsy. But it was obvious that they had not tested for unusual drugs, otherwise they
would have an answer.
LANGDALE: That can go down now, please. Then if we can have instead INQ0003159. This is a two-page letter from Mr Chambers, the Chief Executive,
to Dr Jayaram and setting out there at paragraph 3: "I confirm that a copy of the report was shared
with the Coroner on 20 January following which a meeting with Mr Rheinberg, the Trust Medical
Director and Director of Corporate and Legal Services was held at the Countess on 8 February to
ensure the Coroner was fully briefed on all matters." The Inquiry is investigating, Dr Tighe, what
information the Coroner was provided with and I know you are not appraised with the details of that
and indeed you didn't provide information yourself to the Coroner. But we see here on 16 February
that it's confirmed by Mr Chambers that the paediatricians' letter of --: "Dr Jayaram's letter of 10
February has been shared with the RCPCH College Review team and Dr Hawdon for comment in view of the
fact you are not satisfied with the findings of those reports." If we go to page 2 of this document
stating: "In summary there has been a thorough
internal/external review into the unexpected increase in mortality levels for newborn babies on our
neonatal unit for 2015 and 2016 compared to previous years." And setting that out. You are told,
that can go down now, thank you, you are told by Dr Jayaram that the Coroner has been informed or
given that information and we see your response at INQ0006079, page 3. This is from you, is it? Dr Tighe, you see the email?
TIGHE: Yes.
LANGDALE: Yes: "I am slightly surprised and pleased that the Trust has so rapidly escalated your
concerns verbatim to the Coroner and to the authors the two recent reports." And you set that out.
What did you think was happening at this point when the Coroner had been given information from Mr
Chambers?
TIGHE: Well, I thought that the Coroner had been given the letter that the Consultant paediatricians
had sent to the Chief Executive saying that they still had major concerns that had not been answered
and that they wanted him to open a full forensic inquiry as I had advised them to do. I -- I was
pleased that that had happened because I had confidence in the Coroner and the Coroner's service. I
felt that the Coroner -- it was so obvious to me that what was happening was of major -- at least
demanded forensic, further forensic detailed investigation that the Coroner would also see that and
would take action and if necessary would then refer to the police. It seemed to me that that was the
process that we should go through. I was however, well, not aware that the Coroner, I'm not sure if
it's at this time or later, the Coroner had actually been extremely dismissive and had said that it
was not in his jurisdiction.
LANGDALE: Well, we haven't heard evidence about that. We will I'm sure in due course, Dr Tighe.
That can come down. You say the Coroner could then have considered referral to the police. Did you
at any point with the paediatricians discuss they might go directly to the police if they had these
concerns or indeed you might go directly to the police, one of you, someone?
TIGHE: Well, yes, that was part of the conversation I had with Dr Jayaram on the morning, after the
meeting on the morning of Friday the 27th. We did discuss that and my feeling was that we should go
to the Coroner first. I had confidence in the Coroner that was, it turns out, misplaced. But I felt
it was the Coroner first and the police after if the Trust could not be convinced to do that
themselves. I felt the natural approach here was to encourage the Trust to go through the proper
channels and do it themselves as soon as possible, bearing in mind please that our bottom line was
already met. Ms Letby was no longer working on the unit. It was by this time apparent that she was
never going to go back to the unit under any circumstances. So we had time. As far as I was
concerned at this point, the point of the letter you just showed me after the Coroner had been
informed by the executive, that actually we had -- we had plenty of time. There was no urgency to
contact the police. Our bottom line is our patients were safe and Ms Letby was no longer on the unit
and wasn't going back there. So in a sense, I had some sympathy with the Trust in wanting to see due
process and in particular not wanting the media circus to get involved and upset The Families who,
by this stage, knew nothing --
LANGDALE: And I think --
TIGHE: -- and they had been extremely -- and there was no process in place. They had discussed it,
but they hadn't formulated a policy as to how they were going -- and what they were going to inform
the parents
about when a police investigation -- so I thought it was appropriate that due consideration should
be taken about how that was to be done.
LANGDALE: Indeed you tell us you reflected back in 2020 and you probably can now, about the
position Mr Chambers and Mr Harvey found themselves in. How do you view that?
TIGHE: Yes. Could you be more specific about what you are asking me? Sorry.
LANGDALE: Yes. You made a further comment in 2020 I think about feeling -- who was more responsible
or who was finding was under pressure to suggest -- let me find the exact --
TIGHE: Is this the comment where I had expressed some sympathy with the Chief Executive?
LANGDALE: That's right, yes.
TIGHE: Yes. Okay. Yes. That's a bit semantic really. But do you want me to go into detail about it?
LANGDALE: I just want to know what you think. Whether it was then or now, what do you think?
TIGHE: Right. So I put myself in the Chief Executive's position if I was sitting in the boardroom
with -- surrounded by other non-medically qualified executives and whom the only medically qualified
person in the room was the Medical Director
and the Medical Director was telling you, the Chief Executive, that there was nothing to be worried
about and that the paediatricians were making a huge fuss over nothing, what would I do as a
non-medically qualified Chief Executive who had himself appointed the Medical Director to that job?
Would it not be seen as a lack of confidence in the Medical Director not to accept his -- his
professional medical opinion and so I had some sympathy for the Chief Executive in the position that
he found himself in during this whole process which was in effect, I hate to say it, but in effect
being driven by the Medical Director.
LANGDALE: Why do you say being driven by the Medical Director?
TIGHE: If the Medical Director had taken due consideration of his Consultant paediatrician
colleagues, the experts in neonatology that he had available to him, and involved them from the
start in a thorough external, independent investigation which they lead because they are the experts
and which they subsequently interpret, then I think this whole thing would have gone in a very
different way.
LANGDALE: You tell us at paragraph 19 about the culture and atmosphere at the hospital and if you
go to your statement, you say: "In general, relationships between clinicians and managers, nurses,
midwives and managers and between medical professionals between June 2015 and June 2016 were quite
good at COCH in my opinion. However, there was an element of distrust between consultant
paediatricians, senior nurses and senior managers as a result of the allegations made by the
former." And you refer then to: "... professional rivalry as most Board members were from the
nursing profession." Can you expand upon that, please?
TIGHE: Yes. This is supposition. It's just struck me again that if I was in -- if I was sitting on
the board as an Executive Director or whatever that the board were -- all the professional people on
the board other than the Medical Director were from the nursing profession. The -- some -- most of
them were no longer in practice but, nevertheless, their backgrounds was from -- were from the
nursing profession. The only medically qualified person on the board was the medical. There were
other non-executive directors who were -- who were not to do with -- who were not medically or
nursing colleagues, as far as I was aware, I may be wrong on
that, but as far as I'm aware. So the nursing profession and their views of the nursing profession
were overwhelming on the executive board. The accused was from the nursing profession. Would it not,
therefore, be natural for the nurses to defend their own and perhaps perfectly understandably on the
basis that this situation -- this accusation was so utterly unbelievable and so extraordinarily rare
that surely it cannot possibly happen here and that we must be wrong -- the paediatricians must be
wrong, and that they must be victimising this poor nurse. And if I'm sitting there as an executive,
non-medically qualified, at the board and I'm being told all this I think I might actually accept
it.
LANGDALE: You say: "I think that this obviously did, these relationships, very negatively affect
the quality of care on the NNU as Ms Letby was allowed to continue to murder babies after major
concerns were raised in February 2016." What do you say were the major concerns being raised in
2016?
TIGHE: Well --
LANGDALE: Later on you say -- just to be clear, you then
say: "In my view, she should have been removed as soon as the paediatricians made their concerns
known in late 2015, early 2016." What concerns are you relating -- referring to there?
TIGHE: Well, by February 2016 there had been several more unexplained deaths and there had been --
and Dr Brearey had raised this formally with the executive. I think you should have records of those
meetings.
LANGDALE: Sure. So you don't -- my question then, you don't know specifically when they were
raised. They weren't raised with you in February 2016 or earlier --
TIGHE: No.
LANGDALE: -- this is your understanding of the chronology?
TIGHE: That is my understanding indeed. And so I felt that, with hindsight and the knowledge I have
as a result of this Inquiry, that there was a very strong case to suspend Ms Letby in February and
certainly March 2016 after that meeting.
LANGDALE: In terms of reflections in your statements on page 9, 22(d), you say: "It was clearly
inappropriate for the MD to mount his own internal investigation and to analyse this
himself, with no input from his own paediatric experts, or from any of the expert researchers
employed by the Trust." Are you referring there at 22(d) to that piece of work that the MD was
telling you he'd done in that preliminary meeting before you attended --
TIGHE: I'm sorry, reflections -- could you give me the reference again.
LANGDALE: It is paragraph 22 of your statement and then it is d on the next page?
TIGHE: Yes.
LANGDALE: On the next page?
TIGHE: C?
LANGDALE: D. See are where you say: "... clearly inappropriate for the MD to mount his own internal
investigation and to analyse this himself ..." Can you find that, Dr Tighe?
TIGHE: It's all about the Coroner I'm looking at. I'm looking -- which --
LANGDALE: That's paragraph c go to the one below paragraph --
TIGHE: Para d. Right. It's my hearing again, sorry. Yes. So the Medical Director's first response
was to analyse the staffing data himself and cross-reference that with the deaths and serious
clinical incidents. I'm not sure if he did do serious clinical incidents but it was certainly the
deaths and --
LANGDALE: Do you think it was the deaths?
TIGHE: -- if I remember, Ms Letby was alleged to be present at every single one of them and that
this was one of the main reasons that my Consultant colleagues, paediatric colleagues, had raised
concerns. And he did this himself and he mounted his own investigation. He didn't have any input
from his own paediatric experts on site, or indeed -- we actually had a very well-established
research department at the Countess of Chester Hospital with some internationally renowned research
experts who would have known an awful lot about research methodology and particularly statistical
analysis, and he didn't do that, he did it himself.
LANGDALE: Do you know that? I mean, Mr Harvey can give evidence himself about that, but he may well
have employed assistance from others in the Trust. Do you know he didn't or --
TIGHE: No, I don't know if he didn't --
LANGDALE: No, okay, so we can ask him about that.
TIGHE: -- but the -- it subsequently came to my attention that the -- that the quality of that
report was not particularly good and did not justify the
conclusions that he came to, ie that there were perfectly reasonable explanations for these deaths
and, and unexplained incidents.
MS LANGDALE: Thank you, Dr Tighe, I have no further questions. Does my Lady?
LADY JUSTICE THIRLWALL: No, thank you very much indeed, Dr Tighe. I'm sorry about the echo --
TIGHE: It's all right.
LADY JUSTICE THIRLWALL: -- it is maddening.
TIGHE: It is all right, I need to get a hearing aide.
LADY JUSTICE THIRLWALL: But thank you very much for your help. You are free to go. So, Ms Langdale, tomorrow morning.
MS LANGDALE: Tomorrow at 10 o'clock.
LADY JUSTICE THIRLWALL: I will adjourn until 10 o'clock tomorrow.
(4.49 pm) (The Inquiry adjourned until 10.00 am, on Wednesday 9 October 2024)
LADY JUSTICE THIRLWALL: Ms Langdale.
MS LANGDALE: Good morning, may I call Dr Jayaram.
DR RAVI JAYARAM (affirmed)
LADY JUSTICE THIRLWALL: Thank you very much, doctor, do sit down.
JAYARAM: Thank you.
MS LANGDALE: Dr Jayaram, you have provided a statement to the Inquiry dated 30 August 2024?
JAYARAM: That's correct, yes, I did.
LANGDALE: Can you confirm the contents are true and accurate as far as you are concerned?
JAYARAM: I can confirm that, yes.
LANGDALE: You have a copy of it in front of you, should I refer you to any of that?
JAYARAM: I have.
LANGDALE: Before we begin, I understand there is something you would like to say?
JAYARAM: Yes. I would like to say to the parents and Families of the babies affected by this awful
tragedy that I would like to apologise for any personal failings and omissions that I may have made
in the period leading up to June 2016 and afterwards that might potentially
have made a difference to avoiding problems. I want to acknowledge that I will take personal
responsibility for things that I could have done better and in retrospect seem fairly obvious that
could have been done better. And I would like also to apologise as well for the systemic failings
that could have contributed to this not being picked up as soon as it could.
LANGDALE: Understood, Dr Jayaram.
JAYARAM: Thank you.
LANGDALE: You in your statement tell us that you graduated in 1990 and you were appointed to the
role of Clinical Director for Children's Services in March 2009?
JAYARAM: That's correct.
LANGDALE: I think you were working at the Countess of Chester since December 2004; is that
right?
JAYARAM: That's correct, yes.
LANGDALE: You set out various responsibilities at paragraph 6 in your role as Clinical Director for
Children's Services. What were the additional roles and obligations with that job?
JAYARAM: The role of Clinical Director was very much a sort of a managerial administrative role and
in simple terms as I have outlined in my statement it was being
the representative of the department to management and -- and being a representative, a
representative of management back to the department. In terms of hierarchies, I was the line manager
for my colleagues. It didn't mean that I was more senior. Clinically we were all equals, but I was
responsible for appraisals of my colleagues. I was responsible for liaising with management around
issues around service development. I oversaw other aspects of the department in terms of education
and training and risk and governance although other individual colleagues had specific roles in
those areas. I also had a role in liaising with external agencies such as primary care commissioners
in terms of issues around service development as well and dealing with any issues with regards to
concerns around staff, concerns around the service.
LANGDALE: Before we go to the specifics, what culturally was the Countess like in your experience
over that period of time in terms of relationships between Executives, senior managers, doctors,
doctors and nurses and the like?
JAYARAM: Are you talking from the time I started as Clinical Director?
LANGDALE: Yes, broadly, and whether it altered in 2015/2016?
JAYARAM: Yes, so when I started as Clinical Director, we were part of the division of Women's and
Children's Services, so obstetrics gynaecology, paediatrics and neonatology were under one wing, we
had our own departmental professional managers, people to run risk and governance. Within the
division I had very, very good relationships with managerial staff and there were good links with
more senior Executive management as well. We didn't always agree but people would generally listen
and there were opportunities to actually discuss things openly and find -- find solutions. There
were -- there were always potential conflicts in that the wider issues of the Trust in terms of
finance, there is a limited budget, we may not always have felt we got the priority we wanted to. In
early 2010, there was a reorganisation of the divisional structure and it was proposed that the
division of Women's and Children's became obsolete and that there should be a rationalisation of
divisions in the Urgent Care and Planned Care division. And the discussions at the time I recall it
was felt that essentially, acute medicine was mainly Urgent Care and surgical specialties were
Planned Care. But I remember at the time thinking that was quite a simplistic view because there is
elements of Urgent and Planned Care in all medical specialties. Where it became difficult was with
regards to paediatrics, neonatology, obstetrics and gynaecology because the majority of acute
paediatrics, if you like, was Urgent Care. I think gynaecology there was a lot of planned surgery.
But maternity and neonates being integral to each other didn't really fit into either Urgent or
Planned Care. And there were a lot of discussions really as to how -- how they should be divided and
in the end after a lot of discussion it was -- it was decided that paediatrics and neonatology would
sit in Urgent Care and obstetrics and gynaecology would sit in Planned Care.
LANGDALE: Do you think that was the right decision retrospectively?
JAYARAM: I think the difficulty with that is that it caused difficulties in terms of separating
neonatology from obstetrics and maternity. We were allowed to keep a governance board but it was
never clear to me where lines of escalation would go because obviously neonates sat in Urgent Care
and maternity sat in Planned Care. It also meant that as a specialty, paediatrics and
neonatology had a much smaller voice. I can't speak for obstetrics and gynaecology and Urgent Care,
whereas we had our own division and representation directly to the board we were then, if you like,
treated as another "ology". So, for example, in adult medicine there would be sub specialties such
as rheumatology and I think it was acknowledged that paediatrics needed more time and effort and in
terms of my role as Clinical Director at that point I was changed to a lead clinician but it was
acknowledged that I needed to have an acknowledgement of the increased time, although on paper I had
four hours a week to undertake that work that was paid for. In practice, with my clinical workload,
a lot of the management was done in admin time or my own time. I think --
LANGDALE: How much time, pausing there, is admin time?
JAYARAM: So in our --
LANGDALE: Were you given formally, I mean, within work hours?
JAYARAM: Formally --
LANGDALE: Yes.
JAYARAM: -- it was four hours a week, so one programmed activity.
LANGDALE: Did that change through events that we are looking at?
JAYARAM: No.
LANGDALE: Or was that always the position, four hours?
JAYARAM: No, it stayed that way.
LANGDALE: When we see the countless emails and communications, you are all as paediatricians doing
those in evenings?
JAYARAM: Yes, in our contracts we have around, depending on your contract, between two and two and a
half sessions -- a session is four hours -- for non-clinical work, that includes continuing
professional development, audit, educational supervision and administration time doing paperwork as
well. That's -- that's there anyway.
LANGDALE: Moving now to my first topic, Dr Jayaram, you have clearly covered a lot in your
statement and been referred to a lot of documents. I am going to take the questions today, if I may,
thematically and the first one that I would like to ask you some questions about is guidance around
Working Together to Safeguard Children and processes that should be used. You refer in your
statement to a number of these pieces of guidance and I know that you have seen them. So the first
one, please, if we go to Working Together to Safeguard Children, this is the general 2015 guidance
and this is government guidance. If we go to
INQ0014575, page 91, you make the point, Dr Jayaram, and we see it with this
chart, that in fact this guidance referring to: "Processes for rapid response to unexpected death of
a child very much relates to deaths in the community and/or deaths where family members might be
suspected of causing harm to the child, support for carers, other family members, discussion between
paediatrician and attending police officers and the like." So at the time, would you have found
'Working Together' particularly useful in telling you what to do where you suspected a colleague may
be causing harm to a child?
JAYARAM: I think in answer to that question, for me may I refer to it as the SUDiC guidance, meaning
Sudden Unexpected Death in Childhood --
LANGDALE: Yes, yes.
JAYARAM: Just for brevity's sake. I was fully aware of the SUDiC processes.
LANGDALE: Shall we go to that one that the hospital had, your Dr Mittal's guidance processes, let's
go to that since you refer to it.
JAYARAM: Yes.
LANGDALE: INQ0014165, page 1. So this is, if we go to page 2, this is Countess of
Chester guidance about safeguarding and promoting welfare of children -- sorry, page 33. This is the
guidance, the SUDiC guidance that the hospital had. Do you mean this, are you aware of this?
JAYARAM: Yes. So my understanding of, of the SUDiC process and it's a process we followed frequently
in, for example, babies brought in after Sudden Infant Death at home or arrests at home, and there
was a clear process that in terms of documentation and pathways to follow. In terms of the neonatal
unit, and this is something I have reflected on at length, at the time even at the point where
individually and as a group there was consideration that these events didn't seem to fit, I did not
consider using the SUDiC process because it never occurred to me that it would apply to babies on a
neonatal unit. Now, it says "hospital emergency department or ward".
LANGDALE: It does.
JAYARAM: Again, in those situations usually in this situation, it would be a situation where the
child is on the ward because of an injury, if you like, or an illness that had happened outside of
hospital and I will admit in retrospect that looking at this guidance, there
was potential to initiate SUDiC processes in these situations. I think one of the issues earlier on,
particularly with some of the babies who -- who died during 2015 particularly in the first part of
this time period, is that we weren't at those points thinking outside of natural deaths, if you
like.
LANGDALE: We will come to that.
JAYARAM: Sure.
LANGDALE: Just if I can focus on the process for moment?
JAYARAM: Yes.
LANGDALE: We are in agreement that this does flag up at least if it's unexpected and sudden so that
is not the same as a sudden natural death but sudden and unexpected?
JAYARAM: Yes.
LANGDALE: Unexplained, unexpected, then this process should kick in and there's also reference
here, isn't there, to the Child Death Overview Panel and the purpose of that panel to understand why
children die and put in place interventions to protect other children and try to prevent future
deaths. So standing back, that is what this is all about, isn't it?
JAYARAM: Yes, it is.
LANGDALE: You don't know what's happened, it needs investigation?
JAYARAM: It does.
LANGDALE: Investigation is to be seen as a neutral term --
JAYARAM: Yes.
LANGDALE: -- whoever it involves, whether it is a family member or a staff member, you investigate
and find out what's going on to protect future babies. That is what safeguarding is about?
JAYARAM: Yes.
LANGDALE: So when you look at this now, are we in agreement that this process, the SUDiC process
should have been invoked even when you simply don't know, it's Sudden and Unexplained Death, you
don't know why, you don't know if it implicates anyone or not, you just -- it is a Sudden and
Unexplained Death that merits attention?
JAYARAM: I can't -- I can't disagree that in this situation looking at this SUDiC is a process that
should have been initiated. With regards to CDOP as part of the notification of deaths, there is a
form that's filled in and so the CDOP paediatrician is informed of deaths. I think I have said in my
statement I have no knowledge of what the process is after the CDOP
paediatrician has been informed. Can I also say that it's not that none of these deaths were
investigated -- not, not investigated but they were investigated outside --
LANGDALE: Outside the process, we will come to that?
JAYARAM: Yes.
LANGDALE: We are simply looking at this as a concept at the outset --
JAYARAM: Yes.
LANGDALE: -- and trying to understand where the Countess of Chester was with this?
JAYARAM: Yes.
LANGDALE: Because you are not alone in failing to realise that this process should have been
triggered, clearly?
JAYARAM: Yes.
LANGDALE: But Dr Mittal, he is the designated doctor for safeguarding. Did you have any
conversations with him or did he approach you to discuss this SUDiC process and whether and if so it
should apply to any of the babies --
JAYARAM: No, there were no conversations either way.
LANGDALE: Throughout the whole period we are investigating?
JAYARAM: Not that I can recall with me specifically.
LANGDALE: And not with any of the nurses as well who may have had responsibilities in some cases
for safeguarding, you know there is designated officers for safeguarding et cetera?
JAYARAM: Yes. No, because I think -- and again this is something that I have had a long time to
reflect on, thinking about the concept of safeguarding, you know, as paediatricians we are fully
aware of safeguarding in terms of parents potentially causing harm, other people causing harm and
even in terms of staff members, if we saw somebody verbally abuse a child, physically abuse a child,
or considered it. I think one of the issues here is that initially, again we weren't thinking beyond
natural causes and -- and I will come back to this I am sure in due course. It was once you start
thinking the unthinkable, how do you -- how do you bring it forwards? And I fully accept that had
the SUDiC process been initiated, the difference between what happened in terms of investigations
that were done for each of the events compared to what would happen with SUDiC is that there would
have been other professional agencies, particularly the police, involved as well.
LANGDALE: And professionals who listen with a safeguarding perspective?
JAYARAM: Yes.
LANGDALE: I think later on you refer to when you finally spoke, so Hayley Frame or CDOP and
somebody else, with the same concerns that they were sudden and unexpected, same member of staff
involved?
JAYARAM: Yes.
LANGDALE: The response you got was completely different, you say?
JAYARAM: Completely different yes.
LANGDALE: And again they had understanding of safeguarding?
JAYARAM: Yes.
LANGDALE: So if you were to summarise their response to their facts, the facts that you had been
stating for a long time, what were they?
JAYARAM: They essentially said: so what you are telling us is that you have got a group of seven
paediatricians who have all been involved with babies where they have had sudden unexplained
collapses and haven't responded as you would expect to appropriate treatment and you have noticed
the association with an individual member of staff with each time and you can't explain? You are
not, you can't think of any natural causes that would explain these things? Essentially we need to
look further.
LANGDALE: So an immediate response to those set of facts when you are looking at it from child
protection perspective or what might be happening to babies now elsewhere?
JAYARAM: Yes.
LANGDALE: Was that refreshing to get that observation or clarity of thought?
JAYARAM: It was a relief at that time in -- I think it was late April/early May 2017 because I think
by that stage, we had said exactly these same things to many people so many times and were
repeatedly, repeatedly being reassured, falsely, that yes, it could be that but we need to make sure
we have excluded lots of other things first. Again, you know retrospect again, I only wish that at
earlier stages both myself and colleagues had actually been more assertive and said, you know: we --
we don't think you can look any further without people who can look more forensically at it.
LANGDALE: Just finishing with the guidance, you referred us to something called a Just Culture
Guide, NHS Just Culture Guide which describes the process to follow and if we go, please, to INQ0107964, page 5.
JAYARAM: So I was -- I was asked as one of the questions in my Rule 9 request whether I was aware of
--
now of any specific guidance as to what to do if a situation like this is suspected and my initial
thoughts were no actually I wasn't and, and actually at the time I wasn't. Now, I know many
colleagues have been asked about their awareness of the Beverley Allitt situation and I was aware of
that. That was actually happening when I very first started my training in paediatrics as a very
junior doctor. I was not aware at all of any recommendations that had come out of that in terms of
specific processes and avenues that could be followed.
LANGDALE: One of the recommendations of the Clothier Report, which followed it, was that there
should be heightened awareness in the NHS of this case, of the Allitt case, to let people know that
this could happen in their space, in their watch, and it could be a nursing professional who was
responsible. From what you are saying, that heightened awareness either through Policy documents or
more culturally wasn't in place at the Countess of Chester at the time of these events?
JAYARAM: I cannot recall safeguarding training that I have had, not just at the Countess but in my
training as -- as a paediatrician in training, which ever specifically talked about the situation
where it might be suspected that a professional colleague could be causing deliberate harm. Now, I
found this Just Culture Guide because in answer to that question, I wanted to know if there was
anything. And I stumbled across this.
LANGDALE: Perhaps we can enlarge the first box 1A and also the Just Culture Guide?
JAYARAM: And I believe this was published around 2018 or 2019 but I wasn't quite clear.
LANGDALE: Did you have to dig hard to find it or was this something you were aware of before you
were asked the question?
JAYARAM: I heard about it because a colleague of mine who's a relatively new Consultant had been
involved in -- there is a new structure, PSIRF, the Patient Safety Incident Reporting Framework and
she had been on some training for PSIRF and when I was asking people if they had known -- knew about
anything, she mentioned that she had seen this document and forwarded it on to me.
LANGDALE: I am curious, Dr Jayaram, what you are supposed to take from 1A was there any intention
to cause harm. Intention is very difficult to judge, isn't it, at the outset and the focus ought to
be on the harm caused to the child, shouldn't it?
JAYARAM: Yes.
LANGDALE: What is the harm and then what might be involved?
JAYARAM: Yes.
LANGDALE: Intention is a different step, isn't it, it may be obvious in some cases but --
JAYARAM: Well, it is very subjective because if one is investigating an incident and there is a
possibility that an individual could potentially have caused harm, how do you establish whether or
not there's any intention to cause harm without actually asking that individual? And I think it
would be very unlikely particularly if we apply this document to the situation that we were in at
the Countess, it would be unlikely that they would respond yes to that question. And I would imagine
because in 99.9% of the time there isn't going to be an intention to cause harm because we don't go
to work to look after children and babies with the intention of causing harm, but what I was also
interested when I saw this is the first recommendation is to follow organisational guidance for
appropriate management action and then there is a number of issues. Now, I am not aware of any --
outside of SUDiC processes of any specific organisational guidance even
now but I don't know about in other institutions.
LANGDALE: That can come down now, thank you. Certainly for the cases we are looking at, the SUDiC
guidance was enough, wasn't it?
JAYARAM: Yes.
LANGDALE: It covers first of all what should be done in terms of referral but secondly, as your
experience illuminates, referral to professionals who should understand this --
JAYARAM: Yes.
LANGDALE: -- should immediately get and grasp what you need to do which isn't exercise judgment but
undertake neutral steps and measures to ensure children are safe while you are finding out what's
going on?
JAYARAM: I agree.
LANGDALE: So the SUDiC process made loud and clear that it applies just as much in hospital as out
and when members of staff are involved would cover, do you think, the lack of knowledge around this
area that we appear to be seeing in the Countess of Chester at the time of events?
JAYARAM: Yes, I think so, particularly if we are thinking outside of natural causes, without a
doubt.
LANGDALE: Well, a death that's sudden and no natural causes and we have heard evidence that with
neonates if
they die naturally -- they may die suddenly, but naturally you can see what it is?
JAYARAM: Absolutely.
LANGDALE: So it doesn't fulfil that important component of unexplained, does it; it is a sudden
natural death?
JAYARAM: (Nods)
LANGDALE: Can we move now then to the babies in question and your clinical involvement with each of
them and what you saw at the time and I am going to separately thereafter look at how doctors were
sharing concerns and then concerns with the Execs. I am sure the areas and themes will overlap a bit
but so that we can make it manageable for you and with the documents as well, we are dealing first
of course for you with [Child A]. And you have, if it helps you, your notes of [Child A] INQ0000017, page 18 and 19 of your notes. Go to page 19, the last paragraph.
We see you informed the Coroner and in your written notes you are discussing the possibility of
abnormal heart rhythm caused by a long line or a complication from the umbilical catheter and you
are looking at unrelated events as well, such as a bleed of the brain. But you report it to the
Coroner don't you, and you are concerned about this death at the time?
JAYARAM: Yes. I was concerned because clinically it didn't seem to fit with anything obvious. I
think, as I have written there, I have kind of written my thought processes through things we know
could cause sudden, sudden deterioration.
LANGDALE: You also later on refer to, if we go to INQ0001982, page 11, you tell the police about the discolouration of the baby,
so let's look at that. The penultimate paragraph, you talk about: "He had unusual discolouration,
you would expect babies to look fairly ghastly and pale and grey, but he had an odd sort of
discolouration where there were flitting patches of pink areas on a background of bluey-grey skin.
These patches seemed to appear and disappear. It wasn't like [a] rash [or sepsis] ... it would flit
and reappear and disappear. It didn't fit with anything I had ever seen before." You explain you
didn't put those in at the time in your notes?
JAYARAM: No, I didn't and this is again something that in retrospect I wish I had for many reasons.
At the time of Baby A [Child A]'s collapse and resuscitation, I had been called over, I noted it, I
didn't really at the time appreciate the significance. When I came to write my notes I didn't
document it. You know, I have subsequently been, you know, it's been suggested to me
that it's a false memory but I know that other people saw it as well, so ...
LANGDALE: I am just asking you about the rash. I am not repeating territory you have been through
about that.
JAYARAM: But the -- no, but the description there is what was happening.
LANGDALE: That can go down, thank you. You, we know, had no direct involvement with [Child C], D or
indeed the collapse of B. You weren't -- you were in outpatients clinic then you were travelling to
a conference when [Child B] collapsed, you were on professional leave when [Child C] died and [Child
D] you had no direct involvement with, either. At paragraph 221 of your statement, if we can go to
that, you say about [Child C]: "I don't recall at what point I was made aware of their case although
I knew that Dr Brearey was going to be meeting Eirian Lloyd-Powell on [22 June] to discuss the
deaths of Children A, C and D so I would have been made aware of the death of C by Dr Brearey at
some point between [17 June] ... and when the meeting took place on [22 June]." We are going to come
later on to their meetings and information that they were sharing around the three babies, but were
you very much reliant on their
discussions for information about B, C or D? At this time?
JAYARAM: At this time, yes, and I'm not sure it had a huge amount of detail at this point.
LANGDALE: We will come to it later what you were -- you got from them. Children E and F, you tell
us in your statement you don't have any independent recollection of involvement with Twins E and F.
The case notes record you were present at their deliveries and also that you provided advice on the
management of the hypoglycaemia of Baby F [Child F] on 5 August 2015. You now know of course that
the blood tests that you requested revealed results that the hospital didn't see until much later
and I think you say -- well, tell us when you first became aware of the abnormal results suggested
of the insulin?
JAYARAM: I first became aware of the results with Baby F [Child F] once the police investigation had
been undertaken. It was already ongoing. I wasn't aware until that point.
LANGDALE: So having requested tests would you later on as a clinician go back and look for it or if
you are not around the next few days and you are into another week do you leave other people to pick
that up?
JAYARAM: So it depends on the context and when they were requested. So the way we worked is that
they would be -- there would be a named Consultant for the baby but we worked on a week at a time
covering the neonatal unit. So at the time of the hypoglycaemic episode for Baby F [Child F] I was
the on-call Consultant, it was discussed at handover that the sugars were low. We as a matter of
routine have a serious of investigations that we request when a baby is hypoglycaemic and again
usually there are physiological explainable reasons for it in premature babies, but one of the tests
is as well as looking at glucose and other indicators in the blood is to do an insulin and C-peptide
level. Usually once those results are requested the results will come back -- there is often a big
of a lag time. It wouldn't ordinarily be that the on-call Consultant would be the one responsible
for chasing those results. What should happen, however, because of on-call systems and handovers
that the handover system should be robust enough to note that these bloods have been taken and that
the results are outstanding. And one of the problems with some tests, insulin C-peptide
particularly, there can be a lag time of sometimes several days for those results to come back. At
the time, there were systems for abnormal results for anything to be flagged up by a phone call from
the labs, otherwise paper results come back. I can't explain why this result was not actively
chased, although having done these investigations for many years in hypoglycaemic babies invariably
the results come back normal or slightly high insulin levels because of Congenital Hyperinsulinism
or small for gestational age. And so there's almost an element of well, these results are always
normal and I don't know why this one wasn't looked at, whether -- there are a number of things that
I think need to be considered; process of handover, is it recorded? We have handover sheets that are
updated twice a day, it should have been on the handover sheet as an outstanding result to chase, it
should have been in the notes as an outstanding result to chase. I don't know myself whether this
result was phoned back and I'm not sure at what point the paper result came back or to whom it came
back to. I -- I would say and I don't think any clinician would disagree, that although I was the
one that suggested the bloods should be done it was an out of
hours on-call thing, it wouldn't have necessarily been me that should have actively looked them up,
but there should have been a better process for ensuring that these results were actively looked for
and that should apply to any test, why do a test unless you are going to look at the result?
LANGDALE: Dr Gibbs in his evidence to the Inquiry said that this was a collective failure of the
paediatricians. Would you agree with that?
JAYARAM: I -- I would -- I would agree. Because as I say, if you do a test, you are trying to find
something out. The result should be looked at. You can't assume it is going to be normal. I think
another issue here as I understand is when it was looked at, the significance of the results was not
-- was not understood. I -- I can't comment on that.
LANGDALE: We know from the Beverley Allitt case of course insulin tests were very important in
recognising foul play --
JAYARAM: Yes.
LANGDALE: -- had taken place? This was a missed opportunity here, wasn't it?
JAYARAM: I agree.
LANGDALE: The point of Baby F [Child F]?
How are results taken now, what's the system for --
JAYARAM: So the system is different now. We have an electronic case note system and then electronic
results system. So we don't have paper results. So any, any result for any test comes back on to the
electronic system, it will appear on in the kind of results inbox for the ward of the patient and
also the named Consultant as well and results have to be endorsed. So we get regular updates of
results that have not been endorsed. So when I say "endorsed", somebody has to physically look at
the result and sign that it's been looked at. Abnormal results, be they high or low or outside the
quoted normal range are usually flagged up in red.
LANGDALE: Are they flagged up with an "H" and an "L", something to make it quick and easy to see
what's high and what's lower than normal?
JAYARAM: Yes, and again there is still a system where if there is concern the lab will phone up. But
it's not always clear who they speak to and how the results when they had been phoned through get
communicated through to the right people. So the system is I think now more robust than it was but
there is still potential for things to be
missed. For example, if a baby or a child is admitted under a Consultant's name who isn't the named
Consultant or there's another Consultant in another specialty in the hospital with a similar surname
and the same initial and that happens occasionally, but usually what will happen is person the
result comes back to will say "this isn't my result" and will forward it on. So there are -- there
are safety nets there.
LANGDALE: Has there been internal learning from this case or this set of results actively, or has
this just been the case?
JAYARAM: Yes, I would say there absolutely has particularly with regards to sort of looking at
hypoglycaemia investigations. Number one, understanding of what the actual numbers mean; and number
two, the importance of making sure that all results get looked at.
LANGDALE: Baby G [Child G]., you had limited involvement in the care of [Child G] but you had taken
over as paediatrician of the week on 7th of the 9th and at the morning handover you would have been
updated she had a sudden deterioration overnight but at the time of the handover she was relatively
stable. We know of course there was a conviction in relation to Baby G [Child G] for overfeeding
with milk?
JAYARAM: (Nods)
LANGDALE: And her father gave powerful evidence to the Inquiry about how she vomited and how she
presented. You did not have any other clinical involvement but were you involved in any debriefs or
discussion around the collapses of Baby G [Child G] on 7th of the 9th or 21st of the 9th?
JAYARAM: I don't recall being involved in any of those discussions.
LANGDALE: It's difficult to see indeed if there were discussions around the babies who collapsed or
survived from an Inquiry perspective. Can you help us with what the protocol or practice was if a
baby survived or recovered from a deterioration, was there due attention given to discussing what
may have happened to the baby?
JAYARAM: So I think that's a really important question and I will -- I will try and answer it as
best I can having thought about things. It would all depend on the circumstances of the event and
the collapse. And bear in mind particularly earlier on we were thinking within the realms of, of
natural events. So if the baby survived we would often say: well, they were premature, maybe sepsis,
but they are fine
now. Now, sometimes these would get Datix reported, particularly if it was clear there had been some
kind of error or omission that might have contributed to it, for example a cannula that had tissued
or observations to suggest abnormalities, to suggest deterioration that had been missed and if they
were Datixed they would have got further review. But there was no standardisation of which ones
would be Datixed and again if they weren't Datixed and the babies got better it was kind of, well,
thank goodness for that, let's carry on. Now, in retrospect, I do think that if we Datixed every --
and this is where it gets difficult, do you Datix every deterioration, what is the threshold at
which point you report? You know, so some babies may deteriorate but not arrest and turn around. Had
they been Datixed and -- and one of the things with the perinatal Morbidity and Mortality Meetings
is that we would have ordinarily have discussed, been more likely to discuss babies who had had
non-fatal collapses. What was happening around this time is that there were so many catastrophic
fatal events to discuss that there was almost a lack of time to discuss them.
LANGDALE: Just dealing with the Datix point. A Datix of
course is when you see something that might be a problem or an error so you Datix that error. The
staff error. Of course if we are dealing with a member of staff who is deliberately harming they are
not going to self report that and you are not necessarily going to see?
JAYARAM: No.
LANGDALE: -- that it is not an error, it is a deliberate act, isn't it? So in terms of how the
Datix system might work, simply reporting in the way you are required to report a Sudden and
Unexpected Death because it's sudden and unexpected and you don't know what happened, if it's a
deterioration that is sudden and unexpected as opposed to a sudden deterioration in a naturally
deteriorating baby, do you think that would go some way to triggering the level of discussion? So
there isn't a need to own a particular error or mistake in the circumstance; it is just we don't
know and actually --
JAYARAM: Yes.
LANGDALE: -- this is a problem that we don't know?
JAYARAM: Yes, and I agree and I think now my -- my threshold for thinking beyond natural events is
-- is -- the bar is very low and I do think there is an argument for saying perhaps in these
situations if there is no clear explanation, as well as Datixing perhaps even
thinking going down the SUDiC line as well. Because it can apply to near misses too. I think in
terms of a Datix had some of these non-fatal collapses been Datixed they would have been reviewed
but I suspect the outcome of those reviews would have been we can't see any specific clinical issue
and it may not have brought us any further forwards because again we are thinking within the
confines of natural events.
LANGDALE: Baby H [Child H], and if you go to paragraph 279 of your statement, we know you were
called in at 0132 hours as Baby H [Child H] had increasing ventilator requirements for a few hours.
She seemed to have stabilised by midnight but had a sudden deterioration at 0114 hours. You say you
didn't have specific concerns around the care of [Child H] or the conduct of Letby at that time.
Looking at paragraph 279 and 280, though, you do recall observing to Dr Brearey privately the next
morning something. Can you tell us what you said to Dr Brearey?
JAYARAM: Yes, I --
LANGDALE: Also your thoughts or observations about the valve on the chest drain --
JAYARAM: So having been called in that night and again it -- as I walked in it struck me it's --
it's Letby again. And my thinking at the time is, you know, she's very unlucky that she seems to be
associated with all of these. Again -- and I in terms of the chest drain valve, it was something at
the time there was a lot of hands in the incubator there was a lot of -- of -- of moving, there is a
lot of procedures. I saw it seemed to be in a closed position and opened it and I mentioned to Dr
Brearey the next morning that it was -- it was -- it was Lucy Letby again, simply because I was
thinking, well, she's -- she's very unlucky. Now, obviously knowing what I know now and subsequently
when I -- when the investigation was launched talking about these and sort of before then talking to
Sue Hodkinson, I raised this because again retrospectively and again I -- I can't say whether that
was deliberately closed or not, it wasn't something that I had even considered at the time, because
at that time I was not thinking somebody could be causing deliberate harm. I had noticed that
association with Letby being present but not with any, any thought of anything untoward.
LANGDALE: And the chest drain in a closed position rather than open, is that easy to -- well, what
did you
make of that?
JAYARAM: Well, at the time my thought process -- and again trying to make things fit, there was a
lot of handling going on, there was a lot of hands in the incubator, there was a lot of -- a lot of
examination. I was wondering whether it could just have been accidentally knocked. Now, again,
thinking about it, it could happen but in retrospect it's less likely. The honest answer is I don't
know.
LANGDALE: You mentioned that you spoke with Sue Hodkinson about that in March 2017 and we will go
to that later, if I may.
JAYARAM: Yes.
LANGDALE: But at that point around Baby H [Child H], you had those thoughts and you had that
conversation with Dr Brearey. Baby I [Child I]. You were away from the hospital I think on
professional leave on Friday, 23 October and you were debriefed around 2 November, you say, about
the death of Baby I [Child I] and if we go to paragraph 294, can you tell us what you say at
paragraph 294 and 295?
JAYARAM: So it says: "When I returned to work in early November 2015 and became aware of the death
of [Child I], and the repeated associated presence of Letby, I became concerned for the first time
that Letby could somehow be causing
inadvertent or even deliberate harm. "My initial reaction to this was to tell myself this is
ridiculous but once the thought was there it became harder to ignore given the unusual nature of the
events and her presence every time. I recall there were several informal 'corridor conversations'
between Consultants at this time. I cannot recall who amongst us was the first to articulate
possibility of Letby causing inadvertent or deliberate harm but when expressed openly it became
clear that I was not the only Consultant with these concerns."
LANGDALE: We are going to come to the mortality table later but the informal corridor
conversations, can you remember who they were between at this time? Clearly you, Dr Brearey, anybody
else?
JAYARAM: I think Dr Newby may have been involved and Dr Gibbs as well. And I think -- I can't
remember specific conversations, but my impression was that all of us had begun to consider whether
her presence was of significance rather than just coincidental and bad luck. I -- I don't know
whether all of us had genuinely begun to consider could she potentially be causing deliberate harm.
And again that's something, you know, we are still not -- finding it difficult to think the
unthinkable.
But as I have said in my statement once that thought is on your radar, it's very hard to shut it
away. But you also become very aware of the fact that you run the risk of confirmation bias as well
and seeing things that aren't there.
LANGDALE: Paragraph 304 you tell us with [Child J] you were out of the hospital and you don't
recall being made aware of the collapse on 27 November on your return on Monday, 30 November. You
say: "As [Lead for Children's Services], I had not been made aware of collapses routinely. If [it]
was reported via Datix it would have been escalated and reviewed by the neonatal [lead]." That might
be true ordinarily but in these circumstances did anyone find you or come and tell you about Baby J
[Child J]?
JAYARAM: Not that I can recall specifically. That's not to say they didn't but I don't recall and I
would imagine -- again I am speculating here -- that had I been told I would probably have asked
actively who, who the nurse was. But the genuine answer is I can't remember.
LANGDALE: Baby K [Child K]. You have given evidence in two trials about Baby K [Child K]. If I can
ask you to summarise, what did you see at the time and what did you say to anyone at the time about
what you saw and your suspicions or concerns?
JAYARAM: I would like to talk in some detail about this, if I may. So Baby K [Child K] was a very
premature baby who -- in whom -- the mother had not been able to have been transferred to a tertiary
centre, so at 25 weeks gestation was born at the Countess in the early hours of the morning. Baby
was stabilised on the neonatal unit, unwell but stable and -- I mean, I will go into the details.
They have been widely reported. But another nurse -- I'm not sure if she is ciphered or not so I
won't say names, but another nurse was the named nurse looking after the baby and told me that she
was going to the delivery suite to update the parents and that Letby was -- we used the term "baby
sitting" so another nurse sort of covers while another nurse has to be away. Now, it's been
reported, there is a narrative that, you know, I walked in and caught Letby doing something and that
is incorrect. I was sitting outside the room writing in the notes, but by this stage I had
significant discomfort -- this was February 2016 -- and I just felt uncomfortable knowing that Letby
was in the room.
And actually I was convincing myself that I was being completely irrational and ridiculous and so I
got up and went in just to make sure everything was fine. There's been a lot of speculation about
whether the alarms were there or not and all the rest of it but I didn't walk in and see anything
happening. What I walked in was to find a baby clearly deteriorating and then when I went to assess
Baby K [Child K], the endotracheal tube was dislodged but importantly, the nurse looking after the
baby, who I believe ordinarily by this stage would have flagged up this deterioration, because in a
baby of this gestation whose oxygen saturations are dropping, the first thing you do is look at the
baby, look at the ventilator, the chest isn't moving, it's likely it's a tube problem, not
responding at all. And at the time, my priority was to resuscitate Baby K [Child K], which we did
successfully. I will take this with me to my grave, I at that point thought: well, how has that
happened? Now, in isolation in that if nothing else had happened before or after, I would have
probably thought nothing more of it. But was it just coincidence that this baby who had been stable
to this point in the period where the nurse looking after the baby and Letby was supervising the
baby, this event happened?
Now, it's been said to me in many different fora: why didn't you just pick up the phone to the
police? Or why didn't you raise it with somebody else? Or why didn't you do anything at all? And I
know that, you know, it's been flagged up by one of the previous Executives that if they had known
about that they would have done something and something of a mea culpa: why didn't I? And I lie
awake thinking about this. There is a fear because it's such a seemingly outlandish and unlikely
thing that someone is causing deliberate harm, it's the fear of not being believed, it's, you know,
said to me: why didn't you just stand up and tell everyone what you thought had happened? It is the
fear of not being believed, it is the fear of ridicule, it is the fear of accusations of bullying
and I appreciate -- and I will say this to the parents of Baby K [Child K] and all the other parents
-- that seems entirely selfish, just thinking about me and not the baby. But these are the
realities. I am trying to explain why that -- and I didn't want it to be that. I -- I internalised
it and I -- I -- I wonder and I will never know if I had articulated that concern at that point,
would it have made a difference? Now, bear in mind by this point, the Thematic Review Dr Brearey had
undertaken had already been done
we had seen a draft report. The staffing mortality analysis that had been done had already flagged
up Letby and in the context of those, I should have been braver, I should have had more courage
because it wasn't just an isolated thing, there was already a lot of other information. Now, whether
-- I can only -- I can't speculate on how people might have responded. But I am just trying to -- I
am trying to -- sort of trying to explain my thought processes at that time. And -- and I don't know
whether it's appropriate to say this here, it's been suggested to me that I just made that up which
is, you know, I will refute it is nonsense. There is no reason I would. But what I will say is that,
you know, I think that is somewhere where I should have had -- I should have had more courage.
LANGDALE: Is Baby K [Child K], we will come to it later, one of the babies you spoke to Sue
Hodkinson about in March 2017?
JAYARAM: I can't remember.
LANGDALE: Okay.
JAYARAM: When we come to it.
LANGDALE: Okay, do you remember if you spoke to Dr Brearey about your description of that event at
all about Baby K [Child K] at the time or not?
JAYARAM: I -- I can't remember in detail. I think I sort of mentioned it in the sense another event
had happened and Letby was there but I don't think I specifically articulated the thought processes
I was having at 3 o'clock in the morning.
LANGDALE: So did you articulate those thought processes that you were having at 3 o'clock in the
morning, you say, with anyone in the hospital?
JAYARAM: I think between ourselves not at that point, there was a -- and as time went from February
16 onwards, there was an increasing feeling between all of us that, however unlikely, unwanted,
abominable the thought of Letby causing deliberate harm could be, that elephant in the room was
becoming bigger and bigger and we -- we felt completely impotent to know how to deal with it. We
knew that the Thematic Review had been done and hadn't identified any obvious clinical causes. And I
assume colleagues were also aware that that Thematic Review had been escalated through to the
Medical Director and the Director of Nursing with a request for a meeting. I naively -- I am going
to use the word "naively" quite a lot I think today -- assumed that the Nursing Director and the
Medical Director would look at that and see the pattern and act.
And maybe I was reassured that, you know, there is, there is enough there for people to act anyway.
But, yes, I -- I can't really articulate more about Baby K [Child K].
LANGDALE: Well, again I suppose picking up on what you said about speaking to CDOP it depends who
you are giving that information to someone with a safeguarding perspective --
JAYARAM: Yes.
LANGDALE: -- had that information by this point there had been a number of collapses a number of
deteriorations and you were saying they are sudden and unexpected leaving aside a member of
staff?
JAYARAM: (Nods) And I think it's also and again this is my misunderstanding at the time, I
understand entirely now that having enough grounds for suspicion is enough to escalate and I think
for example had I walked in with Baby K [Child K] and witnessed something then that would have been
very easy, you know, that's -- that's a no-brainer but I think this was all -- you know, it was all
very circumstantial and I think we felt or we believed because it was such an outlandish and
unlikely possibility that we -- you know, did we need more to raise it? And of course it took us in
the end until the third week of June in 2016 to feel we had enough to raise it.
LANGDALE: Did you at that time not understand mere suspicion is enough? I know -- we will come to
the Execs, they were looking for proof and what was your evidence and all that stuff, that comes out
repeatedly. Mere suspicion is enough, that is not what you appreciated?
JAYARAM: Yes, no, I just didn't understand, I don't think any of us understood that at the time,
particularly in this situation involving a member of staff. And of course when you think about
safeguarding in other situations, for example a child who has come in with unexplained bruising.
LANGDALE: You know mere suspicions --
JAYARAM: Of course suspicion is more than enough to trigger the process.
LANGDALE: [Child M]. You say the presence of Letby at the unexpected collapse of Baby M [Child M]
added to your concerns and that is at paragraph 361 of your statement. If we can go, please, to your
police statement at INQ0001982, page 11, [Child M], at the bottom if you go over to page 12. You
attended after he had collapsed. Resuscitation was under way; displayed the same type of unusual
blotching as [Child A]:
"Didn't fit with anything I had ever seen before." You tell us in your statement that you went on to
discuss this with Dr Brearey. So you had seen these patches, blotches again that were odd. What were
you thinking at that point, what did you start to think about?
JAYARAM: Again, I hadn't at that point, although myself and colleagues were -- had begun to wonder
about the possibility of Letby deliberately doing something, we hadn't really started actively
thinking about what might be being done. And again in these situations Letby was there, it was an
unusual, very unusual collapse and this unusual discolouration. Again we are thinking along the
lines could this be sepsis? But it doesn't quite seem to quite fit, could this be some kind of
cardiac event didn't seem to quite fit. And when I discussed with Dr Brearey essentially I
mentioned, you know, it was another one with the blotching but in this situation we actually had a
successful resuscitation.
LANGDALE: So again -- that can come down, thank you -- the pressure fell off that the child
resuscitated well?
JAYARAM: Yes.
LANGDALE: And it wasn't something there was debriefed, discussions?
JAYARAM: It sounds awful to say, had the outcome been different it might well have triggered a more
in-depth response.
LANGDALE: You say at paragraph 374 of your statement: "An event such as that around [Child M] might
usually have been discussed at the [Perinatal Mortality Meetings]. However, given the number of
deaths there had been there was not the capacity in the scheduled three monthly meetings to discuss
the non-fatal collapses." We see in fact Baby E [Child E] isn't even reached in one of the meetings
that Baby E [Child E] is supposed to be being discussed. Just dealing with those meetings generally,
having reviewed a number of notes of the meetings, they don't -- usually because the postmortem
comes in later -- usually review postmortem and clinical findings at the same time in great detail
from the ones we have seen for the babies of the indictment?
JAYARAM: Yes.
LANGDALE: Is that your experience more generally of them?
JAYARAM: So ideally by the time a baby is discussed at the Perinatal Mortality Meeting we would like
to have
the postmortem back and, you know, the pathologist will come down and discuss. This was -- there
were -- this wasn't happening as frequently, so babies were often being discussed without the
postmortem findings. Ideally, when the postmortem findings were back, they would -- they should have
been rediscussed. I don't think that was happening consistently just due to time constraints.
LANGDALE: We have seen the records of those.
JAYARAM: So to an extent the value of the Perinatal Mortality Morbidity Meetings was not as
effective as it might have been without those. I think the important thing about those meetings as
well -- and I have thought long and hard about this -- as to whether they would have been a forum to
flag up the specific concern about deliberate harm. Again, it's very much like a lot of the meetings
looking at systems, looking at processes, looking at what was done, how it was done, was it done at
the right time, was it the right thing, was it too late? It -- I don't think it is a forum where it
would have taken -- if I may use the analogy of the Emperor's new clothes, you would have needed
somebody with the courage of the little boy to actually put their head over the parapet and say,
"There is no clothes" and
I don't think in that meeting it's something that would have necessarily been on anyone else's
radar.
LANGDALE: Before we even get to deliberate harm, what was necessary was that the doctors and the
nurses and the parents in some cases -- let's be clear, the parents had key information to
provide?
JAYARAM: (Nods)
LANGDALE: -- particularly the Mother E in relation to --
JAYARAM: Yes.
LANGDALE: -- her baby. They all needed to be in the same spot discussing this, didn't they, to
share their own observations about who had seen what, because the meetings are dependent on the
notes that arrive there --
JAYARAM: Yes.
LANGDALE: -- and the people who attend?
JAYARAM: Yes.
LANGDALE: We haven't seen notes of meetings with all the various people who make observations, for
example, on Baby A [Child A] or Baby C [Child C] or Baby D [Child D] all in the same room discussing
it with a postmortem report where the contradictions and inconsistencies can be fleshed out?
JAYARAM: Yes.
LANGDALE: It is not possible, is it, in the context of meetings with only one of the doctors who
wasn't there?
JAYARAM: I think that's a really important observation.
So even in terms of Perinatal Mortality Meetings, the doctors, nurses, midwives involved wouldn't
necessarily be available or free to attend the Perinatal Mortality Meetings at that time. The rapid
reviews that were undertaken by the neonatal lead, the neonatal ward manager and the risk
facilitator did not routinely have people in attendance who were there at the time. If it was
escalated to a higher level they might be there if there was a Level 2 investigation and you made a
really important point which I had never considered before, yet it is so obvious: parents'
observations need to be included in these as well, every time, you know, not necessarily present,
but, you know, information from the parents needs to be there.
LANGDALE: You either have everybody who's present writing things down, which of course they
eventually did in a police station investigation, giving statements to the police for that perinatal
or neonatal mortality meeting to discuss, or you have to have them there but would you agree with
me, certainly in the babies we have been looking at, they were relatively superficial analyses and
refer a lot to obstetric care, antenatal care --
JAYARAM: Yes.
LANGDALE: -- things like delayed cord clamping, important but not what this was about?
JAYARAM: Yes, no, I agree.
LANGDALE: They can in some sense give a false reassurance. You see a load of documents and think:
well, that was considered then. Well, not really for the information that we are analysing.
JAYARAM: Yes, yes, and I think -- I suppose if you don't ask the right questions you are not going
to find the important answers.
LANGDALE: And if you have a set process, you are not going to?
JAYARAM: No.
LANGDALE: If you just follow a set process you are not going to get the important answers?
JAYARAM: No, I agree.
LANGDALE: You refer to a Level 2 investigation, I don't know what that means, but if something's
really odd, actually having a debrief, hot debrief -- I don't know what you call it in the NHS --
but everyone around a table to discuss it --
JAYARAM: Yes.
LANGDALE: -- is what was required. Is there room for that thinking outside the box or the
processes?
JAYARAM: So in terms of debriefs, a hot debrief is sitting down immediately afterwards and, you
know, does anyone -- is everyone okay? Any thoughts about what's happened? What can we do
differently? A cold debrief is more when the dust has settled, there is time to think -- there may
or may not be postmortem findings, to have a think through what we did well, what we could have done
better, what for the future can we do. Now, I think those are important, essential. I think
interestingly had those debriefs happened and -- and they tend to be the hot, the cold debriefs are
usually planned to try and find a time where the majority of staff involved can be present. Now, of
course in these situations Letby would have been present as well. So I can only speculate on again
whether those discussions might have been more revealing, but I do think that even with her present
there's an opportunity for the -- for everybody to express -- I suppose to say this doesn't make
sense and it triggers an opportunity to look further.
LANGDALE: Well, Letby's presence might have been helpful to the extent that, for example,
discussing the medical notes around Baby E [Child E], there was a direct conflict between
Letby's notes and Mother E's evidence?
JAYARAM: Yes.
LANGDALE: So again having everybody there can still be useful?
JAYARAM: Yes, yes, and it depends on the level of detail in the discussion as well. But, yes,
absolutely, I couldn't disagree.
LANGDALE: [Child L] was another child that you had actually recommended changes to fluid management
for and requested blood tests, same as my questions earlier about [Child F]. Obviously that insulin
test result wasn't appreciated at the time. Missed opportunity, would you say? As you have said
before, that should have been picked up.
JAYARAM: Yes. So I am aware with -- sorry, it was [Child L], wasn't it?
LANGDALE: Yes.
JAYARAM: I am aware with [Child L] that when the insulin C-peptide result came back, it was
documented in the notes by one of the junior paediatricians in training. I wasn't clear when I saw
the notes whether those results had been discussed with anyone more senior, but an impression was
given that the result was back and I think the error carried forward that there was nothing
abnormal.
Now, interestingly, at the time of the episode of hypoglycaemia, it was the same day as the baby's
Twin had the non-fatal collapse and had problems with resuscitation. One of the things with this
baby's hypoglycaemia is that I was not at the time -- even with Letby being present, I was not at
the time concerned about anything unnatural going on and to the extent that we know that premature
babies who are on the smaller side can become hypoglycaemic, again if they are hypoglycaemic, we
need to do the investigations to exclude other things, but the amount of glucose that was needed to
maintain normal blood sugars, although higher than a normal healthy baby, was not at a point beyond
what I had seen in babies in similar situations with natural reasons for hypoglycaemia. So I saw
this little one a few days later on a ward round on a weekend, and I think I wrote in the notes
"resolved hypoglycaemia". I wasn't prompted to look to see whether the investigations had come back.
So I didn't look back in the notes. One of the reasons I guess I didn't look back is the
hypoglycaemia had resolved. Secondly, I hadn't had a suspicion that there was anything unnatural
going on. Thirdly, and to be honest, I will be honest, I don't recall whether I had been told
whether the results were back or not, I can't remember what was on the handover sheet for that time
to say it was an outstanding result or it may have been at handover, it had been handed over that
the results were back and everything was normal. And again, I have thought long and hard about this.
Was there a prompt for me to look back in the notes and see or double-check? I think because I
hadn't had a suspicion in this particular situation of the glucose, the low glucose being something
that was unnatural, it wasn't really a prompted resolve, as often is the case.
LANGDALE: [Child N], we know you were on annual leave when events occurred in relation to [Child
N]. [Child O] and P [Child P], you were away from the hospital on 23 June and you became aware of
O's death on 24 June and you deal with this at paragraph 392 of your statement and the Inquiry has
heard evidence from both Karen Townsend and Karen Rees about this. Can you tell us now the
conversation and the meeting you had with Karen Rees on 24 June -- you sent us the calendar invite,
we know that meeting had been set up but tell us now.
JAYARAM: Karen Townsend or ...?
LANGDALE: Townsend, sorry, first.
JAYARAM: So Karen Townsend was the Divisional Director
for Urgent Care, so she wasn't clinically based but she was -- had ultimate management
responsibility of the division. I got on well with Karen I didn't meet with her very often and I had
requested a meeting with her to discuss a number of issues around the department and the service
including this as well. Karen suggested meeting on that Friday morning in the Comfort Zone. The
Comfort Zone is a charity-run cafe with a big sort of seating area around it as well. Now, it was on
my list of things to discuss with her about our concerns about Letby. The meeting was set up before
the [Child O] -- before [Child O] had their event. So at the meeting, I think I discussed about
there are a couple of issues around the service in terms of I think the -- I can't remember
specifically around -- I think Karen Townsend kept a note of it but I raised to Karen Townsend the
specific concern that we had; that as a group of Consultants -- and I think this is very important,
because it seems to have been carried forward from here, and this is a narrative that seems to have
become embedded, that it was just myself and Dr Brearey. But I stated that as a group of Consultants
we were concerned, extremely concerned, about these events and we were all at a point as a group
where we felt that natural causes had been excluded as far as they could be
and we were really concerned about her being on the unit. We had -- the Thematic Review had been
discussed with the Medical Director and the Nursing Director who just said: wait and see, but we
felt we couldn't wait and see and my intention really in asking Karen as a Divisional Director was
to get some help and support as to what to do. Because we were not comfortable with Letby at this
point continuing to work unsupervised on the unit. Now, I had not had the specific conversation with
Karen Townsend previously and I know that she said it is the first time she was aware of any of
these concerns. If I may, because I have seen a copy of Karen's transcript, she commented that if
she had had more information she would have put it on the Risk Register. Now, I didn't want to talk
to her that morning because I wanted her to put it on the Risk Register; I wanted to talk to her
that morning because she was in a position where something actively could be done to ensure that
Letby wasn't working unsupervised on the unit. I mean, I'm not sure being on the Risk Register that
day or any time would have necessarily made a difference. So that's my recollection of the
conversation.
It wasn't a confrontational conversation at all, and I just said to Karen, you know, please help,
you know, can you escalate this? Can you do something?
LANGDALE: Then did Karen Rees come and find you and have a further conversation?
JAYARAM: Yes. So I was in my office, I can't remember whether it was late morning or early
afternoon, and Karen Rees came to my office and said that, you know, she had heard from -- Karen
Townsend had told her that myself and Dr Brearey thought that Letby was deliberately harming babies
and wanted her moved from the unit and she said to me: I can't do that without evidence, give me
some evidence. I can't remember what I was doing at the time. But I said to her: look, if you want
the specific evidence, Dr Brearey can give you lots of details. She suggested that I -- I phoned Dr
Brearey, I can't remember whether I did, I knew that he was in clinic at that time. So I knew that
she was then going to go on and talk to Dr Brearey. I left mid-afternoon, I think that afternoon
because I wasn't there for subsequent discussions. So my -- my request really of Karen Townsend and
Karen Rees was to sort of say: look, we are really worried about this, we are not as a group
reassured that keeping her working unsupervised is safe. Please do something. I could have been more
forthright. I could have said specifically, "You must remove her from the unit" and I didn't say
that.
MS LANGDALE: Thank you, Dr Jayaram. I think that's a good moment to take a break. May I suggest a 11.35 return?
LADY JUSTICE THIRLWALL: Yes, thank you, Ms Langdale. So, doctor, we are going to take a break and we will start again at 25 to 12. (11.17 am) (A short break) (11.40 am)
LADY JUSTICE THIRLWALL: I'm sorry to have kept you all waiting. Ms Langdale.
MS LANGDALE: Dr Jayaram, may I move now to the Inquest for Baby A [Child A] in October 2016, so we
are moving on in time. You prepared your statement to the Inquest back in July 2015. In common with
your medical notes at the time, that doesn't make reference to the rash and you tell us because at
the time of events when you did the Coroner's statements in your notes, you didn't appreciate the
significance of that?
JAYARAM: No, and I can't remember writing the statement
but it -- it really wasn't in my mind at that time.
LANGDALE: When you write a statement we have heard from some of the junior doctors you sort of get
a pack about what's required or what's to be done. Did you get anything about guidance on putting
statements together?
JAYARAM: I don't recall getting anything specifically on this occasion. I had written statements
previously for safeguarding proceedings and things.
LANGDALE: Dr Lambie told us she understood it had to be factual about your involvement in the baby
--
JAYARAM: Very much so and we are always told that you should not speculate but just stick to facts.
LANGDALE: The Inquiry has a notebook from a paralegal called Josh Swash about meetings around that
time between Execs and legal department. If I can ask for INQ0108406; page 9. This is a telephone conference on the morning. It looks
like there was a meeting earlier with some of the doctors and but you weren't at that, Dr Jayaram.
Were you invited to an earlier meeting, do you remember?
JAYARAM: Yes, I recall that there were two dates, I think the first one I had other clinical
commitments and couldn't go.
LANGDALE: So you attend for this telephone call between
the people listed, so Stephen Cross, legal, Louis Browne, Queen's Counsel, yourself, Dr Saladi, Dr
Harkness and a Dr MacCarrick. If we go to page 10 we see noted Louis is explaining the Inquest, the
objective of the Inquest, pointing out -- someone is pointing out PM unascertained, the postmortem
says unascertained death. Cross pulmonary arteries, no suggestion it played a part in the death. Dr
Harkness makes contributions. Then if we go to page 11, Dr Jayaram: still to this day Ravi doesn't
know why this happened. 27 years in paediatrics, never seen this kind of situation. Did you say that
in the meeting or is that --
JAYARAM: I probably said words to that effect, that, you know, I couldn't -- I still at this stage
couldn't explain what had happened and it ...
LANGDALE: If we go to page 12, Dr Saladi, Coroner -- he says if the Coroner asks -- it looks as
though it says if the Coroner asks how did it inform future practice -- and I don't know who says
this, do you know who says: "Review Royal College of Paediatrics, pattern of deaths appear unusual,
further inquiry required, forensic review"? Then there is a reference:
"If review is outside of the remit of your knowledge, then say so." Just to anchor us in time, it
says the review is ongoing. At this point, the Royal College review has been received but you
haven't seen the Royal College review but someone has spoken to you about it; is that right?
JAYARAM: Yes, so at this stage my understanding of where things were up to is as follows: the Royal
College review had taken place, I had had if you like a hot debrief from Ian Harvey a few days after
they had been to feed back to me what they had fed back to the Executive board.
LANGDALE: What was that?
JAYARAM: So essentially that we were told that they hadn't identified any significant issues with
clinical practices, that there were a number of recommendations around team working and leadership
although he didn't specifically say what areas, and that they had recommended a forensic -- full
forensic Casenote Review and I think at the time he came to see me I actually sent an email to
colleagues summarising his conversation pretty much contemporaneously of what he had said was due to
happen and it was a full forensic review involving neonatologists, pathologists, all the notes, all
the staffing patterns. My understanding therefore at that time was that the College hadn't
identified any concerns around clinical practices, but they had recommended in terms of
investigating our specific concerns, further there needed to be a more detailed review. Just to take
a step back in July 2016, Ian Harvey had undertaken a review of case notes which we as a group of
Consultants felt hadn't really looked in a way to address our concerns. So we thought, well this is
probably a good thing because it's going to be a full forensic review. I was also -- after this
meeting, Stephen Cross sent me or emailed me a copy of an email he had sent to the Coroner.
LANGDALE: Let's get that one up then. Just before I go down from this meeting -- take this meeting
down. What did you think of the purpose of this meeting was, what was it about the pre-inquest
discussion?
JAYARAM: My understanding of the pre-inquest discussions is just to make sure everybody was aware of
the process and the kind of things that would be discussed. I didn't feel at the time that there was
any specific agenda to sort of direct me as to what to say or not to say.
Stephen Cross, as the legal adviser -- and also we knew that he was an ex detective -- had told us
in July that it would be absolutely inappropriate and the wrong thing to involve the police at that
stage. So again once again naively I assumed that might be the right -- the right advice. So my
understanding was that the forensic review would take place. Now, again, having talked to the
College reviewers and I know exactly what Dr Brearey and I told them, we kind of worked on an
assumption that the findings would either find something that we hadn't seen, in terms of clinical
care, clinical issues, or they wouldn't and then actually that would then be the prompt for the next
step, would be to go on to involve the police. There was, I don't think complacency is the right
word but there was an element that it wasn't as much -- there wasn't as much of a sense of urgency
because at this stage Letby had been removed from the unit and wasn't working clinically and I at
this point had not -- was not aware that actually she and some of her representatives were under the
impression that the College reviews would be used as evidence as to say whether she could come back
or not.
LANGDALE: Sorry, can I take you back to this note?
JAYARAM: Yes.
LANGDALE: It says here: "If review is outside of the remit of your knowledge, say so. Don't say
anything unless you know." Do you know who was saying that?
JAYARAM: I'm thinking it would either have been Stephen Cross or, or I forget the name of the QC.
Louis Browne?
LANGDALE: Louis Browne?
JAYARAM: I think there is another comment -- maybe it's on the page before this where it
specifically said "if you don't know, don't speculate".
LANGDALE: Yes, that is the page before?
JAYARAM: Yes, it is just underneath where it says "I&S" and that was Louis Browne: "If you don't
know the answer, say, no speculation."
LANGDALE: Let's go to the emails you wanted to refer to before. That can come down. If we have INQ0107964, page 24. You see the email at the bottom: "Dear Mr Rheinberg." So
this is an email from Stephen Cross to the Coroner: "You will recall that in your absence I advised
your deputy that the Countess was undertaking a review of neonatal deaths by the Royal College which
was undertaken at the beginning of September and the Trust is awaiting their report. "The Review
Team have indicated they were entirely satisfied with the care within the neonatal unit and raised
no concerns. However, they recommended that a detailed forensic Casenote Review of each of the
deaths from July 2015 should be undertaken, so consequently this is still a work in progress." Then
the next page: "I have instructed Louis Browne ... counsel in the matter and is fully aware of the
review and Dr Jayaram as the Lead Consultant is fully aware of this matter." Pausing there you
hadn't seen the letter of instruction, the response or the report, had you, until the review?
JAYARAM: Not until -- not until this point but this -- when this email was forwarded on to me,
Stephen Cross attached the letter -- a copy of the letter of instruction.
LANGDALE: To Dr Hawdon or the Royal College?
JAYARAM: The one to Dr Hawdon.
LANGDALE: So if we go to the next email, then, go back to page 24: "Dear Louis, "Thanks for the
case conference, most helpful. "Further to our conversation regarding disclosure to the Coroner
regarding the current review being undertaken, please see email below. I attach for information our
letter of instruction regarding the continuation of the review." You saw Dr Hawdon's letter of
instruction attached to that?
JAYARAM: Yes, you can see it was attached at the top, "DrJHawdon.docx". And when I read that it was
very detailed and it outlined what actually had been my understanding of what Ian Harvey had fed
back to me after his initial feedback from the Royal College, of a very detailed review involving
two independent neonatologists with pathological input, looking at all the notes, all the rest of
it. So my impression from this, although I note that Stephen Cross actually says he hasn't sent the
letter of instruction to the Coroner, was that the Coroner, number one, was aware of our specific
concern and that's a big assumption, because reading this, it doesn't specifically say that but --
LANGDALE: Aware of reviews going on --
JAYARAM: Sorry?
LANGDALE: Aware of reviews going on at the very least?
JAYARAM: Aware of our specific concern about an individual. The Coroner was also aware that very
detailed forensic level reviews were going on and so my -- my understanding at the time of the
Inquest is that the Coroner was already aware of the concerns that we had. And that these -- this
had been a recommendation from the College and this was being undertaken.
LANGDALE: That can be taken down. We had various copies of minutes or notes of the Inquest
including the Countess of Chester notes and also the Family representative at the Inquest which is
the fullest. So if we could go to that, we see at INQ0107909, page 5, we see at page 5 beginning the second last paragraph: "Mr
Rheinberg moved on to questioning Dr Jayaram." We see those two paragraphs and over the page the top
three, you are being asked very much factually about that long line position, arrythmia and the
details of your medical involvement. Then we also see if we go to page 8, you are recalled by the
Coroner to assist with knowledge of the circumstances concluding with any cause of death and you
say here, Mr Rheinberg asks you whether or not you have seen anything similar and you say: "Dr J
confirmed that normally death in neonates is the end point in a course of events and normally they
can be resuscitated. He confirmed there have been similar cases of neonates dying in similar
circumstances on the unit which they have not been able to explain. He confirmed that they had
downgraded the unit so that they do not care currently for preterm babies and they have also
requested an independent review and they are still awaiting the formal report. However, the initial
feedback from that is nothing can be found that is wrong with any of the training, any of the
practices or any of the equipment." Were you thinking the RCPCH reports when you are referring to
that?
JAYARAM: Yes.
LANGDALE: "However there is a potential issue with staffing. As far as Dr J is aware, this report
is to go back to the Executive board and they decide whether or not to release it to the public. Mr
Rheinberg asked whether or not it would be possible for the family to receive a copy. Dr Jayaram
said he is of the personal view that it should be made available for the public and he would have no
issue with a copy being provided to the
family. However, as he pointed out, it is the Executive board's decision. He has to confirm,
however, that the events that happened to [Child A] do not make any clinical sense to him at all."
And you set out in relation to the cardiac conductivity your concerns. Is that note accurate, as far
as you are concerned, does that encapsulate it?
JAYARAM: I think that is more accurate than the original Countess report that I was originally
supplied and I think that accurately reports what I said.
LANGDALE: So you were making clear you couldn't explain the cases, they were unexplained deaths,
you had had several cases similar and reports so far had said no issue with care from the RCPCH, but
an issue of staffing is being looked at?
JAYARAM: Yes, and I -- I was aware that the deaths had been -- I think bar one of them had been
reported to the Coroner. And I was also cognisant of the fact we had been told: do not speculate.
And, again, hindsight: I didn't specifically say I or we as a group are concerned that an individual
member of staff is causing harm. I was trying to make it clear to the Coroner that I did not
understand what was going on here and I couldn't think of a clinical explanation and there had been
other things like this as well. But I didn't explicitly say that.
LANGDALE: Stephen Cross's email which was forwarded to you made it clear he was in direct
communication with Mr Rheinberg?
JAYARAM: Well, it gave me the impression that, that the concern that we had, the specific concern
regarding Letby, was on the Coroner's radar. Now I in retrospect don't know whether that is the case
or not because I have not been party to -- to those discussions. But certainly my understanding is
that the Coroner was aware that a very detailed Casenote Review was going on because nothing else
clinically could be found.
LANGDALE: Yes, thank you, that can be taken down. I am now going to move to a different topic, Dr
Jayaram, of the discussions of concerns amongst doctors themselves. So we will go back in time again
to 2015 and if we can go to INQ0003110, page 1. This is a document that we see Dr Brearey copies you in
and it's where there's going to be analysis of the three deaths, A, C and D. If we go over the page,
there's an agreed action plan about how that's going to be done. We know now of course that the
deterioration of Baby B [Child B] was not part of
that review; that was in terms of the value of that review was serious omission, wasn't it?
JAYARAM: I would agree.
LANGDALE: In terms of pulling together the rash, the unexpectedness, the outcomes?
JAYARAM: Yes, I think it -- had Baby B [Child B] been discussed here, it might have added more
context and information and directed thinking in a different direction. But that again is -- is
speculation.
LANGDALE: We then see a series of emails moving on in time in June, INQ0025743, page 1. If we go over to page 2 first, it's the first email from
Dr Gibbs. "Rachel Lambie came to see me this morning to say the Registrars are very concerned about
the recent neonatal deaths and collapses ... [Child B] where all the infants showed a strange
purpuric looking rash that probably wasn't true purpura. I pointed out that [Child C] who also died
did not have this rash but it's true that [Child B] and the recent death, [Child D], did show a
similar strange colour change on collapsing. "Rachel said that all the neonatal nurses are very
worried, they feel they ought to be doing something and also asked what else different the
Registrars can do." Did you ever speak to Dr Lambie yourself? She's
given evidence to the Inquiry about how she felt about coming into work at this time and some of the
nurses likewise thinking something's going to happen?
JAYARAM: I don't recall speaking to her or her speaking to me directly around this time.
LANGDALE: Dr Gibbs says: "They feel we ought to be doing something and also asked what else
different the Registrars can do." And he says candidly to you and his fellow Consultants: "Although
I have mentioned we are looking into this, I am not sure exactly how this is being done." If we go
to page 1 for the other series of emails the one at the bottom of the page, from Dr Newby. She says:
"I agree, I have just been grilled by Dave Harkness. This is causing a lot of concern/upset. Can we
pull something together fairly soon?" If we go up the email, the next one above from Dr Brearey.
"There is a new PMM meeting. Seems well-timed. Happy to put together quick presentation so we can
discuss all of this together. I presume we were due to discuss the other two anyway." The email
further below:
"John and Liz. Please encourage junior nurses to attend and discuss in this forum rather than
privately." So Dr Brearey preferring that's discussed in a forum rather than privately. So that
shows us a number of things, doesn't it? First of all that it's clear the juniors were really upset
about this, they were thinking about this, weren't they?
JAYARAM: Yes.
LANGDALE: And correctly, as we now see the whole picture, that they were concerned and upset about
this?
JAYARAM: I think we -- we were concerned because it was it didn't seem to make sense. It was the --
this run in a short period of time of unusual events.
LANGDALE: It doesn't seem -- and again in a hospital where you are all managing your own rotas and
where you are supposed to be working, it doesn't seem as though a meeting between the senior
Consultants and the juniors to share this level of concern was had at that time, does it, or if
there was, you weren't there?
JAYARAM: I don't recall. So I was actually out of the hospital on "This Morning" and I don't think I
was back in-- I think this was a Tuesday, I wasn't back in until the Thursday. When I was sent this
email it was my first recollection of -- of seeing this email. So, again, I may well not have seen
it at the time. I know that in the senior clinicians' meeting the Monday afterwards this email was
referred to and there was a suggestion that there needed to be a series of formal debriefs arranged.
I don't know if they ever happened.
LANGDALE: We can pick that up with Dr Brearey but if you look at the top, the last email at the
very top, I don't think -- Dr Brearey says: "I don't think they warrant a presentation for all three
yet. I would rather discuss [Child A] in detail. Not sure who's presenting that." Of course viewing
them together as a cluster would have been very helpful, wouldn't it?
JAYARAM: I agree and again I can't speak for Steve Brearey's thinking at this point, but again you
referred earlier to following processes and I suspect this might be -- we need to do this when we
have got more information, postmortems, et cetera. But that's speculation. But I can't disagree that
I think discussing these three and Baby B [Child B] as well could have been more revealing.
LANGDALE: If we take that down, please, and have instead document 0036166, page 1, this is a senior
clinicians' meeting on 29 June.
Dr Brearey is not there but you are present for this one and there is discussion about the business
case for paediatric Consultants and if we go overleaf to page 2, on the fourth paragraph: "There was
also an issue raised around the fact that with the three recent neonatal deaths Registrars had been
quite worried and feel that nothing is being done. "Behind the scenes reviews are going on but it
was felt that formal debriefs should probably take place rather than any specific meeting to discuss
all three." Can you even remember that being discussed now?
JAYARAM: I can't, I can't remember the meeting. I -- I probably put this record together. I don't
remember the discussion. I can't remember whether Steve Brearey was at this meeting or not. Sorry,
can you go back?
LANGDALE: No, he wasn't. If you go back to page 1 he's not?
JAYARAM: But I think that the discussion that had taken place on email might have contributed to
that, but first of all I can't remember the discussion, I can't remember what the pros and cons
discussed of discussing them together or separate debriefs was and how that conclusion was made and
I don't know whether those debriefs then took place.
LANGDALE: If we go to 0005580, page 1, it's an email from Dr Brearey attaching his summary and data
on 1 July --
JAYARAM: Yes.
LANGDALE: -- for a meeting. And you are cc'd with this so in fact stuff was being done?
JAYARAM: Yes.
LANGDALE: But obviously the juniors didn't feel part of that and getting their input as to what
they had seen?
JAYARAM: Yes.
LANGDALE: Felt we have seen their evidence, of course, about how shocked they were?
JAYARAM: Yes.
LANGDALE: Out of blue. Very helpful information to have to assist the thinking of senior
Consultants, wasn't it?
JAYARAM: Yes, I agree.
LANGDALE: So we see he attaches a summary. One of the pieces of information that appears to be put
together quite early on, if we go to 0003191, page 3, is the business of pattern, the pattern of
those three deaths. So Dr Brearey has pulled together the neonatal mortality deaths. I am assuming
it is him, we will check with him, but in his review of those years previously and there's three in
three weeks.
Now, patterns are only part of the picture. But when you see it like that, three in three weeks, it
is a pattern, isn't it, it is an unusual pattern?
JAYARAM: It is an unusual pattern.
LANGDALE: That can go down, please. We then have an illustration but I think you accepted this
earlier, a discussion at the neonatal mortality meeting 0003228, page 1. Dr Brearey's has emailed a
number of people to request at short notice another neonatal mortality meeting on Thursday, that is
not the right one. 0003288, page 1. We see there [Child I], this is the discussion for [Child I] and
considering the circumstances awaiting the PM, there is not much that can be presented or in the
learning there. And we see the attendees at the top, do you agree?
JAYARAM: Yes.
LANGDALE: I think Dr Neame, to be fair, was involved in [Child I] but in terms of setting out
clinical findings against pathology, need for review. It's not very detailed, is it, for --
JAYARAM: Not on these minutes, no.
LANGDALE: The Thematic Review that Dr Brearey is preparing, he gets input from Dr Subhedar, which
we see -- that can come down, please -- at INQ0103111, page 1. We see Dr Subhedar has said one additional comment: "You
might consider adding somewhere that relates to the theme of some of the cases involving babies that
suddenly and unexpectedly deteriorated and whom there was no clear cause for the deterioration/death
identified at PM". So Dr Subhedar is making the point that acknowledging where it's sudden and
unexpected as opposed to a death might bring greater clarity for the reader and generally?
JAYARAM: Yes.
LANGDALE: We then see at INQ0005643, page 1, Dr Brearey's invitation to Dr Subhedar to be an external
panel member. Was that discussed with you about who might be an external panel member or assist with
this?
JAYARAM: It was discussed that we needed to get a senior tertiary level neonatologist.
LANGDALE: Again, looking back, do you think this Thematic Review by the time rotas and staff rotas
were being put together by Eirian Powell and the like, that there was a need even for what the
doctors were trying to do for someone to do this externally, even if the connection wasn't being
made the police that somebody else might be doing it?
JAYARAM: I think in retrospect to have somebody external and independent doing even this exercise,
the Thematic Review would have been helpful more in the sense that any accusations of bias,
prejudice, ignoring things, would have been easier to counter. I think at the time we didn't know
what was going to happen in terms of, in terms of response to the concerns that we -- we
subsequently raised. But I think at this stage, I think knowing what I know now if this had been
done by somebody external, it would have been more powerful. Now, who that should have been, should
it have been somebody from the neonatal network? Was there enough at this stage to say it should be
the police? I don't know the answer to that. But I don't think at this time it was an inappropriate
decision for Steve Brearey to decide to do it himself.
LANGDALE: We see the final version 1 March of the review is -- if that can come down please -- INQ0003251, if we can go to page 7. When you say impactful, numbers 1 and 2 I
suggest are impactful, aren't they?
JAYARAM: Yes.
LANGDALE: "Sudden and unexpected" and "timing of arrests", we know that in the case of Shipman,
Dr Reynolds, a GP, was concerned about the pattern of deaths for some of her patients dying in the
afternoon at home alone and they were Dr Shipman's patients. Patterns can raise suspicion of
themselves. Dr Brearey has put that there, the arrests between midnight and 4 am. Did you understand
what that represented in terms of suspicion, those times or not?
JAYARAM: By this stage, yes.
LANGDALE: What did you think the significance of that was?
JAYARAM: I was aware because there had been in the mortality table and the review that it was
unusual that these things were happening at this time. I was also aware that Letby's presence was a
consistent finding as well. And in conjunction I think if you look at points 1 and 2 together,
that's sort of two massive red flags for indicating things need to be looked at in far more detail.
LANGDALE: That can be taken down and another document --
JAYARAM: Can I just comment as well?
LANGDALE: Yes.
JAYARAM: The action after 2 I think is important because one of the things from a clinical point of
view that we wanted to investigate ourselves in terms of practice was: was there anything that we
clinically had
been missing that might have -- might have flagged up that there could have been interventions that
could have been made if these babies had been deteriorating. So I think that action is a very
important, a very important exercise.
LANGDALE: Thank you. INQ0103144, page 1, please. This email is sent -- and you are cc'd -- by Dr
Brearey. It is after Baby M [Child M], before Baby N [Child N] saying: "We would like to keep an eye
on things. If you do come across a baby who deteriorates sudden or unexpectedly or needs
resuscitation, please could you locate me and Eirian know. We will keep a record of these cases and
review them as soon as practicable." When you read that email, if you read that email, what did you
think was happening at this point?
JAYARAM: I was already aware from Dr Brearey that his report of this meeting was that he had
explicitly expressed the concern about the association with Letby being present, explicitly
expressed the concern that we, as Consultants, were concerned about the possibility of this
association being significant in terms of either inadvertent or deliberate harm and we really were
uncomfortable that this -- uncomfortable at her working and that we felt this needed to be
investigated in a way that was appropriate. Steve Brearey told me that at this meeting, Anne Murphy,
our Matron, and Eirian Lloyd-Powell, our neonatal unit manager, were quite forceful in suggesting
that what Steve was suggesting was completely wrong, unlikely, and Steve Brearey told me that there
was such a degree of push-back that he didn't feel that he could do anything else other than accept
this final decision. So I know that when he sent this email obviously Eirian Powell and Anne Murphy
are copied in but this was where really as a group, we were just frustrated and lost because we had
our concerns. The Medical Director and Director of Nursing had seen the Thematic Review, had seen
the staffing analysis, had heard directly from Steve Brearey on our behalf our concerns, but still
felt at this stage a watch and wait approach was the appropriate thing to do and it was -- it was
very frustrating.
LANGDALE: Just pausing there. On all of the emails between the doctors right until the end when
there is that question of you suggesting or inviting Eirian Powell to sign something to say there is
no rift between the doctors and nurses, the paediatricians, a lot of the emails are shared with
Eirian Powell, aren't they?
JAYARAM: (Nods)
LANGDALE: She is the person that's in that group as the neonatal ward manager. She is a profoundly
supportive of Letby at that time, isn't she?
JAYARAM: Yes.
LANGDALE: And Dr Gibbs said her support for Letby -- I think he used the word "dithering" -- caused
him to pause for thought because obviously he valued her views. What would you say about that, I
mean, first of all what was your experience either talking to Eirian Powell or generally of knowing
what she said about it, about how much she supported Letby at that time, and did it impact on your
assessment of the situation?
JAYARAM: I think for everybody the -- the first moment that it comes into your head that a colleague
could potentially be -- could potentially be causing deliberate harm is a -- is a real -- a real
blow and it's difficult to know how to handle it and as I discussed earlier I think for myself you
lock it away and then more and more comes out and you just can't lock it away and then there is the
danger of confirmation bias but you know that it has to be taken seriously, however improbable it
might seem. And I think for -- again, you know, speculating on Eirian's thought processes, I think
that she hadn't reached that point, if you like, on the journey. But
I think -- and this is important and I think we all do it and I have done this as well -- I think it
shows that we need to have open minds and we need to listen to each other and I think -- I didn't
appreciate this at the time but knowing what I know now, and documents, other documents that I have
seen, I think that there was the initial response of denial because it's so improbable but I think
that denial became the truth for some of these people. And so every action taken after that was,
rather than from a position of considering all possibilities was taken from a position of it could
be anything but that. And I think it's important, you know, as a ward manager you support your
staff, you know, you have to support your staff, you are -- you are responsible, you have to look at
the pastoral care, their welfare as well. But your ultimate duty is the safety of your patients as
well and it, it's a difficult one to balance. I suppose an analogy is if by this stage it was clear
that strange things were happening every time a certain infusion pump was used, you would probably
note that and in a neutral way, take that infusion pump out of service and look at it. Now it's much
harder with people and in terms of what's being suggested here,
it's even harder. Of course, Letby had been moved off nights in the March.
LANGDALE: Let me come to that later, shall I, Dr Jayaram?
JAYARAM: Okay.
LANGDALE: I need to move you on, if I may?
JAYARAM: Sorry.
LANGDALE: Not at all. That can come down. I am interested to ask you now about discussion of
concerns in the meetings, the broader governance meetings and to state at the outset the absence of
discussions of the details of these issues we are investigating. 18 June 2015, if we go to INQ0004235, page 3, we see at the top the Datix of [Child A] being referred
to. Documentation excellent, multi-disciplinary working was excellent, clear reviews etc, etc.
There's no mention of Baby B [Child B]. There's no mention at this stage of any concerns about it
being sudden and unexpected. You are one of the people I think attendant at this meeting. How are
these items discussed, because the minutes are always very short, I don't know how long the meetings
take, and they are not really informative if you are doing what we are doing after the event, the
luxury of going back and seeing how things are fleshed up or fleshed out?
JAYARAM: So the Women and Children's Governance Board was a monthly meeting. It's -- there are Terms
of Reference for it, but it very much was a forum that took an overview of things so rather than
actually investigating things itself reports should have been brought to it. Having said that, I am
fully aware that later on Datix reports of other babies who died were not brought to the meeting.
Usually what would happen if something had been identified that required a change in practice, a
change in systems, any kind of -- or any kind of quality improvement, it would be brought and then
that quality improvement plan, action plan, would then be monitored here and signed off when it was
done. Again, is this a forum where -- two things, really. Had each of the reported deaths been
discussed at this meeting or even flagged up at this meeting, it might have caused other people to
ask the question and raise concerns. The second question is: was it a forum where the specific
concern about a member of staff could be explicitly raised? I would think probably not.
LANGDALE: Pausing there, I am not suggesting that should have happened?
JAYARAM: Sorry.
LANGDALE: Just that the death was sudden and unexpected?
JAYARAM: Yes.
LANGDALE: If you take us back to our beginning conversation, if everybody understood "sudden
unexpected" triggers investigation?
JAYARAM: Yes.
LANGDALE: Concern, what can I add, is there something of importance here? Just the description, a
Datix doesn't really cover it, does it, we know why the Datix was completed?
JAYARAM: Yes.
LANGDALE: It doesn't really cover what the central issue is. And just if I may continue, Dr
Jayaram, we know nothing of notice in relation to these babies 30 July meeting or 19 November. And I
think the 16 June 2016 is the next time we see reference and that's at INQ0004308, page 5. As that document's being called up, Dr Jayaram, I think
there are 18 attendees listed, most give apologies and seven attend. So what's the reality on the
ground for these larger meetings, seven out of 18 doesn't sound great to me, but is that
typical?
JAYARAM: Yes. I think that the trouble with these meetings is that the agendas were very, very
large,
there was a lot of stuff to be covered, a lot of it was almost more process: we have to talk about
this, we have to talk about this.
LANGDALE: So it is process-driven?
JAYARAM: It is very process --
LANGDALE: What you are required to talk about rather than --
JAYARAM: Yes, in my -- in my view it was very process-driven and I think it was therefore difficult
to make it more reactive. I think as well in terms of this being a forum for -- I think it could
have been flagged up, that these were sudden and unexpected, in terms of it being a forum for
discussing therefore potential cause, I'm not sure I would usually be -- myself or Dr Brearey would
only -- would usually be the only paediatric medical person there and there may be one or two people
from the paediatric nursing background. However, I do think if they had been flagged up, then it may
have been spotted. Now, the thing I was never sure of is how these minutes were then escalated and
this is one of the difficulties when we had the division of Women and Children's, there were much
clearer lines. They would have been I think since the Urgent Care governance board and the Planned
Care governance board
but I don't know how they would have been slated beyond that.
LANGDALE: It says on page 1 how they are escalated, it says: "Alison Kelly receives minutes for
escalating to Trust board"?
JAYARAM: Okay.
LANGDALE: So if she chooses to, they can be escalated to the Trust board?
JAYARAM: Okay.
LANGDALE: Just going back to your answer, it was process-driven. Do you mean this committee, do you
mean governance generally in the hospital?
JAYARAM: I think this meeting was, was very, very process driven. I can't speak for other governance
meetings across the Trust but I do -- and I don't think this just applies to the Countess, I think
this is an NHS-wide thing, I think there are a lot of processes that are put in place that are there
to help to achieve an outcome, but sometimes or not infrequently the process, if you like, becomes
more important than the outcome, because it --
LANGDALE: And they become superficial?
JAYARAM: It becomes easier to monitor the process and to actually try and change the process is --
is difficult. I will entirely subjectively say I always found these meetings very difficult because
the lion's share of issues discussed were -- were obstetric related. Now whether that's, you know,
my and/or Dr Brearey's fault for not speaking more, I don't know. But it was -- it was a difficult,
it was a -- it was a forum that I think, given the importance of risk and governance, could have --
could have been more effective, could have been made more effective.
LANGDALE: In terms of its composition, if we go to page 1 and see the composition of members, a
number, as you say obstetricians, Head of Midwifery. We see in a number of the reviews and documents
discussions about antenatal care, obviously important, post delivery care, really important. Perhaps
different from solely focusing on the infant, which is what you are dealing with by the time you
have got a neonate.
JAYARAM: I mean, I think ordinarily if you look at maternity and neonatal care it probably is
appropriate to devote more time to the obstetric midwifery side because ordinarily that is usually
the higher risk area where there are more problems.
LANGDALE: Yes.
JAYARAM: And of course as a consequence, we were in
this unprecedented bizarre situation where we probably over-focused -- no, we -- not probably, we
definitely over-focused on that side of things and under focused on what happened after birth in
this meeting.
LANGDALE: The last meeting that deals with any of babies on the indictment O [Child O] and P [Child
P] is INQ0003213, page 1. And that is 21 July. If we go to page 3, we see --
actually, pause at page 1, we see again around 19 people invited, eight of you I think attend?
JAYARAM: Yes.
LANGDALE: We see on page 3 "neonatal incident".
JAYARAM: Where it says "NPSA Level 2" that means there is going to be a more detailed -- so they
have the initial neonatal review with Dr Brearey, the governance facilitator, ward manager and NPSA
Level 2 is a more detailed tabletop discussion with more people. But there is no other detail on
there. Sorry, what date was this meeting? This is --
LANGDALE: 21 July 2016.
JAYARAM: Yes, so by this stage we are our concerns had been formally escalated and various actions
had been undertaken.
LANGDALE: So there is not really much information being provided there at all at this point, is
there?
JAYARAM: No, no.
LANGDALE: So it does look like a bit of a tick box, we have raised them but not a lot goes on?
JAYARAM: Yes, and I think, reflecting on this, I think -- I can't speak for others but certainly for
me my perception of these meetings being very process-driven was perhaps one of the reasons why,
given the gravity of what we were looking at certainly by the time we had our specific concerns
about Letby, we were escalating these issues outside of the formal processes, if you like. Now, I am
not saying that was right or wrong and it might be that because they weren't being escalated through
the formal processes, it's possible they weren't on the radar of people whose radar that they should
have been on. But having said that, I think that, you know, the -- the processes -- the process we
did follow escalated this to a senior level of the Trust.
LANGDALE: Thank you, that can go down. CQC visit briefly. We know there was an inspection in
February 2016 and if we go to 00173390206, there's the notes of a meeting where you and Dr Brearey
are present. You tell us you don't recall discussing the numbers of neonatal deaths with the CQC
inspectors and you
didn't discuss the draft Thematic Review with them either?
JAYARAM: Yes, I -- I think I said in my statement I have absolutely no recollection of what was
discussed at this meeting at all.
LANGDALE: Yes.
JAYARAM: So I can only go on what's been on these written notes. Dr Brearey may have more of a
recollection, so --
LANGDALE: Well, it looks as though on the first page 206 there is discussion about Mortality and
Morbidity Meetings. And if we go to 0207, at the bottom, does that refresh your memory at all?
JAYARAM: No.
LANGDALE: Number of meetings, times five, times four?
JAYARAM: No, no, I mean I presumed it was a discussion around how frequently perinatal meetings were
taking place but, I can't, I have seen this document. I -- it doesn't trigger any memories of it.
LANGDALE: You tell us at paragraph 331 of your statement you: "... subsequently learnt that the
inspectors were told that as a group of Consultants we felt that we were struggling to be heard in
raising patient safety concerns and not being listened to, although I was not aware they had been
told this at the time. We were also at that time still waiting for the two new consultant posts that
had been approved to be advertised and continuing to regularly act down to cover middle-grade gaps
as well as dealing with a significantly more intense workload on the NNU." Indeed it looks at page
209 as though that's a conversation in this meeting about middle grade Consultants 6 to 8, can you
see at the top?
JAYARAM: Yes.
LANGDALE: When a CQC visit is arranged, are there any meetings that you would have attended in
preparation for the CQC visit or not or does that just --
JAYARAM: I -- I may well have been invited to some because usually when there is a CQC visit there
is quite a lot of anxiety about making sure the various documents, bits of paper, that they are
going to be looking at are up to date.
LANGDALE: Yes.
JAYARAM: And again entirely subjective, cynical view -- and again it comes back to process versus
outcome -- I do feel that much of the time the focus is more on making sure that everything looks
right on paper for the CQC rather than -- and again I don't think this is unique to my organisation,
I think this is NHS-wide,
I -- I think that quite often it's a lost opportunity because if there are things that need
improvement, to my mind surely a CQC visit is an opportunity to get some leverage to improve things.
But I think the problem is is the consequences of getting a negative CQC report are such that
sometimes papering over the cracks is the right thing to do. Now I am not -- that is just an
observation, entirely subjective from me and others may well disagree.
LANGDALE: In terms of feedback or of assistance to those visits, if you had been asked a question,
an open question what are you worrying about the most or what's troubling you at the moment --
JAYARAM: I think in that forum if you go back to the attendance list there, I think that would have
been a difficult one because actually if there had been an open question there is an opportunity. So
by this stage we had had the Thematic Review several, not all of us, had the specific concern. Given
the make-up of the number of people in the room, it would have been a difficult -- a difficult one
to breach but --
LANGDALE: What, because you all had different views of the same --
JAYARAM: And you are also fully aware of professional colleagues having different views, the risk
again of being accused of victimisation, bullying. But again in retrospect, there would have been no
safer environment because there were independent people there.
LANGDALE: What do you mean "the risk of being accused of bullying" --
JAYARAM: Well --
LANGDALE: -- "and victimisation", because we have seen this theme referred to among within the
expert evidence so what's the worry about raising --
JAYARAM: The worry again because the thing we were concerned about seemed so improbable and even
though we had a significant concern there is still that element of doubt and again we didn't have
"evidence", and we had the misguided, as I know now, belief that we couldn't do anything unless we
had evidence, that people would just not believe it, and actually then turn it round and make it an
issue around, as some people believe, cover-ups, bullying, victimisation and, you know, I -- I can't
-- I don't have a crystal ball so I didn't know what was going to happen in the future. But my -- my
view on what happened when we did put our heads above the parapet is exactly that now that is not a
justification for not raising it earlier but
and -- I think there was an opportunity here -- because they were -- there were independent people
there. I was also aware that because Ian Harvey had asked for it, Ian Harvey had specifically asked
for a copy of the Thematic Review.
LANGDALE: Let's go to that, that can come down that document, please. So we see at INQ0003140, page 1, we see at the end: "Dear Steve ..." If we can get that on
the next page. "Am I correct in thinking you commissioned an external review? If so, is there any
early feedback ahead of the visit?" Then we see, if we go back to the previous page, Dr Brearey: "it
wasn't an external review, we did have a review of all the cases to identify themes or common
learning. I have attached the draft minutes and actions. I have only circulated to the attendees so
far. Once I have feedback I will circulate it more widely and make sure actions are completed."
JAYARAM: So I obviously didn't see the email from Ian Harvey to Steve Brearey but I was copied into
this. So I was aware that Ian Harvey had requested a copy of this Thematic Review in advance of the
CQC coming. Now, I don't know.
LANGDALE: Let's go to INQ0003114, page 1. Mr Harvey suggests whether it can be joined up with the
obstetric review when it's signed off at governance board. We know the Brigham review had been
conducted?
JAYARAM: Yes.
LANGDALE: Which was very much an obstetric review, not a neonatal review.
JAYARAM: Yes.
LANGDALE: We see at the top there an email to you and Eirian. "I think we still need to talk about
Lucy, maybe when you are back and free the three of us can meet to talk about it." So at the same
time, Dr Brearey is suggesting you, Eirian and he speak about Letby. Did a meeting as far as you
recollect happen around then to discuss Letby herself?
JAYARAM: There was never a meeting between myself Steve Brearey and Eirian Lloyd-Powell that took
place. I think that various people were on leave at different times but I was never part of a
specific meeting and I think shortly after this was when Letby was moved from nights to days. I
can't remember, I think it wasn't long after this, but I wasn't part of that --
LANGDALE: That is April, yes?
JAYARAM: -- decision-making process.
LANGDALE: If we can go please next, Dr Jayaram, to INQ0003089, page 2. We see there at the bottom you are cc'd into this, an
email between Eirian Powell and Alison Kelly asking to arrange a meeting to discussing how to move
towards with regards to findings of the review. At the top another email reply from Alison Kelly:
"Thanks for the update. Could you please send Ian and I the report? Once we have reviewed this I
think it would be good for me, you, Ian, Steve and Ravi to meet and discuss." Did you ever have such
a meeting around them?
JAYARAM: No. No and I was never -- I was never invited to a meeting and certainly a meeting with
myself, Dr Brearey, Eirian Lloyd-Powell, I think the meeting that eventually took place was the one
that was referred to earlier in May 2016, which was some time after the initial request.
LANGDALE: There's another request for a discussion if we go to INQ0003142, page 2. Later on in time, sometimes --
JAYARAM: Another observation, sorry, is that this was sent on 17 March. But I am assuming that what
was sent
to Alison Kelly by Eirian Lloyd-Powell was the review that had been sent to Ian Harvey in the
February, correct me if I am wrong --
LANGDALE: We will follow that up with them.
JAYARAM: I don't know.
LANGDALE: I am just asking your understanding, if I can?
JAYARAM: Okay.
LANGDALE: So if we look at this, we see an email from Dr Brearey to Alison Kelly: "I am hoping
Karen has spoken to you about our mortalities last week. We are going to discuss the matter at our
senior paediatricians' meeting on Monday. I was wondering if it might save time if you and Ian could
join us to discuss the ongoing issues." If we go back to page 1, Karen did discuss -- the reply
comes: "Karen did discuss this with me last week. I am looking to touch base with her again. I will
discuss with Ian this AM re trying to attend your meeting. from our previous meeting held several
weeks ago we agreed we would meet in July anyway so the timing is appropriate." So in the May
meeting, agreed to meet in July. Was there any ability just to create informal meetings or immediate
meetings depending on the circumstances or the level of concern?
JAYARAM: I suppose there's always an ability to create an immediate meeting if people are free and
there is a high level of concern. We knew that we were going to have all the other relevant people
in the room on -- so I think that email that Steve Brearey initially sent to Alison Kelly was
actually sent on a Sunday so we knew that we would have everybody in the room on the Monday
lunchtime, or the majority of the people in the room on the Monday lunchtime for the senior
clinicians' meeting which is why I think Steve Brearey has invited them to come to that meeting.
LANGDALE: We then see an email from Dr Brearey INQ0005749, page 3. If we go to the next page, please. We need to go to page
3, sorry, thank you: "There has been a watchful waiting approach since our last meeting with Ian and
Alison in March. Since the episodes and deaths last week there was a consensus at the senior
paediatricians' meeting. We felt on the basis of ensuring patient safety this member of staff should
not have any further patient contact." And conclusion to this email: "I understand Ian and Alison
met with Eirian and Ann yesterday and the outcomes from that meeting don't entirely fit with what
was suggested at our senior paediatricians' meeting hence it would be helpful to meet sooner rather
than later with nursing and medical colleagues together." That didn't happen, did it, nursing,
medical colleagues, even Execs together. There seemed to be a separation of meetings by this
point?
JAYARAM: No, from this point, and there were a lot of meetings from this date through to mid-July
but even after that, I do not recall any meetings where any of the senior Executives, the medical
staff and the neonatal nursing staff were in a room together to discuss things.
LANGDALE: There was a meeting, wasn't there, on 29 June, if we go to the handwritten note at INQ0003371, page 1. A meeting arranged to discuss concerns face to face with
senior leadership team taking place in Tony Chambers's office is how you describe it in your
statement?
JAYARAM: Yes.
LANGDALE: What time did that meeting take place? It says 5.10 pm, is that when it took place?
JAYARAM: It is probably about right at the probably at the end -- at the end of the day. I think it
was fairly hastily arranged.
LANGDALE: Earlier in the day there had been email communications, hadn't there, if we can pull
these up. Sorry to change the documents, Mrs Killingback, but we
need to go to INQ0003112, page 3. The email at the bottom, 29 June, is Dr Saladi's email
around we need: "... potentially I believe we need help from outside agencies who can deal with
suspicion. The only people who can investigate it is the police." We see your response above:
"Thanks, Murthy. Steve and I are trying to meet with senior Execs to discuss this issue. They don't
seem to see the same degree of urgency as we do. "Until we have met with them I am reluctant to go
to an external non-medical agency, ie police, off my own back. I am going to speak to the MDU today
to find out where I stand as lead with regards to these concerns." Ian Harvey of course is cc'd into
that and we see his response, page 2: "Ravi, absolutely being treated with the same degree of
urgency. It's already been discussed and actions being taken. All emails cease forthwith." Dr Gibbs
we know responds to you two about that and the request to cease forthwith. Then we see at page 1 at
the top your response. Can you tell us from Dr Saladi's email and yours what had happened in the day
that arrived at you sending that email or whether you already knew that was the case, how
was it that you --
JAYARAM: So I think when -- can you scroll back down to Ian Harvey's "emails cease forthwith"?
LANGDALE: Yes, that is page 2 at the bottom.
JAYARAM: After that was sent, I recall Ian Harvey because the Executive offices were the corridor
opposite to where our offices are in the particular building. He came down to my office and said to
me that we have already had a discussion, we just need to get a bit more information but we will
ultimately go to the police. Now, I am aware, because I have seen a copy of Ian Harvey's statement,
that he says that he can't remember saying that. But I wouldn't have actually put that in an email
unless I had been told it. What I didn't know was what, who had discussed things and what had been
discussed and what action was being taken at that point. So in terms of the sequence of emails,
obviously "all emails cease forthwith", we just took him out of the copy list, because obviously we
wanted to express our concerns to each other. But yes, my understanding -- so that Ian Harvey email
was at 0858, I think I sent my email -- sorry, can we go back up to the top?
LANGDALE: You sent that at 10.24?
JAYARAM: At 10.24. So I think between 0858 and 1024,
that is the time period that Ian Harvey had come down to my office.
LANGDALE: If we go back now to the handwritten notes of the meeting which was 003371, page 1. This
is the meeting in Mr Chambers's office. You are halfway down "Ravi, entirely subjective". What do
you tell us using the notes as you wish to refresh your memory, what do you say at the meeting?
JAYARAM: I think I was saying exactly what I continued to say and what I eventually said when we met
with the CDOP panel; that these were babies who were obviously on the neonatal unit because they had
medical problems or prematurity that meant they needed to be on the neonatal unit. But the majority,
if not all, of these babies were stable and didn't show any signs that they were deteriorating and
then suddenly deteriorated and then also pointed out that they didn't seem to respond to appropriate
interventions as they ought to have done. So essentially I suppose sort of articulating on the first
two points that you highlighted on the Thematic Review, I didn't talk about the timings but the fact
that these were sudden and unexpected and there was always an association with -- with Letby.
LANGDALE: Page 2. Comments attributed to TC, Tony Chambers. Why did we call the police? Presumably
why didn't -- do you remember what you said?
JAYARAM: I can't remember that comment.
LANGDALE: You didn't call the police so we will have to ask him about that. You say -- it says next
to "Ravi police" "what if no conclusion". Do you know what that means?
JAYARAM: I think it was if the police come in and the police say "there is nothing to see here, not
for us", what do we do next, because we still haven't got any explanations.
LANGDALE: We see Mr Chambers goes on: "Issues can explain: is this suspicious, criminal or are we
missing something?" Is that "causal link between nurse"?
JAYARAM: It says "causal link between nurse" and he makes a comment "Dr Harkness is no longer
working here". Now, I am aware that Eirian Lloyd-Powell --
LANGDALE: Not interested in that.
JAYARAM: Sorry.
LANGDALE: Let's move on, sorry, I am just conscious of the time, Dr Jayaram. If we go, please, to
30 June there is another meeting at 0003362, page 1. Again handwritten notes appear to be taken by
Mr Cross and you hadn't seen them before we sent them?
JAYARAM: No.
LANGDALE: Mr Chambers said he had informed the CQC of its plan to downgrade the unit with a model
of care yet to be agreed and commission an Invited Review from the RCPCH due to the increase in
deaths with no obvious explanation. That's what you tell us in the statement. Was that what was
discussed at the meeting?
JAYARAM: I think we -- we discussed at the meeting our discomfort about Letby practising
unsupervised. The downgrading of the unit was discussed and we felt that that would be appropriate
because we had no specific answers and we wanted to sort of make sure we could be safe and that --
the College review was -- was discussed as well. So I think that bit's accurate.
LANGDALE: Page 2 at the top, you say: "Starting point, what is safe? Reduce service but staff
member not addressed. Discussed going to police." As far as you were concerned, was the service
reduction going to address the concerns you had about Letby?
JAYARAM: No, because given -- given the possibilities, it could be that we were looking after babies
that we weren't equipped to look after, so it made sense until we had had further investigation to
downgrade the unit,
but what I was saying there is that we had already articulated that we had a specific concern about
Letby and downgrading the unit didn't address that.
LANGDALE: If we go to page 3, near the top you say: "Do we need to engage our partners now?"
JAYARAM: That's talking about other neonatal units, neonatal network because if we were going to
downgrade and stop taking babies below 32 weeks' gestation it would have an impact on other services
around the region within the neonatal network.
LANGDALE: Over the page, page 4, you comment that: "Concern potentially a member of staff causing
harm, reoccurring theme."
JAYARAM: Yes.
LANGDALE: "These babies should never have died" Sarah says. The actions on page 5. Dr Brearey
saying: "... made my views clear the other night." Is that with his email around the topic?
JAYARAM: Sorry.
LANGDALE: You see at page 5 --
JAYARAM: Yes.
LANGDALE: -- Steve Brearey: "I made my views clear last night" --
JAYARAM: Yes, I think Steve -- Steve was saying actually surely it should be the police at this
stage.
LANGDALE: There is a reference page 6 from you: "Not Execs v clinicians. Appreciate support from
Execs. Plan for a pragmatic way forward." Were you actually thinking you were getting support from
the Execs or was that speak to try and get what you wanted next?
JAYARAM: At the time, it was a really strange feeling because in terms of the words that were being
spoken, to an extent it was: we hear you, we are going to -- we are going to help you, we are going
to sort this out. But it just didn't feel that the issue around our specific concern about Letby was
being taken seriously. I can't remember, I have put it in my statement, but in one of these early
meetings, Mr Chambers made a remark when we specifically suggested the possibility of Letby
potentially causing deliberate harm, that was along the lines of, and I think the wording is really
important here, and I don't know if I got colleagues who can back me up on this, when he said: I can
see how that would be a convenient explanation for you but surely there must be something else. And
I remember that just made me think "convenient?" Because it really wasn't convenient. But what I
realise now is that right from the -- that point there was a reluctance to consider what we were
suggesting could be going on and the possibilities that could be going on. So I kind of -- I have --
this is a very crass analogy and I apologise but I have likened it to -- and I will probably get
slated for saying this, likened it to being in some kind of abusive relationship. I was working on
the naive assumption that the people who run the hospital would all be pulling in the same direction
in terms of patient care and patient safety. And of course what I am hearing is that it just didn't
seem quite right, but I have no reason not to trust these people because they should be pulling in
the same direction and, you know, they are wise, they are paid higher -- large amounts of money to
run hospitals and if they are suggesting this is the right thing, and it couldn't be that, it
couldn't be that, I just I guess I accepted it. I -- I -- I was, I -- I was too trusting with a --
-- well, I was appropriately trusting, why shouldn't I trust the people who run the organisation in
which I work? But it just didn't smell right.
LANGDALE: Paragraph 465, you do say: "I recall Mr Chambers explicitly saying in one of
the meetings around this time he '... could see how it would be a very convenient explanation for
you but there has to be something else'." We also know, if can be put on the screen please INQ0103147, page 1, that on 7 July this external communication was put up
about the downgrade. So a week after that meeting. We can see what's said there, if I give people a
moment to see it. This caused in its draft form and generally some amount of communication between
you as doctors. Again, at this point there is a lot of communication, isn't it, taking you away from
--
JAYARAM: Yes.
LANGDALE: -- the day job. But if we look at this, your email, INQ0002694, page 9, this was thoughts on a draft, we would have to look
carefully if they are still there or not but the reality is you were expressing 2694, page 9: "I am
uncomfortable with the complete absence of any reasons for downgrading. How does this sit with being
open and honest and the duty of candour? The second sentence should reflect in my view 'this is
temporary, not permanent', needs some kind of openness about why has to be given." You say:
"I appreciate we don't want to cause alarm but people aren't daft, they will immediately ask why.
The absence of any reasons makes it look like we are trying to hide something." So obviously the
area of communications is a whole different thing, we all know usually people at the top an
organisation sign off on communications, it's important?
JAYARAM: Yes.
LANGDALE: But to the extent that you were being asked about these communications, you seem to be
flagging up that you know the need to be open and honest is important. Did you think that?
JAYARAM: Sorry?
LANGDALE: Did you think it was important that in communications around the downgrading generally
the Trust ought to be being honest at this point?
JAYARAM: I -- I think there was a balance because obviously to articulate explicitly the specific
concern we had raised may not have been appropriate. But there was no, there didn't appear to be any
sort of reasoning given behind it and I just, I just felt and again it was my, my view that it would
probably although the statement I believe properly in good faith was put out to sort of smooth
calmed waters, there was
the risk that it would actually cause more consternation.
LANGDALE: That can come down, please. And another meeting note of Stephen Cross, 0003365, page 4.
And it's a meeting on 13 July. You tell us it is a meeting that was called to give you the findings
of the deep dive review that had been undertaken and to be informed about the Trust decisions on any
further actions.
JAYARAM: So I think this was the meeting at which so what had happened between the end of June and
now is that Ian Harvey had tasked a number of staff with doing some Casenote Reviews. I wasn't part
of that process and if I know that my colleague John Gibbs was and a number of senior nurses were
and a number of people around the Trust and this is one of the things that came out of the meetings
at the end of June, to do a more in-depth review the case notes to look for any trends or anything
else that might be causing the increase in the death rate.
LANGDALE: Was this the meeting where he produced various graphs and a presentation himself?
JAYARAM: I -- I can't -- I can't remember whether it was this. I think it was this one because there
was another meeting the next day, but looking at the -- I think -- does it mention it in the
minutes?
LANGDALE: You tell us the meeting the next day we know was an extraordinary Board of Directors.
JAYARAM: So I think this meeting was where he presented those graphs and interpreted the data as I
guess what -- what we were being told is the data suggests that it's chicken and egg; you have had a
higher acuity of babies and therefore you have been more busy and therefore the staff have been
busier, it's inevitable that a full-time nurse who's done the intensive care course is more likely
to be involved with any of these babies because she is there more for them and therefore really that
-- and there were graphs presented, I think, that were interpreted as suggesting acuity had gone up,
intensity had gone up --
LANGDALE: I'll come to those in a moment. If you just look at page 5 at the bottom. Somebody has
asked the question about what would we do if this was a doctor? How would we deal with it? It's Mr
Chambers. And you say at the bottom: "Doctor would have been suspended."
JAYARAM: Yes. It was, it was -- it was a strange, it was a strange comment --
LANGDALE: Yes.
JAYARAM: -- because it doesn't matter whether, you
know, if you're a doctor or a nurse or a physio or a ward clerk, or any other person working in a
hospital, if there are suspicions about you causing deliberate harm you would be suspended. And I
have realised, again subsequently having seen other documents, that there was a suggestion that
because the individual we were worrying about was a member of nursing staff we were reacting very
differently. And the suggestion I -- I think here was if this was a doctor, we wouldn't be
suggesting all of these things, you know, and I think the suggestion was if it was a doctor, you
would -- you would perhaps be more nurturing and not as -- not as accusatory. And, I think the other
point I made here is Ian Harvey's data's all very well, but it doesn't actually address the specific
issue of these babies suddenly deteriorating.
LANGDALE: Let's quickly have his presentation on the screen please, INQ0002837, starting at page 2. Page 1 actually tells you how it's summarised.
That's what it purports to do. Did you know if there had been consultation with any of the neonatal
network or others?
JAYARAM: Not that I was aware of.
LANGDALE: Or if it had been taken from MBRRACE or
anything else? Did you have any idea how this was put together?
JAYARAM: No. I think this was BadgerNet and NNAP data, I think. It says it uses BadgerNet data.
Badger is the neonatal database. All neonatal units enter data into Badger
LANGDALE: So if we just pause for a second only, please, Mrs Killingback, on each page 2, 3, 4, 5,
6, 7.
JAYARAM: So this -- this is the striking one where it basically very clearly demonstrates what we'd
been saying: there had been a quite marked and obvious uptick in deaths on the neonatal unit since
2015.
LANGDALE: Yes.
JAYARAM: Now, this was an interesting graph because there are -- again, my interpretation of it --
there are dots that are coloured in red. But it doesn't to my eyes -- and maybe that's because I
don't want to see a trend, I don't know -- it doesn't show a trend. If I look back at 2014, I could
colour in some of those dots red as well. And of course we were -- we did have more activity because
we had sicker babies, but we had sicker babies for reasons that we know about. I think that that's
also -- care days, of course if you've got sicker babies you are going to have more care
days. Now, if you then look at that -- and again, sorry, can you go back to that one? If you go back
to 2014, I could have put some red dots in there as well. But of course care days were going up
because we had sicker babies and those sicker babies, you know, chicken and egg were effect, in
retrospect, rather than cause. Then of course the next one looking at acuity. Yes, of course acuity
was going up because we were having -- we were having sicker babies. And I think there -- was there
one more about staffing as well?
LANGDALE: What do you mean when you say "sicker babies"?
JAYARAM: Well, we were having babies who were more unwell because what we know now is they were
being made more unwell.
LANGDALE: So you weren't saying constitutionally you were getting iller babies?
JAYARAM: No, no.
LANGDALE: You were saying that the ones were presenting --
JAYARAM: There wasn't a trend of smaller babies, more premature babies. The babies that we had were
babies that we had previously always looked after as you can see from the data from previous years.
But again the reason that acuity was going up was because of what was happening to these babies and
of course because of that, of course there were going to be more intensive care and high dependency,
high dependency days. And again if you look back at November 13 and January 14, May 14 there's been
troughs and peaks throughout. And again if you look at numbers, the numbers are small. You know
eight; it goes up to 10 babies with a birthweight below 2 kilograms. It's not to my mind something
that you can then look at and say, "Well, here's your answer."
LANGDALE: The specific point, Dr Jayaram, is that it doesn't address the individual circumstances
--
JAYARAM: Well --
LANGDALE: -- or required scrutiny for each of the babies --
JAYARAM: No.
LANGDALE: -- who died or collapsed?
JAYARAM: It -- it -- these slides as presented did not address the specific question of the specific
concern we had about the association with Letby.
LANGDALE: Let's just -- two more documents before we break, if I may. The first is the
extraordinary Board of Directors meeting, minutes of meetings held on
14 July, INQ0004216. Sir Duncan Nichol is present, Mr Higgins, Mr Chambers, Mr Harvey,
Mrs Kelly, we see on page 1. We see at page 3, again I don't need you to repeat it, we are familiar
with this description, except you add here: not what you have been saying all along about sudden and
unexpected and these babies weren't the ones we were expecting to die. You refer to the fact: "The
unit has been busier as not unusual across the region, neonatal cots are reducing, hard to recruit
staff, lower staffing and higher intensity will lead to more risk. That said, when looked at these
babies no direct effect on each patient." So that the staffing issues were broader across the region
as far as are you were concerned?
JAYARAM: Yes, and I think there's -- there's data from NNAP that actually suggests that although we
were not 100% compliant with British Association for Perinatal Medicine standards for staffing in
terms of the skill mix, we were not an outlier by any means compared to any other organisations. We
were bang in the middle for average. And those also were not new circumstances. There hadn't been a
sudden change in terms of where we were with our staffing compliance.
LANGDALE: Sorry, over the page, page 4, you say
something that you say -- you state what you are going to say was confidential and not to be
minuted?
JAYARAM: I think I explicitly stated the concern about Letby.
LANGDALE: Why did you feel the need in a board meeting like that to say it shouldn't be
minuted?
JAYARAM: Again I had increasing discomfort here. Again this, this dissonance between, you know,
these people should be on our side but there seemed to be a pattern emerging that they didn't want
to listen and I was already becoming concerned that this, if minuted, could potentially come back
and -- and bite me on the backside and be used against me.
LANGDALE: At page 5, the third paragraph, please, and you, I think: "The actions are proportionate
as a holding measure ..." Is this the instruction for the RCPCH?
JAYARAM: Yes, the RCPCH and the regrade.
LANGDALE: "... as far as possible. The worry is at the end there is no conclusion or idea what's
going on and this could be a delay."
JAYARAM: Was it discussed in this meeting about specific measures around Letby being supervised when
I'm just talking about proportionate measures? I can't
remember whether it was this meeting or another meeting.
LANGDALE: So it may have been about staff. But did you see the RCPCH review, which is what you seem
to be commenting on at the end, the review could ultimately be a delay, were you flagging that
up?
JAYARAM: Well, at this time we hadn't seen the Terms of Reference of the RCPCH review, so we didn't
know specifically what they were going to be looking at. I think we had downgraded. I think, I think
by this stage we'd -- I think by this stage we'd -- we'd basically said, "Look, we are uncomfortable
with Letby continuing to work on the unit. You have to decide how you are going to address that, be
it CCTV, be it one-to-one supervision, be it something else." But I can't remember whether that was
this meeting or whether that was the meetings at the end of June.
MS LANGDALE: Yes. Thank you, that's a good place to stop, Dr Jayaram.
LADY JUSTICE THIRLWALL: Thank you very much. We will take a break now. Ms Langdale, how long a break do you think is wise?
MS LANGDALE: 5 past 2.
LADY JUSTICE THIRLWALL: 5 past 2. Very good. We will rise now. Back at 5 past 2. (1.15 pm) (The luncheon adjournment) (2.05 pm)
MS LANGDALE: Dr Jayaram, you tell us at paragraph 518 of your statement that you requested a
meeting with Ian Harvey to update you with verbal feedback from the RCPCH review panel: "... and
also to explain to me why the adverts for the two new Consultant posts that had been approved
earlier in the year, had been delayed." The meeting took place at 4 o'clock on 8 September. The
Inquiry has heard evidence, Dr Jayaram, from the RCPCH interviewers and I don't need to ask you
about the fact that you made it clear as was described at some times with emotion in your voice
about what was worrying you and your concerns including about a nurse and about Letby. So you
clearly set that out yourself with Dr Brearey in those interviews. In your meeting with Ian Harvey
we see you subsequently emailed your colleagues on 9 September 2016, at INQ0103167, page 3. So that would begin -- if we had gone to the previous page
which we don't need to -- to say, "I met with Ian Harvey yesterday afternoon, this is a distilled
summary of things discussed."
Then we see you say: "They did acknowledge the concerns we raised over foul play and recommended a
forensic detailed independent review of all the cases. "This would be far more detailed than the
Thematic Review and be conducted by two teams independently. Sue Eardley gave four names to Ian."
You weren't, at this time, shown the report, were you?
JAYARAM: No, we, we weren't shown the report. I mean actually, at this stage, I didn't even assume
that any kind of written draft report would have been available because I think this was only a week
or so after the two days of the RCPCH visit. So this was a summary of -- of my interpretation or my
recollection about what Ian Harvey had told me at the meeting that I had with him on the day before.
LANGDALE: Thank you. That can go down. Moving to October and the grievance, can we see please INQ0107964, page 43. Sorry -- before we go to that, Dr Jayaram, I should ask
you to confirm, paragraph 520, you say at that discussion with Ian Harvey that we have just looked
at: "The first issue discussed was the RCPCH Review Team feedback, he did not give much detail but
suggested
that the immediate feedback from the team had been that there were no issues around the service
itself that needed urgent attention. He told me that they had noted our plan to appoint two new
Consultants ... And: "He used the words 'no smoking gun' [being] identified to explain the increase
in death rates but didn't detail what data had been looked at to make this conclusion." Is that
right?
JAYARAM: That's correct, yes.
LANGDALE: And when you asked if they had addressed specific concerns around Letby's potential link,
and he told you they had not investigated this specifically but had recommended a detailed
independent forensic review be undertaken; yes?
JAYARAM: That's correct, yes.
LANGDALE: So going then to this letter on the screen. When you received that, what did you think
was going on and in particular what did you think paragraph 2 represented, if anything?
JAYARAM: I was surprised to receive this, to put it mildly. I think it came via email. Now, by this
point, I was aware that Letby was not working on the unit and I had been made aware at some point
prior to this,
I can't remember when, that she was working in the risk and governance department. When I received
this, my first reaction was surprise and -- and anxiety, really. Because I -- I appreciate it's
probably a formal template kind of letter, but it was the line about, "anything I say not only will
form part of this investigation and may be presented in disciplinary hearings should this be
necessary". Now, up to this point -- not even up to this point, even now I am not -- I wasn't sure
whether I had done anything or said anything out of place or that was potentially going to get me in
trouble. As we discussed before lunch, I had been quite cautious to an extent asking for things not
to be minuted for fear of some kind of come-back. And I think as well, it -- I think it recommended
bringing a Union representative. Now, I have been a member of the BMA from the time I qualified as a
doctor, never really had to use them for very much. But the very fact it said that just filled me
with quite a lot of uncertainty and concern and so, as a consequence, I contacted my BAPM
representative. But I actually I think my reply to Dr Green when he sent this email saying "can you
set up a date?" was "yes, I think that's fine but can you tell me what it is I am supposed to have
done?"
LANGDALE: We have seen those can I take you firstly to INQ0004356, page 3. You are asking your Union representative about it. If we
go to page 3, and the advice in short, they suggest to you: "You request a copy of the grievance
policy and an agenda. Inform the Trust you have sought BMA advice and will return contact when you
can establish the availability of your representative. Forward all correspondence to myself along
with a copy of your contract policy and agenda as soon as you receive these pieces of information."
And we know you in fact, not with this person who advised you, attended with another BMA
representative on the day of the interview and you are expressing here, aren't you, at the top: "We
as a group are still uncomfortable that our concerns have not been fully addressed but understand
why the Exec body is being cautious about escalating things. My worry about this HR meeting is what
I will be asked and how I reply. Clearly if I am asked 'did I have any concerns?' I can only give a
subjective view and if I raise the possibility of deliberate harm, am I putting myself at all sorts
of risk? Although I stand
by the fact that we ..."
JAYARAM: It should say "escalated".
LANGDALE: -- yes, "escalated and therefore fulfilled a duty of care". You also, if we can go to a
second document, INQ0006311_01.pdf, asked Mr Cross, the internal -- well, did you see him as
the internal person to go to for legal adviser support?
JAYARAM: Yes, I mean the irony of this now is not lost on me that he was the Trust's legal advisor
and I wanted some kind of advice as to how much I -- how much detail I could give about our specific
concern, given this was an investigation of a grievance. And I in the back of my mind had a concern
that this could be used against me and you know I am, I -- I sort of facepalm and laugh at myself
that the person I asked was Stephen Cross, in retrospect.
LANGDALE: You are saying very clearly the Trust and, as you say, he is legal adviser for the Trust:
"... but we are sure that one of the questions will concern why we had concerns about X. As you know
we had noticed the association between unexplained collapses in the presence of X, felt it was a
matter of patient safety until this had been looked into further. We were not involved in the
decision to move her to non-clinical
services." As you say, that was an Executive decision, wasn't it? You made representations about
your concerns but you weren't writing letters removing her?
JAYARAM: No, so -- so at the meetings in June and July, we asked them to do something about our
concerns around Letby working unsupervised and we discussed CCTV, there was one-to-one supervision
discussed. No conclusions were made in any of the meetings that I was in attendance at with the
Executive board at all and I subsequently heard through a grapevine, really, at some point in the
next few weeks that she had been moved to Risk and Patient Safety. And I think that's important
because, again, it seems to be a recurring theme that there was some kind of ultimatum put by myself
and my colleagues that, "if she's not moved we will call the police". And I am not really quite sure
where that's come from. But we were --
LANGDALE: I just need to ask you one thing about that; did you ever say "threaten to call the
police"?
JAYARAM: No, no, I don't.
LANGDALE: So I need to ask you --
JAYARAM: Others may recollect differently I do not believe at all, at any point an ultimatum was
given that
"if you don't move Letby we will call the police".
LANGDALE: Perhaps you wish there had been now --
JAYARAM: Had we given that ultimatum -- actually, I wish we had done, but we didn't because we were
trying to remain as respectful as possible. So all we wanted was to be reassured that Letby was
either practising in a supervised way or other actions would be taken.
LANGDALE: Looking at the second paragraph of your email to Mr Cross: "If we are asked what concerns
we had how should we play this? I think we should make it clear that the whole Consultant body had
concerns about patient safety and these concerns were escalated appropriately and leave it at that.
Inferences may or may not be drawn but if put on the spot and asked directly, specifically what
duplicate asked directly, specifically what the concern was, it would be wrong not to be explicit.
This however could unleash a whole other cascade of events. Advice gratefully received" Your meeting
had been brought forward that Thursday. We have seen from emails, Dr Jayaram, that Claire Raggett
emailed you and asked you to phone him. You say you did phone him, but don't recall the conversation
now?
JAYARAM: No, I have absolutely no recollection.
LANGDALE: Do you think you did definitely call him?
JAYARAM: I -- if I did I can't remember.
LANGDALE: Okay.
JAYARAM: It would seem there was an arrangement made to have a call, I cannot remember whether I
spoke or not.
LANGDALE: You certainly can't remember advice that shed light on the problems that you are
identifying --
JAYARAM: No.
LANGDALE: -- both to your Union rep and to him.
JAYARAM: No.
LANGDALE: So when you go into the grievance interview have you had any satisfactory answer to what
you should be saying or not, about the suspicions or concerns?
JAYARAM: So my BMA rep said "see what the question is like" but essentially said "don't say anything
speculative" and they were with me and said that they would intervene if they felt the line of
questioning was inappropriate for the purpose of the meeting.
LANGDALE: Let's go to the meeting then that you are in, INQ0002879, page 47.
JAYARAM: I think, before the meeting as well, I had some communication with the HR representative to
ask whether I was there as a witness or as somebody who was
potentially being investigated and I recall the reply that came back was that I was there as a
witness --
LANGDALE: Witness, that's right?
JAYARAM: -- at that time.
LANGDALE: So you had got that back from her -- that was Lucy Sementa I think -- that you were a
witness. Then we see the first question from Dr Green. First of all, did you know Dr Green at
all?
JAYARAM: Yes, in fact I was actually on one of the informal interview panels on the day he was
appointed to Director of Pharmacy. I didn't have a particularly close working relationship with him,
he was fairly quiet and I didn't really have much occasion to have much to do with him but I had met
him on several occasions.
LANGDALE: So no bad blood, no good blood, as it were --
JAYARAM: No. There were no issues, there were no axes to grind from my side.
LANGDALE: If we look here, your paragraph 1, you set out: "Premature babies are at high risk, our
rate comparable to neighbouring units. There was a rise in mortality and they were not the babies
you would have predicted. None of these babies responded to timely resuscitation manoeuvres. As a
group of Consultants, we were very concerned that the babies were deteriorating
and needed to look at why. It was raised to the Executive board about increase in death rates, also
reviewed individual cases internally. Stephen Brearey organised a Thematic Review with external
reviewers. There didn't appear to be anything in terms of clinical practice equipment or the
environment that was relevant. There did appear to be an association with Lucy Letby, either looking
after or being present at the time of the deaths. Discussed with the obstetricians, we were all
concerned we were potentially putting babies at risk when there was something that might have been a
factor concerns were raised with the Executives." Two answers down you also refer to an incident
with the Triplets "babies who were getting better, were stable, who suddenly collapsed". Those, you
make clear, they were stable, suddenly collapsed and the same at the top, you make clear, they are
not babies you'd have predicted to collapse. You don't say "sudden and unexpected with no
explanation", you know we were dealing with that term earlier?
JAYARAM: Yes.
LANGDALE: You do, when you read it as I have, see that you said they were stable and then they
suddenly collapsed? But other than that in that paragraph, do you think
that's a fair summary of the concern for the babies: that they had collapsed and weren't being
--
JAYARAM: I think so, yes.
LANGDALE: Do you think retrospectively, again flagging up sudden and unexpected, well, deteriorated
when we didn't expect them to, might have made that it wasn't simply the association of the nurse
around a death, it was the association around unexpected inexplicable deaths with no medical cause
identified by the paediatricians?
JAYARAM: I don't know whether in this forum, in the grievance investigation with Dr Green,
specifically saying that would have made a difference. Those words had already been used explicitly
with the Executive Team who commissioned, presumably, Dr Green to do this and I don't think Dr
Green's investigation here was specifically to consider what was happening with the babies. It was
very much around Letby's grievance. So I think in my opinion, using those words, in what's
documented in the first paragraph of this transcript, probably wouldn't have made a difference. And,
okay, I'll put myself out here, one of the reasons I also think it wouldn't have made a difference
is that my subjective view, with a little bit of evidence behind it, is that the findings of this
grievance process -- or the -- the desired outcomes of this grievance process -- had possibly been
predetermined to an extent. I -- I don't know but ...
LANGDALE: We have seen all the evidence that was in the grievance pack, Dr Jayaram. I am going to
take you just to some of it but rest assured the Inquiry has seen all of the material that was
available and was interrogated to the extent that it was in that hearing. If we look at page 48, Dr
Green says: "So to clarify, was there any suggestion from any of the Consultant team that Lucy had
been deliberately harming babies?" You say, "We discussed a lot of possibilities in private." He
says that: "That's not a yes or no." You say: "We discussed a lot of possibilities in private and
took our concerns to the Executive board" When you said "discussed a lot of possibilities in
private", what did you expect or hope that he would hear from that?
JAYARAM: What I wanted, by using those words, is I felt that what we had discussed was not --
because I didn't really understand, I still hadn't had -- in fact I still
don't really understand, well, until I had seen the written grievance, understand what the issue
being investigated was. And actually these are very sensitive issues and I didn't feel, on the one
hand, that Chris Green needed to know and number two, again, because of my concern that explicitly
stating my concern in this forum could be used against me. Do I think that had I said it it would
have made a difference to things happening sooner? No, because I think in this situation I don't
think that as previously what I and my colleagues had been suggesting would have been taken
seriously.
LANGDALE: The next Dr Green question: "If Lucy was to return to the unit would you have any
concerns?" You say: "That decision should be made by those who removed her after completion and
outcome of the report." If the report shows no foul play, Dr Green asks, would you have a problem
with her returning? You say: "If the Executive board felt it was appropriate for her to return then
she would be back working on the unit. If subsequently there were further associations
we would raise concerns but that would be speculation." And he says: "The nursing staff have said
that Lucy is a good nurse, very experienced and well trained in looking after the sicker babies.
It's likely that Lucy as a nurse will be looking after a baby that dies, therefore she will be
associated." And you make the point: "In a small unit with high intensity babies every nurse will be
associated with babies that deteriorate." Then it's the HR representative who asks about percentages
or a threshold of the number of deaths for a unit this size. What did you think you were being asked
here? On the face of it, if she is back at work and there is another death, it is just an
association. Was this future planning or future proofing, or what was this?
JAYARAM: I am not really sure where this was going. I remember feeling very uncomfortable with this
line of questioning which is why, you know, I was asked would I be happy and I have given a very, if
you like, third person answer that if the board felt it was appropriate, then -- then she would come
back, but we would continue to monitor things. And I suppose looking at the transcript now,
Dr Green was trying to suggest: well, it's inevitable she will be involved because, you know, she's
very good and experienced and looks after the sicker babies. And I didn't -- I didn't at this time
take away from this I didn't really understand what the subtext may or may not have been, it just
struck me as a very unusual line of questions given that the invitation to this meeting was to sort
of investigate, investigate a grievance, I didn't -- a grievance of which I didn't actually have
knowledge of the substance.
LANGDALE: You subsequently much later made a Freedom of Information Request, didn't you, in 2017 I
think or 2018 even?
JAYARAM: Yes, I did.
LANGDALE: I don't need you to turn it up, I am just going to take you two sections or comments that
were reported to Dr Green and ask for your comment upon them, if I may. My question earlier was you
didn't ever see what people had said about you until you made that Freedom of Information Request;
is that right?
JAYARAM: No, no. So I -- I was subsequently -- I mean, I am sure we will come to it but following
the meeting we had with the Executive board as a group of Consultants with their feedback from the
two reviews, one of the things that we were told was that some of us would have to go through
mediation with Letby and it was -- I guess under duress and we can come to that engaged with this
process.
LANGDALE: I am going to come to that. Can we take it in my chronology, if that is okay, Dr
Jayaram?
JAYARAM: Yes, of course.
LANGDALE: Because we will get to that. It is just to ask for your comments on the information that
was given to Dr Green?
JAYARAM: Okay.
LANGDALE: The first is INQ0002879, page 10. Ian Harvey was interviewed by Dr Green. 2879, page 10. We
see there in the fourth box from the bottom: "There has been a number of behaviours on the ward that
do not reflect too well. I had to go and speak to RJ that some of the trainees had been making
reference to 'angel of death' but no specific person was named. There was behaviour in the clinic it
being heard talking about killing babies on the unit. I had to speak to Ravi about comments about
killing babies. This was not denied and Ravi Jayaram did accept that it was inappropriate."
JAYARAM: I mean --
LANGDALE: Also before you comment on that can I show you
both, because there's another one at 0038: "Ravi Jayaram was heard by a nurse [this is Eirian Powell
providing this information to Dr Green], Nurse T in outpatients and asked if anything had come from
the review to say somebody is causing these deaths on this unit. Nurse T is now anxious to return to
the unit after the Ravi Jayaram statement and Eirian Powell escalated to Karen Rees." So two people
there provide that information to Dr Green. Nurse T, if I can tell you her evidence to this Inquiry
is that in outpatients, she heard something to the effect of you saying after the review: just
because they haven't found anything doesn't mean there isn't something to find. Something like that.
Just something commenting on the review, not calling names, not saying "baby killer", "serial
killer", saying just because they haven't found anything doesn't mean there's not something to find
in reflection on the babies that had died unexpectedly. So first of all, dealing with that. Do you
remember making that kind of observation about the review; that that didn't mean that it was a clean
bill of health and there wasn't something to find?
JAYARAM: So the first thing I will say is, although I can sometimes have a big mouth, I wouldn't
have been
in a public area saying what Eirian Lloyd-Powell was told I had said, explicitly someone is killing
babies.
LANGDALE: Yes.
JAYARAM: I may well have had a conversation with a colleague around the lines of -- well, if, if the
-- "if the review doesn't find anything, it doesn't mean there isn't anything to find". Because I
can't remember whether, whether by this stage we had seen the draft report. Having seen the draft
report there wasn't anything in there that suggested to me that they had -- they had found any
association. So I won't deny I probably made a comment around the fact that even if the report
doesn't find anything it doesn't mean there isn't anything.
LANGDALE: Quite. Well, that is obvious, isn't it? Correct?
JAYARAM: And I don't think that is an inappropriate comment. With regards to the "angel of death"
thing, I remember Ian Harvey came to talk to me because he had reports a member of the junior
medical staff had been overheard referring to Letby with -- with that epithet.
LANGDALE: When you say "that epithet"?
JAYARAM: The angel of death.
LANGDALE: We have heard Nurse Death, was angel of death
something that you --
JAYARAM: I mean, I never heard anyone saying it.
LANGDALE: Either of them: Nurse Death, or angel of death?
JAYARAM: Not explicitly. I think people -- I am aware that the junior medical staff, the trainee
paediatricians by this stage had noted the association with Letby's presence at these unexplained
events. I think in medicine we sometimes have very black humour and, you know, over the years some
people may have a run of very busy on-calls with very ill children and you might say something like
that, but there's never any implication that you are accusing them of doing something. I can't
comment for any member of the trainee paediatricians making that comment. I suspect it was more
about the association because they were -- they had noted the fact that there were always sick
babies when she was on but I can't speak for them and I don't even really know which member of the
junior medical staff it was.
LANGDALE: Going back to page 10, which is Mr Harvey's discussion he says he's had with you, so
let's look at that box again about what he says to Dr Green. Do you now remember him speaking to you
about comments he says about killing babies?
JAYARAM: No. I don't remember, I remember him talking about the comments of the "angel of death". I
don't remember him talking about me apparently explicitly using those words in clinic. And I
certainly wouldn't have in a -- you know, in a, in a -- even if I was in a clinic room, there's
people walking past, there is a lot of traffic I wouldn't have used those words.
LANGDALE: You were not asked yourself by Dr Green about any of that, were you, as you have just
described?
JAYARAM: I don't -- I don't recall -- I have not seen anything in the transcripts.
LANGDALE: We then see there is a meeting on 26 January, if we go to INQ0003523, page 1. We see there who's in attendance. Mr Harvey, Mr Chambers,
Mrs Kelly, Mrs Hodkinson and the list continues. And we see over the page Mr Harvey is giving
details of the Royal College of Paediatrics and Child Health Review and the reasons why it's been
commissioned. Highlights recommendations from the report, that is page 1, then page 2: "Mr Chambers
stated the Speak Out Safely process had been professionally managed. He noted emotions were running
high at the time." He sets out: "We need to remind ourselves how we got into the
position. The Trust encourages staff to speak out and the only reason we went where we did was
because of the Consultants' comments. An apology has been given to Lucy and her family." Was it
discussed with you before this meeting that what you were apologising for with anyone?
JAYARAM: Nothing had been discussed with us prior to this meeting. If I may take a step back.
Myself, Dr Brearey and I think Anne Murphy had had brief sight of a draft report from the College in
November. I couldn't stay for the whole session. I wasn't made aware directly at the point that the
final reports came back to the Trust and in fact I found out because Jim McCormack, who was an
obstetrician, some time in mid-December came to my office and said: have you seen the reports? And I
said: they are not back. He said: oh, they are. I said: how did you know? He said Julie Fogarty, who
is the Director of Midwifery, told him. So I went down and found Ian Harvey and expressed my
annoyance, to put it mildly, that these reports were back and they hadn't told us but other people
seemed to be aware. He told me that the Trust board needed some time to digest the contents and come
up with a plan and they would feed back to us in the New Year.
So the New Year came. I -- I repeatedly asked Ian Harvey could we see them and so this meeting on 26
January was arranged. So we were told that we would get feedback from the reports and an account of
what the Trust's plan moving forwards would be. Now, we were quite concerned that they wouldn't let
us see the reports first and we as a group made a decision that whatever we were going to be told,
we would just take it on board and not come up with any immediate responses and try to digest what
we were, so I didn't -- I thought that we would get the important findings of the service review and
the outcome of the findings of the Casenote Review. The meeting itself was -- I don't think
"bizarre" is a strong enough word to describe it, really. There were seven of us including my
colleague Dr McGuigan who joined us two or three months before who hadn't been with us whilst these
events were taking place and I -- I don't think these minutes really reflect the tone of the
meeting. Ian Harvey didn't actually show us any extracts of the report. He gave us some bullet
points in which my understanding, and certainly I think my colleagues' understanding, was that there
was evidence of deficiencies in care.
LANGDALE: Go back to page 1 for those, just to see how the minutes summarise it. Sorry. Carry
on.
JAYARAM: There were issues around -- so it doesn't really say what he said there. There were issues
around leadership and escalation and there were issues around relationships with nursing staff. He
also said that the Casenote Review hadn't identified anything and I think he used the term "no
smoking gun" quite frequently. So essentially what we were told first was that the Casenote Review
hasn't suggested anything any foul play the service reviewers highlighted a number of issues that
need addressing but there's no single unifying factor and then Mr Chambers then -- and this is where
it became very odd -- started relating to us how there was evidence from the grievance procedure
that we had treated Lucy Letby very badly, how she had -- how she would have good grounds to report
us to the GMC for some of our behaviours, how he had had to have extensive discussions with her and
her family to apologise for her behaviour. It was -- it was strange because he was almost suggesting
that he was somehow our protecter because if it hadn't been for him, we would have been reported to
the GMC.
LANGDALE: So it moved from this report of the RCPCH conclusions or highlights from Mr Harvey
straight into what --
JAYARAM: Yes.
LANGDALE: -- they had to say to Letby and her family and what you should be saying?
JAYARAM: It was more about the grievance I think than the RCPCH report and I think it says in the
first page about I think Mr Harvey is talking about the findings of the reports and the grievance
report being triangulated which is interesting -- we might cover it later on -- about sort of
interpreting all those things together. What -- so we weren't expecting this at all. We -- we did
not know that this was going to be part of this meeting. And then we were, we were, we were told
that, you know, she's coming back, you will have to work with her. Some of you -- he didn't say who
-- will have to undergo mediation and again, I recollect this clearly, I think other colleagues
will, he said: I am drawing the line under it, you will draw a line under it and if you cross that
line, there will be consequences. Now, the difficult thing here, we kind of -- I think I asked for
one clarification when Ian Harvey did his first bit and I said to him: are you suggesting that these
events are related to poor Consultant care?
And he didn't really answer directly, he didn't say yes, he didn't say no. Because we had agreed
that we wouldn't say anything when Mr Chambers made that remark we -- we didn't say anything and it
was very difficult because we were all just absolutely blindsided by this. Then he said "I think we
need to hear from her". And I thought at this point Lucy Letby was going to come into the room but
Karen Rees then read out a statement from Lucy Letby to us which was a very -- assertive, you know,
perhaps even, you know, cocking her nose at us, I don't know, but we kept quiet but -- and I think I
have seen the statement in my pack. But I -- and this is the non-verbal stuff. I remember that being
read out and I remember the tone of it being it was almost like triumphant and the look from Karen
Rees and Alison Kelly almost as if: right, we have got you now. Okay, you know, maybe -- maybe I am
just being lily-livered but it was -- it was very strange because I was thinking: why is this
happening now? Why is this happening in this way? And it struck me that that meeting had probably
been choreographed in some way and then it went back to around mediation although we were --
LANGDALE: Could I pause you there now just for a moment.
So when you were talking about the RCPCH statement you tell us in your written evidence at paragraph
590: "From early January I spoke on more than one occasion to Ian Harvey as to when we would be
allowed to use the RCPH and forensic review reports. He never gave me a clear answer but he
suggested that the Trust would make a public statement in February 2017 and I and my colleagues
could see the reports after this." At paragraph 596 you tell us: "Ian Harvey gave us what he
described as some 'headlines' from the reports. He said there was evidence of poor clinical practice
that might have contributed to the deaths, evidence of poor team working and evidence to suggest
inadequate staffing and higher acuity contributed to the deaths. He said there was no evidence to
suggest Letby was related to the deaths and there was 'no smoking gun', which he clarified meant no
single causative factor identified, but that were lessons to be learnt and improvements to be made."
Finally at 643 you say: "It was not made clear that the issues raised in the report about staffing
were long-standing issues and pre-dated the rise in a number of deaths. It was also not made clear
that these staffing issues were not unique to the NNU and Chester and were common to most
other Level 2 units in the area." When you were in the moment of course you hadn't seen the report,
so when he made those assertions about the impact of staffing, and that the report seemingly might
have contributed for some of the deaths, that is how it was being summarised to you, were you in a
position to respond on the detail of those points as you are now in the way they have all been set
out?
JAYARAM: At that point, in not as much detail, because although it didn't chime with anything that I
had recalled reading in the brief sight of the draft report in November, because had those issues
that Mr Harvey was raising been discussed, both myself and Dr Brearey and Anne Murphy would have
most certainly noted and commented on them, it didn't also fit with the feedback informally given to
me I think on 9 September or 8 September by Mr Harvey, when he had intimated that they hadn't found
any significant concerns about clinical practice that needed immediate action. And it didn't also
fit with the email that Stephen Cross had sent to the chronology and sent to me where he said in
that that the College hadn't identified any significant issues around clinical care. We didn't again
in the meeting query it because we didn't actually have the documents in front of us to counter it.
And at the end of the meeting, we went back to our offices and talked together about how we move
forwards and we felt that we couldn't really move forwards without actually seeing the two reports
which were being referred to.
LANGDALE: Now, can we go, please to INQ0003095, page 1. And this is a letter, 30 January 2017 from paediatricians
to Mr Chambers, agreeing: "... it is appropriate for us to send a letter of apology. Although it was
made clear that the Trust board has drawn a line under this issue, we would be grateful for written
clarification on the board's understanding on the reason for the increased number of unexpected and
unexplained deaths between June 2015 and July 2016 and the actions that you now intend to take." We
understand, so I am just dealing with the grievance point at the moment, how was it you said at this
point it is appropriate to send a letter of apology to Lucy Letby? First of all, did you know what
you were supposed to be apologising for?
JAYARAM: Well, no, so we didn't know what we were supposed to be apologising for apart from our bad
behaviour but we didn't know what that bad behaviour was. There had been a series of emails between
us and also involving Dr Tighe, Consultant anaesthetist, who
was the BAPM local negotiating committee rep, about what we should say. He had advised -- I think he
described as a qualified apology in the sense of we are sorry --
LANGDALE: We have heard from Dr Tighe --
JAYARAM: -- that you felt --
LANGDALE: We have seen how you effectively arrive at something that doesn't say that you have done
anything?
JAYARAM: Not admitting any liability but it is very difficult to admit liability when you don't know
what you have done. But we were aware from the tone of that meeting that, you know, these were
preconditions for us continuing and we were, you know, continuing in our jobs, continuing doing what
we were doing. And also we wanted to move on so that we could start the process of the unit being
regraded back up from Level 1 to Level 2. There was -- it was, if you like, a Cabinet decision.
There was disagreement, some Consultants were uncomfortable with that comment about the letter of
apology particularly when we didn't know what we were apologising for. But I personally felt, you
know, Dr Tighe's advice it would probably be prudent to follow that, if you like, sort of, you know,
shorter term pain perhaps, for longer term gain.
LANGDALE: 3 February 2017, if I can move forward. We know each Consultant received individual
copies of the RCPCH report in sealed envelopes, that is what you tell -- and they had to be
collected and signed for from the Executive office; is that right?
JAYARAM: That's right.
LANGDALE: That is quite extraordinary, isn't it, in the modern age?
JAYARAM: We after the meeting on the 26th wanted to see these reports, we were told: you can see
them once we have made our public statement. We actually -- we were just thought it was completely
inappropriate. We actually contacted -- I don't know whether we all did, I know I did and Dr Brearey
contacted Sue Eardley from the RCPCH to say: look, you know, they are not letting us see the report
you have done on our service and I think -- I don't know what the deciding factor for them to allow
us to see them was, but it was I think influenced by Sue Eardley.
LANGDALE: Did you see a redacted version? You have now seen through the Inquiry the version --
JAYARAM: The version --
LANGDALE: Disseminated version and the confidential version, so what did you see?
JAYARAM: The version we got was a redacted version and
it was quite clear really just reading it that there had been redactions. We weren't told it was
redacted but it was quite clear I think it was either section 3.10 to 3.11 or 3.11 to 3.12 where the
second section, the line started something like "in response to this allegation" but no allegation
had been mentioned. So it was clear to us that there had about there had been redactions, but we
didn't know and we did point this out.
LANGDALE: You have now seen that section about the nurse?
JAYARAM: Yes.
LANGDALE: That whole page, 4.4.1, did you see that?
JAYARAM: Not at that time, we had to ask specifically for those sections. But we were allowed to see
that but they still hadn't released the Casenote Review to us.
LANGDALE: Dr Hawdon's review?
JAYARAM: Dr Hawdon's review, yes.
LANGDALE: If we go to INQ0107964, page 77, this is an email, "Dear colleagues", from Mr Chambers on
3 February. We are not currently clear who this goes to, it is the same date you all pick up the
report. Is this with the report or where have you seen this before, if you have seen this before? I
mean outside the Inquiry, I know you will have seen it in our process.
JAYARAM: I don't know whether this was a something to all employees of the hospital, whether it came
round in an "all users" email. I don't think it was specifically to us as paediatricians. At this
point, what was the date that we had the RCPCH report released to us.
LANGDALE: 3 February?
JAYARAM: So the same day.
LANGDALE: Paragraph 630?
JAYARAM: So it's the same day. You know, he's essentially reiterating what he told us on the -- and
Mr Harvey had told us on 26 January; that there's no single cause or factor identified. Now, I can't
disagree with that because actually when we saw the Royal College report it didn't identify a single
cause. So that's not strictly wrong. However, the Royal College report did not address the specific
question of our specific concern around Letby and whether her association may have been significant
and that, when we finally saw the report, was really worrying because -- and this is before we had
seen the Casenote Review from Dr Hawdon's -- it was being interpreted in a way to almost avoid the
question that we had asked and actually it was interpreted, I realise now, in a way they took it to,
to indicate and prove
that the suspicions and concerns we had had been -- had been -- had been shown not to be correct,
whereas actually in my opinion there was a lot of very important observations made in the review
which I wouldn't disagree with, but it hadn't addressed that issue one way or the other.
LANGDALE: The apology letter now, if we can go to it, INQ00031870001, this is the apology letter that was sent from the Consultants
but we have seen from the evidence that the investigation received any inappropriate comments that
were made at that time weren't made by any of the people that signed that.
JAYARAM: No, but I suppose as Consultants we take responsibility for our trainees, or whoever said
them.
LANGDALE: Dr McCormack found himself sending a letter of apology for something?
JAYARAM: Yes, I found that bizarre.
LANGDALE: Don't worry, I will ask him to comment on that. But there was another Consultant who did
the same and he has commented on that. If I can ask you to go to INQ0006424, page 2?
JAYARAM: I think just to say about this letter of apology, the context of this when we had been told
that you are drawing a line under it and if you cross that line there will be consequences was
ringing very loudly
in our ears. You know, what -- what those consequence were were never explicitly raised although the
talk of GMC and referrals was explicitly raised. So I think that probably perhaps informed my view
on writing some kind of letter at this stage along with Sean Tighe's view on it in that it was a
self-protection thing at the time without sort of admitting liability.
LANGDALE: So the sequence here is you have raised concerns about baby safety, there's a grievance,
and in response to the grievance effectively you are being told there could be a referral to the
GMC; I am just trying to understand the HR sequence?
JAYARAM: Yes.
LANGDALE: That is what's happened here?
JAYARAM: Yes.
LANGDALE: Now, if we can just look at this letter. Mr Harvey says: "I gather an apology letter was
forwarded and would like to thank you for that. I repeat my comments of yesterday that we must
separate concerns and reviews from the grievance procedure." And he says at the end: "I think this
gesture would go a long way to protect you from a possible referral to the GMC from other parties
which, having supported many doctors who
have done no wrong even then isn't a comfortable process." So a suggestion that doctors may be
referred to the GMC when they have done no wrong but --
JAYARAM: I don't think it was so much even if you haven't done anything you would be reported, but
doctors do get reported to the GMC and the GMC process, having had friends and colleagues who have
been through it, is a deeply unpleasant process and quite often the doctors who have been reported
are found to be exonerated. So I don't -- I don't think he was necessarily saying to me: I know you
have done no wrong.
LANGDALE: No.
JAYARAM: But I think what he was suggesting because one of the things that had been discussed
amongst other things in yesterday's meeting, which the email refers to, is around the mediation that
was being set up.
LANGDALE: Well, let's look at the letter at page 1, same enclosure, Mrs Killingback, page 1. This
is your response which addresses the mediation issue. You say at bullet point 3: "We have been asked
to engage you and Steve Brearey alone in the mediation process. We suggest all seven Consultants
should be part of it." You say: "There are still no clear explanations for at least eight of the
unexplained collapses and deaths." You are using "unexplained" and "collapsed" certainly much more
clearly by this point, Dr Jayaram --
JAYARAM: Yes.
LANGDALE: -- in terms of your use of "deaths" as opposed to "unexplained deaths". But you are
coming back and saying you have no answer for these deaths yet, unexplained deaths?
JAYARAM: Yes. So the meeting to which this email refers was a meeting with, between myself, Stephen
Brearey, John Gibbs, Ian Harvey and Nim Subhedar from Liverpool Women's Hospital and Ian Harvey had
arranged the meeting because he had seen -- by this time we had been allowed to look at the Jane
Hawdon's Casenote Review and I think Jane Hawdon initial conclusion that she I think explicitly said
"there are four cases that I still think are unexplained and need further detail or forensic
review", I am paraphrasing a little bit. When we looked at a group we felt that there were at least
another four babies where, in our view, even though Jane Hawdon felt or reported from her analysis
that they were explained, that they weren't. So the meeting that was arranged to which this
email attempts to be a summary was arranged by Ian Harvey because he told certainly me that he had
been tasked with feeding back to the Families of the babies whose case notes had been reviewed what
the conclusions were from which I assumed that the Families knew that this was happening. But he
wanted sort of guidance from people with experience of neonatology to understand what this meant and
what to say and our -- we went through all the cases and we said to him: actually we don't think you
can give any firm conclusions to any parents at this point in terms of our interpretation because we
still think -- it already says there's four that need further forensic review and to our minds, even
thinking about it conservatively there are at least another four where it can't make sense. So in
this email, I --
LANGDALE: You say you can't see any effective mediation could take place, I see that in that
context.
JAYARAM: Yes.
LANGDALE: Can I ask you to look at this document, please, as well, INQ0107964, page 13. You then write to Sue Hodkinson and tell her, we see it on the screen at paragraph 2: "The mediator told me this was an entirely voluntary process and I am under no obligation to engage. This is at odds with the impression given by both Tony Chambers on 26 January when he stated quite clearly that the board had a plan which we expected to follow or would be crossing a line. I have seen no minutes of the meetings [and then you say] now in terms of their depth and also by Ian Harvey who intimated that by not engaging I could increase the chances of being reported to the GMC for whatever I am alleged to have done." So you take that point up. This is when the mediation was being planned that you begin to appreciate this is voluntary, in fact, with Sue Hodkinson and you ask for a meeting and we see one happens with her on 15 March at 2 o'clock. If we can go to that at INQ0003219, page 1. Can you see there meeting 13 March and over the page, look at the top?
LADY JUSTICE THIRLWALL: 15 March.
MS LANGDALE: Sorry, 15 March. If we go to page 4, in this conversation, you are discussing your
concerns about Letby, you say all circumstantial then you remember three occasions when there were
concerns. What were the occasions that you set out there?
JAYARAM: Certainly the issue which we discussed earlier
on about the chest drain. I think the first reference is Baby K [Child K]. I can't remember what the
third one was. But it would have been one of the patients I -- I personally was involved with.
LANGDALE: Sorry, go on.
JAYARAM: That was it.
LANGDALE: Yes. And another, a valve at a different setting, it was explained it was a mistake when
she was looking after the baby?
JAYARAM: That was -- that is -- that was the discussion around the issue with the closed valve on
the chest drain.
LANGDALE: Was that Baby H [Child H] that you discussed earlier, or you can't remember.
JAYARAM: Yes, the baby we discussed earlier on was Baby H [Child H].
LANGDALE: And the third?
JAYARAM: I can't remember which baby that would have been.
LANGDALE: Had you had many conversations at all with Sue Hodkinson before in her role as Director
of People?
JAYARAM: I had met her sort of informally at a number of meetings. The first I got in touch with her
the main reason, initially I got in touch with her was around my discomfort around the mediation. So
when I had been discussing with Ian Harvey about whether it was appropriate for me to engage with
mediation as he had said in his email he strongly advised me because it might reduce the chances of
getting referred to the GMC, he mentioned to me that the mediator would be able to advise whether it
was appropriate. Now, I really had no understanding of how mediation worked. In retrospect it was an
entirely inappropriate line to go down because mediation is when issues are resolved and it is just
for clearing the air, so people can work with each other. But having been advised firmly to engage
with the process and I did and of course when I met with the mediator, I forget her name, she was
from another NHS Trust, I explained the background of things and why I had concerns around whether
this was appropriate and said to the mediator I was told by Ian Harvey that you would be able to
advise whether this was appropriate. She, I think quite rightly I guess from her point of view as a
mediator, said no, I cannot advise you, that is not what I am here to do and I said to her: well,
that is not what I was told, but then she said it is entirely voluntary. And it was just that whole
-- none of this was making sense, you know, it had been suggested by Tony Chambers that we had to
engage in this
or there would be consequences. So the reason I got in touch with Sue Hodkinson was that after that
meeting, because I wanted to ask her whether she felt this was appropriate or not and what it was
all about and that one-to-one meeting then obviously extended. Now, I can't recall but I -- I can't
recall whether Sue Hodkinson was at that meeting on 26 January or not, so I don't know whether this
was the first time that Sue Hodkinson had heard any of this and I had no awareness at this point of
Sue Hodkinson's involvement in the matters around Lucy Letby's redeployment and proposed return
either.
LANGDALE: You emailed her subsequently on 30 March after the mediation INQ0005850, page 3, if we go to page 3/4.
JAYARAM: So this was following the face-to-face meeting that I had with Letby and the mediator. So
just some context. I, after the discussion with Sue Hodkinson, felt on balance I probably ought to
engage with that meeting. I had asked Sue Hodkinson for some detail prior to the meeting of exactly
what it is I was supposed to have said or done to indicate the -- the previously described bad
behaviour and she had initially agreed to give me some information but actually at another meeting
there
was another meeting the evening before this and she said "I will give you some information after
that" and she didn't. Now, actually at the time this meeting took place with Letby there had been a
meeting the night before with Ian Harvey and Tony Chambers, the outcome of which I and my colleagues
understood was that it -- our concerns would be escalated to the police. So I came to this mediation
meeting knowing that. So the way it worked, I was asked to write a statement to read to Letby. I --
I wrote something, it was probably along the lines of the apology letter I don't have -- it was a
handwritten statement, I don't have a copy of it at all. But what was very interesting are the
things that Letby was telling me because she told me that she had evidence from her grievance that
myself and a colleague, presumably Dr Brearey, and I have put it in the email, orchestrated a
campaign to have her removed; I and a colleague, presumably Dr Brearey, had given an ultimatum to
the Trust that if she wasn't suspended we would call the police. And she was telling me that she was
coming back next week whether I liked it or not, would I be happy working with her. And I -- I again
it was another meeting where I you
know, it was, it was I know, "Kafkaesque" is over-used but it was a bizarre meeting and I sort of
bit my tongue and gave some very non-committal answers. But when I came out -- I -- I don't often
get angry but I was angry because I felt that everyone was being misled. I actually, I can't
remember, I think I said to Letby, you know, you are -- you are just being manipulated. But what --
I wanted to know what evidence there was for these things that she was saying I was alleged to have
said.
LANGDALE: Pausing there, just moving back to the comments. That can come down, that letter. The
meeting you had with Sue Hodkinson, INQ0003219, page 2 you tell her and say to her that you feel the board are
more worried about an employment claim worth hundreds of thousands from the member of staff
concerned than patient safety and Ms Hodkinson added they are supporting the member of staff to
return to the unit. You say -- it's 0003219, page 2 -- at the bottom you added again that you are:
"... concerned the board has been misled. Have the board been assured that the information is
sufficient?" So you were raising that issue then.
JAYARAM: Yes.
LANGDALE: That can be taken down. Can I move to a different topic, please, Dr Jayaram it is about
information provided to the chronology generally and it may be you can't help very much here, it may
be you can I just want take you through some emails. The first is INQ0107964, page 80. So this is February 2017. You will see there are three
deaths in two families that are unascertained. This is Mr Harvey to you: "... which is where I think
confusion over numbers comes from. Stephen and I are meeting the Coroner tomorrow and it goes
without saying that they have to be careful ... any pronouncement of causes whilst Inquests are
pending. Ultimately it is for the Coroner to decide cause." And he continues: "I have had further
correspondence with Jo McPartland and Jane Hawdon re issues such as mottling and air embolism which
don't feature in this case review but this will be discussed as part of the meeting. The papers will
be available later in the morning." We also see, so you can comment in one sequence, if you like, Dr
Jayaram, INQ0003159, page 1, a letter to you from Mr Chambers. Paragraphs 2 and 3: "The
Trust first advised the Coroner of Cheshire of this matter on Friday, 8 July and has subsequently
kept
him informed of developments. I confirm a copy of the report was shared with the Coroner on 20
January 2017 following which a meeting with Mr Rheinberg, the Trust Medical Director and Director of
Corporate and Legal Services was held on Wednesday, 8 February to ensure that the Coroner was fully
briefed on all matters."
JAYARAM: So the background to us asking them to talk to the Coroner comes back to post the meeting
on 26 January and we how can we escalate this who can we talk to? And one of the things that was
discussed, should we go to the police, Dr Tighe suggested that maybe we should ask the Executives to
explicitly -- not for us to do it directly, but to ask the Executives to specifically raise our
specific concern to the Coroner.
LANGDALE: We have got the letter, while you are saying that we can put that on the screen, your
letter, INQ0003117, page 1. 10 February.
JAYARAM: Yes.
LANGDALE: So carry on, Dr Jayaram, we see there at paragraph 2: "... requesting you urgently to ask
the Coroner to undertake a full investigation of all..."
JAYARAM: Yes, and again this was -- we were -- we were struggling to know where to go next. And we
thought well, actually the Coroner should have a degree of
independence. Obviously I had been to one Inquest and what we wanted or what we, what we hoped was
that if they spoke to the Coroner, when they spoke to the Coroner they would explicitly raise the
specific concern that we had been raising about Letby to the Coroner. And as I say, we have kind of
outlined and again this was a letter that was -- had a number of iterations and it was agreed by --
by all seven colleagues. We highlighted the fact that the RCPCH College review was all very well but
didn't address the specific issue. We also felt that Dr Hawdon's review which identified four babies
that required a broader review we had identified in our view more than that. I can't remember what
the other points we made were.
LANGDALE: Don't worry about that.
JAYARAM: Yes.
LANGDALE: It is the Coroner point I am interested in.
JAYARAM: Yes.
LANGDALE: If we can go to the next reference, please, INQ0003395, page 1. This is a letter from Mr Harvey to -- sorry to Dr Brearey,
yes, from Mr Harvey. So he confirms: "... you have each had a letter from Tony Chambers but I was
able to give more detail and confirm
Stephen Cross and I had a detailed conversation with both the Coroner and the Deputy." He continues
in that paragraph: "I was able to confirm that not only had we given the Coroner a copy of the
recent letter from you and your colleagues which highlighted your concerns, but Stephen and I also
discussed this at length with them." So this is 6 March, your letter has been sent 10 February: "The
Coroner told us we should not necessarily expect a response from him. He also informed us that his
role wasn't to QA hospitals." Quality assure, is that?
JAYARAM: Yes, I assume that is what that means.
LANGDALE: "I mentioned the conversation with the Coroner because John seemed to get significant
assurance from the detail that Stephen and I had gone to with the Coroner when I spoke with him,
although I accept that, Ravi, you did not feel the same way." "John" is presumably John Gibbs?
JAYARAM: Gibbs.
LANGDALE: Mr Harvey told Dr Gibbs and you how much he said to the Coroner. What did you understand
had been shared with the Coroner through this?
JAYARAM: Well, again second-guessing.
LANGDALE: Try not to guess, do your best. You have seen the documents, what do you think?
JAYARAM: No, no, working back from the Coroner's response was: it is not my role to QA hospitals. If
the information that was shared with the Coroner to my mind was what we had wanted to be shared with
the Coroner, it didn't seem like it was --
LANGDALE: Quality assurance?
JAYARAM: -- an odd -- it didn't seem like it was an appropriate response, which immediately raised
the question what was actually shared with the Coroner.
LANGDALE: Or what did the Coroner understand from what had been shared?
JAYARAM: Yes.
LANGDALE: But you never had a direct conversation other than this correspondence about what had
been shared?
JAYARAM: No.
LANGDALE: You knew there was a meeting, you knew that your letter had been shared?
JAYARAM: No.
LANGDALE: But you had clearly requested that. Thank you, that can go down. There's then a meeting,
a paediatrics meeting 27 March, INQ0003150, page 1. And you tell us that your understanding of the purpose of
this meeting on 27 March
was to give the Consultant paediatricians an opportunity to explain the reasons for their ongoing
concerns to Mr Chambers in person with support of the neonatal network.
JAYARAM: That's correct. So there had been a lot of letters going backwards and forwards. One of the
things that I raised in my discussion with Sue Hodkinson earlier in the month was that it would be
very useful to actually have a face-to-face meeting to actually in real-time discuss our concerns
and get responses. I remember suggesting that she might be there to mediate, maybe even use a yellow
card/red card system to try and keep things on track. I think I also recall saying I would prefer it
if Ian Harvey wasn't there because I lost faith in his judgement by this point. But my understanding
of this meeting was that it was set up following my meeting with Sue Hodkinson so that we could in
detail discuss our explicit concerns with Tony Chambers, having had the opportunity to digest the
Royal College review, the redacted parts, and the Jane Hawdon review as well and we felt that it
would be important to have representatives of the neonatal network present as well.
LANGDALE: If we look at page 2, we see Dr Subhedar, fifth box down, says very clearly:
"The cluster caused concern, the College review is a service review, not case note and followed up
with further detailed review. In-depth review for more than four cases. The standard needs to be
external to some degree." So at the end, page 7, you say in terms: "We appreciate your time, thank
you for listening. one of our colleagues will not have her baby here ... other colleague has
expressed concern. We fully understand the implications and impacts."
JAYARAM: That was with reference to --
LANGDALE: You don't have to tell me who or what.
JAYARAM: Sorry.
LANGDALE: The fact is you are now as a group you have brought in somebody external to the network,
Dr Subhedar, external to the hospital and you are saying your own colleagues wouldn't want their
children delivered in that hospital?
JAYARAM: That's correct.
LANGDALE: That is the force of your level of patient concern?
JAYARAM: Yes, and --
LANGDALE: What -- not looking at the notes but what's the sense? Do you think that's been taken on
board, is there real listening to that?
JAYARAM: So this meeting was -- we were under the impression it was within a few days Letby would be
returning to work although it hadn't been confirmed. We decided before this meeting have discussed
with colleagues that we would explicitly say we just need to talk to the people who are the only
people who can look at this forensically which are the police and if we were able to express what we
were concerned about to the police and the police had said no, there's nothing to see here, we don't
need to be involved, we would have stopped at that point. But we just didn't feel at all that to
this point, in spite of raising these things over and over again the specific concern had been
acknowledged or investigated properly.
LANGDALE: We then see at INQ0107964, page 172, Dr Gibbs sends you all an email saying that Mr Harvey
had come along to look for you or Dr Brearey but you were both in clinic. Paragraph 2: "Anyway Ian's
message is that discussions about involving the police have been held with a senior criminal
barrister, didn't get his name. He would like to meet us to discuss our concerns to advise on how
those might be addressed from a legal perspective. He would like to meet as many of us are able to
attend." If we go to INQ0103211, page 1, Dr Brearey responds: there is a degree of urgency about
this. Middle of the page: "The rationale for this meeting that you communicated to me yesterday was
so that the barrister can let you know the best way of informing the police after getting a better
understanding of the cases from us and not sure therefore why we will all need to be at this
meeting." It is obviously difficult to get you all together and you thought it was about who you
should speak to. You get INQ0107964, page 18. The bottom email, Mr Harvey responds: "As we discussed,
none of us has been in this position before and it about doing it in the best way possible,
therefore we consulted with someone experienced and active in criminal law both as barrister and
judge. I must stress Mr Medland's independence. I think you will be assured of this when you meet
him. It is his advice that he meet with you to fully understand and explore the basis for the
concerns to help frame the approach since letters only convey so much." We then know -- if we can
have on the screen, please, INQ0005857, page 1, there is a meeting between
Simon Medland QC, 12 April 2017 and certain Consultants at the hospital. These notes set out his
minutes of the meeting. I think the meetings is described somewhere one and three-quarter hours. It
is a long meeting, isn't it?
JAYARAM: It was a long meeting.
LANGDALE: We see at paragraph 5: "The minutes record we all agreed if there was an identifiable
common thread between some of the deaths (cf Beverley Allitt) then this would be powerful prima
facie evidence that there was potentially a crime or series of crimes which had been committed." So
Beverley Allitt's case was discussed in this meeting?
JAYARAM: Yes.
LANGDALE: Who raised that, can you remember?
JAYARAM: I can't remember whether it was Mr Medland who mentioned it first or whether one of us made
the comparison.
LANGDALE: He then gives the advice at paragraph 6, or view: "The police being strapped for
resources can only sensibly investigate cases where there is at the very least reasonable grounds
for suspecting that a criminal offence has been committed. He emphasised that this was
very different from there being mere suspicion and also very different from where they were
questions about hospital procedures and processes as distinct from criminal actions. "SM remarked
that officially reporting any matters to the police was a [unclear] step which was effectively a
public action and would incur adverse publicity and raise matters for the families of the neonates
which might be seriously disturbing." Pausing there, was this given -- that advice given that at the
very least reasonable grounds for suspecting criminal offences being committed? Was that what you
accepted at the time or thought was the position?
JAYARAM: Just to roll back a little bit. My understanding and my colleagues' understanding following
that meeting at which Nim Subhedar and the other representative from the neonatal networks was
present was that we requested that the police be involved and they were going to involve the police.
We were then told a week later that a barrister was going to come to talk to us and Ian Harvey had
said: it's to help the Trust frame what we say to the police. We as a group all felt this is just
more fudging and avoidance and we -- I think if we go back to the very first or second paragraph of
this we said we would
ask Mr Medland before we said anything what he felt his brief was and that was really interesting
because what he had been told or what he told us he had been told was very different from what Ian
Harvey had suggested to us his role was in that to frame going to the police our interpretation, or
certainly my interpretation of what Simon Medland said there was: still don't know if it's worth
going to the police, they have asked me to see if there is anything worth going to the police with.
So of course right from the start I think he's starting from a position that there's nothing to see
here. So can you go back to the paragraph, sorry, you asked me about? I mean, I don't think any of
us used the word "prima facie"; that is a very legal term.
LANGDALE: Don't worry, I am not asking about that.
JAYARAM: We agreed that, you know, if there was an identifiable common thread, well, there was an
identifiable common thread; it was Letby. Which is why we had been raising these concerns all along.
LANGDALE: In terms of -- that can come down now, please, and can we have INQ0006136, page 1. This is your email, Dr Jayaram, to Mr Harvey and others
expressing what you have just said now, about whilst you agree the minutes you hadn't had that
respective understanding of the purpose of the meeting, you thought it was simply to frame what
needed to be said to the police whereas he told you it was to discuss whether there was enough in
articulated concerns to make reporting to the police worthwhile. Either way, it was very soon
thereafter that it was reported to the police, wasn't it, and if we see at INQ0107964, page 22, you set out there --
JAYARAM: So this was in our Consultant WhatsApp group. So Dr Brearey was away and myself and my
colleague Dr Susie Holt went to the meeting and this was to summarise to colleagues this was sort of
straight out of the -- straight out of the meeting what the outcome had been and my -- my
overwhelming I think emotion at this point was relief. I mean, almost bizarrely, you know, a sense
of joy because someone had actually taken the trouble to listen to the things we were saying.
Whether we were right or wrong somebody had taken the trouble to listen to what we were saying at
the very least felt it was worth looking a bit further to see whether there was anything. And as I
said, you know, if this process had happened and then they had said there's nothing, we felt that we
would have -- we would have fulfilled our duties of care and it was, it was surreal -- I use that
word a lot -- because after this
whole several months of being told that we were the problem, it was the first time that I felt that
some progress was being made and I -- I do remember sitting in that meeting with the CDOP team and I
just remember Ian Harvey and Stephen Cross sort of the look of shock on their face really because I
don't think I can't speak for what they were thinking, but I don't think that they were expecting
that to be the outcome of this meeting.
MS LANGDALE: Thank you, Dr Jayaram. My Lady, this may be a good moment to take the short break.
LADY JUSTICE THIRLWALL: Very well, 10 minutes?
MS LANGDALE: 10 minutes, 20 to 4.
LADY JUSTICE THIRLWALL: So if we could start again please at 20 to. (3.28 pm) (A short break) (3.40 pm)
MS LANGDALE: Dr Jayaram, just a few more questions from me. INQ0107964, page 0239, please. This is a letter to Mr Chambers from the
paediatricians to explain the context, there's been a newspaper article, the police have been
brought in at this point, the RCPCH review and this appears, and you all respond to say that the
article reports that Mr Chambers said: "There was just a few niggles that our clinicians said: look,
we think we have got 90% of the answers but there are still bits that we need to in a sense be clear
that we have not missed anything." Well, what was the purpose of that letter? What were you
concerned about, all of you?
JAYARAM: We were concerned -- so I think this was an article in the local paper and a journalist had
interviewed Tony Chambers and asked about why the police eventually became involved and this was the
reported response. And given all the concerns that we had raised, the push back that we had, the
fact that a police investigation had been going on for several months at this point to describe our
concerns as "a few niggles" and we just need to be sure we have not missed anything was insensitive
and disrespectful to us and the Families of these babies, because these were not niggles, these were
significant concerns and we by this stage were -- the tone had slightly changed in the sense because
the police were involved, I think there was an element of Tony Chambers and colleagues perhaps
trying to create a picture of saying: we were always going to go to the police anyway, it just
needed to take time.
But it was that thing about niggles, it was, it was just -- you know -- absolutely -- I am trying to
think of the word -- it was -- it was demeaning. That is not the word I am thinking of, but it was
just demeaning to our concerns. So we wanted to flag this up again as a group and just to sort of
really get him to explain why he had used those words that were reported to have been said.
LANGDALE: Thank you, that can go down. INQ0107964, page 213. Also February time. This is an email to you from Sir
Duncan Nichol: "However events unfold following today's release, I will be standing with you. I do
understand how very difficult this is for you and your colleagues and I want you to know that I am
personally here for you, as I will be for any member of the neonatal unit." What was the release on
8 February, was that that article or is that something else?
JAYARAM: No, I think that no this is a year before.
LANGDALE: Sorry?
JAYARAM: I think this is when the Trust were making their public statement on the findings of the
Royal College review and the Hawdon report.
LANGDALE: If we can go to INQ0006681, page 1. 26th: "Further to your meeting with Ravi Jayaram on 26
February 2018, we remain extremely concerned that our relationship with the Executive Board has
deteriorated significantly and no meaningful efforts are being made to repair it. Working in this
environment is not conducive to good clinical practice and we would be grateful for the board to
acknowledge the problem and take urgent steps to improve this relationship in the interests of
patient safety." Was this the first time this had been put in writing to Sir Duncan, as far as you
were aware?
JAYARAM: I think as a group it's the first time things have been put into writing with Sir Duncan.
LANGDALE: When roughly had you first had discussions with Sir Duncan about it?
JAYARAM: I had -- I had met with Sir Duncan intermittently in 2017, not specifically to discuss this
issue.
LANGDALE: Doesn't matter if it --
JAYARAM: I think really from -- I can't remember -- there is a whole series of emails that I've
referred to in my statement and the exhibit bundle, but the meeting I had on 26 February was a --
there was -- I can't remember if it was that one. It was a very difficult one where he and I were in
my office. It was quite emotional because I articulated to him that I felt that
he had not taken our concerns as seriously as he should have done.
LANGDALE: Was that 2017, are you talking about February 2017 or 18?
JAYARAM: No, I think this was later on.
LANGDALE: Later, 18?
JAYARAM: I can't remember, I would have to refer to my statement. But the meeting referred to here
was very much a case of because the police investigation had been ongoing, we had had very little
interaction from that point with anybody from the Executive board. Now I appreciate now that it may
be that Operation Hummingbird had said to the Executives "don't say anything to the paediatricians
for fear of contaminating evidence". But we also knew that the Executive board or members of the
Executive board were having reasonably frequent contact to update members of the nursing staff yet
we were getting absolutely nothing and we didn't know where we stood. We wanted to start making
moves to think about regrading the unit back-up to Level 2 status again. We had as a consequence of
everything that had happened through June 16 onwards, absolutely no faith or trust in the Executive
board. And of course one of the
most difficult things is we -- we go to work every day doing a high risk job and you want to be
assured that the people who run the organisation will support you. Now, doesn't mean cover up for
you, obviously, fair's fair, but you want to know that they have got your back. And we, as a group,
felt we were in a situation where we were not only walking on eggshells, if the moment anybody put a
foot slightly wrong we were potentially at risk of detriment to ourselves.
LANGDALE: We see at INQ0107964, page 263, another email from Sir Duncan Nichol to yourself. It
looks as though that meeting as you says, is 26 February, was when you met: "High on my agenda [he
says] was concern about the damaging breakdown. So the board understands the problem exists and will
press for it to be resolved in the interests of the patients. I welcome an early meeting." There was
a meeting, wasn't there, on 30 April 2018 between Ian Harvey, Mr Cross and the paediatricians?
JAYARAM: Was that just myself and Dr Brearey? Or was that with all of us?
LANGDALE: I think it was just yourself?
JAYARAM: Yes.
LANGDALE: And 26 questions -- actually, I'm not sure
about that, Dr Jayaram. But basically you put 26 questions together, didn't you?
JAYARAM: Yes.
LANGDALE: So there were 26 questions that you wanted answers from that couldn't be given in the
meeting and we know subsequently you got answers I think from Mr Chambers and then you did another
table with answers to the answers, if I can put it like that?
JAYARAM: Yes, observations on the answers.
LANGDALE: I don't need to take us to those, but your observations. So there was detailed
documentation going backwards and forwards and Stephen Cross asked for an electronic copy which he
shared with the Exec Team. 25 May, you tell us in your statement at paragraph 872 you had an
informal and unplanned meeting with Sir Duncan. "I was frank with him at my disappointment that we
had not yet had any responses to our 26 questions, that I felt he was sitting on a fence and
although he had listened to us I told him that I believed that his ultimate priority was not to
ruffle feathers. I also expressed to him I did not believe that Tony Chambers was a fit and proper
person to lead any NHS organisation."
JAYARAM: This was the meeting that I remember as being a very emotional meeting, not the previous
one.
LANGDALE: So the May 2018 one. What was his response to that? If it helps there is another email
dealing with that and he does express -- I don't need to put it up -- at 0292: "I want you and
Consultant colleagues to know how deeply sorry I am for the personal distress that you have and are
all suffering and for my part in not intervening sooner." Do you remember getting that?
JAYARAM: Yes, can you remember what date?
LANGDALE: Yes 25 May at 5 pm?
JAYARAM: 25 May. So that was his conciliatory message, as I have described it, in point 873, I
think.
LANGDALE: Yes.
JAYARAM: No, I do remember getting that and we then shortly after that got a written reply from Tony
Chambers with answers to the questions which we then sat down together, digested and wrote back and
then I emailed Sir Duncan, I have here on 4th July, to discuss the concerns we had around Tony
Chambers's responses and I think as a group, when we had the responses to our questions, as the
document shows, which tabulates it, we have made annotations but most of the
responses weren't -- weren't really answers to the questions that we had. They were -- they were
answers to other questions that we hadn't asked or were quite evasive. Then there was a meeting with
Sir Duncan Dr Brearey and myself in early July which was after the first arrest had been made and we
as a group at this point were struggling because we did not have faith in Tony Chambers. I
articulated it before, and I can't speak for colleagues, but I think we all shared the concern that
I had raised previously to Sir Duncan, that he was not a fit and proper person to be running any NHS
organisation. We had started having discussions about the Medical Staff Committee so the Medical
Staff Committee is essentially the group of doctors employed by the Trust, mostly Consultants but
also career grade doctors, so doctors who aren't in training. And we wanted -- given the confines of
the police investigation, we wanted to flag up to colleagues some of the things that had happened
and the obstacles that we had run into when we tried to raise concerns, but obviously we had to do
that in a way that wouldn't compromise patient confidentiality, wouldn't compromise the police
investigation.
And Sir Duncan encouraged us to organise such a meeting. We had correspondence via Paul Jamieson,
who was one of the anaesthetists who is Chair of the Medical Staff Committee. He was liaising with
the police as to get some guidance as to how much we could disclose. Ian Harvey retired around this
time as well. And I think the meeting took place in September 2024 and we had a lot of discussion as
to whether once we'd told our story, and we also wanted to hear of other people's experience as
well, whether a vote of no confidence should be considered in Tony Chambers. But as it was, he stood
down on the afternoon that that meeting took place.
LANGDALE: Focusing on Sir Duncan again, if I may, INQ0107964, page 0269. An email from Dr Holt. If we look at paragraph 4. She
reflects: "Sir Duncan made it very clear he would not take and no could he/would he get us
acknowledgement or apology. "I feel Sir Duncan was very careful not to promise or suggest he would
offer any feedback on their views on the issues discussed. I expect we will hear no more of this."
You had expressed that, now had she. Was there a concern that he wasn't descending into the fray, as
it
were, and making decisions or determinations about what was the right thing here?
JAYARAM: I think he was -- and I can't speak for him but my impression was he was juggling a lot of
different priorities that he may have had as Chair of the Trust. I think what I have seen in much of
the documentation I have seen as part of this process that I hadn't seen before, there was a lot of
-- well, frequent reference to -- to reputational damage to the Trust and I think that that was a --
may be a driving force and I think that was probably one of the issues that sort of equipoise in
which he was sitting that led to the discussion on 25 May being quite emotional and heated. You
know, we -- we wanted to make him aware and think we made him aware of the fact that we had
absolutely no confidence or faith in the Executive board. Now, actually the priority here is I don't
care who's on the Executive board but I want to know that whoever is sitting on that board that I
can trust because it helps me to look after patients safely and properly.
LANGDALE: Thank you, that can go down now. We asked you, Dr Jayaram, as we have everybody for
reflections and particularly how babies might be kept safer in hospital today. You make a number of
observations, one of them about whistleblowing at paragraph 944?
JAYARAM: Sorry, what number was that?
LANGDALE: Paragraph 944 of your statement?
JAYARAM: 944.
LANGDALE: You say it became clear to you very quickly following the verdicts in this case: "It
became clear to me very quickly that the behaviour displayed by the Executive Team at the Countess
of Chester were by no means unique and that there seemed to be a clear pattern of management
behaviours in response to escalating concerns. Initially dismissive responses from managers would be
followed up by threats that the complaint was being unreasonable, aggressive or misguided. They were
led to believe that they themselves were the problem and were subject to small passive
microaggressions, such as, for example, not being offered opportunity for professional development,
having theatre lists cancelled or being removed from roles on various hospital advisory committees."
So was that you broadening out your understanding of your own experiences to try and understand
other experiences in the NHS?
JAYARAM: Yes, so -- so following -- following the verdicts from the initial trial, myself and Dr
Brearey received an enormous amount of correspondence from not only people who had worked or were
working in the NHS but working in other professional organisations as well sharing their experiences
of what had happened when they raised concerns. And I think certainly for me, as we were going
through the process ourselves, it never occurred to me that -- and again my naivety, that those
people in whom I put my good faith to pull in the same direction and do the right thing may not have
been -- and it's been quite difficult this afternoon talking about all and reliving it all because I
feel a sense of shame that I allowed myself for such a long time to be treated like that because of
my -- my misplaced faith and to believe that maybe I was the problem and maybe I was making
completely unfounded suggestions. But when I started hearing from other people it suddenly hit me
that there's a pattern and -- and hearing the descriptions of what other people had gone through I
suddenly realised I wasn't, you know, although there had been talk of GMC and consequences of
crossing lines I suddenly realised that myself and my colleagues had put ourselves professionally
and personally at extreme risk and if I had known that, would I have done
the same? Well, yes, because ultimately it is about patient safety and I think what really struck
me, and I think this is important, that we were very lucky, I was very lucky to work with a team of
Consultants who, yes, we would disagree occasionally but we supported each other and trusted each
other. And I think there were -- and this may come out in your further inquiries, there were
attempts to sort of try and divide us and play people off against each other but ultimately it's
because there were seven of us who all had the same concern that we managed to stick together. But I
think I never -- I never considered myself a whistleblower and actually I wasn't aware of any formal
whistleblowing policies at that time. You know, I was aware vaguely of the existence of Freedom to
Speak Up because it had been put in after the Francis report. I was also aware I think that Alison
Kelly was the Freedom to Speak Up Guardian at the time and it never occurred to me, you know, how
difficult that might have made things. So -- sorry, I have completely I have forgotten what the
question was.
LANGDALE: No, that is fine, you have answered it. If we can have on the screen finally paragraph
942
of your statement, INQ0107962, page 121. These are your views about how now reports and harm can
be investigated.
JAYARAM: Do you want me to --
LANGDALE: It is going to come on the screen?
JAYARAM: Okay.
LANGDALE: I think it will save you going through them Dr Jayaram if you want to add or elaborate on
any of them, but you have set them out as clear bullet points here.
JAYARAM: I think -- I mean, this might potentially be a lot of work but I think the holes in the net
need to be as small as possible, so all neonatal deaths should at least be discussed with the
Coroner. I think the process for escalating to CDOP needs to be better than it is in terms of just a
form being filled in and sent to the designated doctor. I think if the death is unexplained
absolutely the SUDiC process should be involved, because it's quite clear had we done this, had I
done this, had colleagues done this, we would have had oversight from other agencies outside of the
hospital who would look at it more from a safeguarding point of view. Now, of course should every
death because sometimes they are explained but actually looking back, and this is important, the way
things were happening in 2015 and 2016 almost became our normality; that, you know, these things are
happening, they don't happen anywhere else but it happens here and I look back and think it was so
unusual and it was so bizarre, you know, and I have thought about this recently -- I am thinking
through my whole career and training in paediatrics and doing neonatal jobs, these events just don't
happen. I can't think of any events in my training where a baby who is otherwise stable would just
suddenly deteriorate for no obvious reason and I kick myself, it was so obvious. But I think it's --
it's that definition of "unexplained" and I think it's important that non-fatal collapses should be
reviewed initially locally and then escalated if there's anything untoward. I think my next bullet
point, I can articulate it a different way. It's about -- it's about being empowered, firstly, to
think the unthinkable. We as human beings, as doctors, as scientists, as people, like to be able to
explain things; we don't like uncertainty. And of course as clinicians we are taught to think around
natural causes and think common things happen commonly, think of more uncommon things but think
right to the edge of the playing field of natural causes.
But we are not empowered to think the unthinkable and actually 99.9% of the time there is no need to
think the unthinkable and things like, say, for example that Just Culture document, I think, you
know, it is trying to empower to think the unthinkable but it is how, number one, you can empower
people, so I think in safeguarding training there needs to be reference to -- was it the Clothier
report? -- and the findings of that, I think there needs to be mechanisms at least to prompt people
to think about it. But what's also important is on top of that, there need to be clear processes for
what to do if once you have considered the unthinkable and it could be a possibility of how that is
then processed be that SUDiC, be it safeguarding referral, be it whatever way but there needs to be
clear guidance but most importantly on that point, staff need to be able to work in a culture where
they feel that they are going to be listened to and they feel that they can raise potentially what
might seem outlandish concerns, without fear of detriment. I think that's really important, not
necessarily talking about my experience and my colleagues' experience but what I have heard from
lots of other people post the verdicts who have basically been met with a response of: we don't want
to know about
this problem we will make you the problem if you don't keep quiet and I think that's really
important. I am not -- you know I am very subjective. I am not going to make judgments about how the
people at the top of the organisation may or may not have behaved what their thought processes were
but surely everybody who works in healthcare, be they frontline staff, be they administrative staff,
be they senior managerial staff it all had has to be about safe patient care and patient safety
concerns have to be listened to, however uncomfortable it might make one feel. I think for myself I
acknowledge that because I had those concerns and I didn't act on them as soon as I could have done
and I will reflect forever on why and it's multi-factorial but I think for the future people need to
be able to work in a culture where it is open and I know lip service is paid to being open and
everything else, but from what I have heard from other people around, everybody needs to pull in
those pull in those directions. I think with regards to Freedom to Speak Up I think it's certainly
better now at the Countess there is much more awareness I still worry about the independence of
Freedom to Speak Up Guardians because they are ultimately employees of the Trust. I think the other
important thing is looking at risk and governance departments. I think they are crucial to patient
safety and I know there's wide variation in terms of talking to colleagues in other similar
hospitals in terms of numbers staff background training of staff as well. I think it's a department
and a resource that needs to be prioritised. You need to have the right people with the right
training and they need to be visible and there needs to be communication.
MS LANGDALE: Thank you very much, Dr Jayaram.
JAYARAM: And I think also I think it's a point that you said I think that is really important I do
understand that this has changed involvement if you are investigating a clinical incident such as
ours in making sure that the parents' opinions and views are represented, and also they are not
forgotten about and fed back to. I think it is such an obvious lightbulb moment that I am kind of
embarrassed that I have not even thought about it.
MS LANGDALE: Thank you very much. My Lady, there are some questions from Ms Blackwell, from Mr Baker and then Mr Skelton.
LADY JUSTICE THIRLWALL: Very good. Ms Blackwell.
MS BLACKWELL: Dr Jayaram, I am Kate Blackwell and I ask questions on behalf of the former senior
managers. I want to begin, please, by seeking clarification on some evidence that you gave to the
Inquiry this morning. In your first Inquiry statement at page 294, you say that you first began
having discussions with Consultants about the possibility of deliberate harm by Letby in November of
2015. But in answer to Ms Langdale this morning you said that by that time, the end of 2015, we, I
think meaning you and your Consultant colleagues, weren't at those points thinking outside of
natural deaths. So I just want to clarify what you meant by that?
JAYARAM: So to clarify that I think November it was the first point where I think between us the
association of Letby it began to be suggested that it was significant. Now obviously there was no
thought about was it well -- was it competence, could it be deliberate.
BLACKWELL: Yes?
JAYARAM: But I think the thought at that point about it being deliberate in November it was
discussed but as I have said myself I kind of tried to shut it away really and I can't speak for
colleagues.
BLACKWELL: All right.
JAYARAM: At that point but the association I think from that point was something that we felt was of
significance but we didn't know how.
BLACKWELL: Thank you. At paragraph 302 of your statement you go on to say that the association with
Letby that had been highlighted in the mortality table was being escalated as far as you were
concerned to Sian Williams and Alison Kelly and that was being done by Dr Brearey?
JAYARAM: Yes, there was a series of emails I think Dr Brearey had discussed the mortality table and
I think it was an email back from Eirian Lloyd-Powell saying she was escalating it to Sian Williams
and Alison Kelly. I think there was an email saying at one point one of them wasn't there or someone
was on leave but my understanding was that it had been escalated. I don't know whether it was but my
understanding was that it had been.
BLACKWELL: It wasn't escalated by you?
JAYARAM: It wasn't escalated by me.
BLACKWELL: What was your view at that time of Letby continuing to work on the unit?
JAYARAM: At that time, as I said, we were worried about the association being significant. I at that
point did not feel as I was thinking then that there was enough at that point to justify moving her
from the unit but I felt there was enough to justify an acknowledgement that this could be
significant and work out ways to look
into it further.
BLACKWELL: All right -- you yourself didn't escalate it or?
JAYARAM: No, I didn't.
BLACKWELL: Thank you. By February of 2016, we know that Dr Brearey had conducted the Thematic
Review and that that report had been prepared. You were not involved in that, were you, because of
clinical commitments I think?
JAYARAM: Yes.
BLACKWELL: But you read the report because you say at paragraph 326 in your statement that you
noted that the Letby association was not mentioned within the report and you raised that with Dr
Brearey who told you that he intended to explicitly discuss your concerns and his concerns about the
association with the Medical Director and the Nursing Director. So you noted that that wasn't
contained those concerns were not contained within the Thematic Review?
JAYARAM: Yes, I think the initial mortality review analysis had had her name there.
BLACKWELL: Yes, that was in an annex wasn't it?
JAYARAM: Yes.
BLACKWELL: Yes. Now you said to the Inquiry this morning in justifying your failure to mention your
eye witness evidence of [Child K] to any Executive at the time of the
collapse, in February of 2016, that you were reassured that there was enough in the Thematic Review
for senior managers to act.
JAYARAM: I think there was enough in the Thematic Review to acknowledge that the association was
significant.
BLACKWELL: All right.
JAYARAM: And my -- the events around Baby K [Child K] that morning as I discussed I hadn't seen
physically doing anything. I note that Alison Kelly made a point that if I had raised with her that
Letby might have deliberately silenced the alarms she would have acted. I would contend that -- I
don't know whether she would or not -- -- that is something of a straw man argument, to be honest,
given from that time and onwards when we did raise concerns the response, particularly when Dr
Brearey met with them in the May.
BLACKWELL: So your evidence remains that you considered there was enough in the Thematic Review to
justify you not mentioning to anybody for --
JAYARAM: I think at that time as I discussed this morning it was, it was an event where -- and again
it comes back to the misplaced belief that you had to have evidence.
BLACKWELL: May I just deal with the chronology please --
JAYARAM: Yes.
BLACKWELL: -- because we are going to come to that. The CQC visited the hospital between 16 and 19
February. We know from your witness statement that you had your meeting with the inspectors on 17
February between 2 and 3.00 pm. It was earlier that morning, whilst you were on the ward, in the
early hours of the morning that [Child K] had collapsed. You had been on shift as we know when the
breathing tube was dislodged and you have explained that at that time the nurse tending to [Child K]
was away from the incubator and that you noticed that Letby was there and you were so concerned
about her association with other deaths and collapses that you left your chair and went to the
incubator to see what, if anything, she was doing and you knew that she was on the ward so is it
safe to assume that she knew you were on the ward as well?
JAYARAM: I would imagine that she knew I was there because I had been there from the moment that
Baby K [Child K] was born.
BLACKWELL: Thank you. You told the Inquiry this morning that there was speculation or there has
been speculation about whether or not the alarm was sounding as you approached the incubator but
that's speculation Dr Jayaram has arisen because in your police interview
in April 2018 you said that you couldn't remember if the alarms were sounding?
JAYARAM: Yes.
BLACKWELL: But in February 2023 you gave clear evidence that neither the ventilator alarm nor the
monitor alarm was sounding. So had your memory of events in relation to that detail got clearer as
time when on?
JAYARAM: It had I think in that police interview the initial one it was kind of an overarching
interview to discuss everything and I have read the transcript. I remember clearly I didn't I wasn't
prompted to go into the room because alarms were going off.
BLACKWELL: Right.
JAYARAM: But --
BLACKWELL: Is it your clear memory now that the alarms were not sounding?
JAYARAM: Yes.
BLACKWELL: Right and you it was Dr Jayaram who called the transport team?
JAYARAM: That's correct.
BLACKWELL: After you tended to [Child K] for her to be transferred out of Arrowe Park and the
written record of that call to the transfer team is that you described what had happened in four
words "Baby dislodged the
tube."
JAYARAM: That is what was recorded so the person I spoke to wasn't a clinical person. It was an
administrative person.
BLACKWELL: So do you remember now what you said?
JAYARAM: I would almost certainly have said the tube was dislodged.
BLACKWELL: Tube was dislodged?
JAYARAM: Yes because it had done it passively.
BLACKWELL: You gave evidence about these matters at both criminal trials and you accepted that you
had not made any clinical notes?
JAYARAM: I accepted that at the time yes.
BLACKWELL: Of what you had seen, nor did you compile a Datix report although you agreed with Ms
Langdale this morning that the Datix reporting is for when you see something which is a problem or
an error. Do you think you should have filled in a Datix form?
JAYARAM: I think in retrospect because even if there's accidental tube dislodgment it probably
should be Datixed because then you look into why the tube may have dislodged. But I didn't.
BLACKWELL: No. But you agreed in the second criminal trial that it was a shocking discovery of
finding her next to the cot. You also agreed with prosecuting
counsel that it was your conclusion that she deliberately dislodged the tube?
JAYARAM: That was the thought that went through my head there. Again, as I said this morning, in
isolation it wouldn't even have crossed my mind but in the context of the other concerns ...
BLACKWELL: But you didn't mention that to anybody, did you?
JAYARAM: I didn't because I was as I discussed this morning it was such I think it was the first
time it really hit me that you see I had been hoping to walk in and find everything was okay.
BLACKWELL: Yes?
JAYARAM: But, as I discussed this morning, this fear of not being believed, this fear of detriment
and I acknowledge that as I said I should have had more courage to raise those things.
BLACKWELL: Were you complying with your duty to public safety in keeping that quiet?
JAYARAM: Sorry, could you repeat the question?
BLACKWELL: Were you complying with your duty to public safety to patient safety by keeping that
quiet?
JAYARAM: I'm not sure that I can answer that. I'm not sure that I can answer that.
BLACKWELL: Well, do you accept this: certainly you didn't raise any concerns with any Executive
about either a concern of neonatal mortality rising, or indeed of any deliberate harm being metered
out to any patients?
JAYARAM: I --
BLACKWELL: -- please allow me to finish -- until the collapses and deaths of children O [Child O]
and P [Child P] in 2016?
JAYARAM: Personally no.
BLACKWELL: No.
JAYARAM: But I know that Dr Brearey as neonatal lead had explicitly raise that concern before then.
BLACKWELL: Had explicitly raised what concern?
JAYARAM: The association with Letby.
BLACKWELL: The association but not of deliberate harm?
JAYARAM: I don't know specifically what he said to them, you will have to ask him.
BLACKWELL: You were clinical lead for children's services. If you believed that deliberate harm was
being used it was your duty was it not to bring that to the attention of the Executive Team?
JAYARAM: And we did at a point whereas a group we felt that we had enough. Don't forget that even
when we raised our concerns in June we were under as I have said, the misapprehension that we needed
to have evidence and actually the response we got was: you haven't got any evidence. So actually I
didn't know at
the time. Had I raised concerns earlier within even less evidence I can't speculate what the
response might have been. I agree that there was, and I have said this already, there was
potentially an opportunity to act sooner.
BLACKWELL: Well, this was eye witness evidence wasn't it of a belief that you had that she was
deliberately harming?
JAYARAM: Well, I didn't see it was more the lack of response to what she was doing. I can speculate
on it forever; you are absolutely right, it was an opportunity.
BLACKWELL: There was a meeting as we know on 11 May of 2016 which you were not at, at which Dr
Brearey discussed concerns and we do know that you received an email, you were the first on the list
of recipients on 16 May 2016 which we have looked at already today. And according to that email from
Dr Brearey, he said that the 11 May meeting was helpful he was grateful for the work and that
effectively all was well. But you gave evidence today that he told you that he had explicitly raised
concerns about Letby and was uncomfortable at her continuing to work as of that date?
JAYARAM: That's correct.
BLACKWELL: Yes. Did you as a result of your conversation
with Dr Brearey on 16 May raise any further concerns with the Executives at that stage?
JAYARAM: Not at that point.
BLACKWELL: All right. We know that there was a meeting with the Executives in Tony Chambers's
office on 29 June of 2016. Could I ask, please, that we look at INQ0003371. Now we have looked at this already this morning and we can see who
was present on the top line but I would like to go down please to look at your comments towards the
bottom of the page. The first one is entirely subjective "Staff member almost always nurse in
charge, babies were stable and then deteriorated, why always this nurse. Babies were unwell but
getting better. Babies not getting oxygen then crash babies did not respond as they should." And
then "Steve B disturbing thing ... Twin survived and got better at Arrowe Park. Babies coming back
to Countess of Chester. Babies deteriorate. Nurse 7 out of 9 between 12 noon and 4 am." Can we go
over the page, please. And Steve B more than just an association with this nurse. And your comments
"How: Cannula air embolism crystal ball. Unquestionably got something going on at Countess of
Chester but what? Looked at equipment,
looked clinical matters" and then it goes off to Dr Saladi. So as of 29 June, you were raising
serious concerns about Letby being associated and possibly causing the collapses or deaths of some
of the babies?
JAYARAM: That's correct.
BLACKWELL: Yes. If we go a little further down please to the words attributed to Tony Chambers. It
says, "Why did we call the police [I think that should be why did we not call the police] if Twins
and Triplets why did the Trust take them on? Can we explore more before the police?" And Steve B:
"Can we move member of staff? No, should then be police." And you say: "Why not earlier? Reviews."
Do you know what those comments relate to?
JAYARAM: I don't. I think I was probably referring to the reviews, the case reviews that had been
done by Steve Brearey and the Thematic Review. I can't think what other reviews I would have been
referring to.
BLACKWELL: No. As of 29 June, were you content that whatever had been raised by the Executives had
been treated appropriately and that the reviews that had been commissioned were the right reviews as
of that time?
JAYARAM: Sorry, can you just repeat that question again?
BLACKWELL: Yes, of course. The 29 June --
JAYARAM: Yes.
BLACKWELL: -- I am asking you whether you viewed at that time that that the pieces of work that had
been commissioned by the Executives had been appropriate for the concerns that had been raised at
that time?
JAYARAM: You mean the pieces of work that they commissioned after this meeting in terms of the Royal
College? Or --
BLACKWELL: Well, no. The pieces of work that had already been commissioned, so the Thematic Review
and the various internal reviews?
JAYARAM: Sorry, I don't think any of those reviews were actually commissioned by the Executive Team.
They were undertaken by --
BLACKWELL: Yes, but they come to the attention of the Executive Team, hadn't they?
JAYARAM: Yes.
BLACKWELL: And you were content that as of that time those had been appropriate, but that things
had developed?
JAYARAM: I -- I think that the point of the Thematic
Review being sent on to the Medical Director and the Nursing Director and there were the appendices
with the Mortality Review on, I think I don't know when they were looked at and how they were
interpreted. But I think up until that point the reviews that had taken place were as far as we
could probably go within the department and we had actually had an external neonatologist as well.
BLACKWELL: Yes, thank you. That can come down. We know that there was another meeting the following
day. We have looked at those notes earlier in evidence. You described the meeting on 30 June as
being a strange meeting because in your consideration as at that time the issues around Letby were
not being taken seriously. But following that meeting, the Royal College review was commissioned,
wasn't it, and as we know Dr Hawdon's report came through. As at that time, did you believe that the
commissioning of those reports was appropriate?
JAYARAM: When those -- certainly when the Royal College review was commissioned, and we saw the
Terms of Reference, it was essentially a service review but one of the Terms of Reference was
specifically to see if -- I forget the exact wording -- to see if there are any
factors that could have contributed and I think it said the "apparent increase" in death rate, but
it was the real increase in death rate, and then obviously the Hawdon review was recommended by the
College.
BLACKWELL: Yes.
JAYARAM: Now, we at this point, when we had the College review -- well, the College review hadn't
happened, but when it was suggested we were also expressing our concerns around the continued
presence of Letby on the unit.
BLACKWELL: Well, of course following your meeting on 29 June, and we know that she was on holiday
at that time, she never in fact returned to the ward, did she?
JAYARAM: No.
BLACKWELL: No.
JAYARAM: But we were never involved in any discussions around what happened or informed of her move
and I think because at that point she was off the unit --
BLACKWELL: Yes?
JAYARAM: -- as I mentioned earlier there was a --
BLACKWELL: A lack of urgency?
JAYARAM: There was less urgency.
BLACKWELL: Yes.
JAYARAM: And because we were under the impression that the RCPCH review and the Hawdon review, as
had been
described initially, would be in depth. Now --
BLACKWELL: Well, we are going to come to the Hawdon review in a second.
JAYARAM: Okay.
BLACKWELL: But can I just confirm this; that the reason that I asked whether you thought if things
were being generated appropriately at that time is because we know on 24 October of 2016 you spoke
to your BMA representative?
JAYARAM: (Nods)
BLACKWELL: And said to her that the senior management team took a decision to move Letby to a
non-clinical role temporarily and that: "... we as a group, that's you and the clinicians, are still
uncomfortable that our concerns have not been fully addressed but we understand why the Exec body
was cautious about escalating things." So I want to ask you about that, please. Does that accurately
reflect your consideration at that time?
JAYARAM: So I think at that time, it was reassuring that she wasn't in a clinical role. From the
discussions with the Executive Team in June and July, we were fully aware, and it's been said and
documented, that there they were -- they had concerns about reputational damage. So when I have said
I understood, I didn't say I agreed with their thinking.
BLACKWELL: Right.
JAYARAM: But I understood where they were coming from.
BLACKWELL: Thank you.
JAYARAM: However, I think the -- I suppose one of the elephants in the room here was that, and
looking back, was the fact that all of these actions were predicated on the suggestion from Stephen
Cross that involving the police at this stage would not be appropriate.
BLACKWELL: Yes.
JAYARAM: And I fell for that. And in the context of that if the legal advisor is telling you that:
well, she's off the unit it's being looked at --
BLACKWELL: Yes.
JAYARAM: -- that's something. But I am -- I don't think any of us were ... It was strange. I mean if
you're being told by somebody who is a legal adviser and an ex detective that it's inappropriate to
call the police I am not in a position to argue however uncomfortable it seems.
BLACKWELL: Well, by 3 February, you had seen the RCPCH report and by 7 February 2017 you had seen
the Hawdon report in which Dr Hawdon had found sub optimal care in the cases that she reviewed at
different levels:
significant, major and minor. And having considered that report, you and your colleagues took the
view that in addition to the four cases which she suggested needed a broader forensic review, there
were others as well?
JAYARAM: Yes, that's correct.
BLACKWELL: And you brought that to the attention of the board, didn't you?
JAYARAM: That's correct.
BLACKWELL: Yes. Throughout none of what had taken place since February of 2016, so over the
previous 12 months, had you ever brought to anybody's attention your eye witness evidence of [Child
K], had you?
JAYARAM: Not at that point. It was only when I was interviewed by the police.
BLACKWELL: Well, in fact the first person that you spoke to about it in terms of the Executives was
Sue Hodkinson on 13 March, wasn't it?
JAYARAM: Okay, yes.
BLACKWELL: And we have looked at what you said to her on that date; that this was one of three
cases where you had had concerns and you had seen Letby by the cot. Following that there was a
meeting with the Executives on 27 March. Again we have looked at the notes briefly today and you
have told the Inquiry that
there had been a lot of letters backwards and forwards in preparation for that meeting. You had
requested a face-to-face meeting with the Executives because you had lost faith in Ian's judgment,
you said I think today?
JAYARAM: (Nods)
BLACKWELL: How had that happened, losing faith in Ian Harvey's judgment?
JAYARAM: Because firstly, the whole process of how -- the data that Mr Harvey had presented to us in
July with his, let's call it his deep dive review which he used to suggest that we were
understaffed, more busy, it was entirely plausible that is the reason for the association with
Letby. The fact that -- and we haven't touched on this -- in, in that particular meeting there was,
there was there were slides with patient identifiable data including the data of a -- of a colleague
which was unforgiveable. The way that the --
BLACKWELL: Are you talking about a meeting back in July of 2016?
JAYARAM: Yes, this is July which I think July 13th or 14th where he presented the data from the deep
dive.
BLACKWELL: All right. Can we have a look at the notes of
this meeting, please of 27 March 2017. They are at INQ0003150, please. Now, we have already looked at the attendees and we can
see that there's a welcome by Tony Chambers and the three items on the agenda which were for
discussion. If we could go to page 2, please. You say at the top of the page: "As a group of
paediatricians we accept the Royal College review, the Casenote Review and Jane Hawdon's review [and
identified further ones, that's the further deaths] It's a difficult thing. What level of review do
we need to do? We have a collective view that this now needs to be at the level of a rota review,
who, where, involved, a forensic investigation. We accept that we may not find a cause. We have our
names at the end of the incubator. We need more assurance. The interpretation of reports differs to
the board. We were presented with a plan and we have explored every avenue with the BMA." So you
were prepared to accept, it seems from this note, that the Royal College review, the Casenote Review
and Jane Hawdon's review had been appropriate in terms --
JAYARAM: No because if you look at the comment that Steve Brearey's made lower down, and I don't
recall making that comment, and it's quite obvious that we didn't accept the review if you look at
the correspondence that had come through since the time we saw the review, I don't think that's -- I
don't know who's made these notes. I think with regards to the RCPCH service review, absolutely some
of the recommendations in there were quite clear.
BLACKWELL: Yes.
JAYARAM: Absolutely I did not agree -- well, I agreed, what I agreed with with Jane Hawdon's review
was that there were definitely at least the four further cases.
BLACKWELL: Yes. We see that at the bottom of this page --
JAYARAM: I did not agree -- I did not agree that -- with her conclusion that she made at the time
that deficiencies in care were able to explain the deaths.
BLACKWELL: Yes.
JAYARAM: And I have said that lower down.
BLACKWELL: She had found delayed intubation, delayed cord clamping, delayed transfer, delayed
attendance by Consultants, hadn't she, and a whole host of things which she suggested may well have
contributed to the collapses or deaths?
JAYARAM: Well, I think in the context of the
information that she was given and the briefing she was given --
BLACKWELL: Yes.
JAYARAM: -- I understand that subsequently with more information she's actually disagreed with that.
And as I say our interpretation of the information Jane Hawdon provided even with what she had got
we were still concerned that there were further babies in whom --
BLACKWELL: Yes, of course --
JAYARAM: -- there was no explanation.
BLACKWELL: And we see that at the bottom of the page. Could we move over to the next page, please.
Steve Brearey says: "But we have not interviewed nurses, junior doctors which is really important."
And you say: "Who could do that level of investigation? Does not look good on the Trust's
reputation. As group of clinicians we do not know what to do but all of which are disturbed by this.
All unusual ones where they have not responded and should. Board felt reassured, accept
inefficiencies." Then you go on towards the middle of the page: "Our career would be on the line if
we contact
police. It would be whistleblowing. Following BMA advice if there is an alternative of a deeper dive
we should go for it, but this is a worry." So weren't you there suggesting in this meeting that a
deeper dive before you go to the police would be appropriate?
JAYARAM: No because if -- what I was suggesting is if there is any way of doing a deeper dive --
BLACKWELL: Yes.
JAYARAM: -- but we didn't feel that there was, absolutely. And I was concerned, you know, already.
Don't forget this meeting took place --
BLACKWELL: 27th --
JAYARAM: -- a month or so, sorry, two months after we had been told quite clearly about the
consequences that would happen if we crossed the line. I had been told that if I didn't engage with
the mediation process, I was at risk of being reported to the GMC. I had been told that there was
significant evidence from the grievance process of bad behaviours. So, absolutely. And, yes, I can
argue, you know, my patient safety should come above my career --
BLACKWELL: Yes.
JAYARAM: -- absolutely. But also at this point Letby was away from work and actually our purpose of
this
meeting, as I understood this meeting, would be an opportunity for us to have a discussion and put
down and actually state explicitly, "We don't feel that there is any alternative other than going to
the police at this point."
BLACKWELL: Did you agree that that comment seems to suggest otherwise?
JAYARAM: No, I said if there is an alternative. But there was no alternative.
BLACKWELL: All right.
JAYARAM: There was no other way. We could start looking at the same information over and over and --
BLACKWELL: Yes.
JAYARAM: -- over again and still not find anything.
BLACKWELL: Can we just turn over the page because you do make some more pertinent comments as well.
Thank you. Ian Harvey says: "There is three options, contact the police, internal with NS support.
Other experts conduct further review." And you say: "What would be the level of depth?" Then there
is further comments from Ian Harvey: "We've had the meeting with Jane Hawdon [that was our meeting].
There has been subsequent work done." And you say: "We need to speak to all individually. Most of
the time they are not on unit. All we want as a group is 1) that we feel assured enough that this
cannot be investigated any further and 2) is that the board understand where we are coming from and
that there is the board's interpretation. We are now more aware than you guys." If we can turn over
the page, please, you say in the middle of the page there: "The Consultant body has asked about it a
lot. We honestly can't see, get level of detail that's needed. We need the resources and the
interest." And over the page, please. And you say: "I agree with NM, the focus needs to be on the
babies who have died. We have discussed a lot of implications to the unit, the Trust and parents and
colleagues but this is for the greater good, the future. It's a big issue, it's huge." And then
there's a discussion between you and Tony Chambers. He says: "You absolutely believe we have a
criminal behaviour." And you say:
"We need to clarify it beyond reasonable doubt." And Steve Brearey says: "On the balance of
probability, words used from the child protection perspective, you say honest answer is we don't
know. It's not been sufficiently explored or reassured, there is a subtle distinction." And Tony
Chambers says: "To get the distinction the only thing is to do a police investigation." And you seem
to agree: "Not sure anyone can do an investigation like that." And then finally on this page, you
say: "For me personally I have a vague media profile. Recognise the impact, but so be it. It's for
the greater good." So what were you saying there, Mr Jayaram?
JAYARAM: I think with that comment, what I meant was I don't think anyone else other than the police
can do an investigation like that.
BLACKWELL: Yes.
JAYARAM: And actually, you know, if there is an impact on me in other things I do, so be it because
we needed to know. So I -- I, as I said earlier my understanding at
the end of this meeting is that it was accepted that we explicitly said we want to be able to talk
to the police.
BLACKWELL: Yes.
JAYARAM: And they agreed.
BLACKWELL: Thank you. Now, drawing all of that together we seem to have reached this point; that
nothing was raised by you until June of 2016. We have looked through the notes of the meetings that
took place at the end of that month. Letby never went back on to a patient-facing role and you
expressed in October of 2016 to your BMA representative that you understood why the Executives were
cautious to escalate up until that stage. We have heard this afternoon that following March of 2017,
you felt that your relationship with the Executives, and certain of them, had broken down and you
were raising that as a problem with Duncan Nichol. But you don't say, do you, Dr Jayaram, that any
reluctance on behalf of the Executives to look into matters prior to June of 2016 causes you any
concern and you can't say that because you yourself hadn't raised anything until that date?
JAYARAM: No, personally I hadn't.
BLACKWELL: No.
JAYARAM: But I am concerned that from the time that the Thematic Review was on their radar --
BLACKWELL: Yes.
JAYARAM: -- that they didn't feel that the association with Letby was of significance. I don't know
whether that is because they hadn't looked at it, wouldn't consider it. But that is --
BLACKWELL: Well, nobody was saying it was anything other than an association, were they, at that
stage?
JAYARAM: But it's an association in the absence of any other clinical explanations for what was
going on.
BLACKWELL: You were kind enough to provide us an appendix to one of your Inquiry witness
statements, the many postings and Tweets and media interviews in which you have engaged and much
later in August of 2023 you posted on Facebook the following: "There are people out there now still
earning six-figure sums of taxpayers' money or retired with their gold-plated pensions who need to
stand up in public and explain why they did not want to listen and do the right thing, to
acknowledge that their actions potentially facilitated a mass murderer and to apologise to the
families involved in all of this. However I suspect the response will be fudge and misinformation
and it is now my mission moving forwards to make sure that they are held to account." You have just
agreed that you understood why the Executives were cautious about escalating things. How did their
actions potentially facilitate a mass murderer?
JAYARAM: I said I understood. I didn't say I agreed. Lucy Letby was on the 27th of March I believe
five or six days away from coming back to work --
BLACKWELL: But she didn't, did she?
JAYARAM: She didn't --
BLACKWELL: No.
JAYARAM: -- because at this meeting we, as consultants and the team from the neonatal network, said
we want to speak to the police. I now understand that Lucy Letby had been led to believe, by Sue
Hodkinson, that that meeting on the 27th was actually a meeting at which myself and my colleague Dr
Brearey were going to be told that we were going to face disciplinary action. Now, it's all he
said/she said. But there's a clearly a discrepancy between where we are going why, at the meeting on
26 January when we had not had sight of the final Royal College report nor of the Casenote Review,
were we told quite explicitly that there's
nothing to see here.
BLACKWELL: No, this is -- with greatest of respect, Dr Jayaram, this is not about what you were or
were not told?
JAYARAM: No, I am talking about -- about things people could have done differently.
BLACKWELL: Yes.
JAYARAM: At that time, why were those interpreted in a way that was clearly to my mind designed to
minimise our concerns and bring her back to work? Why was Tony Chambers having conversations with
her mother and father? Why was Sue Hodkinson having conversations with her mother and father? Why
was the RCN rep? These are the things I am talking about. And when I talk about people justifying
their actions I will put my hands up and I hope I have acknowledged the things I could and should
have done differently and better.
BLACKWELL: Yes.
JAYARAM: All I meant by those comments -- and bear in mind there was a lot of pent up anger at that
point -- all I want is for these people to acknowledge that they too could have done things
differently.
BLACKWELL: Fair enough. You also on the same day said to ITV News: "The horrible thing to say is I
do genuinely
believe that there are four of five babies who could be going to school now who aren't." Now, given
that you have accepted that Lucy Letby never returned to a patient-facing role following your
concerns raised to the Executives about deliberate harm, do you still stand by those comments?
JAYARAM: I would stand by that had she been moved earlier, I think from the time the Thematic Review
was on the radar or whether it was considered, I think if, if when the Thematic Review was seen --
and I don't know when it was seen -- but if when it was looked at by the Medical Director and the
Nursing Director, had they looked at it and come to us -- and maybe we should have been more
proactive and said, "Please can we talk about this with you?" although there were emails to try and
get it on the radar --
BLACKWELL: Yes, but what did you do, Dr Jayaram, about the -- following the Thematic Review to go
to the Executives as clinical lead for children's services?
JAYARAM: As I have said Dr Brearey was running it as neonatal lead.
BLACKWELL: But you didn't --
JAYARAM: I personally didn't.
BLACKWELL: Right. Finally I would like to ask you about Dr Brearey's drawer of doom. He has made an
additional
statement to the Inquiry. Have you seen that?
JAYARAM: I haven't seen the additional statement.
BLACKWELL: No. Right. Did you ever have sight of Dr Brearey's drawer of doom?
JAYARAM: I'd never even heard of the concept of a drawer of doom. It seems to come up in a lot of
statements.
BLACKWELL: Yes.
JAYARAM: I have never heard it referred to as a drawer of doom.
BLACKWELL: Right. Is it your normal practice to keep one drawer storing important documents dealing
with concerns?
JAYARAM: Certainly not for me. I mean, you'll have to ask Dr Brearey about drawers of doom. I mean,
this seems to come up a lot. I --
BLACKWELL: He never discussed it with you?
JAYARAM: He discussed all the information he had. I never knew about a drawer of doom or --
MS BLACKWELL: All right. Thank you very much.
LADY JUSTICE THIRLWALL: Thank you, Ms Blackwell. Mr Baker.
MR BAKER: Dr Jayaram, I have only got two very brief questions. I represent a number of the
Families. First of all, you were asked some questions about the point at which your belief moved
from concern about the possibility of negligent care or deliberate harm into thinking the
unthinkable. Could we go, please, to INQ0102345 and to page 31, please. This may assist your memory. So can you see
the bottom left-hand corner. I'm afraid it's very small?
JAYARAM: Is it possible to enlarge it a little bit.
BAKER: Yes, here we go.
JAYARAM: Thank you.
BAKER: So you are being asked questions here by Mr Myers KC and can you see there a section:
"Question: Right, I am asking you about your state of mind though by the time we get to February the
thought had crossed your mind, hadn't it, that she may be deliberately harming babies?" And you say:
"Unfortunately that unthinkable thought had crossed my mind and other colleagues as well."
JAYARAM: Yes.
BAKER: So is it fair to say that by the time we get to February 2016, you and your colleagues have
begun to think the unthinkable?
JAYARAM: Yes. I mean as I discussed, I think
by November we were wondering about the significance of the association and as these -- as there
were more of these unexpected and unusual events, the -- the thought about deliberate harm had
become more prominent.
BAKER: Yes. So you came back from holiday I think on 5 November 2015 and you were informed about
the death of [Child I] and it's that point where you say in your witness statement concerns began to
appear. And so would it be true to say that between that date and November 2015 and February 2016,
those thoughts had coalesced into thinking the unthinkable?
JAYARAM: As I discussed, I think the November corridor conversations were really the first time that
I was aware other colleagues had been having similar thoughts. I think in that time, absolutely,
once you -- once you start having those thoughts it's very, very difficult to ignore them. But --
and you know I admit I got this wrong, I did my utmost best to hope it wasn't that and it was always
there nagging because, yes, I am aware of Beverley Allitt and Shipman and other cases but even now
in retrospect it's staring you in the face, it doesn't happen to you, it happens to other people and
I -- I talked about courage and I have said that I understand now I -- I, you know, the very fact I
had those thoughts
and others did and I suppose I was almost, you know -- I was also aware of the fact that you know
maybe I was starting to see things that weren't there. And it's so obvious now. And yes, I accept
that I should have, I should have been -- I should have put my head over the parapet and, and been
more --
BAKER: Thank you.
JAYARAM: -- explicitly articulated it. And I can only apologise to the parents of the babies that
had tragic events after those times. I can only speculate as to whether had I raised those concerns
at that time things might have been different. I honestly don't know.
BAKER: Well, we are going to look at an email. I think you have been taken to it already. You were
asked a question just now: "As of 29 June, were you content that whatever had been raised by the
Executives had been treated appropriately and the review that had been commissioned was the right
review at that time?" If we can go please to INQ0003112 and to page 2 of that document, please. It's the email at the
bottom dated 29 June 2016 from Ian Harvey to you. How did you feel receiving that email from the
Chief Executive of the Trust?
JAYARAM: Well, from the Medical Director.
BAKER: Medical Director, sorry, of the Trust?
JAYARAM: I was familiar with similar emails from Ian Harvey, not to do with this issue, you know
Consultants may be moaning about car parking or admin time or something and, and it was not unusual
to get an email saying: All emails cease forthwith. I think the email that I sent to which he sent
this response, me suggesting that the Executives didn't seem to have that degree of urgency, was my
honest opinion at that time. But of course he hasn't said here it's been discussed and what action
is being taken. And it -- in terms of how it made me feel it just made me feel frustrated and angry
really and then obviously he then came down and intimated that they are going to try and get more
information and then probably contact the police, which is why I think I sent the subsequent email
just after 10 o'clock.
MR BAKER: Thank you, my Lady, I have no more questions.
LADY JUSTICE THIRLWALL: Thank you, Mr Baker. Mr Skelton.
MR SKELTON: My Lady, I am very conscious of the time and I will try and be as swift as I can. I appreciate Dr Jayaram has had a very, very long day and I am not going to make it any easier for him.
LADY JUSTICE THIRLWALL: No, all right. Dr Jayaram, would you like another break?
JAYARAM: No, I'm fine. Let's just carry on.
LADY JUSTICE THIRLWALL: I can't remember, I think you are down for 20 minutes.
MR SKELTON: I am. I will do my best.
LADY JUSTICE THIRLWALL: Yes. Well, I think we have already had a substantial overrun on one of the time estimates. So if you could keep it to 20 minutes.
MR SKELTON: Okay. Dr Jayaram, the duty of candour. Sir Robert Francis defined it as the
volunteering of all relevant information to persons who have or may have been harmed by the
provision of services whether or not the information has been requested and whether or not a
complaint or report about that provision has been made. I presume you agree with that?
JAYARAM: I couldn't disagree with it at all.
SKELTON: And it's one of the fundamental axioms of medical practice --
JAYARAM: Yes.
SKELTON: -- in paediatrics and elsewhere. You have been asked many times during the evidence
today about the meeting you had with the Executives on 29 June. I won't go into it in any more
detail. But it suffices to say that this was your first direct contact with them in which you laid
out your concerns that you thought a nurse, Lucy Letby, was murdering the babies and that was
responsible --
JAYARAM: Potentially yes, yes.
SKELTON: And indeed you speculated in that meeting about the mechanism of murder; possibly air
embolism and via a cannula or some other mechanism?
JAYARAM: (Nods)
SKELTON: You spoke out loud?
JAYARAM: Yes.
SKELTON: But didn't have the answer?
JAYARAM: No.
SKELTON: You have also said in your evidence in writing that after that, you thought: I better have
a look at this and you found Tanswell and Lee paper --
JAYARAM: That's right.
SKELTON: -- and we know the history of where that ended up.
JAYARAM: Yes.
SKELTON: And I think you subsequently said to the Royal College you fund that chilling when you
first found that paper?
JAYARAM: I think when I read the description of the skin changes because it tallied with what
colleagues and myself had been aware of.
SKELTON: So that's the end of June. Two months later, or thereabouts, the Royal College actually
arrive on site and they speak to you and Dr Brearey and in fact you have a rather similar
conversation if not in more detail with the Review Team in which both of you lay out in full and
articulately all of your concerns about the mortality, including the fact that a particular nurse
was on shift at night when they happened and then when she was moved the collapses and deaths
happened on the day shifts as well?
JAYARAM: (Nods)
SKELTON: And you mention that a lot of information, I won't go through all of it in the interests
of time, but one of the things that you mentioned was the unexpected unexplained nature and the
failure to respond as you would expect physiologically to standard resuscitation?
JAYARAM: Correct.
SKELTON: All of which is highly significant because it's unusual and that's correct?
JAYARAM: That's correct, yes.
SKELTON: And as you had done at the end of June, you
have speculated out loud in front of the reviewers as to how the murders might have been committed
and you queried injecting air into babies. Do you remember that?
JAYARAM: Yes. I think we -- we discussed these are possibilities and we hadn't found any other
obvious clinical causes. I don't think I was saying, "This is what's happened", but it -- it was a
possibility.
SKELTON: And I think you specifically mentioned [Child A] in that context?
JAYARAM: Sorry?
SKELTON: You specifically mentioned [Child A]?
JAYARAM: Yes.
SKELTON: As well as the Triplets and others, it's right to say. And I think you also mentioned the
police and the possibility that they could be called which had been discussed with the
Executives?
JAYARAM: Yes.
SKELTON: You may not remember all of that, but have you jogged your memory --
JAYARAM: Yes, we discussed that and I think I discussed that we'd also been told that it wasn't the
right thing to do at that time.
SKELTON: Scroll forward another few months and the Inquest final arises quite a long time after the
death of [Child A] in respect of his death. And you must have involved been involved in a number of
Inquests over the years sadly?
JAYARAM: In the past, yes.
SKELTON: And given evidence at them?
JAYARAM: Yes.
SKELTON: So you were aware of the basic statutory purpose of an Inquest?
JAYARAM: Yes.
SKELTON: Who the deceased was, how, when and where they came by their death and your bit as the
physician is the how bit, the how question: why have they died medically?
JAYARAM: (Nods)
SKELTON: Yes. You are nodding.
JAYARAM: Yes.
SKELTON: You are also aware, I would assume, that the coronial system is one of the ways in which
this country investigates whether or not something untoward has happened, whether or not a death is
unnatural in the sense that there's been foul play?
JAYARAM: Yes.
SKELTON: And it used to be that they could commit people for trial from Inquests. These days they
are linked in with the police and the criminal justice
system and you know that the police will often be involved with Inquests?
JAYARAM: Yes.
SKELTON: You provided a statement a month or so after Baby A [Child A]'s death in which you dealt
with, in a very standard way, with precisely your involvement with his care, so coming on scene, the
collapse, the administration of resuscitation and of course his untimely death and that must have
been a familiar process for you providing that kind of statement?
JAYARAM: Yes.
SKELTON: A year or so later, because the Inquest is delayed for many, many months, you -- there are
a series of meetings about the Inquest and I think you have now jogged your memory and seen that
there is in fact a note of I think possibly a telephone meeting or a direct meeting --
JAYARAM: Yes.
SKELTON: -- at which you were in fact present. May I ask you about that insofar as you can now
remember having jogged your memory. Was it discussed or did you discuss, or anyone else discuss in
any of those meetings the possibility of a criminal act having been committed?
JAYARAM: I can't remember in that meeting, that
pre-Inquest meeting whether I specifically raised that concern. Stephen Cross, who was running that
meeting, I was aware was fully aware of the specific concern because he had been involved in the
meetings in June and July where we -- we discussed it. But in those pre-meetings I didn't
specifically raise that. I had wondered how in a coronial Inquest I could raise that specific
concern. Stephen Cross, as we discussed, sent me an email which he had sent to the Coroner saying he
had discussed it with the Coroner's assistant before and that the Coroner was fully aware of our
concerns. He also attached to that email the Terms of Reference for Jane Hawdon's Casenote Review
that were very detailed and specifically said that this review would be looking for other causes
including things such as air embolism. So I guess at the time of the Inquest, my understanding was
that the Coroner was fully aware and again when I re-read the email it is an assumption but the
Coroner was fully aware of those specific concerns and --
SKELTON: There isn't any evidence in fact that he was, is there, and I don't know whether you have
seen his statement but I don't think --
JAYARAM: No.
SKELTON: -- he was aware. So he hadn't been told by Stephen Cross?
JAYARAM: No.
SKELTON: And I don't think you proactively said in the conference meeting that you had that you had
suspicions, you didn't tell counsel?
JAYARAM: No.
SKELTON: There may be -- it may be for counsel to answer --
JAYARAM: Yes.
SKELTON: -- whether he in fact received that information via another source --
JAYARAM: Yes.
SKELTON: -- such as Mr Cross. But that's not matter for you?
JAYARAM: Sure.
SKELTON: You don't know if he did or he didn't?
JAYARAM: Yes.
SKELTON: The GMC's Good Medical Practice at the time, it was the 2013 version, obliges doctors to
not deliberately leave out relevant information when they give evidence to legal proceedings. Were
you aware of that broadly speaking?
JAYARAM: Broadly speaking, not the specific clause.
SKELTON: You were called to give evidence at the Inquest in fact twice because there was something
of a discussion in respect of the cause of deaths, which required you to come back. Were you in fact
sitting together with Dr Shukla or did you sort of go and sit down and come back up again?
JAYARAM: Sorry, we went up and then I think I was -- I was in the courtroom.
SKELTON: And then you went back to your seat and then came back up?
JAYARAM: I think so. I can't -- I don't think I went out of the room and had to come back in. So I
think I was ...
SKELTON: The first time you gave evidence, and please in the interests of time I am going try and
truncate what you said --
JAYARAM: Sure.
SKELTON: -- but if I am getting it wrong you must correct me, please. You said that [Child A] was
stable when you came on shift, you discussed the long line insertion and there's a great deal of
analysis of the long line insertion during the Inquest?
JAYARAM: Yes.
SKELTON: And the administration of dextrose. Again
that's another issue which is discussed in detail. But you say, quite candidly, that there's nothing
you could think of to explain the sudden deterioration and that included the dextrose and the long
line?
JAYARAM: That's correct.
SKELTON: You mention your thought processes at the time, this is back in June. So you are
describing what's going through your mind as a senior doctor back in June 2015 when the child
collapsed and died and you weren't thinking -- you couldn't think of what had caused it at the time,
that's correct?
JAYARAM: That's correct, yes.
SKELTON: You made it clear that this was an unexplained collapse and that the child hadn't
responded in a timely or normal way to resuscitation?
JAYARAM: That's correct.
SKELTON: And you ruled out the causes I have mentioned but also cardiac arrhythmia, the mother's
medical condition and the possibility of a thrombus which could have caused a blockage and led to an
arrest. All of those you ruled out clinically?
JAYARAM: (Nods)
SKELTON: Dr Shukla then gives evidence and he is unable to give a natural or an unnatural cause. He
clearly was baffled by why the baby had died. Do you remember that?
JAYARAM: Yes, and I have seen the summaries as well.
SKELTON: Then you are recalled after that and as you will have seen from the prior's note, which I
know you have read because you mentioned it earlier and I think you consider it to be a more
accurate note than the other notes we have seen --
JAYARAM: Yes.
SKELTON: -- your task as recorded in the note is to try and assist with your paediatric knowledge
in relation to the circumstances in Dr Shukla, or in other words help Dr Shukla reach a conclusion
about the cause of death. So you have moved slightly from being an expert -- sorry, a witness of
fact about your recollection to being something of an expert, trying to explain to the Coroner what
might have happened. Did you understand that shift?
JAYARAM: Not explicitly in -- in those terms, no.
SKELTON: Does it make sense to you, as I put it to you now?
JAYARAM: It does make sense in those terms, yes.
SKELTON: I mean, to put it bluntly, you are not being asked what you did or thought in June 2015.
You were being asked what you think now --
JAYARAM: Yes.
SKELTON: -- has caused the child's death, how they have
died.
JAYARAM: Yes.
SKELTON: On those points, in answer to the various questions from the advocates and from the
Coroner, you consider the downgrading of the unit and you mention the review, the independent
review, and you talk about the initial feedback of the review that nothing had been found
systemically with the training practices or equipment. You mention -- well, this phrase is recorded
and I would like to understand what you meant by it: "A potential issue with staffing." Now, does
that mean understaffing, the classic NHS lament, or does it mean a staff member?
JAYARAM: That's a really good question. I have to assume that those were the words that I used. I am
aware that the kind of hot feedback, if you like, from the College review discussed staffing
numbers, but that wouldn't have been what I was referring to because I didn't feel there was that.
And I think it was an oblique reference to an individual member of staff and actually if I -- you
know, I've reflected on this for a long, long time, what I was -- and again I guess my response is
predicated on an understanding which it seems is not correct; that the Coroner was aware of our
concerns based on what Stephen Cross had told me and that he was aware of the things that were being
or were supposed to have been investigated in the forensic review and because of that, I was to an
extent slightly surprised that the Inquest was happening when a forensic review was going on. But I
-- I didn't query that. But clearly the Coroner didn't have the understanding that I knew. I -- you
are absolutely correct, you know, I am there in a Coroner's court and I should say what I think and
again I didn't. I think and again -- and I, I reach out to Baby A [Child A] and B [Child B]'s
parents for this, and maybe I should have done a supplementary statement or talked afterwards -- I
was trying to in my discussion about the fact I couldn't explain this, you know, in the context that
my understanding was that the Coroner knew of our concerns I was trying to sort of throw as many
breadcrumbs as possible for the Coroner to pick up without explicitly saying what the suspicion was.
Why did I do that? And again -- and I appreciate that this was the wrong judgment -- I had Baby A
[Child A]'s parents sitting 10 feet away from me and, yes, absolutely, duty of candour. I just
didn't have the courage to say it and
I think part of this, part of this was already from, you know, I guess being influenced by the --
the pushback that we were getting that, "There's nothing to see here" and, and, I can -- I regret
not explicitly saying that then on many, many levels because it should have been said, you know, and
I am not going to make excuses. I did have an understanding that the Coroner was aware of our
concerns because I interpreted that's what Stephen Cross had told the Coroner and I should have done
better.
SKELTON: You should have told the Coroner that a member of staff may have been responsible for the
child's death?
JAYARAM: Yes, I should have done.
SKELTON: And one of the reasons why that was required was not only candour for the parents, mother
A was sat there, but also because the Coroner has the equipment and the wherewithal --
JAYARAM: Yes.
SKELTON: -- to do exactly what you needed to get done?
JAYARAM: Yes.
SKELTON: The expert investigation, the forensic pathology?
JAYARAM: Yes.
SKELTON: The radiology review?
JAYARAM: Yes.
SKELTON: All the things that in fact occurred later on?
JAYARAM: Yes, absolutely. And, as I say, I am not using this as an excuse at all, but I was under
the impression the Coroner was aware of those concerns. But even if the Coroner was aware of those
concerns, I should have still been explicit.
SKELTON: Can I try and deal with [Child M] as well and --
JAYARAM: Yes, of course.
SKELTON: And his parents are watching these proceedings. I know you have followed these proceedings
and I don't want to assume that you followed them as closely as listening to all of the evidence.
But they are particularly concerned that as your concern arose in respect of their child's collapse
-- you recall [Child M] collapsed just like [Child A]?
JAYARAM: Yes.
SKELTON: And I think you told the police at one point in 2019 they were the two children who really
haunted you --
JAYARAM: Yes.
SKELTON: -- in effect, those collapses. You had a chat or you had a discussion with the parents
after [Child M]'s collapse. But again you didn't mention your suspicions. And this -- we are now
into
2016, well into the terrain, long after the terrain, sorry, long after the suspicion has arisen in
your and your colleagues' minds. Why was that?
JAYARAM: The discussion that I had with Baby M [Child M]'s family after he was resuscitated was I --
I discussed that again I couldn't explain it. It didn't fit with things. I think I -- I would, I
would ask any colleague how, how, to parents sitting there, with the nurse there as well, can I
express such, such a concern? And again at this stage, yes, we were thinking the unthinkable, but it
was this issue of not having evidence and I wish I could turn the clock back and wish I could have
said it, and I didn't, or later on. I think it's really difficult to appreciate my thought processes
then compared to what I know now, but I think I still probably wouldn't have expressed that concern
immediately at that point, but --
SKELTON: You didn't have to, did you? In fact you could have waited until the horror of the
situation --
JAYARAM: Yes.
SKELTON: They were immensely affected by it as you recall?
JAYARAM: Absolutely.
SKELTON: You could have waited until that had abated somewhat --
JAYARAM: Yes.
SKELTON: -- and revisited that issue?
JAYARAM: Yes.
SKELTON: And I have to put to you that candour requires you to at least alert them to the
possibility that there was an explanation that hadn't been looked at which needed to be looked at
and that included deliberate harm?
JAYARAM: I don't disagree.
SKELTON: Overall, I think you accept the proposition that once the suspicion arose that Letby was
deliberately harming children investigation was required to confirm or rule out that suspicion by
hook or by crook?
JAYARAM: I -- yes, absolutely.
SKELTON: We know from the evidence of you, Dr Brearey and others that discussions occurred
internally really from the start of the cluster of deaths in June and continued throughout the next
year as to understand why the babies were dying in an increased rate at an increased rate?
JAYARAM: (Nods)
SKELTON: However, no clear causes or thematic causes were found and you didn't identify the method
of crime at any point yourself at that stage?
JAYARAM: No and I am I wasn't looking for methods of crime at that point. It -- it was -- I wasn't,
it was one of the possibilities could these be unnatural events but until June I would say I had not
specifically considered how.
SKELTON: To be fair, it wasn't your job to --
JAYARAM: No, no.
SKELTON: -- investigate a crime?
JAYARAM: No, absolutely, and, you know, it's my job to raise the concerns.
SKELTON: It is right, and I think you acknowledged today, that there were in fact some significant
signs in the records which had a more comprehensive analysis been conducted might have been spotted,
the insulin C-peptide results for the two children --
JAYARAM: Yes.
SKELTON: -- for example and of course [Child K] about whom you have been asked?
JAYARAM: Yes.
SKELTON: There were those signals which were slightly more positive than --
JAYARAM: Yes.
SKELTON: -- inferential. But the concerns had been raised with Eirian Powell very early on in 2015
and of course you had ultimately
gone to the Executives, they had been alerted to it via Alison Kelly early on and then directly by
you in the meetings. Is it fair to say that you found yourselves -- this is the Consultant body,
you, Dr Brearey and your colleagues -- locked into a process of investigation, the Royal College
review, the Hawdon review, which wasn't in fact going to answer or confront the question that needed
to be confronted: was she harming babies?
JAYARAM: Yes, so I think in terms of being locked into that process you are absolutely correct. When
we had formally raised late June/early July we discussed what the correct -- what the right way
forwards we discussed the police, my colleague, Dr Saladi in his email explicitly said he didn't
think there was anyone else who could do it, yet we were told explicitly that it would be
inappropriate to involve the police at this stage and I remember -- I forget which meeting it was in
June/July, we were told that it would be the end of the unit, there would be blue and white tape
everywhere, the whole place would be a crime scene, everyone would be a suspect. Now, I understand
this now that that's not how it works when these issues are raised actually, there are actually
mechanisms in place for raising these issues
without disruption to service. I think from that point, because we knew Letby had been moved, as I
mentioned I don't think complacency but there was slightly less urgency and I -- I suppose what I
can't speak for colleagues, what I anticipated the College review and the Casenote Review would
support what had been found by our own Thematic Reviews and at that point the police would be
involved. And there was a delay in us seeing, having access to those -- the information from those
and then events went from there and I am, I am glad that we from that point were assertive enough to
not accept the Executives' interpretations of what they found, but I do feel we were -- we were
locked into that. Now, could we have actually put our hands up at any point and said: look, this is
all very well but this isn't the right thing to do? We could have done. I think it's very difficult
when we have been told by the Executive body, particularly someone who has a legal and policing
background, that it is the wrong thing to do and I should have been more curious and challenged it.
SKELTON: Without going into great detail, because I am in danger of going over my time with you,
but were you fully aware that the Royal College were never going to answer the question that you
needed to confront, and likewise with Dr Hawdon, in fact; they were really staging posts, as it
turned out?
JAYARAM: I think if I look at the Terms of Reference of the Royal College review, you know, to -- to
look for any -- I forget the exact terms but any factors that could have contributed to the deaths.
SKELTON: Yes.
JAYARAM: And if I look at the Terms of Reference of -- the original Terms of Reference of the Hawdon
review, in particular the original Terms of Reference of the Hawdon review, I think either those
Terms of Reference would have found something that would have flagged up something unnatural or they
wouldn't have and if they had found something unnatural, it would have gone down the police line and
if they hadn't, I anticipated that then the next response would be to escalate to the police. Now,
obviously I shouldn't assume what any review is going to find but given that these were
paediatricians undertaking these reviews, and I talked to them and my colleagues had talked to them,
and they had heard what we had said, I felt at that point although I felt it needed to be escalated
and there is an element of -- I think I said it it's minuted
somewhere, that there was part of me that was almost hoping that they would find something
explainable and clinical, you know, because that's -- so in many ways, awful as it is, it is so much
easier to deal with than the reality of things.
SKELTON: And ordinarily the probability is that they would have done and when you have a cluster of
deaths, there usually is a clinical explanation for it?
JAYARAM: Usually and I think again, you know, this is all about us or me -- I can't speak for others
-- trying to make things fit -- and, and not having the courage to think outside the box.
SKELTON: I am not going it take you through all the various committees and groups that existed back
in 2015/2016 but I am going to try and deal with it sort of compendiously, if I can. There clearly
was a patient safety issue as suspicions arose in respect of Lucy Letby harming children and there
clearly was a parallel safeguarding issue, they are -- in the context, it's the same point, isn't
it?
JAYARAM: Yes.
SKELTON: Safeguarding patient?
JAYARAM: Yes.
SKELTON: Patient safety.
There was an opportunity to take your concerns and suspicions to the safeguarding team and that
opportunity was not taken in terms?
JAYARAM: Yes. I think by engaging the SUDiC process for the deaths it would have automatically been
on the safeguarding radar.
SKELTON: That could have occurred really early on?
JAYARAM: It could have occurred early on. I don't know whether early on deliberate harm would have
been considered but the pattern as things progressed could well have been recognised earlier on.
SKELTON: In terms of the external lifelines, again without discussing them in detail, but trying to
deal with them all in one go, there is obviously the CDOP route --
JAYARAM: Yes.
SKELTON: -- which you have discussed but there is the wider national bodies, the GMC, the NMC the
CQC, NHS England and of course you have already talked about the Coroner and the police. But those
other bodies, they all have abilities or they all have the capacity to receive concerns or
whistleblowing issues and to start to help with them being raised. As I understand your evidence,
really, you didn't feel that any could you really go anywhere outside the
Trust?
JAYARAM: Yes, I -- I think again speaking for myself but I think I speak for colleagues, we just
didn't know where we could go and I think there's some levels, number one about the concern, but
also subsequently about the response to concerns when we raised them and I was not aware at the time
that all the bodies to whom you refer had processes that we, we could have followed and I will be
honest now, I am still not entirely clear specifically what they are.
SKELTON: Did you look at -- I mean, you can type in GMC, NMC, and up come a whole raft of --
JAYARAM: My understand of the GMC and NMC was again you had to have a degree of evidence.
SKELTON: Well, what they might have done is say: you need to go to the police?
JAYARAM: Yes.
SKELTON: Any of those bodies in fact may have said this isn't really --
JAYARAM: Yes.
SKELTON: This isn't really an issue about the adequacy of care; it is not your standard
whistleblowing?
JAYARAM: Yes.
SKELTON: This is much more serious?
JAYARAM: Yes.
SKELTON: It's criminal.
JAYARAM: And -- and in many ways I wish somebody had just said that to us, you know. When we
initially raised it in June '16 we were told: not the police, when we discussed it with the Royal
College reviewers we were told -- why don't you just go to the police. Well, I don't know what the
Coroner was told in February 17, I don't know what Simon Medland was briefed, but absolutely. I
think, looking back, we shouldn't have had to have waited for permission to go to the police. We
should have just gone.
SKELTON: Because the only way that Lucy Letby was either going to be incriminated or exculpated was
by full investigation, of which the police were best equipped?
JAYARAM: Yes, absolutely and again there was the misapprehension that -- and we thought it was
reinforced to us by -- by people in the Trust we raised issues to that: you hadn't got enough
evidence to go to the police, which I understand now is absurd because, as you say, the people who
find the evidence are the people investigating.
MR SKELTON: Thank you, Dr Jayaram, those are my questions. My Lady, I hope I haven't gone too far over my limit.
LADY JUSTICE THIRLWALL: Thank you very much.
MS LANGDALE: My Lady, I don't think Mr Kennedy has any questions? No, he doesn't and I have no further questions of Dr Jayaram.
LADY JUSTICE THIRLWALL: Very well, and I don't have any questions either, Dr Jayaram, so thank you
for bearing with us on a very long day.
JAYARAM: Thank you, can I just say thank you very much for inviting me here today. Can I say again
to the parents of the babies involved that I am sorry for my own personal failings and I apologise
for things that I could and should have done better. I know that my words will never ever help to
ease the grief that you feel and I also want to reach out to you and I'm sorry that you are having
to go through the external noise that's out there of people taking another view on everything that's
happened and I appreciate how painful that must be for you and how insensitive it is of the people
who are trying to suggest that other things happened. And once again, I thank you for your patience
with me very much.
LADY JUSTICE THIRLWALL: Thank you, Dr Jayaram. So we will rise now and we will start again tomorrow at 10 o'clock .
(5.24 pm) The Inquiry adjourned until 10.00 am on Thursday, 14 November 2024 )
LADY JUSTICE THIRLWALL: Ms Langdale.
MS LANGDALE: May I call Dr Brearey?
LADY JUSTICE THIRLWALL: Yes, Dr Brearey, come forward, please.
DR STEPHEN BREAREY (sworn)
LADY JUSTICE THIRLWALL: Thank you, Dr Brearey, do sit down.
MS LANGDALE: Dr Brearey, you have been a Consultant paediatrician at the Countess of Chester
Hospital since March 2008, a neonatal unit Lead Clinician from March 2008 to July 2020. You have
provided us with three statements to the Inquiry dated July 2024, September and November 2024. Can
you confirm the statements are true and accurate as far as you are concerned?
BREAREY: Yes.
LANGDALE: Before I begin to ask you questions, Dr Brearey, I understand you want to say
something.
BREAREY: Yes, I would like to speak to the Families. Sorry. Sorry for my part in not being able to
protect your babies. I can just say that I tried my best and I acknowledge that at times my best was
not
enough. This apology is to the parents in the indictment but also parents who are involved in the
ongoing police investigation. I hope that you all get the truth and justice that you deserve.
LANGDALE: Dr Brearey, I am going to ask you questions today under different themes, there is
obviously a long period of time you were involved in different aspects with raising concerns to
Execs, conversations amongst medical staff, so I am going to break topics down, if we may. So
occasionally we might move back slightly in the chronology or forwards, but I think this might
assist understanding for those who are less familiar with every document, as you and I both are by
now. First of all, if we can turn, please, to guidance that is relevant to Sudden and Unexpected
Deaths and if I can ask Ms Killingback, please, for INQ0014165, page 33. Dr Brearey, I would like to trace through with you what
was prevalent then, what you deal with now, and safeguarding generally and your understanding at the
time about who to contact, what to do.
BREAREY: Okay.
LANGDALE: So this first piece of guidance is a Countess of Chester policy and it's section 6 that
deals with
Sudden and Unexpected Deaths in Infancy and we see how that is defined at the top of the page. So
Sudden and Unexpected Death, unexpected in the 24 hours prior to death, of a child under the age of
24 months irrespective of the place of death, so at home or in the community, in the hospital
emergency department or ward. And a SUDiC should be managed in accordance with the SUDiC guidelines.
You tell us in your statement, Dr Brearey and perhaps you could expand on it, that you interpreted
it as referring to a cot death scenario rather than an unexpected death in a healthcare environment.
Was that your understanding at the time of this policy?
BREAREY: My understanding was that it was certainly treated as, as such, yes; that it's
predominantly written for guidance regarding children or babies that had died unexpectedly from a
community home setting rather than a hospital setting. And it was even more detached in a way from
the reality of working on a neonatal unit, where you could argue that any -- any baby who died in
the first 24 hours of life you might not have expected that to happen and, you know, because there
might be maternal reasons for the cause of death.
So already there's -- there's scope for misinterpretation, really, on a neonatal unit.
LANGDALE: Would most babies that died early on from natural causes, would that natural cause be
evident? Even if it was unexpected for a parent or even if it was sudden for a healthcare
professional, you could understand a naturally evolving cause?
BREAREY: Not always, no, and actually the one death that we have had since 2016 -- I don't want to
go into the details.
LANGDALE: Please don't.
BREAREY: But that did involve a diagnosis that was established after postmortem and after specialist
had assessed the case, that that family certainly, certainly weren't aware of until afterwards and,
you know, considered the baby as healthy until the baby is born.
LANGDALE: Was a SUDiC process followed for that to get the proper forensic investigation or medical
testing in a clinical --
BREAREY: There wasn't a SUDiC process triggered for that, yes.
LANGDALE: So in terms of at the time, and the number of unexpected and unexplained deaths that you
were dealing with, was it a deliberate decision to effectively ignore this guidance, was that
consciously decided upon at any level within the hospital or how was it from your perspective?
BREAREY: I can't remember a discussion with colleagues that it should have been a SUDiC process or
any of these cases should have been a SUDiC process, really, over the course of 2015 and 2016.
LANGDALE: Did you ever speak to Dr Mittal? We know that Dr Mittal and Dr Gibbs had a conversation
about Baby C [Child C].
BREAREY: Yes.
LANGDALE: And although it wasn't a SUDiC process there is a document that looks as though there is
a meeting between Dr Gibbs and somebody who deals with safeguarding, a safeguarding manager, but it
wasn't referred as a SUDiC and somehow he was in that meeting?
BREAREY: No.
LANGDALE: So you yourself, would you have had a conversation with Dr Mittal at any point about
these deaths or the processes?
BREAREY: Well, he worked in the same building, but I can't remember any specific conversations with
him regarding whether SUDiC should be followed with any of these cases but I always got the
impression that he felt that neonatal deaths weren't in this remit of SUDiC or CDOP actually at the
time as well, they weren't included.
LANGDALE: What gave you that impression? You said he worked in the same building, what was your
sense that that was what he thought?
BREAREY: Well, the Form A for CDOP, Form A and Form Bs that we had to complete after deaths went
through him to CDOP. So I was assuming he would have been aware of the deaths.
LANGDALE: Why would you assume that, did you have any conversations with him about it? We know Dr
Gibbs referred Baby C [Child C] and spoke to him about Baby C [Child C].
BREAREY: Well, those -- those forms are completed after every death and -- and he's on the CDOP
panel and he would see what's been submitted to the CDOP panel.
LANGDALE: So even without the SUDiC process you think there is a form that is filled in for every
death?
BREAREY: Yes, the Form A, Form B.
LANGDALE: Form A/Form B?
BREAREY: Yes, yes.
LANGDALE: Did you ever fill any of those in? Who was expected to fill those in?
BREAREY: I would have filled one in for a non-indictment baby that died in September.
LANGDALE: Okay. So that was a Form A, you think, or B, you can't remember?
BREAREY: It starts with Form A which is the immediate
form and there is a little bit more time to fill in the details of the Form B form.
LANGDALE: So irrespective of SUDiC that form gets filled in and did you understand where that ended
up?
BREAREY: I knew it is for CDOP processes. We don't -- the process of CDOP takes a little while to
filter down before the panel discuss things at a regional level and then we would get feedback some
time after that about lessons learned that are quite general, really, rather than anything specific
to any babies.
LANGDALE: What about referral to the Coroner for a death, did the doctor phone the Coroner or how
was that done?
BREAREY: The Consultant who was in the hospital covering the neonatal unit at the time of death
would normally be expected to phone the Coroner or the Coroner's officer to notify them of the
death.
LANGDALE: If we can go, please, to INQ0108408.
LADY JUSTICE THIRLWALL: While that's going up, I wonder if I just might observe that everyone who's
speaking is competing with a quite a loud fan which is off to my right and it may be that people are
struggling a bit to hear, notwithstanding the microphones, so if you could both remember that.
BREAREY: Okay.
LADY JUSTICE THIRLWALL: I think it's probably because it was very cold in here yesterday so the heating is on, but it's obscuring your voices a bit.
MS LANGDALE: Noted, thank you, my Lady. Actually I think the reference may not be that if that can
come down. If we go to INQ010848. And it's page 41 of that document, thanks, Mrs Killingback. 10848,
page 41. Can we try again, it may be you exhibited it Dr Brearey, INQ0108408. And it's page 41. It's the checklist you provided us, Dr Brearey,
while it's coming up?
BREAREY: Okay.
LANGDALE: You say this is what you have to complete now?
BREAREY: Yes.
LANGDALE: You say from your own experience, completing this child death guideline requirements took
you about six hours to complete?
BREAREY: Mm-hm, yes. So this is our current guidance at the Countess of Chester Hospital in which
one of my colleagues has tried to make it as simple a process as possible for what to do in the
event of a death, child death or a neonatal death and I felt it was important to share with -- with
the Inquiry really to highlight it's not a simple process and I think colleagues and myself find it
quite onerous to do. You -- you are having to deal with the fall out from a death in terms of family
and staff and talking to them. There's obviously involvement with other agencies possibly. The -- I
think the fifth line from the bottom of the first table, the Form A and B is now changed to an
e-CDOP referral, so that is a slight change from 2016. But the SUDiC paperwork in itself was the
majority of that work, really. Included in this form would be a debrief with staff and the six hours
it took me to complete the -- the actions needed in this case was excluding the debrief which a
colleague from the emergency department undertook in the case that my most recent memory, which is
last month.
LANGDALE: When you comment on the time presumably you are not commenting on the purpose which is
effectively to notify external agencies and I think we probably agree at the outset if more external
agencies --
BREAREY: Yes.
LANGDALE: -- had been involved in events we are examining --
BREAREY: Yes.
LANGDALE: -- there would have been greater forensic scrutiny earlier, wouldn't there, of the
deaths?
BREAREY: Yes, yes.
LANGDALE: So is it the process that it's bureaucratic or do you think the information is necessary
if you are going to catch those cases like the ones we are examining, where it really did need a
forensic --
BREAREY: I am not questioning the need for any of the statutory processes that need to be taking
place, that is absolutely essential. But I am also minded that Inquiries can add to the requirements
of clinicians and I wouldn't want to make something more complicated or more onerous when actually
it feels like it could be simplified as well.
LANGDALE: How could that be simplified, do you think -- two options, isn't there: fewer questions
raised, but maybe you wouldn't get your purpose fulfilled; or other people supporting in the
hospital to fill them in, Risk Teams and the like? Does it need to be a doctor that puts this
information in and does it?
BREAREY: It doesn't need to be a doctor. No. I think as well, you know, I have mentioned in my main
statement that dealing with this sort of thing out of hours in the middle of the night after a
traumatic event isn't very conducive to making the right decisions sometimes, immediate decisions,
you know, nought to four hours after the death, and that actually, you know, if any of these tasks
can be shifted to the next working
day and be done in a more sort of collegiate thoughtful way, then that's probably more likely to
lead to the right decisions and referrals being made.
LANGDALE: We see at page 45 of this guidance Learning from Child Deaths, it states: no meetings
should take place without the presence of an acute paediatric Consultant with knowledge of the case.
You reflect there, Dr Brearey, that, perhaps the next day, having the essential people in the room
that were involved in the case may lead to better decision-making and the provision of the best
information within any form than one person doing it on their own within nought to four hours?
BREAREY: Absolutely, yes.
LANGDALE: So would your suggestion be if this system of referral has value, which you don't seem to
question, it needs to be factored into the time and effort and quality of information that can be
put into the referral in the first place?
BREAREY: Yes, yes. And I recognise the difficulties in that because people have got to factor in,
you know, these deaths don't happen in a -- in an arranged way, so they can happen any time of day
at night, at weekends, and, you know, the important people need to be at those sort of subsequent
meetings.
But I think, you know, today's age of Teams and that sort of thing, I think it is easier than it has
been, certainly.
LANGDALE: The Inquiry legal team, Dr Brearey, has prepared a document it's INQ0108517
[unavailable], with the assistance of legal representatives from other Core Participants,
particularly the Countess of Chester lawyers. So I am not asking you to comment on the detail of
this now, Dr Brearey, but by all means when you leave today and at any time that is convenient to
you if you notice something that you think should be there, do let us know. But within this
document, we set out an index to all the reviews conducted in respect of the indictment babies and
if we look at 0108517000, we see there is a section halfway along the table, a bit further, "Sudden
and Unexpected Deaths in Infancy and Childhood" and we see if we scroll through the table that in
fact none of the babies on the indictment go through that process of referral. We do see for Baby D
[Child D] there is a STEIS referral and we will come to that later when we look at documents and
scrutiny, Dr Brearey. But it's quite stark, isn't it -- it's not appendix 1, we need to go further
up, please, if we could, to the STEIS Level 2 report. We are looking at those two columns of Sudden
and Unexpected Deaths in Infancy and the STEIS Level 2 report. It's very stark when you see it on a
single table like this, the absence of scrutiny in this way, independently through other agencies,
isn't it --
BREAREY: Mmm, yes.
LANGDALE: -- for all of the babies or even a majority of the babies who died?
BREAREY: Yes.
LADY JUSTICE THIRLWALL: Sorry, Ms Langdale, so we are looking at two column headings are we? Sudden Unexpected Death in Infancy and Childhood?
MS LANGDALE: Yes, and the STEIS.
LADY JUSTICE THIRLWALL: And then further along STEIS. Thank you.
MS LANGDALE: We see next to the babies on the indictment there is no, no, no and we see for Baby D
[Child D] there is a reference to a STEIS referral in her case which of course involves NHS England,
automatically brings the parents in.
BREAREY: Yes.
LANGDALE: Different process?
BREAREY: I mean, there's a few things I would like to say about Sudden and Unexpected Death in
Infancy
guidance at the time and why we didn't. I mean, it's worth pointing out that nobody was suggesting
at the time who were aware the deaths that were happening, people like Dr Subhedar from the
Liverpool Women's Hospital, when he did the Thematic Review, didn't make any suggestions that we
should have been doing that. I think still today there's some uncertainty about whether to refer for
a SUDiC or not. I -- I have read some of Dr Garstang's evidence and I think she stated that one --
one baby might be referred for a SUDiC in the West Midlands every year I think was the rough numbers
she was talking about from a neonatal unit. And I think if you are using the strict definition of --
of unexpected death and not being aware that that baby was going to die or having any clues to that
24 hours beforehand, I think those numbers were probably going to be larger so it suggests to me
that I don't think people were following the strict definition still. I have become a part of the
working group for the British Association for Perinatal Medicine for governance for child deaths
because I feel that I have had some experiences that I can add to that, that work process. That's
chaired by Dr Eleri Adams, who is the President of BAPM. She opened, in the first meeting we
had as a working group, to explain why that working group was happening. I think this -- these
events obviously might have triggered things but she actually said that they, they -- she polled
members of BAPM, who are predominantly neonatal doctors and nurses, as to what the members wanted
from BAPM in terms of guidance and clearly death governance was one of the top things that was asked
for. So that is immediately telling me that the neonatal workforce generally have difficulties with
this sometimes.
LANGDALE: You say in your statement that you were involved in a peer review programme since these
events and --
BREAREY: Yes.
LANGDALE: -- able to discuss with other neonatal networks how they were dealing with deaths as well
or Sudden and Unexpected Deaths?
BREAREY: Yes, yes, so that was -- I can't remember the year precisely. I don't know what year I
might have put it in my statement, I think it was 2017 or 18.
LANGDALE: You said that, yes.
BREAREY: So there was an NHS England quality surveillance programme peer review that entailed every
neonatal unit in the country being visited by the
reviewers with one peer reviewer from another neonatal unit, so I participated in that and
peer-reviewed three hospitals in the south west of England. The format of the review was quite
structured with certain questions and standards to meet and mortality processes weren't one of the
questions that were asked, but obviously I was interested in this with our own experiences and --
and the doctors I spoke to in those peer reviews really stated that they didn't have a child death
policy in -- in their hospital for their neonatal unit. It struck me firstly because the reason for
that was that the number of the deaths were so few which obviously made me reflect on we could have
missed our -- our sort of issues for so long. But secondly, it struck me that I don't think we were
out of the ordinary in terms of a neonatal unit at the time in terms of what we were doing and the
processes that we had. I -- I think we were doing the same as our peers, really.
LANGDALE: Indeed when you raised the point about how striking it was I think Beverley Allitt, it
was between February and April in 1991, and the rise in deaths and the suspicions and ultimately an
insulin result as well. It was far too long, wasn't it? I mean, any death was bad, but the period of
time before which this was detected was -- well, how would you describe it, really?
BREAREY: Yes, yes, and that's why we are here, I suppose, to work that out. Yes.
LANGDALE: If we can take that down, please, and put up INQ0108346, page 45, 0045 and it should be a flowchart that was alluded to
yesterday. You made reference to Dr Mittal being in the building and indeed everyone else and of
course we know Alison Kelly was involved in your discussions with Eirian Powell early on and the
charts highlighting Letby and the like. So people with safeguarding responsibility, certainly Ms
Kelly, and I doubt she was alone, are looking at this, knew about these deaths and suspicion and
concern and Eirian Powell conceded in evidence the fact she was pulling the tables together in the
end, looking back, there was suspicion about: could someone always be there that was causing this?
If we look at this flowchart, we heard evidence yesterday from Paula Sindall, who I think was Paula
Lewis at the time. Was this readily apparent? We were told this was around the hospital and indeed
in the neonatal unit, this flowchart was on the wall, sort of Working Together-type approach where
you make it clear
who you speak to, try and make it direct. Do you remember seeing that around the unit?
BREAREY: I can't remember seeing it on a wall or a -- you know, anywhere in a clinical area but, you
know, I was aware of it because I attended the safeguarding updates and training every year, yes.
LANGDALE: You would have known the people involved anyway. Dr Mittal you have already referred to
and we know --
BREAREY: Yes.
LANGDALE: Dr Howie Isaac, I think, shared a room with Dr Holt, who was of course involved later on
with the paediatric discussions around everything. So we will come to this later but broadly, how
aware were the hospital, firstly about the concerns within the hospital that you had and, later on,
how you and the other doctors felt victimised and pressured by the -- by the Executives? How widely
were those two issues; they are very separate? The first is suspicions about a member of staff and
the second is how you were being treated as doctors. Were you quite open about -- certainly in the
latter about how you were being treated as doctors? We know Dr Tighe was involved and other people.
Did you speak widely about that?
BREAREY: Can you just clarify the question?
LANGDALE: Yes, when you were going through the grievance and you were asked to do the letter of
apology and you were asked to do mediation with Letby, were you very open with colleagues about all
of that stuff?
BREAREY: Open about our concerns?
LANGDALE: Not concerns about Letby, but about how you were being treated. We will come to how you
treated your concerns and suspicions about Letby, but in terms of the second part of that, how you
were treated as a consequence, were you open with people about that?
BREAREY: I think we made it very clear to Executives that we didn't feel we were being treated
appropriately with this.
LANGDALE: To other members of staff, I am thinking safeguarders are the people who --
BREAREY: Well, the -- the flowchart that's in front of me is really what to do if you are worried a
child is being abused. So I don't think the escalation names on this list would be relevant to what
to do if you feel you are being victimised by some Executives.
LANGDALE: Sure, definitely not. My question is really if you knew these people and were talking to
them, because we can speak of roles, can't we, but often the same person occupies a number of roles
and
responsibilities so I am just trying to get an understanding of how many medical colleagues you
would have discussed how you were being treated with, we will come on to how that was or wasn't
later?
BREAREY: I thought it was quite important -- I think the team felt it was quite important throughout
this process that we were, we were confidential about our concerns because it involved a member of
staff and quite significant concerns and we didn't think that discussing that with anybody and
everybody was, was appropriate, really. So we tried to limit our discussions to the group of
paediatricians who had the concerns and to the Execs that we were talking to predominantly.
LANGDALE: That can come down, please, and if we can go to the policy for reporting of incidents
which is INQ0006466, page 1. If we just flick through this guidance, Dr Brearey, we see
at page 3 what should be reported as an incident, near misses. Over the page, how to report an
incident. Then over the page, Never Events. Over the page, 7, how -- sorry back to 6, sorry, point
7, how staff can raise concerns, for example whistleblowing, open disclosure, et cetera. Was this a
policy that you ever sat down with anyone in Risk or elsewhere or any of the Executives as events
were unfurling with the deteriorations of babies in some cases, deaths of others, did anyone discuss
with you how these should be reported and how they might be escalated and triangulated and brought
together?
BREAREY: No.
LANGDALE: Was this a policy you would even have looked at at the time?
BREAREY: I would have been aware of it, but I -- it wasn't committed to memory and I wouldn't be
referring it on a frequent, referring to it on a frequent basis.
LANGDALE: What was your understanding about when Datix were completed, for example we know the
Datix for Baby D [Child D] was completed around a delayed giving of antibiotics. So with everything
else going on it was the delayed antibiotics that actually triggered the Datix, not other suspicions
or concerns. What did you understand a Datix needed to be completed for and did you think it was a
useful process?
BREAREY: From -- from my memory I think more than one Datix was -- was submitted on Baby D [Child
D]. I think one was for the delay in antibiotics, one was for the delay in reviewing the baby and
admitting to the neonatal unit, but -- just from memory, that is. But I was the neonatal Risk Lead
so it was my job
to encourage a healthy, risk aware neonatal unit and I was trying my very best at that and I think I
was relatively successful. I think the staff were all aware of their requirement to report a Datix
incident, no matter how significant, whether they felt any problem with the care of the baby might
have been compromised.
LANGDALE: And indeed that's right for Baby A [Child A], the context of the Datix report said "drug
administration error, sudden and unexpected deterioration and death". For Baby C [Child C], "sudden
deterioration and death, delay in receiving documentation regarding the death". And for Baby D
[Child D], "baby required resuscitation after delivery and death". So they were being completed at
the time, weren't they --
BREAREY: Yes.
LANGDALE: -- in those cases? What --
BREAREY: So there was --
LANGDALE: Sorry.
BREAREY: There was a dual process for the Datix reporting really because you would be reporting an
incident if you felt there had been a problem with the care of the -- of the baby. But it's also the
policy at the time to report the death per se and I think that's where some confusion in terms of
the grading of the
incidents came in some cases, when -- when it was a death of a baby but it was designated low harm
because they were just following the process of reporting the death as opposed to reporting a
problem with the care that the baby had received. And -- and therefore the grading becomes a little
bit confused because the person completing the form isn't sure -- obviously, you know, it's
significant harm because the baby has died but they are being asked about whether there's an event
that caused that harm or -- in terms of clinical incidents in addition to that. I think that's
sometimes why the grading was variable.
LANGDALE: Can that document come down, please, and can we have INQ0001954, page 17. This is a paragraph from the RCPCH report, which we'll
come on to later and its wider purpose and effect. But if we just look at this 4.4.9, please. So one
of the recommendations was that: "The death near miss reviews process requires further strengthening
to involve the Risk Management Team systematically and to follow corporate process. All deaths
should be raised as in a Serious Incident ... the case reviewed promptly by paediatrician, Risk
Midwife, neonatal nurse and obstetrician and then either stood down or investigated informally."
That sounds a sensible recommendation. Did you think that was, in the light of what we now know and
have seen?
BREAREY: Well, there's certain parts of it I would agree and disagree with. I would agree that the
deaths should be raised as an SI and the cases reviewed promptly by a paediatrician and Risk Midwife
and neonatal nurse and obstetrician. In terms of the Serious Incident, the process would be if the
Datix is completed and the case is discussed at the Neonatal Incident Review Group, the Risk
facilitator would then take that information to the Risk and Governance Team who would then classify
it as an SI or not. I think actually it was Debbie Peacock that would submit the SBAR form to the SI
Panel to decide on whether it was an SI or not. So the decision for an SI was really out of my
remit, but clearly it seems sensible to suggest that every -- every death's an SI.
LANGDALE: What would you say now -- and if you can't say it now and you would rather do a further
statement later that is fine, Dr Brearey, it may require thought and you might want to look at that
document first. But looking back, how should the deaths have been reported as far as you are
concerned, the Sudden and Unexpected Deaths and the deteriorations to encourage that early capture
of what was going on?
BREAREY: I think what happens now would be that the Serious Incident Panel would sit and decide
this. I think then the, I mean, in retrospect, looking at the final deaths of the two Triplets, I
think there's an argument -- there's a very strong argument then that we should have triggered a
SUDI protocol for them with the concern that we had as well, although, you know, we decided to
escalate it quite significantly at that time anyway.
LANGDALE: So when you say the Serious Incident Panel would deal with the others, so what would you
envisage if you were -- if this happened now with Baby A [Child A], just think of the exact
cases.
BREAREY: So it would depend on the gestation of the baby. So if it was a term baby that died now,
that would prompt what used to be HSIB but now is MNSI, Maternity Neonatal Safety Investigation,
which is a nationally mandated process where external reviewers would come in and review the care
that that baby received. But that only applies to term babies, not preterm babies. For preterm
babies, there will be the Perinatal Mortality Review tool which was being developed in 2016
but not completely embedded and established then. And that involves a multi-disciplinary review of
the case as described in 4.4.9 with an external clinician and an external midwife to review those
cases. Yes, so that that would be the process as it stands at the moment.
LANGDALE: Thank you. That document can go down and I am going to turn now please, if we can, Dr
Brearey, to the individual babies and your involvement with them at the time. We will move on
subsequently to the Thematic Review and the like, so we will confine ourselves to the chronology of
events and the babies as far as you were involved. So we begin with [Child A]. And we know of course
Letby had taken over his care at 8 o'clock and within half an hour he was apnoeic. You were not
involved or responsible for his care at any point?
BREAREY: No.
LANGDALE: Dr Jayaram was and told us that he didn't put in the notes at the time about the rash,
the unusual rash when he wrote his notes up that he had seen. [Child B] arrested the day after and
if we can go, please, to INQ000698, page 28, so these are medical notes from [Child B].
Dr V's note. And we know before this note, I'm not going to put all the notes up, Dr Brearey, but Dr
Lambie had recorded widespread discolouration of skin with white patches and a gradual reduction in
heart rate. Dr V then notes: "Soon thereafter went apnoeic suddenly, purple blotching of body all
over with slowing of heart rate." If we go to the next page, page 29, near the bottom: "Purple
discolouration almost resolved ?? cause." You tell us you did see those notes at paragraph 90, you
say you reviewed both sets of case notes and read Dr V's record of purple discolouration which had
almost resolved. You can't remember talking to Dr V directly about it. When you came to do case
notes, do you think it would have been helpful now to have gone to speak to both Dr Lambie and Dr V
about what they had seen?
BREAREY: Yes.
LANGDALE: [Child C] died on 14 June. You don't recollect when you were informed about [Child C]'s
death. You address that at paragraph 92 of your statement but you say it's likely Dr Gibbs informed
you as he was [Child C]'s Consultant, and we know Eirian Powell held a debrief on the morning of 2
July, so a couple of weeks
later. So if we could look at that please at INQ000010827 [page 27]. This is the debrief on 2 July so it's Dr Gibbs, Eirian
Powell, some nurses, Mel Taylor, Kathryn Davis, Sophie Ellis and also Lucy Letby. What was the
purpose of these debriefs? They are not hot debriefs, it is not the same day or the day after, this
is a couple of weeks later, what is your understanding of the purpose of this?
BREAREY: There's no strict sort of definite guidance for this nationally and I know hospitals and
individuals treat these debriefs slightly differently. I think the predominant thing for me in these
debriefs is to get the team together to run through the events again, and to allow time for staff to
sort of reflect on the event and feel that, get any feedback from the -- any provisional postmortem
results, to have an opportunity to thank their colleagues if they were particularly supportive or
helpful and to, if anybody had has got any concerns that they don't think has been addressed in any
way, to raise those as well. But I think from my point of view they are more of a mentoring,
learning, supportive environment-type debrief rather than a strict more analytical look at the care
that was received and any deviation from what should have happened. But clearly somebody taking this
sort of debrief, it is a bit clearer now that the people that take these debriefs tend to be the
ones that aren't or it's encouraged they are not the people that are involved in the actual case at
the time, somebody independent would hold this debrief at this time and go through those things.
Then if there was anything significant, other than things I have talked about, then they can take
that to the reviewers after that.
LANGDALE: We see here Dr Gibbs has included at the beginning: "Events leading up to arrest, did not
seem unwell. Active." Et cetera.
BREAREY: Yes.
LANGDALE: You say in your statement at paragraph 95 you have a number of reflections. You also say
that Dr Gibbs, at paragraph 92, presented the case of Baby C [Child C] at a Perinatal Morbidity
Meeting and the two issues that struck you following his presentation were the completely normal and
stable observation chart in the 12 hours before the sudden collapse of [Child C] and continuing to
make some respiratory effort after resuscitation had been stopped.
So that -- that point was made clear to you when you were watching his presentation?
BREAREY: Yes, yes. The -- he did two presentations, I think he did one as a Neonatal Mortality
Meeting earlier in 15 and then one in January 16 with the obstetric team in the Perinatal Mortality
Meeting. And through -- through all of this you question yourself about what you are thinking at the
time but there was a definite acknowledgement that in neonates babies can desaturate and -- and
deteriorate suddenly without much warning and I was aware that, you know, people were making efforts
to try and prevent that happening and the thought was sometimes that the observation charts that you
have on a neonatal unit when a nurse just ticks a box every half hour or 10 minutes to say what the
blood pressure, heart rate and temperature and those sort of things are is a fairly crude way of
doing things these days. Liverpool Women's Hospital had developed something called the HeRO system
which takes on a number of metrics from the monitor, including heart rate variability, for example,
and will give the clinical staff a score of sickness in that baby and the thought was that if the
HeRo score would get to a certain level then that baby would be screened for infection and have
a medical review and that would pick up babies with sepsis, for example, earlier than it would do if
you are just doing a traditional observation chart. So those are the discussions I had with Dr
Dewhurst at Liverpool Women's Hospital after Dr Gibbs' presentation with a mind of thinking: well,
were we missing something with this completely normal set of observations? And were they just too
crude to pick up Baby C [Child C]'s deterioration? Obviously in retrospect we know what the answer
was, but it -- I am trying to demonstrate to you that, you know, natural causes were still very much
in my mind but at the same time certainly at that stage when we are discussing it in January, I
think 2016, Professor Dixon-Woods mentioned soft signals, you know, that would be one of those soft
signals to me at the time that was -- was making me feel slightly uncomfortable.
LANGDALE: You say at paragraph 95 of your statement: "All of the postmortem examinations for babies
in the indictment were done on the assumption of a natural cause of death." You have just set that
out yourself looking at it thinking of a natural cause of death until something forced you to think
otherwise?
BREAREY: Yes.
LANGDALE: Would that be a fair assessment of what you have just said?
BREAREY: I think everybody was -- was working on that premise and I think that's -- that's generally
the case for ...
LANGDALE: You also say none were forensic postmortems. What's the significance of that?
BREAREY: Well, I am not a paediatric pathologist so, you know, I wouldn't be able to answer that
detail with -- with much confidence. But a forensic postmortem would -- would be looking at
toxicology, for example, and have two pathologists present, one of which is a forensic pathologist
used to detecting or expert in detecting the possibility of intentional harm.
LANGDALE: Would you accept that when they were instructed to do those postmortems, none of those
pathologists were given the details that they could have been subsequently of the rashes, the
unexpected nature, the response of staff, various suspicions that might have assisted in looking at
the cause of death?
BREAREY: Well, they were given a clinical background in the pro forma that they are given prior to
the postmortem, so they would have had some clinical details --
LANGDALE: Yes, some clinical details?
BREAREY: -- about sudden collapse and that sort of thing.
LANGDALE: Yes, but not the detail, for example, for Baby A [Child A] in the notes; the rash doesn't
appear, does it?
BREAREY: Yes -- no. Yes. I mean, my own reflections about the comments about the rash, rashes, from
the babies in June was that it's not unusual sometimes for a sick baby to be mottled for example and
it's trying to equate what, what is a normal, if you like -- I know none of it's normal, but what's
mottling in terms of a sick baby with -- with sepsis or some other illness and with the case of
[Child A] and B, it was known that (redacted) which can cause rashes as well and whether, you know,
(redacted) might in some way have caused a rash in the babies and obviously this was early, you
know, in -- in all of these cases and intentional harm was very low down on -- on the list of
differential diagnoses and on anybody's radar, really. So I think most of the clinicians who -- who
noticed those rashes at the time either thought they were a septic rash or maybe mottling or may be
associated with mum's (redacted) rather than considering something a little bit more sinister.
LADY JUSTICE THIRLWALL: I think in terms of reporting of the information that you have just given, the Inquiry has taken the approach of talking about a medical condition but no more than that, so there must be no reporting of the nature of the medical condition and it will be redacted from the transcript.
MS LANGDALE: Dr Brearey, can I ask you to speak up as well?
BREAREY: Okay sorry.
LANGDALE: We are competing with background noise I think but if you are properly heard at the back,
that would be helpful.
BREAREY: Okay.
LANGDALE: [Child D]. You don't have any recollection of exactly when you were informed of [Child
D]'s death but you reviewed the case with Eirian Powell on 22 June 2015, so can we have a look
please at INQ0003110, page 1. We see you send to Dr Jayaram, you have met with Eirian
and reviewed the case notes of [Child D]. And over the page, if we can go to page -- the action plan
at the bottom of that page. You have agreed an action plan: "Review [Child C] case notes in detail
this week and I will review [Child A]." You didn't at that time add [Child B] who had had that
collapse, the Twin of [Child A]. Looking back, do you think it would have been helpful? And dealing
with
the rashes point for example you would have had more evidence of those four babies together, A, B,
C, D, wouldn't you, that might have caused you concern?
BREAREY: I was already very aware of [Child B], I had seen [Child B] clinically and scanned [Child
B]'s heart and I was aware of the discussions that were going on between the clinical team and the
experts in Liverpool Women's Hospital and Alder Hey Hospital haematology experts. I think there were
some discussion as well with the team in London. So I was already very familiar with [Child B], so
although it's not mentioned in this email, I don't think if I had included a review of [Child B] it
would have added any extra information that I didn't know already.
LANGDALE: If we can go, please, now to INQ0025743, page 2. This is an email from Dr Gibbs reflecting on Dr Lambie
coming to visit him. To put it in context, these events have all happened between 8 June and 22 June
with A, B, C and D; it is a lot, isn't it?
BREAREY: Yes.
LANGDALE: Dr Lambie gave evidence to the Inquiry about how anxious coming into night shifts people
were, thinking: is something going to happen? Or, you know, worried about coming to work, really. If
we look at Dr Gibbs' email, it sets out
Registrars are very concerned about the recent neonatal deaths and collapses and in the last
paragraph he says: "I have mentioned we are looking into this. I'm not sure exactly how this is
being done but I didn't say this to Rachel." Just curious that in terms of Consultants and junior --
or Registrars, is there any reason not to say: we don't know what's being done yet, it's happened so
quickly, to be more open than that, than ...
BREAREY: Well, I think of all us would like to think we are quite approachable as a team of
Consultants and it was nice the Registrars were coming to us and asking and mentioning their
worries. I can't remember this conversation on email but --
LANGDALE: Let's go to page 1, the page before, because it flows up and you can see your
responses?
BREAREY: Yes.
LANGDALE: So Dr Newby comes in at the bottom of the page, you have to go backwards in the way of
the world to see the sequence: "I agree. I have just been grilled by Dave Harkness. This is causing
a lot of concern/upset." Then your email to Dr Newby gives and others, Dr Murphy, Dr Jayaram: "I
have reviewed [Child D]'s care with Eirian and looked to see if there are any common threads in the
deaths. I emailed an action plan to Ravi yesterday. [Child D]'s death appears to be due to an early
neonatal sepsis after PROM." And you say: "PMM tomorrow afternoon. Please encourage all juniors and
nurses to attend and discuss in this forum rather than ... privately." Then as we go further up, Dr
Newby suggests he is "happy to put a quick presentation so we can discuss all three together, I
presume you were due to discuss the other two anyway". And you say: "I would rather discuss [Child
A] and don't warrant a presentation for all three yet." Clearly Dr Newby thought it might be a good
idea and a Registrar had been worried. Would that have been a good idea straight away to get people
together, the people in the room, Dr Newby, Dr Lambie, the people that were concerned about
different things, it would appear?
BREAREY: Obviously in retrospect, yes. However, you know, it was -- it was felt at the time that the
three different deaths were different in terms of their nature in that we had a maternal illness for
[Child A], we had a very small poorly grown baby in [Child C] and we had a more mature baby with
sepsis from birth in [Child D] and
my interpretation of the concerns that were being raised it's an impression that I had at the time
was it was more to do with the lack of knowledge of what was going on with [Child A] and B rather
than a sort of generic overall concern about all three babies had died. I -- I may have been
mistaken with that. And the Perinatal Mortality Meetings, they only occur four of five times a year
and we were having one the following day and I thought, and -- and we are very open in terms of
discussions and that sort of thing. So if the junior doctors that were there that wanted to discuss
the other babies in that perinatal meeting they would have been quite welcome to do so if they felt
there was a link between all the babies. And that is an open, you know, collegiate type meeting
where different specialties are there and can add their opinions so I didn't think it was
unreasonable at the time to use that as a forum to discuss these cases if needed, we needed to
formally review so many babies at every perinatal meeting, so [Child A] wasn't the only baby we
discussed at that meeting, there were two others.
LANGDALE: We are going to come to the meeting, so let's pause there, we are going to do Perinatal
Mortality Meetings and Neonatal --
BREAREY: But what I am saying is that --
LANGDALE: Yes
BREAREY: -- you know, there was a restriction in the numbers we could -- we could discuss in one
meeting and the two babies that weren't mentioned here that had to be discussed at that meeting were
also very important to discuss and -- and had waited longer, if you like, for it -- for that
discussion to happen. So --
LANGDALE: Dr Newby had offered to pull the presentation together. I appreciate that doing one at a
time allows a very careful going through the notes. But what was being expressed to Dr Gibbs was a
worrying spate of deaths and collapses; it was a bigger picture thinking, wasn't it, it wasn't
looking at each one necessarily as you described now. It like, what's happened there, that is an
unusual three weeks? Looking back, did anybody talk to you about how the three weeks felt for them
at the time? You know, like I have given you Dr Lambie's evidence coming to the Inquiry about that
and others who were becoming worried. What -- did anyone say to you at the time they were feeling
like that?
BREAREY: I -- I can't remember any specific conversations. But I can remember a general sort of
confusion in terms of particularly [Child A] and B and what was going on certainly. And clearly it's
worrying that we had three deaths in such a short period of time which is why we triggered a meeting
with the Risk Team and Alison Kelly, the Director of Nursing, to discuss those cases in more detail.
LANGDALE: And one of the doctors I think had some time off, didn't he, because he was so shocked?
You refer in your statement to the psychological shock of a death of a neonate for --
BREAREY: Yes.
LANGDALE: -- first of all their parents but for staff with them, working with the neonates, it can
be hard, can't it?
BREAREY: Absolutely.
LANGDALE: So you were sensitive then to how people felt around you or may have felt around you at
that time?
BREAREY: Yes. But I was -- I was interpreting the -- the discomfort people had as a sort of lack of
knowledge particularly in [Child A] and B --
LANGDALE: And you were thinking natural causes?
BREAREY: Yes.
LANGDALE: And you weren't particularly worried with your experience about the natural causes
presentation, as far as you were concerned?
BREAREY: At that time no.
LANGDALE: There is a senior clinicians meeting, if we can go to INQ0036166, page 1. You are not there, I am only going to refer you to one
paragraph of it. Dr Jayaram is there, Dr Newby, Eirian Lloyd-Powell Dr Saladi and Dr Gibbs. If we go
to the second page, this is the senior clinicians' meeting and: "There was an issue raised around
the fact that at the three recent neonatal deaths, the Registrars had been quite worried and feel
that nothing is being done. Behind the scenes reviews are going on but it was felt formal debriefs
should probably take place rather than any specific meeting to discuss all three." So your email
exchange on the 23rd to say let's deal with one, and we are getting there, didn't seem to allay
concerns, did it, that they felt nothing, the Registrars, was being done?
BREAREY: I -- I don't, I don't know whether that's -- minutes of that meeting referring to the
concerns we have already talked about or whether those concerns were ongoing. It's -- it's not clear
and I wasn't at the meeting, I can't really comment on that.
LANGDALE: But it does sound as though they had a sense that something may very well be wrong at a
time that you
were thinking those deaths at the time were pointing towards natural causes. Looking back, do you
think that was a moment for a sense check? Just because we are more experienced doesn't necessarily
mean we have the right sense check at every time, does it? Might there have been some value in that
sense check from the Registrars?
BREAREY: Possibly.
LANGDALE: I mean, it is quite an email to send, isn't it, from Dr Lambie to Dr Gibbs and then for
Dr Harkness to say, you know, Dr Newby referred to other concerns being grilled?
BREAREY: Yes.
LANGDALE: I mean, they are clearly at the time writing that they feel like that and presumably speaking like that too, if anyone is asking them?
LADY JUSTICE THIRLWALL: I think Dr Lambie went to see Dr Gibbs, didn't she?
MS LANGDALE: Yes, Dr Lambie went to see him as well.
BREAREY: But it was at a time when we were still information gathering, if you like. You know, we
didn't have the postmortem results. The review in July with Alison Kelly hadn't happened yet, you
know, it hadn't been discussed at that level, which was effectively --
LANGDALE: About to happen?
BREAREY: The sense check meeting, if you like. But I -- I take the point that that would have been
the meeting without the input of the Registrars and that might have been helpful.
LANGDALE: So you arranged for the 2 July to have a meeting to discuss the three deaths and if we go
to INQ0103164, page 2, we see there an email from you attaching your summary and
data to Debbie Peacock. You are emailing Dr Jayaram and if we can go to your summary, please, we see
that at INQ0003191, page 1. You summarise the case of [Child A], [Child D], and at
page 2 you set out learning, there we are, of these cases: "Notable excellence in practice and
record-keeping. Surely it appeared to be excellence in record-keeping at these stages. It is just a
point we notice going through all the reviews about excellent record-keeping and of course we come
to Baby E [Child E] where the record-keeping is by Letby and it is not accurate, is it? Evidence
given about -- from Mother E about that note-keeping not being accurate. So when you are reviewing
it, how do you know if it's excellent if you don't know what's happened to the baby? I mean, you
have got to compare the two things,
haven't you, what someone is writing and what's happening?
BREAREY: Well, you can't criticise an omission of something if you can only make a critique of
what's written in the case notes and there are a set of standards in case notes that doctors have to
follow like any other professional to make them contemporaneous, to record the date and the time, to
sign them appropriately and to describe what happened in a -- in a manner that is appropriate and
thorough. So that would be the critique that I was commenting on there.
LANGDALE: You say in your statement that in retrospect you regret not paying more attention to the
description of the rashes and skin abnormalities and you have explained now that some of the doctors
had described or explained them as a sign of sepsis although it is clearer now they weren't typical
of that. Does that just indicate the limitations of a Casenote Review and that you need to talk to
people really, that sitting back and reading and going through the case notes isn't as effective as
bringing the people together and speaking to them and getting a real flavour of what they are
telling you?
BREAREY: Yes. And, you know, the systems we have in place now would have -- would be more likely to
involve a discussion with clinicians concerned, although not always.
LANGDALE: And later in your statement you are critical of Dr Hawdon for doing just that, a Casenote
Review, and it doesn't even look like she had all the case notes and some of the material.
BREAREY: Exactly, yes
LANGDALE: It can be quite high-handed and a bit aloof, can't it, looking at things like that and
giving comments to those who may have more information on the ground?
BREAREY: Certainly, you know, it's more helpful, yes.
LANGDALE: You at page 3 set out neonatal mortality data in this first document that you put
together. Why do you do that? First of all, do you have to look them up and why do you put that in
to this summary?
BREAREY: Because it was in anticipation with the meeting with Ruth Millward and Alison Kelly that we
had in early July and I think I might have had a discussion with Eirian Powell, the unit manager,
prior to that meeting, regarding what information we would bring to that meeting and knowing what
our annual mortality rate is historically obviously informs Alison Kelly, who's the Executive lead
for patient safety, as to how
significant three babies dying in that short period of time was.
LANGDALE: You don't provide comment on that, you just provide the data for that. Is there a reason
for that? Did you have a comment on that, did you have a thought about it?
BREAREY: Well, it was for bringing to the meeting to -- to explain and then obviously I would -- I
would comment at the meeting. It was -- it was just the raw data.
LANGDALE: What's the data that you include at page 4 and 5?
BREAREY: So that was information regarding -- can I just have time to digest this? So that is number
of admissions to neonatal units in the Cheshire and Merseyside Neonatal Network in the period from 1
January to 30 June, for the first six months of 2015. And the purpose of that table would have been
along with mortality data to see how we compare to other units in terms of admissions. If we were --
sorry, I haven't -- I am not too familiar with this document. Did I follow with anything on this or
is this the last part of the --
LANGDALE: No, you just have 5, 6. This is your summary?
BREAREY: Okay. So I have got a table of the admissions, I have got a table of the deaths --
LANGDALE: Yes.
BREAREY: -- for the network.
LANGDALE: And gestation at page 5.
BREAREY: Yes, by gestation between 22 and 31 weeks.
LANGDALE: And survival percentages if you are born at those weeks?
BREAREY: Exactly, yes.
LANGDALE: So you have pulled that together and then we know on 2 July you meet with Alison Kelly
and others. If we can have INQ0003530, page 1. You tell us at paragraph, the bottom bits can be removed,
it is just that top bit relating to [Child D] -- you say at 114: "The reason for the meeting was to
meet with Alison Kelly and describe the events and what had been done since. I anticipated Alison
Kelly would then advise us as to any actions that were needed. I was reassured that we could share
everything with her." What did you mean "reassured we could share everything with her"?
BREAREY: I'm not sure whose notes these were because I have seen Alison Kelly's notes of this
meeting which are a little more detailed than this.
LANGDALE: Do you remember the meeting, just tell us --
BREAREY: I do, yes.
LANGDALE: -- about the meeting. That can come down.
Just tell us about the meeting and what was discussed. Do you know how long it was roughly, first of
all?
BREAREY: I -- I can't remember but it was, it was at least an hour, I would imagine. We discussed
with Alison Kelly that we had had three -- three deaths in a short period of time, this was unusual.
This amounted to what would be our normal annual mortality rate in -- in that short period of time
and I discussed the cases and reviews that we had undertaken already regarding the three babies. And
I discussed with the group where I felt there might be any deficiencies in care that we could be,
could be improved on, and following the sort of specific discussion regarding the babies, then we
discussed other factors in terms of what might link these three deaths together, so we were thinking
of that and Eirian Powell had done a number of things which included looking at the spaces where the
babies were cared for, whether there was one common incubator or cot space that was common to the
three babies, whether there was any microbiology evidence linking the three babies together, always
a concern if that is the case. But there wasn't any microbiology evidence that there was any -- any
links. There's already also a consideration of the IV fluids that Baby D [Child D] had had, because
we were buying a commercial product for parental nutrition for use in preterm babies and obviously
there was a thought whether that might be contaminated or not. But only two of the babies had TPN
and Baby D [Child D] wasn't on TPN at the time so that was excluded. And finally, we looked at
staffing or I say -- Eirian Powell looked at staffing, nurse staffing, and had identified that one
member of staff was present for all three of the -- of the cases.
LANGDALE: And you say in your statement at 116: "Towards the end of the meeting Eirian Powell
raised the observation that Lucy Letby had been on the NNU on the three occasions when the three
babies had collapsed. My first reaction was to say 'not Lucy, not nice Lucy' as before this meeting
I was unaware of which Nurse Eirian Powell had identified." Is that what you said?
BREAREY: Yes.
LANGDALE: Later on I think in the grievance there is a reference to Eirian Powell that you said
something about Mel Taylor being nice, "not nice Mel Taylor", did you ever use that phrase in
relation to her as well at any point?
BREAREY: I have no recollection of that and I think the
accusation that I said it didn't refer to this meeting anyway.
LANGDALE: No, I just wondered if at any point you had, while it is in your mind?
BREAREY: No.
LANGDALE: So you didn't refer to that, but you said that about Lucy Letby. What made you say that?
Why -- why would you say that, why would you comment on that at that point?
BREAREY: It was a spontaneous comment that came when her name came out and it didn't necessarily
sort of signify anything. And I think with all of this, there is a little bit of denial going on,
isn't there, of the cause for everything? The -- the whole of the nursing team that we worked with
were, you know, I believed to be good people, so I probably would have said that for any of the --
any of the nursing staff to be honest. Yes. That's it.
LANGDALE: You say: "Although the association was significant enough to remain in my mind following
the meeting I was not overly concerned at that stage."
BREAREY: Yes.
LANGDALE: So was your superficial impression of Letby -- I say superficial in the sense of she is a
colleague,
you don't know her really well, do you at this point?
BREAREY: No, no.
LANGDALE: So was that falsely reassuring in some way at the time?
BREAREY: I -- I don't think it was reassuring or not. I -- I didn't have -- you know, I was more
interested in the facts, really, and I felt at the time that it was a small unit, there were, you
know, 13 members of nursing staff around, maybe less than that, sometimes on the workforce and I
didn't think it was particularly unusual that a member of staff might condense their shifts into a
period of time like this, you know, to allow for holidays and other commitments and staff did do
that at times. So over, you know, a two-week period somebody might work a good number of those
shifts. So I didn't see it as being overly concerning that she was present at all, on all three
occasions. And I was aware that sometimes you do get clusters in, in medicine, in neonatology, where
your, your deaths for a year won't be spread out evenly. You know, there will be times when you have
more than others and, and I thought that wasn't within the realms of, you know, it didn't strike me
as -- you know, obviously it's something to concern and consider the factors we
concerned. But once you have, you have done the things that we were doing, there -- there was
nothing too concerning at that stage for me.
LANGDALE: You say that Alison Kelly's reaction to the association with Letby was to say, "We will
have to keep an eye on it". Do you remember her saying, "We will have to keep an eye on it"?
BREAREY: Keeping an eye on it, as in keeping an eye on the mortality cases, I thought that was more
to do a generic thing rather than keeping an eye on her. I think she was alluding to the fact that,
you know, we would have to keep our eye on things going, going forwards in the future.
LANGDALE: Did the meeting discuss how you would keep an eye on it?
BREAREY: No.
LANGDALE: We see INQ0003625, page 1: "Hi Steve, just wanted to thank you for your contribution.
Reassuring to know each case has been looked at in such detail and we recognise some areas required
further review. I know it's been a particularly challenging few weeks for all the team. I am mindful
that currently Ian Harvey is on leave but if you wanted to discuss anything outside of the unit then
I am happy to meet with you." Had you had dealings with Alison Kelly before this meeting?
BREAREY: No.
LANGDALE: That seems a very open email saying: If you want to discuss anything. Did you take it as
that? Did you think you could follow that up with her?
BREAREY: I didn't exactly understand what she was trying to get at really because I didn't know what
she was referring to when she said "outside the unit".
LANGDALE: Might that just mean physically not in the unit? I don't know. What did you think of
it?
BREAREY: I don't know either actually.
LANGDALE: But did you see it as an invitation? She said, you say, keep an eye on it, the situation.
She is recognising this has been a challenging few weeks. If you want to discuss further, come, do
discuss with me. It looks like you don't leave with a plan at the meeting?
BREAREY: Yes.
LANGDALE: So was that keeping a dialogue open or not? How did you view that at the time?
BREAREY: I think, in retrospect, it was an opportunity where I could have come back to her with, you
know,
a suggestion of how we are going to keep an eye on it going forwards, yes.
LANGDALE: Did you choose to do that or not?
BREAREY: No.
LANGDALE: [Child D]. We know [Child D] was referred to STEIS. I think was that a decision of -- you
say that Alison Kelly decided that Baby D [Child D] should be the subject of a STEIS report and she
was. We have seen the STEIS report. My question, please, would it have been appropriate, do you
think, to undertake a Serious Incident Review in respect of the cluster of the deaths A, C and D. I
know you say you were familiar, you might get clusters. But they are a cluster, aren't they, and
there could be all manner of things that that kind of scrutiny might throw up at an early stage. Do
you think that would have led to greater scrutiny?
BREAREY: It would have led to greater scrutiny, certainly. As I say, the -- the Serious Incident
classification wasn't usually a decision that I would make certainly alone and usually through the
SI panel and I wasn't overly familiar with the criteria for an SI. You know, you would always have a
fairly confident idea which ones were and weren't, but ...
LANGDALE: You weren't the only one in the meeting. So others --
BREAREY: Yes.
LANGDALE: -- could have thought of that too?
BREAREY: Yes.
LANGDALE: But it would have led to greater scrutiny, wouldn't it, and family involvement?
BREAREY: Yes.
LANGDALE: And external reporting?
BREAREY: Yes.
LANGDALE: Increased objectively. We know as we move forward it's you and Eirian Powell are looking
at what's happening on a unit where you both work and a nurse that she backs, openly backs all the
time, through this?
BREAREY: It certainly would have done that and there was the Head of Risk at the meeting with the
Head of -- Safe Executive lead for the Trust there as well.
LANGDALE: Moving on to [Child E]. You had no clinical involvement with [Child E] yourself, but you
did a review of [Child E], didn't you, which we find at INQ0003296, page 1. So this is an incident review you undertake October 2015.
We know the SUDiC procedure that should have been initiated wasn't and there wasn't a postmortem
required in this case, accordingly.
And the working diagnosis for [Child E] before their death and for you was necrotising
enterocolitis; is that right?
BREAREY: That's correct, yes.
LANGDALE: We see at the summary, page 3, again: "Neonatal care was appropriate. Record-keeping of a
high standard possible learning points are described below. Unlikely any changes in management would
have prevented this sad outcome." As I indicated earlier, we know that Mother E had substantial
evidence to bring to the care of Baby E [Child E] arriving as she did with expressed breast milk for
her baby and seeing blood on his lips and realising when she saw the medical notes that Letby had
covered her tracks with the timings on those notes. Reflecting there, this kind of review, did you
think to speak to the parents or to see what they had to say about their understanding? And do you
think that was an opportunity missed to do so, particularly with Baby E [Child E]?
BREAREY: I think what I was doing at the time with these reviews was in line with what neonatal
teams across the country would be doing for similar cases. I don't think the way we were doing it
was -- was much different to any other hospitals and I think I -- I agree with you, it would have
been really helpful to have the parents there but it just wasn't the process at the time.
LANGDALE: Other hospitals weren't having this rapidity of unexpected unexplained deaths. Did that
cause you to pause and think: I need to speak to people around and see if they have got any relevant
information?
BREAREY: It's quite difficult to pause in the job that we are doing actually and it -- it's an
exceptionally busy job anyway at the best of times and -- and when you are getting these through,
there is a rate you are talking about then obviously that adds another workload as well and
obviously a clinical workload that I shared with all my colleagues. So the -- the capacity to even
-- even do this in more detail including families takes time, more time, and obviously it's another
sort of soft indicator that things were getting busier and harder to fulfil. But I -- I think with
the -- with the resource that I had and the resource of time that I had at the time, it would have
been very difficult to -- to spend enough time reviewing these cases adequately in the way that you
suggest.
LANGDALE: Did you feel able at the time to express that time was pressured and we understand you
had four hours,
Dr Jayaram said four hours --
BREAREY: Yes.
LANGDALE: -- for admin time effectively?
BREAREY: Yes.
LANGDALE: So did you have more than that when this was happening?
BREAREY: No. Yes. The Trust's financial situation was such that I knew what the answer would be if I
did ask for -- for more time and I don't -- I didn't think my position at that time was any
different to any of the other neonatal lead Consultants in other local neonatal units in the region.
I did bring it up at network level, the workload for neonatal leads, and it became a standing item
for the board meetings for a period of time before they took it off but there was no actual action
to improve that and shortly after these -- the deaths in the indictment occurred, we had approval
for more hours for a Risk Lead Consultant to help with the role and she had four hours of her job
plan designated for managing risk so that I could concentrate on the other parts of the neonatal
lead role. So it was being talked about, identified, that even without these -- these deaths, the
workload was excessive and close to unmanageable. But at the time,
I just did the best that I could do with the resources available.
MS LANGDALE: Dr Brearey we will take a break now and resume at 11.45.
BREAREY: Okay, thanks.
LADY JUSTICE THIRLWALL: Very good, we will start at 11.45. (11.31 am) (A short break) (11.45 am)
LADY JUSTICE THIRLWALL: Ms Langdale.
MS LANGDALE: Thank you, my Lady. Dr Brearey, I have just asked you about Baby E [Child E]. Which
point is it that you say you were concerned that Letby may be deliberately harming babies, at which
baby or point in time? You said you weren't thinking about it for A, C, D, but as we will move
forward now, when were you thinking that was a possibility or you were suspicious about it?
BREAREY: Well, obviously I was aware of her association from the first three and it was more of a
growing nagging concern rather than any one seminal moment. I can remember a conversation with Dr ZA
--
LANGDALE: Yes.
BREAREY: -- after I came back from leave who actually
did mention that.
LANGDALE: When was that? Orientate us in time, when would that be?
BREAREY: It would have been August, late August, maybe early September when she mentioned the death
of Baby E [Child E] and mentioned that Letby was present but reassured me that she felt there the
cause of the death was natural. She didn't use those words, I think she said it was quite clearly a
small baby with IUGR and probable necrotising enterocolitis. So I was reassured by her somewhat and
reassured by the review that I did as well. Obviously there were -- there were further deaths in
September that weren't in the indictment that did have medical diagnoses which reassured me at the
time. I can't remember knowing at the time whether Letby had been present or not.
LANGDALE: Let's go through the babies one by one. I thought you might on reflection be able to say
X or Y?
BREAREY: Yes.
LANGDALE: Let's stay with where we were in the chronology. So Baby E [Child E], you said at the
time you thought natural causes, but you were also aware of Letby's presence?
BREAREY: Yes.
LANGDALE: When you made the comment in the meeting in the Serious Incident meeting "oh no, not nice
Lucy", what was the point of the "oh no"? What was the link that was being made in your mind, why
would it be an "oh no"?
BREAREY: Well obviously some -- some part of my mind was thinking that -- the worst really.
LANGDALE: Yes, suspicion?
BREAREY: Yes.
LANGDALE: "Oh no, it's her, it can't be"?
BREAREY: Yes.
LANGDALE: So in that meeting, and keep an eye on it, there was suspicion and concern -- I am not
putting it higher than that, but suspicion and concern -- and Eirian Powell had identified that was
the person who was the link at that point, if anyone was?
BREAREY: I don't think "suspicion" would be the right word at that time. But concern, yes.
LANGDALE: Your mind jumped to something to say "oh no", didn't it?
BREAREY: Yes.
LANGDALE: What did it jump to?
BREAREY: The concern that there might be somebody harming babies.
LANGDALE: Yes. So you leave the meeting with that concern in your mind and Alison Kelly says: let's
watch
the situation, discuss with me if you want to. Then Baby E [Child E] happens and you have the
conversation with Dr ZA. She gives you from your perspective reassuring information about Baby E
[Child E].
BREAREY: Mm-hm.
LANGDALE: What do you tell her? Do you tell her you have met with Ms Kelly, Ms Powell and you have
been drawing up a link with a member of nursing staff or not at that time, when she tells you about
Baby E [Child E]?
BREAREY: Not at that time I was still quite firmly in my mindset that these were natural and this is
me just being paranoid, if I was even getting that far as to thinking -- thinking it through that --
that much in the front of my head.
LANGDALE: So Alison Kelly knows you are thinking that, Eirian Powell knows you are thinking that
and you are having those conversations together at that Serious Incident time. Is there anyone else,
who are you speaking to first about that? Just those two at the point of Baby E [Child E]?
BREAREY: I don't have any specific memories of talking to colleagues about it, but I must have done
because Dr ZA was aware enough to talk to me about it.
LANGDALE: She would tell you about a death, wouldn't
she, she's telling you about the death of E, so she would have to talk to you about that?
BREAREY: Yes.
LANGDALE: Did she mention Letby being there, in a suspicious way or not?
BREAREY: No, no.
LANGDALE: Just a factual way?
BREAREY: Yes.
LANGDALE: So from her point of view she is telling you a baby has died and the nurse on shift, but
she is not communicating concern about that association herself, in any way, at that time, is
she?
BREAREY: Exactly.
LANGDALE: You don't tell her you have got a concern because you say it's evolving in your mind at
that time?
BREAREY: Well, for her to tell me would have meant that she would have been aware of the association
in -- in June.
LANGDALE: Or that she was just caring for her, it is an assumption to make, isn't it, because if
she was just telling you who is looking after her?
BREAREY: No, because it followed after her telling me of the -- the presence of Letby but I am quite
happy that this baby died of necrotising enterocolitis; one followed the other in our discussion.
LANGDALE: Babies F and L, we know you were given the task of reviewing the care in the police
investigation and you came across those insulin results at that time and the police were informed
both in relation to [Child F] and [Child L]. Your reflections in your statement about this, if we
can go to your statement, INQ0103104, page 24, paragraph 149. While we are finding that, Dr Brearey, you
say in your statement to the Inquiry prior to this you had been told by the Executives there is no
smoking gun, and when you saw these results, both you and I think you say Dr Holt were looking at
those results, it was a moment, wasn't it, where you realised what had been missed and the
importance of them?
BREAREY: Yes.
LANGDALE: Do you share Dr Gibbs' reflection upon that, that that was a collective failure of the
paediatricians not to note those results at the time and to potentially appreciate their
significance?
BREAREY: It was a collective failure of the paediatricians and the labs, in Chester and Liverpool,
and the system generally in terms of flagging what should have been a Never Event. Yes.
LANGDALE: Dr ZA's evidence about the results of Baby F [Child F] at the time was saying she
discounted insulin poisoning as "so fantastical and unlikely". Looking back, do you think if you had
shared your suspicions or the thought, the concern, however you want to put it, that you had in that
Serious Incident meeting: oh no, that there was a concern about someone or that something might be
happening, her reaction may have been different to that or not because fantastical and unlikely at a
time when you have got someone saying "we will watch and see", and the meeting you have had?
BREAREY: I don't think Dr ZA's knowledge or view was any different to mine at that time in that she
would have known the same association as me, not thought that it was particularly worrying at that
time. So I don't think there's any -- any provenance in terms of sharing information either way with
-- with her. I think we were both in a position where we, we couldn't quite believe that something
like this was, might have been happening.
LANGDALE: Were you familiar with the case of Beverley Allitt and the learning around that?
BREAREY: Yes.
LANGDALE: You were?
BREAREY: Yes, yes.
LANGDALE: When did that case in your presence, the Allitt case, when was that first discussed at
any time
between whoever?
BREAREY: I- I can't remember discussing it with colleagues because I -- I think we all were aware of
the case historically. It was there and might have been the reason why I said "not nice Lucy" in
June. I think we all would have been aware of it historically but there's one thing to be aware of
it historically; another thing to be considering that it's -- it might be happening on your unit.
LANGDALE: You set out at paragraph 149 your reflections regarding the insulin and you have listed
thoughts about how it might be avoided in the future at A and B and you also say -- we don't need to
turn to it: "NHS should consider making a blood test result from a baby on NNU of a raised insulin
and low C-peptide level and Never Event. This would mandate an urgent Serious Incident Review in all
cases." We looked at the Serious Incident reporting guidance earlier. So the Never Event, set out
what the significance of the Never Event is and why you suggest it should be a Never Event?
BREAREY: Well, Never Events as -- as described really they are, they are stated, there's a list of
them in the guideline. That includes taking out the wrong organ, for example, leaving in metal
equipment in surgery
things that should never happen and when they do happen, mandate a Serious Incident and
comprehensive review and the Trust reporting to national bodies to say that they have taken steps to
make sure they never happen again. So, yes, I mean, if it had been a Never Event, then, you know,
that would have triggered a significant review and a look into this and more -- more thought would
have obviously gone into the results than went into the results at the time.
LANGDALE: Can we go to paragraphs 158 and 159 of your statement, please, which addresses Baby G
[Child G]. We know of course that Letby was convicted of attempted murder of Baby G [Child G] with
the method of attack being excessive volume of feed and air via nasogastric tube. You say at
paragraph 158: "I have never heard of air or milk being forced into a baby's stomach and it didn't
cross my mind this might have caused [Child G]'s collapse. In retrospect and prior to the trial,
what struck me as being very abnormal was the amount of gas or fluid that was aspirated from [Child
G]'s stomach ..." Was that something -- one of the matters the Inquiry is exploring is what the
parents have been told at various times. Was that something that you discussed
with the parents of Baby G [Child G] at any time, the amount of gas or fluid that was aspirated? I
don't need to take you to the notes of that.
BREAREY: (Redacted) But in response to your question, the significance of what you have just read
out wasn't as clear to me then as it is now and, yes, if it had that significance at the time then
certainly I -- I think it would have been appropriate to discuss it with Baby G [Child G]'s parents.
LANGDALE: That can come down, please. [Child H]. You say in your statement you can remember Dr
Jayaram talking to you about [Child H] in late September. "This was regarding the unusual nature of
her pneumothoraces and need for more than one chest drain but I don't recall anyone at the time
raising concerns regarding the conduct of Letby during [Child H]'s care." You say you: "... became
more aware of the unusual nature of [Child H]'s care later, probably in late 2016/2017, when the
team of Consultants were trying to recall unusual events that had occurred in relation to Letby." So
you have commented in that earlier paragraph we had on the screen that there were so many deaths
that actually looking at the deteriorations or other events or the babies who did not die you didn't
have as much time as you might have liked. It certainly does appear that there wasn't at the time
sufficient gathering of people who might have information about deteriorations and discussion to
reflect on those at the time of the events occurring, would you agree with that?
BREAREY: Yes, that's correct, yes. Yes, you know if you compare it to today, I mean not only have we
got more people doing the job that I was doing but the perinatal Morbidity and Mortality Meetings
will be entirely meetings to discuss morbidity because we don't really have any deaths at the
moment. So we have time to go into those in more detail and -- and gain learning from them. And the
fact that those meetings in 2015 and 16 were taken up with Mortality Reviews meant that we didn't
have that time to discuss morbidity in the form of a perinatal meeting that I have described.
Obviously there's other opportunities to review these cases and obviously if staff feel an incident
is, is significantly unusual or significant then they can Datix those, those incidents in which they
will be reviewed appropriately as well. But there's -- there's also issues in terms of how
you define a collapse, for example, when you are dealing with patients and babies who are known to
have apnea of prematurity which is, you know, a well-known sort of thing with preterm babies, that
they can stop breathing briefly for a time. Or, you know, if they did have a blocked tube when they
are on a ventilator. That's not necessarily an incident, it's secondary to care and you would have
to change that tube and the baby might deteriorate before, you know, you realise that's the case. So
there are some things that might be considered to be normal practice or -- or normal care where a
baby might deteriorate that -- so the point I am saying is that which ones become an incident and
which ones don't and I think in retrospect, although I thought our reporting systems -- our
reporting culture on the unit was good, and that staff were very aware to report things when they
thought things went wrong I think some of the incidents occurring in the indictment period, and
probably before the indictment period, were babies that deteriorated that could have been -- could
have triggered an incident and on reflection I think it's, it's likely that Letby didn't start
becoming a killer in June 2015 or didn't start harming babies in June 15 and I think it's likely
that she -- her actions prior to
then over a period of time changed what we perceived to be abnormal.
LANGDALE: Can I ask you now please to go to paragraph 170. Perhaps have it on the screen 170, 171
and 172, and this is detailing events around [Child I]. Dr Jayaram's evidence was that he, after
[Child I], became suspicious of the link between Letby and that she was deliberately harming babies
and that he remembers saying to you about [Child I]: Letby was present again or some reference to
her presence. Do you have, before we go to the detail and the documents, a sense of that around
[Child I] thinking this is a real suspicion that she's doing something now of deliberate harm?
BREAREY: It was certainly a significant moment that raised my level of concern quite considerably.
The -- the nature of her care, having come from Liverpool Women's Hospital, being relatively mature
when she arrived with us, then having abdominal problems and having to go back to Liverpool Women's
Hospital with assumed necrotised enterocolitis where she stabilised for a week, then coming back to
Chester and then deteriorating on a number of occasions, before going to Arrowe Park, recovering
very quickly and coming back to Chester again, before having the same problems again,
and collapsing and dying, to me set a few alarm bells going. Yes, yes.
LANGDALE: If we go, it is INQ0103104, page 28 for those paragraphs in his statement, thank you, Mrs
Killingback. Her death is 23 October 2015. You say at paragraph 170 you were emailed by Eirian
Powell giving her views about [Child I]'s care and attaching a staffing analysis of the deaths,
including [Child I]. Eirian Powell throughout all of this, all the way through, was a defender of
Letby, wasn't she, didn't believe she was capable or had done these things but she was still giving
you the staffing analysis that pointed out it was Letby who was present and seems to here straight
away let you know that it was Letby who was present; is that fair?
BREAREY: Yes.
LANGDALE: When you gave her the tasks, right from that early action plan, what's supposed to be
done around the incubator, she does -- she goes off and faithfully sends you the material back?
BREAREY: Yes.
LANGDALE: Her analysis of it is different, very different from yours but she is giving you the
information and tells you there is an association and you say: "I was keen to talk about Letby with
Eirian Powell because I felt we both needed to acknowledge the association between her presence on
the NNU when these deaths occurred. I didn't feel completely reassured by Powell's assertions that
all the cases were different." We will come to those assertions later. But at this point, you are
sent that staffing association. We know Dr Gibbs holds a debrief and refers to the multiple
transfers, you set that out at 171, we don't need to go to that. You say there is discussions with
the surgical team, Professor Kenny who had -- the transfers had taken place and there was a
discussion that there should be a tabletop to review her care. You also produce a document, 31
October 2015, if we can go to it please, INQ0003286, page 1, Mortality Review for [Child I]. If we go over the page,
the summary of page 3. So we know you discussed the association at this point with Eirian Powell,
Alison Kelly previously, Dr Jayaram, mentioned Dr ZA in August. So you have discussed with a number
of people the association of Letby and this summary doesn't mention that at all, does it? Any
concerns about it being an unexpected -- Sudden and Unexpected Death, multiple transfers and who
might
have been involved?
BREAREY: The -- the purpose of these reviews is to review the care the baby received. That was my --
my role in terms of -- and I think this is the expert witnesses previously have stated that the NHS
isn't particularly -- the way that risk management is -- is set up isn't particularly good at
picking out bad apples and, you know, we are very focused on reviewing these deaths, the care that
was received without actually looking at a possible cause because it's assumed that the cause will
come out in the postmortem and various investigations. So the focus of all these reviews was on --
on the care that was received, not a forensic look at staffing associations and things like that.
The purpose for this was not for me to say this is the cause of death or it isn't. Obviously I had a
concern but I also had a duty to consider other things as well and the other things that were
thought to have that were being talked about at the time more predominantly firstly was the fact
that there had been a lot of input with the surgical team at Alder Hey, and you can see higher up on
that page, the surgeon saying possible chronic stricture and I think -- sorry, excuse me --
LANGDALE: But you don't refer, when you refer to the transfers and the surgical team there, to what
you said earlier that it was concerning she kept needing to be transferred out and she had come back
and then the same was happening?
BREAREY: Yes, so --
LANGDALE: That is the key importance in terms of what was happening to Baby I [Child I]?
BREAREY: But if you look at -- I am sure if you look at the case notes and the -- the discharge
letters, they will say there is a possible abdominal pathology going on here, possible NEC, possible
something surgical in terms of the abdomen. And I think the clinicians in Liverpool, at Arrowe Park
and in Chester thought that was what they were treating when she went to those hospitals.
LANGDALE: You go beyond a differential diagnosis in this, though, don't you? You say a baby is
likely to have died. You are not saying this is an option, it is unexpected, we are not clear, we
are getting more information. If you were reading that as a standalone, do you think that might be
more reassuring than your thoughts were at that time?
BREAREY: Yes. I would -- I would take that and as I say, my concerns were being raised and I can't
say
precisely at the point that, you know, I -- I sort of flipped to thinking this is more likely than
not.
LANGDALE: Did you think to email Alison Kelly straight after Baby I [Child I] and say: this has
happened?
BREAREY: I think my -- I considered my role at the time was to look at the other factors that might
be responsible because if -- if the postmortem came back as this baby having necrotising
enterocolitis or having a chronic abnormality that caused her collapse, then you have got a natural
cause for the death and there will be no reason to go to Alison Kelly at that stage.
LANGDALE: Well, really, because you have already said that those postmortems were conducted on the
basis that they were looking for natural causes? They weren't forensic postmortems. Had anyone known
you were suspicious of a nurse, it would be different?
BREAREY: No, what I am saying is I am saying if there was a clinical concern of an abdominal
pathology, prior to death, then you are not obliged to wait until that natural diagnosis is
confirmed on postmortem before you start having concerns about a member of staff being present.
LANGDALE: You do, as you say -- INQ0103121, page 1. It is an email that you send to Dr Subhedar and Caroline
Travers. You say: "I think her care ought to be reviewed by these centres and the surgical team.
Parents have spoken to the Consultant here and feel the same way. I was wondering whether the
different teams could review their own contribution before we discuss it at the next Network
Mortality Review." Then if we can go please to INQ0103135, page 1, this is the tabletop review meeting which was held on 26
February at Alder Hey Hospital to discuss the case of [Child I]. Now, you are listed as attending
but you say you didn't go to that meeting?
BREAREY: That's correct, I wasn't there.
LANGDALE: Why didn't you go to that meeting?
BREAREY: Because the network administrator that was organising the meeting forgot to copy me in to
some of the emails when they were organising it and I only found out about the meeting I think just
over a week beforehand and I wasn't able to attend.
LANGDALE: Do you think it would have been important for you to attend and to express your concern
to this meeting and suspicion at that point?
BREAREY: I think given the timings of the meeting which was after the Thematic Review it would have
been useful; it would have been more useful for me, though, to know
what the postmortem result was that was completed in February 2016 because if -- if that had said
that the there was no abdominal pathology in the postmortem, that would have been more significant
in terms of the presence of Letby. I didn't actually know the postmortem result until June 30 2016.
LANGDALE: Thank you. That can be taken down. Could we please have INQ0103104, page 31, your statement, paragraph 186 about Baby J [Child J].
While that's coming up, we know that you take over the care of Baby J [Child J] in the morning when
she is stable and Dr Gibbs had been called in in the early hours to assist with J when she had
collapsed and the jury couldn't reach a verdict in relation to whether that collapse was an
attempted murder. Did you nevertheless ask Dr Gibbs much about the deterioration in the night or
what happened or try and find out who was there, anything like that, given where you were in the
chronology by this point?
BREAREY: No.
LANGDALE: Why not?
BREAREY: It's -- you know, it's -- you are describing one baby and one item of care in -- in many
that we would have been discussing frequently every day on the
unit and on the children's ward. Baby J [Child J] or [Child J] was a baby with known abdominal
surgery and stomas, and I think the deterioration overnight with Dr Gibbs had been put down to a
seizure. He was the epilepsy Consultant expert at the Trust at the time. You can have electrolyte
disturbances with babies who have stomas and at the time I didn't see it as overly concerning in
terms of again the categorisation of what represents normal care and expected deteriorations or
unexpected deteriorations, if you like. So no, it wasn't considered that for every patient that
might need an escalation of care that I -- you know, that was asking people who was the nurse
looking after them overnight when that happened. No, that wasn't something I considered at the time.
LANGDALE: That can come down now, thank you. It appears that with the deaths you were suspicious
and looking for an association and arrived would you say, as Dr Jayaram did, with concerns by Baby I
[Child I] that there was deliberate harm, potentially being caused here; is that fair?
BREAREY: Sorry, can you --
LANGDALE: By the time of Baby I [Child I], you thought that there was deliberate harm maybe being
caused here?
BREAREY: Yes, there was considerable concern at that stage, yes.
LANGDALE: Even before then at the meeting of the Serious Incident back in July when you said "oh
no", a causal link was made that somebody could be doing this --
BREAREY: Mmm.
LANGDALE: -- in bad faith?
BREAREY: Yes.
LANGDALE: How is it then if you thought somebody could be killing babies in bad faith or harming
them you didn't make a link with deteriorations or, what we now know, attempt murders to think: what
are the cause for those? Because they do seem to have been treated very separately in your mind and
in terms of how you review yourself, even if there are only Casenote Reviews reviewing them?
BREAREY: Yes, and I -- I accept that, that it wasn't in my mind and it's something that I have
obviously reflected on and thought I should have been and -- and again I think it probably comes
down to the workload and the time that I had in doing this -- you know, most -- most of the reviews
you are talking about, you know, the documents here were done out of hours. You know, the -- dealing
with the mortality on -- on their own was, was quite a considerable workload along with my other
duties and I do on reflection feel that there was a lot of clues and incidents in terms of the
morbidity side of things that would have brought us to the conclusion that earlier -- that something
was -- was wrong.
LANGDALE: I am just looking for an email that you send, Dr Brearey, saying that you wish to be
notified about any deteriorations. So it's --
BREAREY: That was in May 2016.
LANGDALE: So it's INQ0103144. So this is you in May, as you say: "Keeping close eye. If you do
come across a baby who deteriorates suddenly or unexpectedly or needs resuscitation, please could
you let me and Eirian know." Did anyone respond to you as a consequence of this email?
BREAREY: No.
LANGDALE: Pardon?
BREAREY: No.
LANGDALE: Pursuant to that email, one of the babies on the indictment, Baby N [Child N], is a child
you attended I think on 15 June, I don't need it on screen, but if you look at paragraph 235 of your
statement, Dr Brearey. You arrive and you are solely focused on his airway management and you don't
recall seeing Letby. You can't
recall a discussion regarding the cause for the need for intubation other than the possibility of
sepsis and Dr Saladi was the Consultant in charge and you say. "I can't recall when I was told about
subsequent events regarding his care. Colleagues had been discussing his management and his
difficult intubation. In retrospect, I can see these two clinical problems completely blinded me and
colleagues to considering the reason for the need to intubate him in the first place and the
difficulties staff encountered due to Letby's actions." And you can't recall: "... anyone talking to
me regarding concerns about Letby or involvement with [Child N]." One doctor, they have been
ciphered, a trainee doctor, said when you asked them about [Child N] and whether they had noticed
anything unusual, they said that they mentioned Letby's strange behaviour in that she was agitated
when staff arrived from other departments in Alder Hey. Do you remember that doctor saying that to
you or discussing anything about Letby with that doctor? You say you didn't, around the time of
[Child N]?
BREAREY: Doctor S?
LANGDALE: Yes?
BREAREY: I can remember that doctor.
LANGDALE: Can you remember this conversation --
BREAREY: No.
LANGDALE: -- about [Child N] and them saying to you something about Letby being agitated -- strange
behaviour, agitated when other medics or staff arrived from other departments in Alder Hey?
BREAREY: I can't remember that conversation at all.
LANGDALE: I think you say you didn't -- you don't remember any conversations until after Baby P
[Child P] with that doctor?
BREAREY: Exactly, yes.
LANGDALE: But they recollect that. Were people discussing with you by this time concerns or
anything about Letby?
BREAREY: I -- I can't, certainly no junior doctors were discussing any concerns with me. There is
likely to have been private conversations between Consultants in that time period, but nothing
formal or of that nature.
LANGDALE: Which Consultants? Because it looks as though Dr Jayaram early on and Dr Saladi and Dr
Newby, perhaps because she was involved in [Child D], are on your emails but the list expands
further down, doesn't it?
BREAREY: Yes.
LANGDALE: So what was your thinking about who you could
talk to about this suspicion or concern and who you couldn't talk to about it?
BREAREY: The -- you know, it -- it was a significant thing to be thinking about, wasn't it? It's not
something that you can just sit and, you know, chat informally to people outside of the tight circle
of the Consultants with certainly -- you know, I discussed it with Eirian Powell fairly regularly
and -- and her view was quite clear and most of the conversation she tried to close down. But
outside that, I didn't share it with any junior doctors or any more junior nurses than the --
LANGDALE: Generally, your working relationship with Eirian Powell up until then was a positive one,
wasn't it?
BREAREY: It was, yes, yes.
LANGDALE: So when she tried to shut it down or said to you: that is not going to be the case, she's
great, she is excellent, whatever she said, did that influence your own thinking?
BREAREY: It naturally -- if somebody has a completely opposing view of things, then clearly that,
you want to reflect on that and challenge yourself as to whether your -- your opinion is rational or
not. There were soft sort of concerns that were creeping through in that time period. I mean, more
-- there was -- I can remember Dr Mayberry, for example, in the corridor just notifying me of one of
the deaths and I can't remember which one it was, but in the way that gave me a few concerns. There
was a doctor from Liverpool Women's who arrived for something unrelated and mentioned, "You are
having a bad run, aren't you?" So there were those sort of soft indicators that something wasn't
right. But you know, I could, so I was questioning my views. I felt that those soft indicators were
literally that; just soft. And looking in retrospect, I could see that Eirian Powell had this, this
cultural entrapment, if you like, of her views and didn't want to move on from that.
LANGDALE: What do you mean "cultural entrapment"?
BREAREY: I think Dr Dixon-Woods explained that as -- if somebody is raising concern and that concern
is so significant that the hearer the receiver of that information can't believe it and -- and it
creates this credibility gap and that hearer has got that entrapment and can't move on and that's
obviously made worse by denial and -- and that sort of thing.
LANGDALE: Did you feel it became nurses versus doctors further down the line with this, with Karen
Rees,
Eirian Powell's views, your views?
BREAREY: I had worked with Eirian Powell for three or four years by then as the -- the unit manager
and I thought we -- we had a reasonably good and positive relationship. I considered her to be a
friend, really. We -- we had been to different parts of the country and to Germany planning the new
neonatal unit that was going to be built, so -- and the reason for escalating in the way that we did
was -- was -- that I said at the time was to try and preserve that working relationship that we had
which -- which made it quite surprising and upsetting when she acted in the way that she did with
the help of Karen Rees. I didn't know Karen Rees. I hadn't knowingly attended any meetings with her
prior to June and she was the nursing lead for a big division and we just -- our paths hadn't
crossed. So I think Karen was -- was working from a point of not knowing me and not knowing the --
the Consultant team and not having the confidence and relationship in that team that maybe a senior
nurse in a Women and Children's division might have had previously. And I think the combination of
Karen Rees' behaviours and Eirian Powell's denials created certainly what we felt was a nurse v the
Consultant body relationship, which wasn't helpful.
LANGDALE: That can come off the screen now, please, and if we can have paragraph 238, 239 and 240
of your statement on screen, which is INQ0103104, page 42. So we know, Dr Brearey, you were asked by Dr U to assist
with [Child O]'s intubation. You did note what appeared to be the purpuric rash on the right side of
his chest, but with otherwise normal perfusion. You say you were very worried at this stage. Can you
tell us what you thought when [Child O] died and then we will move on to discuss or ask you about
the conversations that you had with Karen Rees and the one Karen Townsend says she had with you. So
do you want to in your own words tell us -- you no doubt remember, do you, those two days and what
happened?
BREAREY: So the conversation that I had with Karen Rees was following the death of [Child P].
LANGDALE: Yes. So deal with O first. So when [Child O] died, what did you think?
BREAREY: I was exceedingly worried. Although we were talking about this in the morning, the -- the
rashes that you talk about had been mentioned in June 2015 and hadn't been a huge topic of
conversation in the intermediate time. So I clearly had enough memory to think that this
rash was unusual and might have been similar to previous ones that had been noted in 2015 and it was
-- I was present at the resuscitation with Dr Gibbs and Dr U and as far as resuscitations go,
everything was done smoothly and efficiently and well, in -- in my opinion. And the baby just didn't
recover from -- from all our resuscitation efforts. The parents were present but I can remember
[Child O]'s grandmother being present as well.
LANGDALE: You say you were worried, you were very worried, at paragraph 239 and you intended to
discuss with Eirian Powell as soon as possible with an intention to escalate to the Executives
--
BREAREY: Yes.
LANGDALE: -- and request action to make the NNU safe. You didn't know that Letby was returning to
work, you couldn't conceive senior nursing staff would allocate her to care for the surviving
Triplets. Did you say that to anyone as soon as [Child O] had died: do not allocate her to any of
the Triplets or don't have her in the unit? As soon as [Child O] had died?
BREAREY: I mean, the -- the normal processes following a death would have happened but I can't
recall any conversation and I can't -- the, I can't think of the timings of when it happened but I
think it was, it was early evening time when most sort of senior people would have not been in the
hospital. So, yes, I was worried. I did think it needed escalating. Eirian Powell wasn't present,
other Consultants, other than the ones involved with the care, weren't present and it was something
I wanted to address as soon as possible the following day and obviously I regret waiting until the
following day to act. It would have been far more appropriate to trigger something on that Thursday
evening rather than wait to the following morning.
LANGDALE: You set out at 241 and 242 of your statement that on the morning -- just the top two
paragraphs, please, just 241 and 242, you say that you were asked to undertake an echocardiogram for
[Child P] on the 24th. When you returned [Child P] had died and Dr Oliver Rackham was leading a
debrief. Karen Townsend gave evidence that she spoke to you on this day and spoke to you in terms
where you described having a "drawer of doom". You have provided the Inquiry with a third statement
detailing your clinical moments and where you were on that day. So ignoring the movements and the
events that you have set out for us, what do you remember or not
remember about meeting with Karen Townsend on that day?
BREAREY: It's Karen Rees.
LANGDALE: Sorry, Karen Rees.
BREAREY: So after [Child P] died -- I will go back to the beginning -- as in my supplementary
statement, I was in clinic all morning on the Friday morning doing a cardiology clinic that involved
echocardiograms and one of the junior doctors came to me during the clinic to ask for an urgent echo
on [Child P]. I had to finish the clinic first, which I did, and then I went directly from the
clinic to the neonatal unit. The -- in my supplemental statement I have, I have given you the times
of the scans that I did in that clinic and on the neonatal unit and the time between the last image
being stored in the clinic and the time between the first image being stored on the neonatal unit,
seven minutes, so in that time I would have had to finish the consultation with the patient in
clinic and explain to them what the follow-up would be and that sort of thing. Close the scanner
down, pack up my notes, walk out of the clinic, walk to the neonatal unit, reboot the scanner, take
a handover from the staff about what was happening with [Child P] and find an appropriate time to do
the scan. So it tells you the urgency of what I was
doing in the -- seven minutes doesn't seem like a lot of time to do all those actions. And I am only
giving that detail because Karen Rees has given evidence saying that she was waiting for me in the
clinic and then walked back to my office with me for a discussion which I have no memory of. So --
LANGDALE: Is a "drawer of doom" anything that you would have said, you say very clearly you didn't
say anything on that day. Would you comment on having a drawer of doom to anyone?
BREAREY: As I have said in my supplemental statement, I -- I have a memory of saying it may be on
one occasion to somebody informally. I don't think there's anything really too exciting about saying
this and as I have explained in my statement, most Consultants will have a drawer they keep
important files, medico-legal files, files from Inquests and I had a drawer in which I would keep my
reports of the babies who had died and those important sort of documents there.
LANGDALE: Who do you remember using that phrase to, "drawer of doom", at some point in time?
BREAREY: I -- I -- it's a difficult memory because I didn't -- I didn't know Karen Rees at the time
and if she had spoken to me without introducing herself
I wouldn't have known who she was. I had only recognised her name on emails, for example, at that
stage. But I think the conversation I can vaguely remember with that was with somebody who was
standing in the doorway talking. I don't know whether it -- it's hard to imagine that it could have
been on that day, but the point I was trying to make was that normally that drawer is fairly unused.
LANGDALE: We have got the point, and there were more deaths and more events; yes?
BREAREY: So it was -- it was getting full and then I think the way that that phrase has been used by
Karen Rees and was used by others in the following year or so was, it was belittling the concerns
that we had and distracting from the concerns that we had and that seemed to be an issue with other
behaviours from that level of management at the time, in that, you know, they felt there was no
evidence and that the Consultants were acting inappropriately and to mention things like the drawer
of doom seemed to hold some significance to them that was really just distracting from what the
important question was, which was why these babies were dying.
LANGDALE: You do remember speaking with Karen Rees later that day as you tell us that you phoned
the switchboard on the evening of 24 June and asked to speak to the duty Executive who happened to
be her. Can you tell us how that conversation went?
BREAREY: Well, I knew that it was -- it was by chance that I was speaking to her because the
switchboard put me through, I didn't ask to speak to her specifically. But when I realised that's
who I was talking to, and she was at home at that time, I let her know that [Child P] had died. I
let her know that all the Consultants had concerns regarding Letby and that I had just been told
that Letby was going back to work the following day on the Saturday during the debrief that occurred
after the death and that I wanted the neonatal unit to be safe and the only way for us to be sure
that it was safe at that stage was for her not to come to work the following day. Karen Rees then as
I have described previously said no to this. She said that I had no evidence, was quite categorical.
I said: well, if you are saying "no", does that mean that you -- that you are happy to take
responsibility if anything were to happen on the following day with any further babies and override
the wishes of seven Consultants? And she said "yes" to both of these. And the call ended shortly
afterwards.
LANGDALE: That can come down now. Thank you.
Dr Brearey, moving on to meetings that were held to discuss the deaths of babies and what could or
could not be ascertained from them. The Neonatal Mortality Meeting record, please, if we can have INQ0003297, page 1. I am not going to take you to all of these, Dr Brearey,
just an example. This is the type of discussion that was held. Who decides who are the
attendees?
BREAREY: Well, the -- the dates for the Perinatal Mortality Meetings were given in advance and
scheduled as half days so everybody would know that that schedule beforehand had been told by email.
The difference with the Neonatal Mortality Meeting was that we -- we didn't have capacity in the
Perinatal Mortality -- scheduled Perinatal Mortality Meetings to discuss all the babies that we
needed to discuss which again is -- is a sign in itself, isn't it? But I wanted to discuss these in
a timely fashion, so organised a Neonatal Mortality Meeting. The difference being that because of
the short notice organisation of it, it wasn't a joint meeting with the obstetric team, it was just
the paediatric and neonatal team and neonatal nurses that would have been invited.
LANGDALE: So we don't have Dr Jayaram there who of course would have known about the rash on [Child
A], if
C and D were being discussed, because you are dealing with individual babies at these meetings,
yes?
BREAREY: Yes, so the whole team would have been notified beforehand, but the other problem with
arranging meetings outside the -- the perinatal meetings is that it was held at a lunchtime session
that would normally be scheduled for teaching, so normal clinical activities wouldn't be cancelled
for it. So people attended that meeting in addition to the clinical work that day.
LANGDALE: Are these meetings for mortality, discussions around mortality limited when you don't
have any postmortem findings and when you don't have a discussion about what type of postmortem is
indicated?
BREAREY: Yes. But there is still something to be learned from them. You know, they are -- they are
educational meetings in the main and a chance for the doctors involved to present what they did that
day and any reflections they have on them but also an opportunity for the people attending the
meeting to critique what went on and maybe suggest things they might have done differently. And
that's all of benefit without the knowledge of the postmortems and at the time it was taking us six
to 12 months for the postmortem results to come back anyway
and you couldn't wait a year to have a meeting like this. You had to do the meeting without the PM
results most of the time.
LANGDALE: Would you automatically schedule one when the PM results were back in for a mortality
meeting? It might be more meaningful around cause of death to have those reports and reflection
together about pathology and clinical findings.
BREAREY: Yes, in the ideal world it would have been good to have a further meeting down the line to
update that meeting. But again, this meeting was primarily for learning and education and rather
than a governance risk procedure, where you are identifying the cause of death, which -- which is
obviously down to the Coroner and that sort of thing.
LANGDALE: You also say that in relation to the Neonatal Perinatal Morbidity and Mortality Meetings
if we can go to INQ0005445, page 1, you say of these meetings the Perinatal Morbidity and
Mortality Meetings that they were for learning and discussion rather than governance?
BREAREY: That is what I have just explained, yes.
LANGDALE: Yes, so it is the same for these?
BREAREY: Yes.
LANGDALE: So in terms of understanding risk to babies, I can see there is discussion about care and
staff learning about delayed cord clamping, for example, in one of them. But in terms of babies'
safety, are these the events we are looking at, are these able to drill into the matters that we are
examining? Governance, risk, elevated risk? Decisions that indicated to be made wider than the
neonatal staff? HR decisions about moving someone off a unit?
BREAREY: Clearly particularly the Consultant body who would have attended all these or been invited
to all these meetings and would have received all the minutes, they will be getting a theme if they
are attending these meetings of how many babies are dying and a feeling for the overall trend, as I
was, for the junior doctors who do six-month stints here, I think purely sort of learning and
education benefit. But in answer to your question, no, they are not particularly helpful in terms of
risk and governance and identifying a bad apple, if you like.
LANGDALE: If we can have, please, INQ0005449, page 1 on the screen. This is obstetrics, neonatology and
midwifery meeting and you tell us in paragraph 140: "It was not an appropriate forum to discuss
confidential concerns regarding a member of staff and I cannot recall anyone discussing this or the
number of deaths that had occurred on the NNU. However, all the
paediatric Consultants would have been aware of the number of deaths." That does sound artificial,
that you are having a meeting where not even the number of unexpected deaths can be referred to,
even if you are feeling protective about the name of the nurse or that a nurse is suspected, not
even the number of deaths are being raised? What's the point?
BREAREY: I think the point is looking at the individual cases, if somebody had brought something
like that up, it would have been acknowledged and I am sure it was acknowledged in the room
informally on a number of occasions. But in -- in terms of where you can take it from there in this
meeting with junior members of staff, nursing and medical staff, so that people were clearly able to
express opinions and comments there, but as -- as a forum for discussing an association with one
member of staff, it would have been inappropriate.
LANGDALE: There were also Neonatal Incident Review Groups, weren't there, and if we can on screen
please INQ0010005, page 1 the Neonatal Incident Review Group before each meeting a
list of the NNU Datixes for the period to be considered was circulated by Debbie Peacock and then
the Datix were discussed at the meeting and although there is no minutes or notes for the meetings
you would circulate a newsletter to NNU staff afterwards; have I summed that up correctly?
BREAREY: Debbie Peacock would minute the meetings on the Datix system and the actions from each case
but yes, I would generate this neonatal incident newsletter for all staff as soon as I could after
the -- the meeting to disseminate learning to clinical staff. So, for example, in this case in July
15, you know, it was -- the top learning in terms of any neonatal sepsis was I think in reference to
Baby --
LANGDALE: Don't worry about which baby. We are not worried about which baby.
BREAREY: [Child D], it was --
LANGDALE: Yes.
BREAREY: -- because of the --
LANGDALE: Let's, let's not worry about that --
BREAREY: -- delay in antibiotics. But, I mean, generally you can see from the sentence at the
bottom, which is me encouraging people to report on the Datix system and the more reports raised,
the better, more risk aware unit it was generally accepted, is that the case. So it was for learning
generically without pinpointing any members of staff and it was to encourage people to use that
system and --
LANGDALE: Would you ever --
BREAREY: -- seek feedback from it.
LANGDALE: Sorry. Would you ever complete Datixes yourself as a doctor --
BREAREY: Yes.
LANGDALE: -- or was it for nurses to do? You did do it?
BREAREY: Yes, yes.
LANGDALE: Thank you. That can go down.
BREAREY: I thought the -- the incident reporting culture and rate in the neonatal unit was -- was
good and comparable to others and that was supported by network reports, other incident reporting
that we had to feed back to as well.
LANGDALE: You then have Clinical Effectiveness Group meetings. That's -- if we can have on screen
INQ0005531, page 1. While that comes up, you tell us in paragraph 61 of your
statement that this group met every three months until September 2015 and then every two months
thereafter and it was attended by the neonatal Lead Clinician and nurse manager from the nine
neonatal units in the region along with the network clinical lead, nurse lead and administrator,
serious incidents of mortality would be discussed as well as quality improvement and educational
initiatives. And if we look at this document, over the page, we see the list of attendees. So you
have got paediatricians from surrounding hospitals. If we go to page 5, mortality for Countess of
Chester, three deaths under review will be discussed at subsequent Clinical Effectiveness Groups. By
the date of this meeting of course E had died on 4 August, so it might well have been four that was
referred to there. But the number, did any of your colleagues just reporting -- first of all, how
was that reported? Mortality, it doesn't say "Sudden and Unexpected Deaths", for example?
BREAREY: This system with this group that had been developed in 2015, it was new, and the -- the
network would give you three-month windows to report on and a deadline for when to submit your --
your reports. So for this meeting -- sorry, in September, it would have been the -- I think it was
May, June, July, but it was a three-month period that only covered the three deaths that we had in
June which is why only three deaths are reported at this time. It was the requirement at the meeting
that the deaths in that time period were -- were discussed at this meeting.
LANGDALE: This wasn't a meeting where you raised either
suspicions about a nurse or, on the face of it, suspicions and concerns about Sudden and Unexpected
Deaths, a number of Sudden and Unexpected Deaths; is that fair? Looking at the notes or the records
of the babies on the indictment and discussions, we don't see in-depth discussion about concerns
about any aspect and I just wonder what was it about this forum that didn't encourage that?
BREAREY: It was -- you know, these discussions had -- the reporting from the -- from the CEG, the
purpose of it was for learning lessons following on from -- from reviews of -- of deaths and to
disseminate learning to other neonatal units. I -- I -- the -- certainly in September I didn't think
it appropriate to talk and share with clinicians from around the region that there was a commonality
between one nurse.
LANGDALE: Well, at any time, never mind September, the whole period of the indictment babies?
BREAREY: Yes, I just didn't think it was the forum for that with the -- you know, something which is
so grave is the sort of worry that was developing to share that with people that go back to work in
every hospital in the region, I didn't think appropriate. But I did -- I can remember at this
meeting
discussing with Dr Subhedar at the end of the meeting privately that we had had some more deaths in
addition to the three that were discussed in the meeting.
LANGDALE: At that meeting, did you tell him, was that adding Baby E [Child E], as I have said that
would have happened by September?
BREAREY: I didn't tell him that association with Nurse Letby, but I did tell him that we were having
more than expected and I can't remember the precise response but it was more or less well, you know,
just keep us informed and we will just go through the normal process of -- of what's described in
the meeting.
LANGDALE: Why didn't you tell him about the concerns at that point about a nurse?
BREAREY: Because they weren't at a level that I felt I needed to talk to him about at that time.
LANGDALE: Just one more question before we break again, please, Dr Brearey, a brief topic: the CQC.
It looks clear that no doctor raised the issue of Sudden and Unexpected Deaths and collapses in 2016
at that February 2016 CQC visit, that nobody said as you are saying now at that point in February
you were concerned about three deaths. Is that the kind of issue that you think should be capable of
being raised with the CQC? Did you think
about raising it with the CQC? And if you didn't, why didn't you raise it with the CQC?
BREAREY: Well, we had had the Thematic Review meeting the week beforehand in February and I had
provided a draft report from that meeting and I sent that to Ian Harvey, the Medical Director, with
a request for an urgent meeting to discuss and I was very keen to get that to him prior to the CQC
inspection because I felt it was important to do that, with his knowledge, because I was really
expecting the CQC to ask us about mortality and to tell them that I've taken these actions and
escalated to the Medical Director would have been the appropriate thing to do. But there was a bit
of an internal dialogue going on with myself in terms of what -- what to say to the inspectors
because if he can, effectively I would be raising concerns to the CQC before I raised concerns to
the Medical Director. I was expecting an urgent meeting within a week or two with him to discuss the
report and to discuss the concerns and I -- so I was in a little bit of a dilemma about it. I think
I came to the conclusion that if asked, I would talk about it but otherwise I would leave it to a
discussion with the Medical Director which I assumed was going to be imminent at that time and --
and obviously assumed at the time that the response would be appropriate as well. Knowing what I
know now, we should have discussed it.
LANGDALE: Would you have to have been asked? You say you would have only said anything if you were
asked the question, what would the question had to have been: have you had a number of deaths that
you are worried about in the unit and are you worried about anyone? I mean, how specific did it need
to be? Just in terms of the learning, I suppose, moving forwards for the CQC and generally what kind
of question would have made you in conscience answer as you knew to be the case at that point?
BREAREY: I think that the first thing would be whether the CQC actually knew about mortality or not
already and I was assuming they did but I -- I don't know whether they did or they didn't.
Therefore, the flagging up that problem then I would be to be honest with you and say that this is
what we have done and we have done a Thematic Review. In terms of what sort of question I think any
probing question into mortality that went deeper than: when are your meetings? would have sort of
been enough really.
LANGDALE: You said in a statement you had no opportunity to speak with the inspectors
confidentially, you were obviously in a group, but even if you had been are you saying you would
need to have specific questions to know what you should be saying?
BREAREY: That was the point I was -- at the time because I had some confidence in -- in getting the
Thematic Review to Mr Harvey and him taking the appropriate action soon.
LANGDALE: Can we look please at INQ0103141, page 1. That's a letter from the CQC Compliance Lead Risk and
Patient Safety Team within the Countess of Chester Hospital?
BREAREY: Yes.
LANGDALE: It looks like Gill Mort has explained: "You would like to attend the CQC interview to
represent neonatal care. While I understand you would be able to answer any specific neonatal
questions I think this interview is aimed at being an overview of children's services and that any
specific questions will be dealt with during the rest the inspectors'. "I am conscious that there
are quite a few individuals already attending the interview so perhaps the best thing would be if
you arrive at the interview and ask the inspector if they would like you to join
them." So how did this work when you got to this? Were you expected, not expected?
BREAREY: I think the -- the background was that we were asked if anybody wanted any individual
conversations with the inspectors and I thought one with me would have been helpful. So again it
sort of reflects that it was in my mind that I am likely to have to share this information and it
was turned down, wasn't it? It was, it was turned down and that opportunity went basically for me to
have a one-to-one with them, the inspectors.
MS LANGDALE: Thank you, my Lady, this might be a good time to break. Would it be possible to take a slightly shorter break than usual?
LADY JUSTICE THIRLWALL: Yes. 45 minutes?
MS LANGDALE: Thank you.
LADY JUSTICE THIRLWALL: So we will rise now and start again at 10 to 2. (1.05 pm) (The luncheon adjournment) (1.50 pm)
MS LANGDALE: Dr Brearey, I am going to turn now to the Thematic Review and lead up to that meetings
after your Thematic Review. If we could have on the screen, please, INQ0005643, page 1.
This is an email from you on 22 January to Debbie Peacock and others. Have a read of that now and
let ... (Pause) You have had a conversation with Dr Subhedar about increased mortality. It looks
like you have asked him if he would be an external member for a Mortality Review, he was a little
reluctant to commit to that. So your thinking around the Thematic Review in January, what -- how did
it come about who was involved and what you did? Who did you have discussions with apart from Dr
Subhedar about that?
BREAREY: Well, I had an increasing level of concern about the mortality, about the association with
Letby and the -- I felt there was a need for some external objectivity from somebody outside the
hospital to sense-check, if you like, where we were at that time. I thought it was as relevant to
show what we had done so far and the way we had looked at all the cases and excluded any significant
sort of problems in terms of care and there were -- and that we had learned as we were going that
year various things and improved the care that we were giving babies generally and I think it was at
a time that needed somebody external to just validate everything that had been done so far and help
us regarding any suggested next steps.
LANGDALE: If we can have, please, INQ0003251, page 1, this is your Thematic Review. It's actually the final
version that was circulated, 2 March, even though the date stays there, 8 Feb. So we know you had
circulated a draft and the final version on 2 March. Looking at the attendees, as far as you were
concerned then were all these people involved in the Thematic Review and where does Dr Green fit in
as "apologies from pharmacy" on that list?
BREAREY: So I wanted to be as inclusive as possible in terms of people that were attending in terms
of the expertise that was there so we had some medical attendance, myself and Dr V and obviously
medical help with Dr Subhedar from Liverpool Women's Hospital, we had some nursing input from Eirian
Powell and Anne Murphy and Laura Eagles that was deputising for a deputy, Yvonne Griffiths, I think,
we had somebody from governance and --
LANGDALE: Debbie Peacock is from governance?
BREAREY: From governance and Chris Green was the Director of Pharmacy.
LANGDALE: Did he ever come to a meeting or have anything to do with it?
BREAREY: He didn't -- he was invited to the meeting,
but didn't attend.
LANGDALE: Yes. So in terms of active engagement with the topic clearly Eirian Powell, Dr Subhedar
you are talking to and he is the only external one. Who on that list was the most useful to you in
terms of input in what we read in this document, I will go to bits of what we read, but who actually
assisted with that? The reviews themselves, the comments in the document?
BREAREY: Well, the people that were reviewing the deaths were usually myself, Eirian Powell and
Debbie Peacock -- Debbie Peacock, the governance facilitator.
LANGDALE: So three of you were the essential drivers of this?
BREAREY: Yes, yes.
LANGDALE: Why was it done in this way, a Thematic Review, rather than a Serious Incident
Investigation which would have followed more recognised methodology, involved other people and would
have been disclosed to parents?
BREAREY: I wasn't aware that the Serious Incident methodology could be applied to a group of cases
like this.
LANGDALE: Did you ever think about the sharing of this review or information with parents when you
had taken
effectively your own route of a Thematic Review as a Trust? Did you think about who should see it
and when?
BREAREY: I mean, in terms of duty of candour, that was really sort of focused on the individual
reviews themselves rather than doing this as a collective. So I think clearly if something had come
out of these reviews that changed our opinion regarding the care that the babies received, then that
would clearly be something that you would want to share with parents, certainly.
LANGDALE: If we look at page 7. Themes identified. You have got the sudden deterioration and I
think Dr Subhedar says "add suddenly and unexpectedly", you know that' --
BREAREY: Yes, yes.
LANGDALE: -- clearer, isn't it, than just talking about neonatal deaths because death can be
natural causes sudden and unexpected needs investigation; that is the difference between just
describing a neonatal death and a Sudden and Unexpected Death, isn't it, there is a need for
investigation in one for sure?
BREAREY: Yes, yes, they were investigated but, yes.
LANGDALE: You comment "timing of arrests between midnight and 4 am". But you don't include as a
common
theme a member of staff, even if you didn't want to say who it was, a nurse or a doctor or their
name, you don't say "timing of arrests and a member of staff". That is the pattern that you have
identified, isn't it?
BREAREY: Yes.
LANGDALE: You have identified midnight to 4 am, you say why that is unusual. Were it to be natural
causes you wouldn't expect that and you have identified and indeed one of the reasons for doing it
is your cause for concern about Letby. So why isn't that there as a common theme?
BREAREY: So I was aware of Eirian Powell's feelings about this in terms of it not being significant.
I wanted some objectivity from Dr Subhedar and Dr Subhedar wasn't aware of the connection, the
correlation with Letby at the time when we went through the care of each baby because I didn't want
to affect his -- his judgment of -- of those case by case but at the end of the meeting we discussed
the association with Letby and there was some discussion, there was a pause whilst he took on that
information.
LANGDALE: Which meeting are you saying with Dr Subhedar you discussed the association with
Letby?
BREAREY: The one -- the Thematic Review meeting.
LADY JUSTICE THIRLWALL: Was it a single meeting, the Thematic Review meeting?
BREAREY: Yes, the Thematic Review meeting on 8 February.
LADY JUSTICE THIRLWALL: 8 February?
BREAREY: Yes, yes. So from that there was an agreement to do another review of the babies 12 hours
prior to their collapse to see if there was anything we missed. Essentially that was myself and
Eirian Powell going through the records and the observation charts again to try and exclude anything
that might have been missed from that respect and I think that might have been suggested by Dr
Subhedar after we had had the discussion regarding Letby. But there was no other suggestions from
him following that discussion, so again, in retrospect I wish I had put the association with -- with
Letby in at this stage. I think at the time my thinking was that I'm not sure Eirian Powell would
have been particularly keen to put it in.
LANGDALE: Was that a determining factor, timing of arrests and a member of staff --
BREAREY: Yes.
LANGDALE: -- would have highlighted something very clearly, wouldn't it?
BREAREY: It would have been but I -- I thought this was concerning enough already for somebody to
read this in terms of the fact that we hadn't found any other common themes, the numbers, the sudden
deterioration, the timing of the arrests and the report did have a name by every baby bar one --
LANGDALE: On reflection --
BREAREY: -- in the appendix.
LANGDALE: Sorry, Dr Brearey, but on reflection, do you think that because the concerns were obvious
to you because you were steeped in it and you may even have been occupied in many of your thoughts
about it, that you overestimated what someone would take from that without knowing all that you and
Eirian Powell knew at that time?
BREAREY: I -- I did under-estimate because I would have thought from just reading it that it would
have warranted more in-depth reading because I think anybody who would read all of it would have
seen the association with -- with Letby.
LANGDALE: Let's have a look at an email that indicates what you have just said about Eirian
Powell's views. INQ0005609, page 1.
BREAREY: It's worth pointing out as well, that I asked for an urgent meeting with Ian Harvey and
Alison Kelly --
LANGDALE: No, no, we will come --
BREAREY: -- to discuss.
LANGDALE: -- to the stuff about meetings but look at this. This is after Baby I [Child I], so
Eirian Powell adjusts that document that shows very clearly now Letby's presence at I as well and
the death. She says: "I designed the document to reflect the information clearly. It is unfortunate
she was on, however each cause of death was different. Some were poorly prior to their arrival and
other were [query] NEC or gastric bleeding/congenital abnormalities." So that is what she is saying
to you but in the end you are the Consultant, you have found that link and she's clearly defending
her member of staff, her nursing staff member on the ward there. So was it really the case that that
strength of feeling was so clear to you that you thought Eirian Powell would object to it if you
added it as a theme, or was there something in addition to that, for example worrying about whether
you should be even mentioning a category of staff on a document that would be circulated more
widely?
BREAREY: In reference to this email, it felt important
to -- to get that postmortem result because she's questioned NEC here as a cause but at the time
when she wrote the email we didn't know that for sure, although it was suspected by the clinical
teams. So it was important for me to try and exclude, you know, if we were going down the route of
trying to confirm the submissions are founded, of her being involved. If it was proved that NEC
occurred in Baby I [Child I], then clearly that would be reassuring.
LANGDALE: If we go to one of your emails, please, INQ0003114, page 1. You are emailing the summaries the reviews and the
Thematic Review report, the report includes a summary of the cases discussed: "Themes identified [we
have just looked at those] and an action plan. The appendix has embedded documents of all the
previous reviews prior to the Thematic Review." Ian Harvey asks if it can be joined up with an
obstetric review, we know that doesn't happen. Then above the email that you send just to Eirian: "I
think we still need to talk about Lucy. Maybe when you are back and free, the three of us can meet
to talk about it, Dr Jayaram and [Eirian]." So you are sending the report to everyone, but only that
to her?
BREAREY: And Dr Jayaram.
LANGDALE: And Dr Jayaram, yes. If it was significantly important to have further conversations, do
you think on reflection when you circulated that report it should have been much clearer and if you
had put "member of staff" without saying who, where or what, it would have if you were concerned
about anonymity have dealt with that, or were you really worried about offending Eirian Powell in
this?
BREAREY: I wasn't worried about offending her and it's quite difficult to offend her generally. But
the -- the purpose of sending the report to everybody was -- or those people that contributed to it,
including risk leads and obstetricians, so they are aware of the report. The purpose of sending it
to Alison Kelly and Ian Harvey was to talk about Letby's association and I didn't think it was
appropriate to open up that conversation to the -- the larger list of recipients of the email on 2
March.
LANGDALE: We then see emails, if we can, on INQ0003089, page 2.
LADY JUSTICE THIRLWALL: Ms Langdale, I wonder if I might ask a question for clarification while we
wait for that to come up. Just really to ask you to make sure I have
understood this correctly. There was the schedule prepared by Eirian Powell which showed Lucy Letby
against most of the -- most of the babies. That document went, did it, with the Thematic Review to
all these people?
BREAREY: It was an appendix, yes.
LADY JUSTICE THIRLWALL: Yes.
BREAREY: It was in that document, yes, the -- the staffing that said "Letby" next to the allocated
nurse or whatever it was.
LADY JUSTICE THIRLWALL: Yes, thank you.
BREAREY: That was in there, yes.
MS LANGDALE: If we look at this email at the bottom, Eirian Powell to Alison Kelly: "I was hoping
that we could arrange a meeting to discuss how to move forward with regards to our findings: High
mortality ... a commonality that a particular nurse was on duty either leading up to or during. This
particular nurse commenced working in January 2012 without incident. Doctor was also identified as a
common theme." That is how Eirian Powell summarises that. Alison Kelly says: "Thanks for the
update." Then if we go back to page 1:
"Hi Alison, "I was wondering what your thoughts were after going through the Thematic Review. I
notice the Thematic Review did not include the medical team that were involved, I have therefore
attached ..." Did you have cause to have a conversation with Eirian about the tone or content of
either of those emails that she sent then or not?
BREAREY: I can remember -- sorry, excuse me -- talking to Eirian wondering when we were going to
have the meeting with Alison Kelly and Ian Harvey because as far as I was concerned, we had -- we
had asked for it some time earlier and there was a degree of urgency about this. But in terms of the
content of her email, no.
LANGDALE: What did you make of the one -- I notice it didn't include the medical team. What do you
think the purpose of that addition is or do you think it in any way impacts on the commonality that
you have identified or she's identified thus far of Letby?
BREAREY: That had been agreed following the Thematic Review that we had put the names of the doctors
in to her table and as far as I was concerned, we had done that. But maybe the copy that she sent to
Alison Kelly hadn't included the most up-to-date one with the medical staff. But I am recall fairly
sure that we did that as
an action following the Thematic Review in February.
LANGDALE: If we go, please, to INQ0003115, page 1. There's a meeting on 2 May and there are a number of
documents, Lucy's shifts and mortality document, continued NNU monitoring process and a neonatal
unit review assurance document. This states: "Obviously we would like to have a meeting with Alison
Kelly and Ian Harvey as a matter of urgency, primarily for reassurance and to ensure that we have
covered all the relevant actions." You don't go to the meeting I think on 2 May; is that right?
BREAREY: That's correct, yes.
LANGDALE: But they -- you are suggested as having gone but you say that's inaccurate, you weren't
at that meeting?
BREAREY: No.
LANGDALE: The meeting you say was Ms Powell, Ms Rees, Ms Murphy but not you?
BREAREY: That's correct. Well, I mean I can't say who was at the meeting but I certainly wasn't
there.
LANGDALE: The neonatal assurance or review assurance document, can we have a look at that please INQ0003243, page 1.
BREAREY: So I wasn't aware of the meeting and I wasn't aware of these documents and the email until
after the meeting we had with Alison Kelly and Ian Harvey on 11 May, I think I was a hot week
Consultant the week when these meetings happened, so I was busy clinically and didn't get a chance
to read them but when I did, I was quite surprised by the content.
LANGDALE: Did you feel Eirian Powell had strayed into areas of expertise that were not her own in
this document?
BREAREY: Yes.
LANGDALE: Would you like to highlight where that was done and why you say that?
BREAREY: Well, the first sentence saying there is no evidence whatsoever other than coincidence
overlooks the timing of the deaths and the sudden/unexpected nature of the deaths. The increase in
numbers above anything we'd expected and the rashes that we have discussed already, although that
wasn't at the forefront of my mind at the time. The second sentence says there was no performance
management issues and no members of staff have complained to me about her regarding performance, we
now know about the -- I didn't know at the time, about the morphine overdose or any other issues
that have come to
rise since then because during risk management meetings we don't identify the member of staff that
have made those mistakes in the meeting. It is up for the unit manager and senior nursing staff to
address that with the individual member of staff. So I wasn't aware of her name with that one. But
clearly there were performance issues, so 3: "I found LL to be diligent and of excellent standards
within the clinical area." Well, I couldn't really argue with her at the time which made it more
worrying in a way that if there was no concerns regarding her clinical competence, what was the
cause of her association with the deaths? Number 4: "Whilst our mortality rate has risen in January
15 to January 16 we have had three mortalities from January 16 to date. Two have died due to
congenital abnormalities." I mean, the babies had congenital abnormalities but the point and the
level of concern was that it wasn't clear from the postmortem results that those congenital
abnormalities led to the sudden collapses. Dr H and Dr G is Dr Harkness and Dr Gibbs, appear to be
involved in many mortalities. Well, they were involved more than some of the other doctors but it
was
still less than half of the episodes that Letby had been involved with. And I did explain in the
meeting on May 11th regarding the fact that Consultants tend to come along towards the end of a
resuscitation or certainly not at the beginning, when -- when juniors have escalated concerns to us
and we are attending, so it makes it less likely that even if Dr Gibbs is there on a number of
occasions he was actually there at the beginning when the collapse occurred. So that didn't seem to
make any sense. Number 6: "Cheshire and Mersey Transport Service have been involved in a few of
these mortalities and they may have survived if the service was running adequately." I don't think
there was any evidence that a delay in a transport caused a death or led to a death; that was
established with all the cases and obviously the transport service had problems to all the other
neonatal units in the region who hadn't seen an increase in our mortality. 7: "Alder Hey Children's
Hospital's failures in facilitating a cot also add to the complexities of these mortalities. If
there been a bed sooner, the infant may not have died."
I don't think there was any evidence for that in any of the cases. Number 8, "some of the issues
related to midwifery problems." Well, there were some items of care that might have been improved on
in terms of midwifery but certainly none that related to something that might have caused a
mortality. Number 9: "Two of the babies' postmortems diagnosed congenital pneumonia." And it's
attributed to transport team issue. I don't actually understand what she's trying to get at with
that and the children with congenital pneumonia were improving and stable and getting better a
number of days after treatment before they collapsed and died. Number 10: four babies had congenital
abnormalities. It's a repeat of point 4 which I have mentioned already. Number 11 on maternal
syndrome, I am assuming that was the mother of [Child A] and B., where we may have been still
waiting for the Coroner's Inquest for that baby but certainly not a common theme at all. Point 12,
two with possible necrotising enterocolitis. We had one without a PM with this and [Child I] must
have been the other one, but we didn't have a PM result by then, well, I did not, I didn't have
sight of it, although it had actually been completed in February 2016.
LANGDALE: Was this list discussed with you --
BREAREY: No.
LANGDALE: -- at all in advance?
BREAREY: No, no.
LANGDALE: So you say to us that after learning of that meeting, you felt: "... let down by Eirian
Powell and very disappointed she had not invited me to the meeting and she didn't feel able to talk
to me herself about these opinions without going to a senior manager ..." Meaning Karen Rees.
BREAREY: Yes.
LANGDALE: About them. You had very little contact with Karen Rees before then and knew that she
would be relatively unfamiliar with the events on NNU since June 2015 and you weren't sure whether
she had any neonatal experience or expertise. When you look at that document, when you looked at it
then and certainly when you look at it now, should that have communicated to you a lack of
objectivity and yet she was so firmly involved with yourself in this ongoing evaluation or watching,
as you might have
described it, did that concern you?
BREAREY: It did concern me, and it did show a lack of objectivity and I was concerned that she had
developed this document for assurance with Karen Rees with her lack of neonatal expertise and
without discussion with any of the Consultants and the -- the arguments and the summary of this
report was essentially what was used in the meeting that we had with Alison Kelly and Ian Harvey the
following week on 11 May at which point I did obviously have a chance to argue the case in terms of
why I wasn't reassured by any of these items.
LANGDALE: The reassurance case had been put first, as it were, before 11 May --
BREAREY: Yes.
LANGDALE: -- with the documents. Let's have a look at Alison Kelly's note of that, INQ0003181, page 1. This is the meeting on 11 May that you have, Alison Kelly,
Anne Murphy, and yourself and Ian Harvey. You tell us in your statement that you said at the meeting
that the number of deaths in 2015 and early 2016 were exceptional and you raised the common theme:
the association with Letby on duty. What do you remember about that meeting? You set it out at 230
to 232 of your statement but what was your impression of the response particularly from
Alison Kelly and Ian Harvey?
BREAREY: Well, I put forward the results of the Thematic Review, the association with Letby, the
concerns of myself and my colleagues about this and how we were worried. The new information at the
meeting was that Letby had been moved on to day shifts as well in April for a matter of mentoring
reasons and support and that there had been no collapses or deaths at night between the beginning of
April and this meeting which was further weight to everything. And I was trying to be objective and
measured and stating the facts and essentially I was interrupted by Anne Murphy and Eirian Powell
with quite a forceful view expressed by both of them with a fair amount of emotion, essentially
saying this was wrong, and it's just coincidence that, you know, there is no evidence, these are our
assurances, as mentioned in that document.
LANGDALE: Was that document available before that meeting? We know it was done on 5 May by Eirian
Powell?
BREAREY: It was, it was sent before the meeting, yes, but I hadn't had a chance to -- I hadn't had a
chance to read it personally. But --
LANGDALE: You had or hadn't?
BREAREY: Hadn't. No.
LANGDALE: So when did you first read that?
BREAREY: I read it after this meeting.
LANGDALE: After the 11 May meeting or after 5 May meeting?
BREAREY: After the 11th meeting, it was sent on the day after the 5th meeting, I think.
LANGDALE: So you got that, you had got the Letby association with the staff association
document?
BREAREY: Yes. So, I mean, essentially the Thematic Review I felt had enough information in it to
take some action and the assurance document that had been created by Eirian Powell and Karen Rees
essentially with a sort of counter to it, if you like, that they created the week before and it got
quite heated, the meeting. I was taken a little bit surprised because I hadn't read their document
beforehand and Ian Harvey and Alison Kelly were quite passive throughout the whole meeting, really
and they didn't interject too much with things. I made it very clear it wasn't just my own
individual view, it was the views of my -- all my colleagues, concerns about this and I was very
much hoping that the Executives in the room could bring some oversight and objectivity to the
discussion.
LANGDALE: And we see on Ms Kelly's notes absolutely no issues: nurse circumstantial?
BREAREY: So if you -- if you are going through that document, the bit above that, most of that is in
relation to how I started talking about concerns. Obviously it's -- it is her record and in my
memory I would have said much more than that but from absolutely no concerns and circumstantial
that's her documenting Eirian Powell and Anne Murphy's point of view at the time --
LANGDALE: You say -- sorry. You say they countered your concerns quite forcibly and with great
emotion?
BREAREY: That's correct, yes.
LANGDALE: What action did you think was necessary to make the unit safe at this point? What do you
think in retrospect you might have been saying at that meeting?
BREAREY: I -- I thought that the Execs should have been discussing it outside the hospital with --
with experts, whether that be safeguarding experts or the police or NHS England, whoever. It just
felt like so much of a significant concern that doing nothing didn't seem to be an option.
LANGDALE: What did you think was going to be done after that meeting? Did you chase for anything to
be done from Mr Harvey or Ms Kelly?
BREAREY: Well, Ms Kelly asked about Letby towards the end of the meeting. So there was no doubt
about what
concerns I was raising, both myself and on behalf of my colleagues, and the note at the bottom of
that record saying "trained at Chester" suggests she was inquiring regarding the background of Letby
at the time -- sorry, I can't remember what your original question was.
LANGDALE: Yes, what action you wanted, what did you want done when you were at that meeting?
BREAREY: As I say, something significant in terms of sort of escalation and assurance of safety.
Obviously, the --
LANGDALE: Were you relying on the Executives attendant to say what should be done next?
BREAREY: Well, I was really hoping they would or at least give us some fairly solid guidance about
what to do next, yes.
LANGDALE: Because you had reached a point where you and Eirian Powell had a different view,
certainly, of the involvement of Letby?
BREAREY: Yes.
LANGDALE: You are still both working on the ward with very different views about a member of staff
on that ward?
BREAREY: Yes.
LANGDALE: Was that acknowledged in the meeting, the difficulty of that, that you have got a
neonatal lead
and a ward manager have a completely different view and how this might impact on safety?
BREAREY: No. No.
LANGDALE: If we can go, moving forward in time and away from that meeting to an email you sent to
Ms Kelly and others on 28 June now, INQ0005749, page 3. This is after the deaths of O [Child O] and P [Child P].
Is that what made you next write to an email to Ms Kelly, those deaths of O [Child O] and P [Child
P]?
BREAREY: The discussion I had had with Karen Rees on the Friday, where she refused to take Letby off
-- off the unit.
LANGDALE: Yes.
BREAREY: And an anxious weekend when [Child Q] also collapsed and ...
LANGDALE: Let's have a look at this email and --
BREAREY: Yes, yes, so --
LANGDALE: -- focus on what you say here. 28 June in the third paragraph. "There's been a watchful
waiting approach since our last meeting with Ian and Alison in March. However, since the episodes
and deaths last week, there was a consensus at the senior paediatricians' meeting. We felt on the
basis of ensuring patient safety on NNU this member of staff should not have any further patient
contact."
BREAREY: Yes.
LANGDALE: If we go to page 2 we see a response to Karen Rees and then above an email from you:
"Just to confirm you are happy for LL to work on the NNU in the same capacity as last week despite
the paediatric Consultant body expressing our concerns this may not be safe and that we would prefer
her not to have further patient contact."
BREAREY: So this is Karen Townsend, who is the divisional manager, rather than Karen Rees.
LANGDALE: Yes, sorry.
BREAREY: And following the weekend I had emailed Alison Kelly on Sunday to say can we meet early on
Monday, we are having a Consultant meeting at lunchtime programmed anyway, if you and Ian Harvey
wanted to attend that to make it easier for us to all be together, that would be fine. She said she
couldn't meet at the lunchtime meeting. When we had the lunchtime meeting, without the Execs, the
Consultants agreed that it would be appropriate for me to approach Ian Harvey and insist that Letby
was removed from the unit to assure safety until further actions could be taken. Ian Harvey agreed
to that removal of Nurse Letby and I was reassured by that. However, I understand, reading some of
the documents, that Eirian Powell then had a meeting with Alison Kelly and Anne Murphy, I believe,
on the Monday afternoon, where Alison -- sorry, Eirian Powell and Anne Murphy had been present at
the lunchtime meeting, where we had agreed that Letby should be removed from the unit. But then on
meeting outside the Consultants' sphere, if you like, on their own with Alison Kelly, they must have
provided some reassurance -- I think Karen Townsend might have been there as well -- that Nurse
Letby could continue working on the unit and therefore a decision was made for her to continue
working on the unit that week despite Ian Harvey agreeing to take her off that day. These emails
follow on the 28th I think is a Tuesday, when we -- I was -- I was learning that Nurse Letby was
still on the unit. This meeting had taken place, and that Karen Townsend was then notifying me of
the decisions made on the meeting on the Monday afternoon without us, regarding what the Trust were
doing in regard to our concerns which didn't now include taking Letby off the unit.
LANGDALE: We know she was subsequently moved to the Risk and Patient Safety Team?
BREAREY: Yes.
LANGDALE: Were you involved in any discussion about that
placement or anything like that?
BREAREY: No, none at all, no, I wasn't.
LANGDALE: Whose decision was it where she went to?
BREAREY: I wasn't informed of the decision, I don't know what made the decision, I only found out
secondhand later.
LANGDALE: We know around this time, 29 June, there is various emails between the Consultants, we
don't need to take you to them, where Dr Saladi is saying isn't this time for external
investigation, we need help from outside agencies and the discussion between you. Then there is a
meeting on 29 June, if we can go, please to INQ0003371, page 1. It's a meeting with the Executives at 10 past 5 on
Wednesday, 29 June. While we are finding that, you recollect in your statement at paragraph 266
that: "Mr Chambers explained we were very lucky to have Stephen Cross involved because of his
experience as the head of CID in Chester and Stephen Cross explained the implications of calling the
police." First of all, what did you know about his career? Did you think he had been an experienced
police officer or what did you know about that, if anything?
BREAREY: We, we knew he was an ex-policeman but we didn't know anything else other than that at the
time,
it's only later that I found out that although he had been the head of CID as they had mentioned in
terms of talking about his credibility, I understood that he had been demoted from the rank of Chief
Inspector to Police Constable, I understand.
LANGDALE: When did you find that out?
BREAREY: About two years ago.
LANGDALE: Right. So at the time, when he was working there, you didn't know that?
BREAREY: No.
LANGDALE: And you were being told --
BREAREY: No.
LANGDALE: -- he has experience of this capacity, "and Stephen Cross explained the implications of
calling the police". What do you say -- we have got the note here. What do you say Stephen Cross
said about that?
BREAREY: I think it's quite well described in the handheld note -- handwritten note, sorry, of -- I
think it was Sue Hodkinson, the HR Director. She's more or less dictated it verbatim but essentially
it was saying that the unit would be closed, it would be made a crime scene, there would be arrests,
there would be people called for questioning and it would be a very upsetting for the Families and a
disaster for the Trust's
reputation.
LANGDALE: What did you say it that given your level of concern? And we see if we look at these
notes on page 2 --
BREAREY: Well --
LANGDALE: -- Dr Jayaram says something: how? can the air embolism. All sorts of things are being
discussed, Dr Saladi: babies don't suddenly deteriorate and collapse. Mr Chambers looks like he may
have said something to the effect of: why did we not call the police? Then at the bottom, Mr
Chambers: "Issues cannot explain is this suspicious, criminal or are we missing something, some
causal link? Causal link, nurse." Over the page, 3: "Concern, shut unit, commission a review then
police or police and consequences. Balance needed." Et cetera.
BREAREY: It's worth pointing out this these are the notes of Stephen Cross who I have just mentioned
and, you know, sometimes they don't always give a fully sort of accurate impression of everything
that's discussed.
LANGDALE: Lorraine Burnett's evidence to the Inquiry was at this meeting no one wanted the police
to be called and her recollection was that everyone was open to a number of explanations and getting
more information to inform the next steps?
BREAREY: No, I wouldn't agree with that. I wouldn't agree with that at all really. The -- my
response to the original question about Stephen Cross' comment and how the unit would be treated was
so be it, really. You know, if that's what's needed and that makes things safe, that's fine. It was
clearly having a major factor in terms of the way the Executives were seeing things and --
LANGDALE: We --
BREAREY: I can also remember in the, in the meeting trying to reassure Tony Chambers regarding the
unit itself and the quality of the care that we -- we were able to give and my confidence in -- in
the unit and the quality of the staff and, you know, definitely comparable to other -- other units
in the region because obviously --
LANGDALE: Was that because shutting the unit was an option at that meeting?
BREAREY: No. It was trying to reassure him because clearly by them thinking that coming to the
conclusion that the police -- it wasn't appropriate to go to the police they, the alternative
suggestion was that there
is some other alternative cause for these deaths and one of those being practices on the unit,
staffing, all those sort of things and acuity and I can even -- I can remember at that time even
suggesting, you know, this is -- this is not an issue and -- on our unit.
LANGDALE: Did you think you need the permission of the Executives to go to the police, would you
have thought: I will go and just contact someone via CDOP or a police officer via the local
authority's safeguarding process? I don't know if you ever had experience of contacting the police
in the context perhaps of a suspicion of a family member. Have you ever had to deal directly with
the police in your work as a paediatrician over the years?
BREAREY: It wasn't something that we considered was the right thing to do at the time. I thought the
right thing at the time was to engage with the Executives and persuade them this was the right thing
to do and to do this together because it is a big step to make. No is the answer to your other
question about contacting police directly. I have got experience of child protection cases where --
where children have been harmed intentionally.
LANGDALE: Have you had to call the police then because paediatricians sometimes have to, don't
they, from
hospitals?
BREAREY: The scenarios that happens in either the child or the baby comes to A&E collapsed and
usually the police are already there with the family and the child and the ambulance and they all
arrive together almost. So most instances like that, there's no contact with the police needed. If
you admit a child on to the ward who, for example, has been bruised and you are investigating for
possible non-accidental injury, then your first port of call is emergency social care worker. So no
is your answer, I had never contacted the police directly before and would have been uncomfortable
doing it or knowing who to contact and at this time, I felt that she had been removed from the
neonatal unit, we were in a position of safety and there was some breathing space to get a
collective view on this and agreement on it. Obviously in retrospect, knowing now how the Trust
responded and the Executives responded I think actually picking up the phone would have been a much
easier and quicker way to get things done.
LANGDALE: There was then a meeting on 30 June, if we can go to INQ0003362, page 1. And you tell us at paragraph 271: "[Your] recollection of
the meeting was that
Executives were looking for reasons to either not go to the police or to defer this decision. Tony
Chambers opened the meeting and explained the Trust had commissioned an external review and that the
NNU would be regraded in the meantime." You also tell us at paragraph 271 that -- you say: "I can
remember us raising our concerns regarding the possibility of Letby harming the babies in the
meeting. Tony Chambers answered by saying 'that would be convenient'." What did you think that meant
if that was said? Can you remember it being said?
BREAREY: I can remember it vividly, yes. It really struck me and it -- it struck me that he had
formed his opinions already. Whether they were his own or whether they were put to him by people
around him, I don't know. But the impression that we were getting already three or four days into
this escalation was that Mr Chambers and his colleagues felt that our actions in highlighting the
commonality of Letby and asking to be removed from the unit was a convenient, in his words, way of
maybe hiding our own failings. I don't know, you would have to ask him.
LANGDALE: Page 6 of this meeting, there is a point Karen and Steve Brearey: "Apologies of
aggressive defensive, Karen. "Steve Brearey: apologies if defensive." Can you remember what that was
about? Was that to do with the email you had sent about just to be clear or what was that about?
BREAREY: Well, most of the meetings Karen Rees was -- was attending she would normally raise her
voice from across the table telling me that there was no evidence repeatedly and it didn't strike me
that she understood that the evidence was in the Thematic Review and I think that was enough
evidence to escalate things to another level and that, you know, you didn't have to witness somebody
pulling a tube out or, you know, injecting something to have enough evidence to go to the police. I
thought we had enough concern evidence at that stage to do it and clearly Karen with her limited
understanding of neonatology felt otherwise.
LANGDALE: Can we go now, please, to INQ0103147. That's a press release and you comment in your statement I think
you were only involved in one early press release. The usual process is somebody asks people, don't
they, for somebody who knows the content, the doctors in this case or the Execs and they pull it
together and a media team put something out, is that how it worked? Early on there was a discussion
we know
around what should be put together for this press release around downgrading. You tell us you were
concerned about any implication that the increased mortality rate was related to the most poorly
babies and those under 32 weeks gestation because this was not the case?
BREAREY: That's correct. This was the only communication I had with the Trust comms, Gill Golt was
the communications -- one of the communications team at the time who I was helping when she was
trying to draft this, all further communications none of the paediatric team had any input in. But
even with this input, I felt that the third paragraph talking about the poorly babies was -- was
misleading because it seemed to suggest that the unit was struggling with the smaller babies that
were the focus of the rise in mortality and that clearly wasn't the case and I think over half the
babies who, who died in that 13 months were of a gestation or age where we would have been looking
after them in our changed designation from looking after 32 weeks and above. So I -- I felt that was
misleading.
LANGDALE: So the combination poorly and/or the gestation?
BREAREY: Yes.
LANGDALE: That can come down, please, and can we have INQ0003365, page 9. You are unable to attend a meeting on 13 July where Dr
Saladi, Dr Jayaram, Dr Gibbs, Dr ZA and the Execs meet and it looks like Ian Harvey has a catch-up
with you afterwards. "Update following meeting: Steve Brearey still concerned but is mindful to
follow his colleagues in the decision not to report to the police. Trust are taking the matter
seriously. Nurse to be supervised." Effectively there's discussion around the RCPCH as well
subsequently, isn't there, about them being instructed instead of going to the police?
BREAREY: Mm-hm.
LANGDALE: Can you remember this conversation with Mr Harvey?
BREAREY: No, no. I mean, the reason why I didn't attend the meeting was I was in clinic that
afternoon, so my colleagues attended. So by the timing of things in that document, it would suggest
that he must have come to me in clinic to talk to me and I don't have any memory of that
conversation and I can remember going to the meeting, the board meeting the following day and --
LANGDALE: We are going to go to that.
BREAREY: -- the information that was put to me being new.
So if -- if there was a conversation there's really no substance to it, but I really can't remember
it and would have been busy in clinic all afternoon anyway, certainly at that time.
LANGDALE: The board minutes or the meeting on 14 July we have at INQ0004216, page 1. I think you say you hadn't seen these minutes and you
doubt their accuracy in part I think at some point --
BREAREY: I think they were drafted some months after the actual meeting, I think at least six months
afterwards, I understand.
LANGDALE: How do you know that, what's your understanding for that?
BREAREY: From -- I think it might have been even later than that. I'm not sure whether we even
received them prior to Susan Gilby starting in the Trust which is 2018, certainly not in that year,
we didn't receive them that year at all.
LANGDALE: There was a handwritten note we know of Stephen Cross, it is just a page and there is
these typed notes but either way this isn't something that was circulated and that you saw at the
time. We know -- perhaps we should go to the PowerPoint instead, INQ0002837, page 1. We know that Mr Harvey presented a PowerPoint presentation
and you say in your statement: "My impression of the presentation was that it was of poor quality
and didn't show any data that might explain the rise in mortality we had seen." We see page 1 --
page 2, sorry, there we are. What comment do you have on this slide, if anything? And also on the
one on acuity on page 5?
BREAREY: I -- from memory I don't think this set of PowerPoint slides are the ones that Ian Harvey
presented.
LANGDALE: You don't think that?
BREAREY: I don't think they are the same ones that were presented at the board meeting to us that --
that afternoon.
LANGDALE: Why's that? Why do you think that?
BREAREY: Well, I don't -- firstly I don't recognise some of the slides. I do remember one slide he
presented with three dots on them showing a trend that he said was a trend in increasing acuity that
clearly isn't in this PowerPoint presentation.
LANGDALE: Right.
BREAREY: And I also remember him putting up a spreadsheet of late pregnancy losses/early stillbirths
which he had factored into his -- his internal review as well and this wasn't a summary slide with
information
like this; that was a slide he had -- it was almost like he had screenshotted an Excel spreadsheet
with the mother's names and baby and mother's details on that PowerPoint slide which obviously
included patient identifiable information, one of which included a colleague.
LANGDALE: Could it have included these plus those or do you think they didn't look like these at
all?
BREAREY: From memory I don't think this is the PowerPoint presentation that we looked at. There was
some similarity in terms of his arguments and his presentation in terms of the acuity and activity.
The first slide you showed that there was certainly the -- the argument he was putting forward to
the board that day but I am pretty confident these aren't the slides that he presented that day.
LANGDALE: We know subsequent to that meeting, Dr Jayaram -- we don't need to take you to the email
-- suggests to Mr Harvey and Ms Kelly that the network has a very large pool of data it collects on
a daily basis and suggests they have a role here and you are asked, aren't you, to provide various
documents? If we look at INQ0103148, page 1. This is you sending to Ruth Millward embedded documents
for each baby's review and I think you tell us you were being
asked now to give information because Mr Harvey was collecting or doing his own analysis, is that
the position?
BREAREY: Yes, so the decision in the meeting in the week following the Triplets' deaths was that
Letby would go on leave for two weeks, that was planned leave already, and in that two-week period,
then Ian Harvey would do a forensic drill-down, I think the decision was, was made to do -- to
investigate all factors and then report back to the board before she was due back off her holiday so
they could make a decision on whether she was going back to work or not and what other actions were
needed. So Ian Harvey set about that. There was a Silver Command created with data analysts and risk
facilitators and various people pulling that data for him to analyse. And it's really striking that
he was doing that on his own in terms of medical expertise. There was -- he had asked John Gibbs to
provide some information regarding babies that had been transferred out of the hospital that he did
with Anne Martyn, one of the sisters on the children's ward, but I was completely excluded from any
of those investigations as far as Ian Harvey was concerned. However, the information that he was
requesting
went to people in the Trust who then asked me for the information because, you know, I was the
neonatal lead and I had most of it at hand on my computer, and it just felt ridiculous actually and
I had expressed to him concerns that he trained as an orthopaedic surgeon and he was taking on a
review of these -- this very complex case with hardly any neonatal experience. And it was fine if
you wanted to exclude me, clearly at that point, even at that point we sort of understood that, you
know, they were treating us as potentially part of the problem, so I -- that is when I indicated to
Mr Harvey that he should seek the help of the Neonatal Network, Nim Subhedar I mentioned. But, you
know, it wouldn't be appropriate for him to do this internal review looking at all these things
without some neonatal expertise and the -- just the PowerPoint slide you showed before in terms of
acuity and activity levels in which he was trying to argue to the board that those were a factor,
negated two really important things that would have been picked up by a neonatal specialist: firstly
he was just noting changes within the hospital without any reference to other hospitals and other
neonatal units.
LANGDALE: I am going to come to that later when we look at the audit for your hospital.
BREAREY: Yes, yes.
LANGDALE: But yes, didn't pick up relevant data?
BREAREY: The other factor was that acuity goes up when babies start collapsing and dying. You know,
a baby who's in special care cot area who suddenly collapses and needs intubation and ventilation
immediately becomes an ITU baby who needs one-to-one nursing, so that instantly increases a unit's
acuity for that shift and also reduces the likelihood of -- of the nursing staff on that shift being
able to meet the -- the staffing standards set by BAPM, both of which he was saying was a cause for
the deaths rather than actually them causing the lack of compliance. And he just didn't have that
insight or perspective that you would have if you had been in neonates for a year or two.
LANGDALE: Understood. You then -- INQ0006769, page 1, I don't want to spend much time on these, Dr Brearey, but
you send an email to Ruth Millward, we see there at the bottom of the page, moving on to the next
page.
BREAREY: So this is as I have already described in a way that Ruth Millward, the Head of Risk, or
actually she was -- she was asking for information regarding baby deaths over a time period going
back from 2010. So I was having to give that to -- to her for this internal review that Ian Harvey
was -- was doing without any
expertise from the network. And it was a point of frustration from me because of the reasons I have
given in the email really; that, you know, I was still very concerned about the -- all the babies'
deaths, particularly after Baby O [Child O] and P [Child P], but I was expressing my concern
regarding the support the Risk Department had given me over the preceding certainly six months.
LANGDALE: If we go back to page 1, please, we see Mr Harvey's email to you cc'ing the others: "I am
also not in the habit of sending angry emails. I will in recognition of the strain that everyone is
under at the moment resist the temptation now. I will, however, say that I am disappointed at the
tone and some of the phrases of your email to Ruth which is, as I read it, simply a request for
copies of existing reviews, not a request to undertake fresh reviews. If you are going to get angry
at anyone then aim it at me. I have requested the Invited Review and ... responsible for needing
this data." You were required in September, I think, to mediate or it was suggested you should
mediate as a consequence of this email?
BREAREY: Yes, yes. So the -- I think the phrase when -- I use in the second paragraph of my email
saying
that is I was completely "underwhelmed by the support your department has provided this year" was
the pretext to the mediation process. Considering the stress we were under and the level of support
I had received from the Risk Department that year, I thought it was quite restrained, to be honest.
Yes.
LANGDALE: And --
BREAREY: And it was also interesting to know why firstly Ian Harvey didn't act on any of my concerns
about the Risk Department that I had mentioned in that email, which I thought was more important
than the -- than the -- whether it --
LANGDALE: Just dealing with that, we see that the successor David Semple, INQ01031341, it is an email?
BREAREY: So Mr Semple was a Consultant obstetrician who took over a role at quite a high level in
risk after Ruth Millward left and his summary is there, really, of the issues that himself and Julie
Fogarty, the ex head lead midwife but then Associate Director of Risk and Safety found, including
previous poor leadership, members of the Risk Team on short-term secondments, a lack of
communication, no feedback on Datix reports, no feedback on incidents, no feedback on Never Events,
no training for clinicians to lead investigations --
LANGDALE: We can see it, Dr Brearey, we see it.
BREAREY: Yes, it is all there.
LANGDALE: My question was going to be this: how widely is that circulated, I am seeing all
Consultants as groups but how widely has this been circulated by Mr Semple?
BREAREY: He sent it to every Consultant in the Trust.
LANGDALE: Every Consultant?
BREAREY: Yes. He wasn't put into mediation with anybody.
LANGDALE: All right. Thank you, that can come down and I want to move to a different topic, the
RCPCH report. We know from paragraph 331 of your statement that Ian Harvey's secretary sent an email
to you on 23 November requesting a meeting with you and Ms Hodkinson. When you arrived, Ms Hodkinson
was recording everything that was said. Do you mean recorded as in tape recorded, or just
writing?
BREAREY: Hand -- handwritten notes, yes.
LANGDALE: Making a note. Yes. You had I think before then been one of the Consultants, it was you,
Dr Jayaram and it was also Anne Murphy who had had sight of a redacted copy of the RCPCH report; is
that right?
BREAREY: That's correct, yes.
LANGDALE: You turned up, read it, realised it was redacted. How did you realise it was redacted,
briefly?
BREAREY: There was black ink over the lines that we couldn't read, yes.
LANGDALE: You came to a meeting -- while you are telling us about the meeting, perhaps we can have
on the screen INQ0003094, page 1. It looks as though you -- well, tell us what they wanted
to discuss with you?
BREAREY: So we had had the meeting, we were only allowed an hour to read the draft report or the
College report and obviously it was redacted. We made comments about some changes and factual
inaccuracies there. I asked Ian Harvey towards the end of the meeting what his thoughts were about
sharing what we had read with others, he didn't really give any straight answer actually and wasn't
categorical anyway. Staff were really keen to hear what the results of the report were because this
was December by now. The review had happened in September. People wanted to get back to the previous
designation of the unit and find out the results and we were also waiting for the Hawdon report as
well. So I was on leave and contacted and asked by the secretary for a meeting, we were waiting for
the Hawdon
report then he hadn't seen a draft report or any report of and I thought it may be related to that
or something more significant in terms of deciding about the police. So I cancelled things and
anyway turned up at the meeting and was a little bit surprised to find Sue Hodkinson there with Ian
Harvey in which he said that I had -- I had talked to members of staff on the unit about the draft
report and when I shouldn't have done against his instructions and, you know, I wasn't to do this. I
explained to him that he hadn't given me an answer when I had asked him when I had read the draft
and he was very clear that, you know, if this was to happen again, there would be consequences and
he would be following this up with a letter. Sue Hodkinson left the meeting after she had finished
recording all of this but we were both still in his office for a short time as I was walking towards
the door and it was then that he -- he was saying that I ought to be very, very careful, that his
office was a funnel, a receptacle of information from lots of different areas including the neonatal
unit and yes, that I should be very careful. I think in the -- in the context of that meeting it
should be accepted that we had, we had just come out of the grievance procedure as well which had
felt very
adversarial and felt that we were being accused of mistreating a nurse and very one-way
conversations with Chris Green in the grievance procedure and obvious with the -- with the mediation
with Ruth Millward on what seemed to be fairly minimal grounds. It felt very hot to me that, you
know, I -- personally I was being pressurised, really, with all of this information and probably
being portrayed as somebody who was being unreasonable and irrational and unprofessional and that it
felt like this was part of that process.
LANGDALE: What did you make of "we expect a factual response as above", the last paragraph? Did you
think that was controlling?
BREAREY: Yes.
LANGDALE: Did you understand why there needs to be controlling?
BREAREY: Well, he had talked about that everything, it was an intensely frustrating period of time
because of the lack of communication we were having from him about the College review, about
anything, really, and, you know, his term of trimming the grapevine really was just making
everything as confidential as possible and not letting out any information. And I accept that, you
know, there's degrees of
confidentiality. We weren't sharing information about our concerns about Letby but, at the same
time, it -- the -- it was combined with the lack of urgency as well, you know, that why you know in
December had we not seen both reports, you know, when the College report had been in September it
just felt -- I mean, I think I mentioned in my statement obfuscation and delay and secrecy seemed to
be the theme of those months.
LANGDALE: If we could please have on the screen INQ0103159, page 1, it is an email you write some time later in 2018 but
closer to the events than now. So INQ0103159, page 1. You are summarising or commenting with your colleagues on
the RCPCH report and the Hawdon report. We see at the bottom the letter: "Fundamentally, the Execs
treated the service review as a review of mortality and treated the Hawdon report as a robust review
which it wasn't at her own admission then used the grievance procedure as evidence suggested or
triangulated in IH's words. This was all very incompetent and misleading." Is that broadly your view
of the reports that were commissioned and the --
BREAREY: And that's what we kept putting to Executives particularly in 2017, after they told us of
their plans, yes.
LANGDALE: That can come down and can I ask you about another document, please. INQ0103210, page 1. This is going to be a Countess of Chester neonatal unit
annual report, January to December 2016. It's an annual audit report and if we go, please, to page
4. Who's responsible for compiling the data for this?
BREAREY: The -- the information historically used to be a nurse collecting data on the neonatal unit
but actually for most of these years of the indictments it came from something called BadgerNet
which is a computer -- national computer system which all neonatal units enter data for across the
country and is amalgamated so that we can interrogate the data on a Trust basis.
LANGDALE: So we see at paragraph 2 the outcome and activity data showing your admissions. Decreased
from 2014, it looks like, in 2015, slightly up in 2016. If we can work through it, please, and get
to page 15 of the document. Annual admissions by gestation 2012 to 2016. Were you ever asked in any
meeting to get this data together or did anyone ever actually get this BadgerNet data together?
BREAREY: This is freely available to anybody with access to BadgerNet within the Trust.
LANGDALE: Right.
BREAREY: But I'm not sure whether Ian Harvey was even aware of it when he was doing his internal
review. The reason why we did that annual report, it was one of the suggested recommendations from
the RCPCH College review that we should be doing an annual report. So this was the first one that I
wrote. But all data, as I say is -- is pulled from BadgerNet.
LANGDALE: When did you pull that together in the period --
BREAREY: That would have been late in 2016 -- sorry, 2017 for the year before.
LANGDALE: The report received by the clinical audit group of yours in 2015, if we can have a look
at that briefly, INQ0103194, page 1. This is timeframe 1 January to 31 December and overleaf a
shorter report than the other one. Go to page 2. Thank you. So a different format. Were you
developing the formats of these audit reports?
BREAREY: No. Normally the -- the statistics and the data by the time it becomes available it's about
a nine-month lag from the previous year. So for 2015 data it would have been available towards the
end of 2016 and there is a National Neonatal Audit Programme
that measures audit standard you can see on the left-hand side, quality measures for neonatal care
and we would be report -- the Trust would have a report of it -- its performance regarding those
standards through the NNAP programme and I would be expected to produce a report for sign-off with
the Executives to inform them of the results of the report effectively. So the first -- this one was
-- was the format of me reporting the NNAP results, but in the 2016 annual report that was done on
the recommendation of the College reviewers and it incorporated all the information I would normally
put in this anyway, so the annual report replaces this but also adds the recommendations of the
College review.
LANGDALE: That can go down, please, and if we can now have INQ0003357 [unavailable], page 51?
BREAREY: It's worth adding that our National Neonatal Audit Programme results for the years 15, 16
before and after were all very positive, all above usually above the -- the mean for the local
neonatal units both regionally and nationally and there were never really any significant outliers
in terms of our results NNAP although it didn't include mortality.
LANGDALE: We have here Dr Hawdon's recommendation. Just number 5, you point out as does Dr Subhedar
in an email
I am going to go to next, that there was no case that Dr Hawdon was reviewing of undiagnosed
pneumothorax or duct dependent congenital heart disease and that that recommendation seemed
irrelevant to the deaths reviewed?
BREAREY: That's correct.
LANGDALE: You had tried to assist, hadn't you, that can come down, in an email if we look at INQ0103171, page 1, you had tried to assist the process of Dr Hawdon actually
getting meaningful records or notes to conduct a Casenote Review, I think we can all agree how
limited casenote reviews are anyway by their nature --
BREAREY: Yes.
LANGDALE: -- compared with speaking to people but you had flagged up the need to have the reviewer
having access to BadgerNet, some of the X-rays' importance and "let me know if I can be of any
help". You sent that to Mr Harvey?
BREAREY: Yes, it is worth noting as well in this last but one sentence I am talking about reviewers
will need access to BadgerNet. I was assuming that there would be more than one reviewer as
recommended by the College. It seemed to me that it was going to be more than just one person doing
Casenote Review.
LANGDALE: Can we look, please, at INQ0103192, page 1 and this is a letter to Mr Harvey from Dr Subhedar where he
says the same as you on a number of things about the RCPCH report. "The unit in Chester is by no
means and outlier either of terms of processes around Mortality Reviews or Consultant presence and
supervision on the neonatal unit. The COCH team's commitment to the Network Steering Group and
Clinical Effectiveness Group is exemplary ... demonstrates a commitment to improving safety and
quality of neonatal care." So you had been having at least one external -- not external to the
region but external to the hospital, commenting and seeing the Hawdon report as well and feedback --
providing feedback to Mr Harvey?
BREAREY: Yes.
LANGDALE: Can we turn now please to the grievance, just briefly. You were sent a letter, INQ0004349, page 1, in October 2016. What did you think when you got that?
BREAREY: So this is preceding the grievance procedure?
LANGDALE: Yes.
BREAREY: That took place where Chris Green, Head of Pharmacy, had been instructed to undertake.
LANGDALE: We know the background. Don't worry, we know this very well.
BREAREY: So essentially --
LANGDALE: What did you think when you got it? What did
you think you needed to turn up for?
BREAREY: It wasn't clear what the grievance procedure was for and the paragraph at the end is
talking about bringing a representative -- sorry, it is the second paragraph, isn't it, bring a
representative. Worried -- worried us both, actually, myself and Dr Jayaram, I didn't get a chance
to talk to Dr McCormack about it because, as I say, the -- the impression that we had since July was
this seemed to be turning into a narrative against us rather than concentrating on the cause of the
deaths and it did worry me, yes.
LANGDALE: Of course. You were worrying about your position, your job?
BREAREY: Well, yes, yes. I mean, I wanted to focus on the -- on the babies and the cause of death
but there was an escalating amount of pressure I felt along with Dr Jayaram that yes, it was -- it
felt intimidating.
LANGDALE: Yes. INQ0005341, page 3. Dr Green emailed you both saying it is for him as
investigating officer to establish the facts leading up to the removal of Lucy Letby from the
neonatal unit and subsequently to that in terms of her continued redeployment in the Risk Team he
says he understands you need to -- you wish to be accompanied by your Union representative. You both
go and consult with Union representatives and you attend
with yours. Jenny Bremner, I think --
BREAREY: That's correct.
LANGDALE: -- is your Union representative? We understand that in your conversations with her, you
had discussed going to the police but that you were concerned about adverse consequences and felt
the Executives needed to be doing it; is that the case?
BREAREY: I can't remember specifically talking to her about the police actually and I know her
record was from memory, wasn't it, recently. And we talked about a lot of things in terms of
everything around this grievance and the worries we had. I can't specifically remember a discussion
about the police one way or another, to be honest, but yes, she was certainly aware of all of our
concerns, yes.
LANGDALE: She was aware of all your concerns and did she suggest contacting a local Member of
Parliament or suggesting the parents do that, was there any way of her -- any suggestion she made of
pushing through your concerns to get them reported externally, however that might have been?
BREAREY: She -- I think I remember her discussing going through the parents to contact the MPs, but
as I say I can't remember making a suggestion regarding the police.
LANGDALE: What did you think the parents had been told at this point?
BREAREY: Well, nothing in terms of -- of this and -- and everything that had gone on since July,
really.
LANGDALE: And was that troubling you as well?
BREAREY: It was. It was. I can remember having a conversation with some parents of a baby who died
who wasn't in the indictment and it was -- it was because in my position as neonatal lead because
the baby's Consultant, Dr Newby, had already left the Trust to go and work at another Trust so I
took on the role of talking to them at their request about the care their baby's received, and
feeling quite awkward about it, to be honest. And the -- the concerns they had I could easily answer
in terms of specifics. It's almost they could tell that something wasn't quite right but they didn't
quite have, you know, their senses were up but they didn't know the specifics or the worries that we
had So I could reassure them about the care their baby received and their concerns and reassure them
about that but it didn't sit with me at all well and I felt very uncomfortable doing it but I didn't
feel in a position to let them know that I -- I was worried about a nurse murdering their baby as
well as others, I didn't think -- because then it would be in the public domain. So I spoke to Ian
Harvey after that discussion and told him of my discomfort, if you like, at the discussion I had
just had and how I didn't really feel it was appropriate to be doing this and he said basically:
don't worry, I will take over the care of or take over the role of speaking to the Families.
LANGDALE: When was that, roughly?
BREAREY: I think -- I think it was some time in 2017, I can't remember for sure, but, yes.
LANGDALE: If we can go to the grievance interview please, INQ0103176, page 3. We see the interaction here with Chris Green's question at
the end: "Was there any suggestion of foul play in any way relating to the babies' deaths?
"Suggestion from whom?" Says your Union rep. "From the Consultants." The Union rep: "Can't speak for
other Consultants, only for yourself. "No, I wasn't directly involved with the Triplets' deaths.
"Just answer the question, only answer the question. "What was the question? Can you repeat the
question? "It's been suggested [Chris Green says] it's been said that there was a suggestion of air
embolism and twisting of tubes that led to babies' deaths? Was that on the table as the cause of
death?" Overleaf you say: "I have never come across a case of air embolism before." Were you aware
that Eirian Powell had forwarded the email that had gone through the Consultant group about the
links to air embolus; in other words, the Consultants had Eirian Powell as a ward manager on your
own email groups for some time?
BREAREY: Yes.
LANGDALE: That had been sent to Dr Green. Had you any idea he had got that email?
BREAREY: I didn't, no, no.
LANGDALE: When you look back and there was conversations happening between you about where's this
information coming from or how do they know this, as things got more factioned between the doctors
and the Execs, looking back now does it surprise you that something you are circulating in that way
ends up being used by Dr Green in a grievance?
BREAREY: Not really by the way that everything else was
happening around us at the time and I talked about the incident discussing something with a -- with
a nurse. The only thing that I actually discussed with that nurse when I was called into the office
with Ian Harvey and Sue Hodkinson was I mentioned the College's agreement that we needed two new
Consultants before going back to a Level 2 unit, I think that was the only definite comment that I
had made which I didn't think was very contentious or in depth at the time. But -- and the warning I
had been given by Ian Harvey after that, clearly there seemed to be a source of information coming
out of the unit that would feed into Execs' ears and help sort of carve a narrative that we were
being unreasonable and often taken out of context. It felt sometimes as if I was working in North
Korea or, you know, the old DDR or something. You know, it was, it was that level of -- we should
probably not have this open conversation with a nursing colleagues as we normally would really in
that situation which is really sad and took a lot of working on afterwards to get trust back on both
sides.
LANGDALE: So how would you describe at that time the culture on the neonatal unit in terms of
relationships between the doctors, doctors and nurses, doctors and Execs, you know, just across
different groups generally?
BREAREY: Well, I thought we managed it as a -- as a team quite professionally in terms of
patient-facing contact and I think a lot of junior doctors at the time had no idea all of this was
going on and said so afterwards. Some of them are Consultant colleagues now. So from a junior
nursing/junior doctor point of view, I thought we managed it reasonably well in that respect. But I
think a lot of the nursing staff had been given a narrative as well by Executives during this
period, and that seemed to be sticking the blame on us for things without knowledge of what concerns
we had which was quite hard to -- to manage on a day-to-day basis for us. I thought the teams as a
whole, you know, were professional enough to cope with that and just concentrate on either the best
care we could deliver to the babies or concentrate on the concerns we had outside the unit when it
was confidential.
LANGDALE: There was a meeting between the Executives and paediatric Consultants on 26 January, INQ0003523, page 1. This is 26 January 2017. Dr Tighe we know is in attendance
and Mr Harvey had told you to ensure fair play. What did you make of that?
BREAREY: I-I didn't know what to make of it, really. We had been told we are going to be given an
opportunity to read the College report and the Hawdon report. I -- I had a clue as to it being
slightly more different to that when I had a discussion with Mr Semple that we mentioned before in
the delivery suite, when he's in his new risk role, I think he had a one-to-one meeting with Tony
Chambers and Mr Semple warned me that -- to be very careful at the meeting on 26 January. He said
that if you are going to do anything, do it together, because he mentioned the word "decapitation"
in terms of the consequences of anybody speaking on their own out of turn in that meeting. So that
was my expectation going into the meeting, I shared that information with colleagues and we all
agreed before the meeting that if there was anything significant to say we should probably hold off
for the time being, unless we absolutely had to.
LANGDALE: If we look at page 2 of the meeting, in terms of the RCPCH Mr Harvey said it was: "...
not about raising concerns, that's fine, but the review by a high-powered team does not call out a
criminal act. It does raise other issues. There is a need to draw a line under the Lucy issue".
First of all, had you seen the unredacted version at that point about the section on the nurse and
Lucy Letby?
BREAREY: No.
LANGDALE: Secondly, you say in your statement the tone of the meeting was aggressive, intimidating
and direct. We know a statement was read out at that meeting from Letby by Karen Rees; is that
right?
BREAREY: That's correct, yes.
LANGDALE: What did you make of that at the time?
BREAREY: It felt -- the whole meeting felt choreographed and -- and Ms Rees was quite dramatic in
her reading of it. We were all quite stunned, really. As a sort of synopsis of Executive behaviour,
I can't imagine there's an example of anything more incompetent in the history of the NHS. How you
can start a meeting saying you followed Speak Out Safely practices and then tell seven Consultants
who all have significant concerns like this that they are to apologise to the person and that she
would be going back to work or else there will be consequences, was quite -- quite striking and
surprising and quite upsetting for -- for most people there.
LANGDALE: You said in your statement, if we could have on the screen please INQ0103104, page 64, beginning at 354, if we go down -- to the next page. You
say at paragraph 358:
"... concerned at the discrepancy between what I read and the negative way it had been portrayed at
the meeting 26 January. No mention by Ian Harvey of the cohesive and enthusiastic group of
paediatricians and a nursing complement that well led and supportive ... good engagement with
network colleagues, trainees positive about their experience or that morale had remained robust with
generally good communication between teams."
BREAREY: I think that's true. There was lots of positive in it. But actually the -- the whole nature
of the meeting on the 26th was Ian Harvey trying to pick out the negatives to make them triangulate
as he said when all he was representing was -- was a grievance procedure that didn't actually look
into the cause of the deaths, a College report that was a service review and didn't adequately look
at the deaths and a Hawdon report that I thought was overly critical and not what had been
recommended by the College and somehow he had managed to create a narrative that ignored so much
positives -- so many positives regarding the neonatal unit, our practices, and falsely represent the
investigations that had been done to date.
LANGDALE: That can come down now, thank you. We know that you were involved, just as Dr Jayaram
and other Consultants were, in a series of letters in January and February, pressing your concerns
with the Consultants and there was discussion around the Coroner, the Coroner was and wasn't told.
So I don't need to ask you about any of those letters or communications. You do receive one letter
from Mr Harvey, INQ0103207, page 1. This is at a time when the apology letter has been
forwarded to Lucy Letby, I don't need to ask you about that and how the wording was arrived at. But
look at the second paragraph: "Can I counsel you [Mr Harvey says] to make every effort to attend the
preliminary meeting with the facilitator. It is an initial meeting just with the facilitator to
enable you to address some of the issues that were called out yesterday." You in fact pulled out of
this, Dr Jayaram went and he said he felt he was hung out to dry. Very briefly, why did you not go
and why did you think it was inappropriate?
BREAREY: Well, I did attend, I attended two sessions which were the two sessions prior to the third
session which would have been the meeting with Letby.
LANGDALE: So with the pre --
BREAREY: Yes, and I did that because I felt under threat of GMC referral. I know it's only implicit
in the email but, you know, I think the tone of everything that had gone on beforehand is very clear
as to what he was getting at and the first meeting with the mediator said it was confidential,
voluntary and I could pull out at any stage. I explained to her that I didn't think it was voluntary
for reasons I have just explained and after the second meeting, it was put to me what I would like
it say to Letby and I told her I didn't have anything to say to her because I didn't think it was
appropriate and things still needed further investigation and at that impasse she agreed to put
things on hold. And before I got back to my office I had a phone call from Sue Hodkinson saying: I
hear you pulled out of the mediation process, which clearly then it wasn't confidential or -- So
yes, I engaged as far as I could in terms of avoiding GMC referral and -- and stopped.
LANGDALE: There was a meeting on 27 March with the paediatricians and Mr Harvey, Mr Chambers, if we look at INQ0004407, page 1, you tell us: "This meeting took place on 27th. Attending were Tony Chambers, Ian Harvey, Dr Jayaram, Dr Subhedar, Julie Maddox, Sue Hodkinson and myself. Stephen Cross was on leave and Sue Hodkinson might have been responsible for taking the minutes." You say: "I can't locate emails or discussion prior to the meeting. However the situation for Consultants was becoming more desperate. Colleagues felt their jobs and careers were under threat, the prospect of LL returning to work on NNU seemed imminent and we had done everything reasonable to raise our concerns within the Trust without success."
LADY JUSTICE THIRLWALL: I wonder -- I'm sorry to interrupt, Ms Langdale, I just noticed the time and the shorthand writer has been going a long time. I wonder if we might just take a break. Would 15 minutes be acceptable? Yes, sorry.
MS LANGDALE: Not at all.
LADY JUSTICE THIRLWALL: You can repeat the question when we get back. So 10 to 4, please. (3.34 pm) (A short break). (3.50 pm)
MS LANGDALE: Dr Brearey, we were looking at INQ0004407, page 1, and it was the meeting that took place on 27 March and you
say and tell us: "... colleagues felt their jobs and careers were under threat, the prospect of
[Letby] returning to work
on the neonatal unit seemed imminent and we had done everything reasonable to raise our concerns
without success." You said: "Also I was considering going to work at another hospital and I could
then raise concerns from outside the Trust." Just tell us what that pressure was like and how it was
being exerted or why you thought it was being exerted?
BREAREY: Well, we -- we had the sort of direct threat from Mr Chambers in January -- 26 January you
know "or else there will be consequences, do not cross a line". We -- we had the sort of imminent
threat of GMC referral and there is a prospect of her coming back to work on the neonatal unit,
which scared us all really. The more we thought about it, the -- the more concerned we got about
some of the cases and some of the morbidity cases that we had overlooked earlier on were coming to
the fore in terms of our thinking. The results of the work that John Gibbs had done eventually came
back to us so we are a little bit more aware of the morbidity cases as well as that. So our sort of
concerns were coming to a head, clinically, but the pressure on us to comply from the
point of view of the -- that pressure was becoming greater as well in terms of the mediation and --
LANGDALE: The letter of apology?
BREAREY: The letter of apologies, the three letters we had had to send, yes, it was -- it was -- it
was all there and my colleague, Dr Gibbs, there is a few emails there where he is starting to waiver
a little bit when he had been approached by Ian Harvey on his own at the end of a very long day
where he thought maybe we have got as far as we could go. So you could feel the cracks in the team
and the cohesion of the seven of us, you know, one of my colleagues who was (redacted) at the time
was (redacted) at the prospect of Letby coming back and I just felt that we were reaching the end of
the line in terms of what else we could do. And --
LANGDALE: Was it ever suggested to you that somebody might go to the GMC about you, did you -- was
that suggested to you or not?
BREAREY: Yes, I -- I picked up on -- it's hard to get an aspect of what it was like at the time
because obviously subsequent to all of this, you know, I learned about the sort of suggestion that,
you know, we were going to be subject to some disciplinary sort of procedure for all of this from
the -- the senior managers and Executives who were -- were following that narrative. But I can't
remember anything directly specifically at that time, although it was very clear, what -- what was
being inferred and what the likely consequences were and it wasn't that I wanted to stop raising my
concerns, it just wasn't a safe environment to be working in and, you know, through all of this we
are having to look after children and babies on a daily basis.
LANGDALE: What does your working week look like? How many hours are you working a week at this
point?
BREAREY: I am contracted for 40 hours a week of which 75% of that will be clinical work -- probably
over 40 hours of a week will be clinical work and -- and -- the extras are extra, if you like. So
and that's -- you know, I don't mind that, you know, it is a good job.
LANGDALE: You have done all this stuff, these admins, these emails, these meetings, these
responses, just getting a sense, how many hours were you working outside the clinical hours at this
time?
BREAREY: My colleague Dr Gibbs always had the reputation for leaving the office last and, you know,
he was sending emails at half past midnight on one occasion and it wouldn't be uncommon for him to
be leaving at
say, 11 o'clock, 10 o'clock in the evening most days, and a lot of the time it would be just me and
him in the office talking from across the corridor really with the doors open, when the cleaners are
coming round and that sort of thing. Yes.
LANGDALE: Taking yourself back to that level of worry. How worried were you about all of it, not
just your own job but the babies and Letby coming back and what was that like, in that time?
BREAREY: It was extremely worrying because, you know, I sorted of committed to working in Chester
and it's -- it is -- there is some wonderful people that work there and wonderful clinical staff.
And, you know, I still enjoy working there and doing my job, but the -- it was a fairly intolerable
pressure that we were under and it -- there's always a risk of overspill into your own clinical
practice if you are under that pressure in the non-clinical work that, you know, that's going to
spread to the clinical work really and that is quite a stress for medical professionals to --
raising concerns to have to sort of counter, you know that you -- if you did make a mistake it is
likely you are not going to be supported in a fair way given everything else that's going on. So
yes, I did worry about that and hence the job application to another hospital.
LANGDALE: We know that there was then a suggestion that you as Consultants meet with a barrister,
then Simon Medland QC, if we can have the minutes on the screen, his minutes INQ0005857. If we go to page 1 and then sit at page 2. First of all, what did
you think the purpose of the meeting was, what did you think you were all being invited to meet with
him for?
BREAREY: Well, going back to your previous slide, that meeting was a meeting where we directly told
or asked the Chief Executive Tony Chambers to go to the police. I don't think that was the intention
of the meeting. The meeting was talking about the reviews and what further forensic work was needed.
It was a meeting that we asked for Nim Subhedar and Julie McCabe, the Director of the North West
Neonatal ODN, to be at and before discussions at a meeting the sort of point of desperation had been
reached and I had agreed that I would just go to the meeting and say: you have just got to go to the
police. So that was the previous meeting that you just had a slide up for which I think was some
time in late March -- was it 27th, I think?
LANGDALE: Yes.
BREAREY: And after a fairly heated meeting -- interestingly Stephen Cross wasn't at that meeting and
it felt like we had ambushed Tony Chambers and Ian Harvey a little bit, but they agreed to go to the
police in that meeting. But then -- and Tony Chambers said "Clear your diary for the week, this is
what we will be doing", you know, his comment was, and we thought we had finally made some progress.
And then I got an email a week later from Nim Subhedar saying: what's going on, have you heard
anything? Because we hadn't heard anything and we only heard an email from Tony Chambers saying:
your absolute discretion and confidentiality is needed. So we weren't updated at all in that time
and the first we knew of anything then was Ian Harvey approaching us over a week later saying that
they still intended to go to the police but this is an unusual step and we have asked a very
experienced barrister to advise us on the best way of doing it and he would like to meet you and I
was obviously keen to get this rolling. So we offered early dates for a meeting with myself and Dr
Jayaram and he says no, it has to be all of you, all seven Consultants, because you all raised
concerns and wrote to us. So we had to wait even further, you know, for a meeting where all seven of
us were available with Mr Medland. So that was our understanding going into the meeting; that -- I
did have some suspicions that I had been misled a little bit because Mr Harvey had verbally told us
about the reason for this meeting individually, together -- individually at separate times and when
he suggested it had to be the seven of us I did try and clarify in an email saying can you, can you
confirm this is because email and he wasn't specific in his response to that either.
LANGDALE: This is an hour and a half, this meeting, wasn't it, we see from the minutes?
BREAREY: With Mr Medland?
LANGDALE: Mr Medland, yes.
BREAREY: Yes, he started saying so, you know, "the purpose of this meeting, I have been asked is to
clarify whether there's enough evidence to go to the police". And we had to point out to him at the
beginning of the meeting that was not the reason we had been given for why we were having this
meeting and he -- he said "that's not a very good start, is it?" And then we cracked on with the
rest of it really, yes.
LANGDALE: It looks as though paragraph 5 of these minutes: "We all agreed that if there was an
identifiable common thread between some of the deaths [cf the Beverley Allitt] this would be
powerful prima facie evidence that there was potentially a crime or series of
crimes which had been committed." Who mentioned Beverley Allitt or spoke about that case, can you
remember now?
BREAREY: Sorry, I didn't hear.
LANGDALE: Who spoke about Beverley Allitt's case, the significance of that?
BREAREY: I think he -- he might have mentioned it. But I can't remember off the top of my head.
LANGDALE: He then says: "In [his] view the police being strapped for resources in any event can
only sensibly investigate cases where there is at the very least reasonable grounds for suspecting
that a criminal offence has been committed ... different from there being mere suspicion." Then did
he say: "Reporting the matter to the police was a condign step which was effectively a public action
and would incur adverse publicity and raise matters for the families, which might be seriously
disturbing"?
BREAREY: Yes. He was very clear about the negative consequences of the police investigation and the
high, high bar needed to initiate one and the fact that it would upset families. He even put it to
us -- I'm not sure it's mentioned in these minutes -- that if we had
similar concerns about a medical colleague, we wouldn't have, be doing this or making these concerns
which I thought was quite offensive.
LANGDALE: The next paragraph, 7, he records: "There was a commonality of concern amongst the
Consultants; they all felt although these matters expressed in different ways, that this matter had
not in some significant respects been dealt with happily by the hospital. They felt that they had
sometimes been excluded from a frank and inclusive discussion of the deaths and had been told
different things by different people. They all felt there had been an unacceptable delay of nine
months when little seemed to have happened." Then the barrister emphasises: "It was the first order
of importance [at paragraph 9] that the hospital and the Consultants work together on this issue and
that positions did not become entrenched or opposed." He advised at paragraph 12, he made the point:
"As things stand [he] did not see there was such material as might give rise to reasonable grounds
for suspecting that a criminal offence had been committed. He expressed the view that it was
important to remember that such a step may well have far-reaching
ramifications and should not be taken lightly." At paragraph 13: "... posited a situation where a
member of staff who might come under very damaging suspicion was not a nurse but was a Consultant,
no doubt that Consultant would only want the matter to be put into the hands of the police after
very serious thought about potential consequences of such a step and where the evidence justified
such a step." What did you make of that observation?
BREAREY: I am not quite sure what he's trying to say actually. So again --
LANGDALE: Paragraph 13, I am asking you about?
BREAREY: Yes, I think he is trying to suggest that we wouldn't make that step unless we were clear
about our concerns and that we were aware of the potential consequences of that step.
LANGDALE: Would that make any difference whether it was a nurse or a Consultant?
BREAREY: None at all, no.
LANGDALE: That's what I am asking, the question. How did you receive that piece of advice or
comment?
BREAREY: I thought it was -- it was fairly judgmental and untrue, really. There was -- and, you
know, we would be in the same position if we had a -- had a concern about a colleague. You know, our
concern was about patient care and safety of babies, full stop.
LANGDALE: What he does suggest at paragraph 14 is that: "The Consultants should make short notes
setting out their best points those matters which they say most clearly indicate in their minds
reasonable grounds for suspecting that a criminal offence has been committed. This would help to
crystallise matters and push them forward to a sensible conclusion. It would help everyone to deal
with the matter head on in an inclusive collegiate way which included taking the views of the
Consultants and including them in the decision-making process." He also set out at paragraph 15 the
possibility of a private discussion with Detective Chief Superintendent Wenham, because he is a
senior officer, independent and experienced and he has sat on CDOP. That document can go down now
please. That's in fact what happened, wasn't it, we see a series of emails pursuant to that meeting
between the Consultants, thinking between themselves and going through INQ0103217 onwards, and if we could have on the screen please INQ0011915, page 1.
BREAREY: I mean, it struck me that his recommendation to have a -- put our points down on paper of
key points
and have a discussion in an inclusive and collegiate way was exactly what had been missing over the
last nine months, really. There had been no -- nothing like that at all and, you know, obviously
that was the opportunity back in July 2016, when Ian Harvey was tasked to do this deep dive is just
sit down and understand the Consultants' concerns. I think that was one of the actions from one of
those meetings anyway, and there was nothing inclusive or collegiate about anything that followed
really. Yes.
LANGDALE: Indeed, that was going to be my question, Dr Brearey: had this been done earlier what in
fact Mr Medland advised and the culmination of communication between doctors and generally this
document --
BREAREY: Yes.
LANGDALE: -- going to the police --
BREAREY: Yes.
LANGDALE: -- of course meant there was a police investigation because matters had been pulled
together in this way?
BREAREY: Yes, there is nothing materially different in this document to the concerns we were raising
nine months earlier. The only difference is the morbidities that we had added which was Dr Gibbs'
work that fed into Ian Harvey's work that hadn't been shared with us for,
you know, a good period of time until 2016 --
LANGDALE: And the formality of putting it together, you had also, if we go to the end of it, dealt
with the acuity and staffing point in this document INQ0103225, page 1.
BREAREY: Because obviously Ian Harvey had argued about acuity and activity, so we were keen to
include we thought was relevant data that came from BadgerNet and had come from the network which
would hopefully reassure the police that mortality, acuity and staffing wasn't an issue contributing
to the mortality of all these babies. So, you know, summarising there that nursing staffing in the
unit was above the national average, yes it was below BAPM levels, the percentage of shift staff to
BAPM standards -- if you can scroll down to the next slide, this is a basically a synopsis of where
we were as a unit -- sorry it is the following one.
LANGDALE: Page 3?
BREAREY: It is the funnel plot. So if you -- this would apply to Chester in a number of different
areas. I know there is staffing here but this is the percentage of eligible shifts on the Y axis so
the orange line there is the national average, so nationally 58% of shifts were staffed to
BAPM standards for all neonatal units. The yellow dots represent larger neonatal intensive care
units and the green dots represent local neonatal units like ours and you can see there is a fair
spread of staffing there and the pink dot is the Countess of Chester which again is above the
national average, not the best, but above the average and certainly not an outlier. And I could show
you graphs like this for most other audit measures for the neonatal unit in terms of our compliance
with retinopathy screen for bronchopulmonary dysplasia, for most other national audit standards that
we -- we were doing okay, other than mortality. And that was the point of this slide, or these,
these graphs and data, to reassure the police that the impression that Ian Harvey and his previous
reviews had done were skewed and irrelevant relevant.
LANGDALE: And indeed Eirian Powell's assurance, NNU reassurance document that we went to --
BREAREY: Exactly, yes.
LANGDALE: -- earlier that repeats those comments?
BREAREY: Yes.
LANGDALE: Finally, Dr Brearey we know that there was at this point a breakdown between the
Executives and the Consultants and there was correspondence with Sir Duncan Nichol about that,
certainly between he and Ravi Jayaram. You also attended a meeting I think on Monday, 9 October with
a Rachel Hopwood, who had been appointed Children's Champion. Can you say anything about that role
for us, the Children's Champion role that was then created, how effective was that?
BREAREY: Some Trusts had incorporated Children's Champion -- I can't remember the exact document or
body that recommended it but having a Children's Champion at board level to concentrate on the
wishes of children and children's services and we hadn't had a Children's Champion up until that
point and it was a recommendation from the College review that was then put in place in October or
-- later that year. And Rachel Hopwood had been present at the meeting on 26 January when we were
told not to cross the line, although I think she said she couldn't remember that meeting. But the
meeting that you are describing where we were introduced to her with Ian Harvey and she described
her reason for wanting to do this role, I think, for (redacted) who had received paediatric services
in the past --
LANGDALE: Yes.
BREAREY: -- and was very positive about the department.
LANGDALE: Was it positive, the role moving forwards, did you find that a useful role to have a
Children's
Champion or did it not impact, it is really the --
BREAREY: Well, after that meeting with her I didn't see her again and I can't remember ever seeing
her on the ward or the neonatal unit and I think it's difficult for a Non-Executive Director to have
a meaningful influence on the affairs of the hospital and the paediatric service, I think it needs
to be somebody at Executive level who's there every day, or knows the people involved.
LANGDALE: INQ0006681, page 1, on 29 March 2018 we see as Consultants you email Sir
Duncan expressing that you remain extremely concerned that the relationship with the Executive board
has deteriorated significantly and that no meaningful efforts are being made to repair it. We can
see what you say there, Dr Brearey, and we know you send a list of concerns, you get a response from
the Execs and you as paediatricians respond to their responses?
BREAREY: (Nods)
LANGDALE: That all is from this point onwards. But a question here: in terms of Sir Duncan Nichol,
how useful did you find his intervention or involvement at this stage when you have written that
letter?
BREAREY: Well, he seemed to be supporting the Executives through most of the issues up to May 17,
before the police investigation started. I know he had some private issues he was trying to get over
at the same time. But it was only really when Mr Harvey left the Trust and Susan Gilby took over
that Sir Duncan seemed to realise maybe what had been going on at Executive level and started -- you
got the impression he started to feel that he might have been misled at times and his input at this
time, which I think was just before Mr Harvey left, was to try and build bridges and try and repair
the damage that had been done. There was nobody at Executive level that was, was really doing that.
There was no communication that we had with the Executives after the police investigation started.
It's all very cursory and the impression we were given always was that the police investigation
would come to nothing and, you know, it would take a long time to prove a negative, in Mr Harvey's
words. So Sir Duncan I think was trying to build bridges at this time in communicating with us and
because I don't think the Executives were prepared to.
LANGDALE: Thank you. That can come down. Finally reflections, Dr Brearey. We see in the Countess of
Chester Hospital records a reflective note, I don't need to put it on the screen now. It says "CPD
activity", hone dated 31 October and one 2016, and one slightly earlier, 1 March 2016. Were those
personal reflection documents things that you do at the time as part of HR?
BREAREY: Yes. So every Consultant has a revalidation and annual appraisal that keys into the
revalidation. So you would meet with an appraiser annually and present a portfolio of your
achievements and challenges that year and that would normally be -- you would expect to have a
couple of reflections in that appraisal, sometimes about difficult cases. But in both these case I
was reflecting on my role as the neonatal lead in the years 2016/2017 I think.
LANGDALE: You commented earlier that with the CQC you didn't speak to the inspector in a
confidential setting I think you may have had a one-to-one with a Dr Odeka in February 2016; can you
remember that?
BREAREY: That's correct, yes.
LANGDALE: So you did have a meeting but you didn't mention it in that one-to-one?
BREAREY: That's -- that's correct, yes.
LANGDALE: CCTV. In your statement, you make an observation about you do see a use for video cameras
to be used during resuscitations. At paragraph 453 you say: "I know that this is practised in some
other hospitals and countries. It would be a useful tool to promote learning for staff for
medico-legal use and might also be useful for the very rare occasions of intentional harm. As with
all cameras in clinical areas there are data protection laws that need to be adhered to." So are you
thinking sort of almost bodycam footage for the doctors or above the scene or what? We know the
police work with bodycams now which they wouldn't have imagined a decade ago but they do?
BREAREY: I think my understanding of where they are used in other hospitals would be, obviously with
the consent and all the information governance problems overcome, they would be attached to what's
call the Resuscitaire, which is the device trolley, if you like, on the side of the delivery suite
where the baby would go to full resuscitation. So it is from the top there, so you would just be
filming as the baby came on to the Resuscitaire and that resuscitation effort really, although
equally it could be used in the intensive care incubators from a sort of bird's eye perspective from
the top really, which obviously staff I think would feel a little uncomfortable with at the
beginning but I think research shows that people get used to it and it can be
helpful in feeding back information about resuscitation procedures and learning from it, yes.
LANGDALE: One other observation you make in your second statement relates to data systems and
reliable signals being triggered and you say at paragraph 31 of your second statement: "Rather than
MOS running in parallel to MBRRACE UK, the two systems would be better integrated together earlier
and more reliable signals could be triggered if preterm and term babies were analysed together. I
think this is vital for a neonatal alerting system. "Obstetric care metrics such as stillbirths and
hypoxic brain damage, should be analysed separately as well as part of the wider measures of
perinatal care."?
BREAREY: So the MOS system which is in a prototype, if you like, was developed as a result of the
East Kent Inquiry which was predominantly obstetric and midwifery care that was the problem, so the
markers for that were term babies dying or term babies with brain damage and it didn't include and
the MOS that is devised doesn't include any preterm babies or babies over 28 days of age. So it
would exclude most of the babies in the indictment, for example, and wouldn't be particularly
helpful for neonatologists, it might be more helpful for
maternity services, for example. And the problem with the MBRRACE data is that it -- although it is
a real-time system it doesn't -- it doesn't have any statistical tools to let you interpret the data
and it can include babies that are born in Chester, for example, stabilised in Chester, moved to
Alder Hey for cardiac surgery, then died following surgery. So that would be still attributed to
Chester and likewise it also includes babies who might not be of viable gestation who have signs of
life after birth that die who didn't die on the neonatal unit, but died on the delivery suite. So
the data for neonatal doctors for MBRRACE isn't particularly useful at the moment even though they
have got the real-time reporting now and MOS, as it's proposed at the moment, wouldn't cover all the
babies in this indictment either and sort of going back to what I was saying with SUDiC processes
and things like that that what we want is something simpler that is overarching rather than another
system to add on to other systems that aren't perfect. It's easy for me to say, I know it is a
complicated process to do that, but ideally to have a combination of MOS and MBRRACE that covers
more babies, more gestations and to include some metric of babies who die on
a neonatal unit rather than including others I am sure would be quite helpful, yes.
MS LANGDALE: Thank you, Dr Brearey those are my questions. My Lady, Ms Blackwell, followed by Mr Baker, Mr Skelton and Mr Kennedy at the end if he has anything to ask.
LADY JUSTICE THIRLWALL: Very well. Ms Blackwell.
MS BLACKWELL: Good afternoon, Dr Brearey.
BREAREY: Hello.
BLACKWELL: I ask questions on behalf of the former senior managers. As you have acknowledged this
morning in answer to questions from Ms Langdale we are here partly at least to work out why it took
so long to detect the level and cause of the deaths on your unit and I have some questions about
what was or wasn't known by the senior managers at what time. You told us first of all this morning
about a meeting on 2 July of 2015 and that was a meeting you remember lasting about an hour?
BREAREY: Mm-hm.
BLACKWELL: During which you discussed the deaths of [Child A], [Child C], and [Child D] and you had
prepared a summary of the cases in preparation for that meeting. You told us that during the meeting
you discussed the fact that there had been three deaths in a short space of time which was unusual
for your unit and you felt that there may have been deficiencies in the cases that could be improved
on, but you were looking for what might link the three deaths. You also told us that Eirian Powell
had done a number of things before the meeting. She had looked at spaces, microbiology links and
also the possibility of fluid contamination?
BREAREY: (Nods)
BLACKWELL: Yes. Now, it was put to you by Ms Langdale that those deaths were unexpected and
unexplained and that might well be the narrative and the understanding now. But will you take it
from me, Dr Brearey, that nowhere in your summary document are the words "unexpected" or
"unexplained" and I want to suggest to you that those were not words that were used during the
course of the meeting. Would you agree with that?
BREAREY: No. But -- I mean, yes, they weren't explicitly said but at the same time the timelines for
each events were talked about and it was very clear that the babies collapsed suddenly as described
in the narrative of all three cases. So obviously that is the sudden side of things. We had -- we
didn't have an explanation for Child A
and we didn't have an explanation for [Child C] at that stage, so they were unexplained. Whether
those words were explicitly used, I can't say one way or another if there's no record of them. But
it was very clear from those cases that of the sudden nature of -- of their deaths and the
unexplained nature of two of the deaths, yes.
BLACKWELL: All right. I would like you to look, please, at a paragraph in your witness statement which again was put to you by Ms Langdale this morning. It is at INQ0103104, paragraph 116, please. I don't have the page, I'm afraid.
LADY JUSTICE THIRLWALL: 17.
MS BLACKWELL: 17. Thank you, my Lady, it is page 17. Thank you. Here you are recorded as saying:
"Towards the end of the meeting Eirian Powell raised the observation that Lucy Letby had been on the
NNU on the three occasions when the babies the three babies had collapsed. My first reaction was to
say 'not Lucy, not nice Lucy' as before this meeting I was unaware of which Nurse Eirian Powell had
identified. Although the association was significant enough to remain in my mind following the
meeting I was not overly concerned at that stage."
Now, your evidence this morning was that sometimes you do get clusters of deaths in neonatology and
there was nothing too concerning, certainly not suspicion that was crossing your mind at that time
of deliberate harm; is that right?
BREAREY: Although we had done a staffing analysis, hadn't we? We -- as I said, Eirian Powell had
done a staffing analysis.
BLACKWELL: Yes.
BREAREY: So that had been some degree of cognitive process to do that.
BLACKWELL: Yes.
BREAREY: And then comment on it, yes.
BLACKWELL: All right. Julie Fogarty has given evidence to this Inquiry that she was very clear that
Lucy Letby's name was not discussed during that meeting and Eirian Powell has given evidence to the
Inquiry that she has no recollection of being at the meeting. I want to, please, now look at INQ003530, which is the note of the meeting to see if this assists you in
terms of who was present. INQ0003530. Thank you. When it comes up, we can see top right-hand corner the
initials of those present, Julie Fogarty, Ruth Millward, yourself, Alison Kelly, Sian Williams and
Debbie Peacock.
Do you agree, Dr Brearey, that Eirian Powell's initials don't seem to be in that list?
BREAREY: Debbie Peacock?
BLACKWELL: Yes.
BREAREY: And I don't know who the one is before that.
BLACKWELL: Sian Williams. Alison Kelly, Sian Williams, Debbie Peacock.
BREAREY: It's also got the details of an obstetric secondary review for [Child D], hasn't it, a bit
later?
BLACKWELL: Yes. But this is the -- this is the reference to who was present and Eirian Powell's
initials don't seem to be there, do they?
BREAREY: You know, it's a three-page record and I don't know whose record it is.
BLACKWELL: Might it be, Dr Brearey, that you are wrong that Eirian Powell mentioned Lucy Letby's
name at this meeting?
BREAREY: Absolutely not, no, because where else would I have got that information from?
BLACKWELL: Well, it may have come to you in another meeting or in a discussion with Eirian
Powell?
BREAREY: No, no.
BLACKWELL: But what I want to suggest to you is that Eirian Powell and Julie Fogarty are right that
Eirian Powell wasn't there and Lucy Letby's name wasn't mentioned?
BREAREY: Well, Eirian Powell was there because she presented those -- those, that data to me. I am
absolutely sure and I think you are saying that she's right but actually she can't remember, did you
say? Anyway the meeting happened, we had that review.
BLACKWELL: Yes.
BREAREY: And I don't know whether you have asked Debbie Peacock about it as well to confirm your
suspicion because as far as I am concerned that meeting definitely happened and her name was
definitely mentioned.
BLACKWELL: There's no other person who was present there who confirmed that Lucy Letby's name was
mentioned or that Eirian Powell was there?
BREAREY: I'm sorry, it happened.
BLACKWELL: All right. It was put to you by Ms Langdale as a fact that Alison Kelly knew that you
were thinking that there had been deliberate harm to Letby in this meeting. That is not right, is
it? You -- you agreed with me that even you weren't thinking in the realms of deliberate harm?
BREAREY: Yes, yes.
BLACKWELL: Thank you. You say at paragraph 121 in your statement that you felt uneasy with the
decisions made
at the meeting. But we know that following the meeting, Alison Kelly, as you have accepted, invited
you to contact her with anything you wanted to discuss, and you didn't take her up on that
invitation?
BREAREY: Mmm.
BLACKWELL: You were then taken through the chronology of deaths and you were asked by Ms Langdale
to indicate when you became convinced that deliberate harm may have been carried out to some of the
children on your unit and you told us that certainly by the time of [Child I]'s death in October of
2015, there were a lot of clues and incidents which would have brought you to the conclusion that
something was wrong. But that indicated that you were ruminating on it but not raising it, certainly
not with any Executives at that stage?
BREAREY: I had raised it with Eirian Powell who had written the email to me saying that she is going
to raise it with Alison Kelly on Monday.
BLACKWELL: But you didn't email Alison Kelly or contact her?
BREAREY: No, no.
BLACKWELL: And in fact the next emails that you sent to Ian Harvey and Alison Kelly were around the
time of the Thematic Review, weren't they?
BREAREY: Yes.
BLACKWELL: We looked at the final report of the Thematic Review earlier today but I would like to
look, please, very briefly at the draft report, the first version, which is at INQ0003217, at page 7, please. Eventually, the themes identified were amended
in the final report to add sudden deterioration and timings of arrest to the top of the list,
weren't they?
BREAREY: Yes.
BLACKWELL: But in its original iteration, we can see that you had placed delayed cord clamping in
preterm deliveries as the number one theme identified. What caused you to amend that?
BREAREY: I wanted to put them in order of importance in the final version of the report.
BLACKWELL: Well, in fact in this first draft, I don't think that sudden deterioration appeared at
all, did it, as a theme?
BREAREY: No, it was a suggestion from Dr Subhedar, as we have discussed already.
BLACKWELL: Now, you have dealt with the fact that there is no mention in the body of the report of
Lucy Letby as a theme?
BREAREY: Mmm.
BLACKWELL: Or as any nurse being a commonality and you
have explained that you regret not putting her presence or the presence of a nurse in that list?
BREAREY: Although her name was in the --
BLACKWELL: In the appendix.
BREAREY: -- table with all the cases.
BLACKWELL: Yes. I would like to ask you please -- we can take that down, thank you -- about the
sharing of the Thematic Review because your evidence today is that you sent it to Ian Harvey and
asked him for an urgent meeting?
BREAREY: Yes.
BLACKWELL: Now, could we look, please, at the email thread that's relevant to this. It is INQ0003140 and if we can go to the bottom of the thread first, please. Thank
you. This is an email from Ian Harvey to you. "Am I correct in thinking that you commissioned an
external review of recent neonatal deaths? If so, is there any early feedback ahead of this week's
visit." He is referring there to the CQC visit, isn't he?
BREAREY: Yes.
BLACKWELL: If we go to the next page up, we can see that was sent to you by Ian Harvey on the
morning of 15 February and your response is above, you respond within the hour explaining that it
wasn't an external review but that you had invited neonatologists from Liverpool Women's Hospital to
join and you attach the draft minutes, which is in fact the draft report, isn't it?
BREAREY: Yes.
BLACKWELL: Yes. Do you agree then that it was as a result of Ian Harvey asking you about the
Thematic Review that you sent to him that you had cause to send him the report?
BREAREY: I -- the plan had been to send it to him anyway.
BLACKWELL: Yes.
BREAREY: He might have pre-empted me sending it but it would have gone to him anyway before the CQC
inspection no matter what.
BLACKWELL: You, I know, Dr Brearey have searched for the email that you say you sent to Ian Harvey
asking for an urgent meeting?
BREAREY: Yes.
BLACKWELL: And you can't find it?
BREAREY: No.
BLACKWELL: Is it possible that you are wrong in your recollection about asking for a meeting with
him?
BREAREY: I don't think so, no.
BLACKWELL: All right. Well, I just want to come away from the Thematic Review for a moment to ask
you about
your knowledge of [Child K] because we know that by the time you met with the CQC in the presence of
Dr Jayaram there were -- there was a group of you, wasn't there, that was at the CQC meeting?
BREAREY: Mm-hm.
BLACKWELL: Yes, that earlier that day Dr Jayaram had witnessed [Child K]'s collapse and had
concluded that it was a shocking event, and that the dislodging of the breathing tube had been
deliberate. Did he mention that to you either before or around the time of your CQC meeting?
BREAREY: I can't remember him mentioning it, no.
BLACKWELL: No. If he had mentioned that to you, what would you have done with that information?
BREAREY: Well, I would have instigated a review of the case and spoken to him in detail and if I was
concerned, I would have shared that with others.
BLACKWELL: Yes, you would have brought it to the attention of the Executives, wouldn't you?
BREAREY: Yes.
BLACKWELL: Yes. Because in his evidence at the criminal trial, INQ10309 [unavailable] I don't ask
that we look at that now, he said he didn't make a note of it in his clinical notes for [Child K],
but it was one of the things that we discussed as a team together and added to the list of
concerns we already had and escalated it to the senior management at the hospital. If he's right
about that, you were not a member of the team for that discussion and you didn't escalate it to the
management, did you?
BREAREY: Well, that statement isn't dated, is it, so I don't know what date he's referring to that
because clearly we escalated our concerns of the morbidity cases when we were presenting the
evidence to the policy inventory.
BLACKWELL: Yes well, we know from his evidence that he didn't mention it to any Executive for 13
months until his meeting with Sue Hodkinson on 17 March of 2017. When do you say you became aware of
his conclusion that Letby had deliberately dislodged [Child K]'s breathing tube?
BREAREY: I -- I can't remember and from -- from my impression of his recollection of it, it was, it
was something that stuck with him and I think all of us had these moments and I think parents as
well where they experienced something that is abnormal such as an abnormal cry or a light not being
on when it should have been, which on its own at that time might not trigger an immediate action but
stays in somebody's mind and I don't know whether that's because you can't quite
believe what you are trying to think or whatever.
BLACKWELL: But I am asking when you became aware of it --
BREAREY: I can't remember.
BLACKWELL: -- Dr Brearey. All right. Could we put up, please, INQ0003089. You have been taken to one of the emails in this chain already
this morning by Ms Langdale. It's an email from -- if we could scroll down to the bottom, please,
thank you very much. And then the next page up. 17 March in the afternoon, Eirian Powell is emailing
Alison Kelly: "I have been informed [she says at the bottom of the email] that Ian Harvey is aware
that we have had an external Thematic Review." Alison Kelly's response on 21 March that lies above
is: "Could you please send Ian and I the report in the first instance, then once we have reviewed it
I think it would be good for me, you, Ian and Steve and Ravi to meet to discuss." That is 21
March?
BREAREY: Mmm.
BLACKWELL: So six weeks or so after you had prepared the draft Thematic Review and it's being --
the final version is now being sent to Alison Kelly. Do you think that that's the first time that
any meeting between yourself and the Executives was being first raised as a possibility?
BREAREY: No, no. Both myself and Eirian Powell were asking for meetings much earlier than that.
BLACKWELL: I want to now take you to the meeting of 11 May which you have been asked about. You
tell us that what you sought from the meeting on 11 May as well as discussing your Thematic Review
was the need for guidance on how to take things forwards?
BREAREY: Mm-hm.
BLACKWELL: You described Eirian Powell and Anne Murphy's behaviour during the course of that
meeting as countering your concerns forcibly and with great emotion and you also said that they were
emotionally driven and seemingly in denial of the facts?
BREAREY: Mm-hm.
BLACKWELL: What was the relevance of the fact that they were in your opinion, Dr Brearey, acting
with emotion?
BREAREY: Because I thought that their -- certainly Eirian's relationship with Letby was getting in
the way of her objective analysis of the facts.
BLACKWELL: Did you tell her that --
BREAREY: Yes.
BLACKWELL: -- at that meeting?
BREAREY: I made it very clear to them at that meeting yes.
BLACKWELL: Right. Now, Eirian Powell had brought with her the document that she had prepared
following your meeting of 5 May, hadn't she?
BREAREY: Yes.
BLACKWELL: And that document had been emailed to you well in advance of this meeting?
BREAREY: Yes.
BLACKWELL: Yes, but you tell us today that you were too busy to read it?
BREAREY: Yes.
BLACKWELL: A few moments ago, towards the end of your evidence, you were questioned about Simon
Medland, Queen's Counsel, as he then was, and the advice that he gave to you about listing your best
points. Isn't that what Eirian Powell was doing here?
BREAREY: Do you mean that Eirian Powell was listing her best points?
BLACKWELL: The best points as far as her argument was concerned about Lucy Letby?
BREAREY: Well, to create a document at a meeting without the clinicians isn't very collegiate, as
Simon Medland has suggested, or inclusive.
BLACKWELL: I'm sorry to interrupt you, but my point is
this: you could have -- you could have prepared your own document, couldn't you, and taken it to the
meeting or you could have prepared a document after the meeting and sent it to the Executives?
BREAREY: Well, the best points document was the Thematic Review report which I produced and asked
for a meeting with the Executives with. That was the best point, and that was the inclusive
collegiate meeting with nursing staff and medical staff and external doctor to come up with the best
points that came up, with the -- all the themes that I have mentioned in terms of sudden and
unexpected collapse and timing of the deaths and -- and the fact that we couldn't identify any
natural cause or care problems that might have been responsible. They were the best points for that
meeting. It had already been sitting there waiting for that meeting for two or three months.
BLACKWELL: Yes. And you say that you were disappointed with the outcome?
BREAREY: Well, I was worried by the outcome. Yes, certainly.
BLACKWELL: Worried and disappointed?
BREAREY: Yes.
BLACKWELL: Yes. All right, let's look at your response,
please, at INQ0103144. This is the email that you sent five days after the meeting to Dr
Jayaram and other Consultants and you also copied in Eirian Powell and Anne Murphy: "Eirian, Anne
and myself met Ian Harvey and Alison Kelly last week to discuss the rise in neonatal mortality last
year. It was a helpful meeting and they were grateful for the work we have done in the various
reviews and involving an external clinician." Nothing there about you being disappointed?
BREAREY: I -- I have said in my statement that I didn't think there was anything helpful in the
meeting at all and I regret writing that and wrote it in a -- in an attempt to try and be positive
about a meeting that there really wasn't anything to be positive about.
BLACKWELL: You are asking your colleagues to keep a close eye on things and if they do come across
a baby who deteriorates suddenly or unexpectedly or needs resuscitation on your unit, could they let
you or Eirian know?
BREAREY: Mm-hm.
BLACKWELL: We know that you were aware of [Child N]'s collapse on 15 June of 2016 and you tell us
that you planned to review that but you didn't get round to reviewing it before the collapse and
death of [Child O] and [Child P]?
BREAREY: Yes.
BLACKWELL: Did you discuss your concerns about [Child N] with Eirian Powell?
BREAREY: No.
BLACKWELL: We also know that Doctor S says that --
BREAREY: It is worthwhile saying that [Child N] was a morbidity case and I have said in my statement
as well, that I was -- I was blinded by the medical issues in the case in terms of the haemophilia
that [Child N] had and the difficulty with the airway that was -- was encountered which blinded me
to the actions of Letby. So in my mind, it didn't trigger the response that I would have expected in
terms of the previous email, raising concerns for a sudden collapse.
BLACKWELL: Doctor S has given evidence that on 16 June, they spoke to you about strange behaviour
which Letby had exhibited. You have no recollection of that --
BREAREY: No, no.
BLACKWELL: -- conversation?
BREAREY: But I can, I can remember her talking to me on the neonatal unit when, when [Child O] and P
[Child P] died, which was a similar conversation and I do wonder whether she's got those two cases
mixed up.
BLACKWELL: Right. If she did tell you that before the
collapse and death of [Child O] and [Child P] what would you have done about that information?
BREAREY: Well, I would have shared it with Eirian Powell and obviously it's hard to say now, but I
would have liked to think that I would have shared it with the Executives as well.
BLACKWELL: Right. Thank you. We know the interaction and involvement that you had with [Child O]
and [Child P] and I just want to ask you, please, about your conversation, if indeed there was one,
overnight between 23 and 24 June with Dr Jayaram?
BREAREY: I can't remember having a conversation with him.
BLACKWELL: Well, Karen Townsend has given evidence that the following morning she met Dr Jayaram in
the cafeteria and she discussed several issues with him including the third in a list of three was
the NNU Triplets. And it's during that conversation that Karen Townsend said that Dr Jayaram told
her about the drawer of doom; the collated evidence that was in your office. Karen Townsend then
went to speak to Karen Rees about it which is what prompted her to come and speak to you, to find
you in the clinic and walk back to your office with you. And we know that Karen Rees's evidence
of that conversation includes her asking to see what was in the drawer and you refusing her access
to it. Now, your evidence is that none of that happened?
BREAREY: No. And the timings don't entirely fit either because that suggests that Karen Rees already
knew I was calling it the drawer of doom before we had -- I'd had that meeting with her that
afternoon, whereas my understanding of her statement is that she said I mentioned it then and that's
what she remembers. But that was after, after she had been tasked by Karen Townsend to go. So the
timings don't add up, do they?
BLACKWELL: Did you speak to anybody on the night of 23 June about your concerns in terms of
Letby?
BREAREY: I honestly can't remember whether I did or not.
BLACKWELL: All right. But you did speak to Karen Rees on the evening of 24 June?
BREAREY: Yes.
BLACKWELL: And it was during that conversation, I suggest, that she asked you again for evidence of
your concerns about Letby and said in the absence of evidence she couldn't take her off the rota for
the following day?
BREAREY: As I have explained already, firstly, I don't
think that conversation happened and Karen Rees's repeated comments about "there's no evidence",
really, were based on the fact that I think she assumes that the evidence we, somehow, were hiding
was some event in which we witnessed harm being done and we were hiding that from her. Actually, the
evidence was quite clearly and it was all in the Thematic Review: the evidence of Letby's
association; the sudden and unexpected nature of the collapses; the timings of the collapses; the
numbers of the collapses; the fact there was no other explanation for this, that was the evidence.
And again, you know, she was entrapped in those thoughts having spoken to Eirian Powell who was also
in that position and unwilling to consider the concerns we were raising.
BLACKWELL: Right. But finally this, please, Dr Brearey: the meeting with the Executives on 30 June
of 2016, you have told the Inquiry that Tony Chambers accused you of your concerns about Letby being
a convenient way of hiding your own failings. I have to suggest to you that he didn't use those
words, he didn't express that sentiment and there's no reference in the meeting notes to suggest the
same?
BREAREY: Well, I have explained already that I don't think the meeting notes are particularly
reliable anyway.
BLACKWELL: Stephen Cross' notes?
BREAREY: Yes.
BLACKWELL: Yes.
BREAREY: I specifically remember him saying it, I can specifically remember talking to colleagues at
Alder Hey that same summer; senior colleagues at Alder Hey, talking about our problems and
mentioning what he said and their reaction being similar to ours, really. If you would like to
corroborate that with them I am quite happy for you to give them the names and you can talk to them,
you know, to corroborate that. He definitely said "that would be convenient", he definitely looked
away and said it, yes.
BLACKWELL: You express that you were irritated with Karen Rees's interjections during the course of
that meeting and in your view, you didn't need evidence of someone pulling out a tube or injecting
something in order to take matters further?
BREAREY: Well, I think the evidence that we did have was enough to escalate it to another agency.
BLACKWELL: Yes. Interesting, if I may make this point, that you chose those two examples because of
course Dr Jayaram did have evidence where he had concluded that the breathing tube of [Child A] had
been deliberately
taken out and, of course, Dr ZA had noticed that the insulin levels were suggestive on another child
of external provision. But neither of those two matters were brought to the attention of the
Executives at that stage?
BREAREY: Well, we weren't aware of the insulin at that stage --
BLACKWELL: Yes?
BREAREY: -- and Dr Jayaram didn't witness her taking the tube out of the baby.
BLACKWELL: But concluded that that is what had happened?
BREAREY: Well, he -- he witnessed her coming to the side of the cot side as described in the court
case.
BLACKWELL: Yes.
BREAREY: Yes.
BLACKWELL: Thank you?
BREAREY: So as you -- that would be the epitome of "no evidence" but actually it turned out on
further that it was.
MS BLACKWELL: Thank you, Dr Brearey. My Lady, that is all I ask.
LADY JUSTICE THIRLWALL: Thank you very much indeed, Ms Blackwell. Mr Baker.
MR BAKER: Thank you, Dr Brearey. I ask questions on behalf of a number of Families including the
Family of [Child G].
BREAREY: Okay.
BAKER: You deal with [Child G] from paragraph 155 of your witness statement and you have given
already some evidence about [Child G] and your interactions with her parents and you have expressed
your views on her parents and the quality of care that they provide?
BREAREY: Yes.
BAKER: You had some involvement with [Child G] at or about the time of her collapse in September
2015?
BREAREY: Yes.
BAKER: Now, your opinion initially about the cause of that collapse was that it was caused by
sepsis but the condition of [Child G] up until that point had actually been very good considering
that she had been born a little under 24 weeks?
BREAREY: Yes.
BAKER: By this point she was the equivalent of about 37 weeks gestation and you describe how, in
your witness statement, she was very different to the other babies on the indictment?
BREAREY: Yes.
BAKER: She was much bigger, more robust, she was
drinking milk, she was interacting with her parents?
BREAREY: Yes.
BAKER: Her parents' view -- and they expressed this to you -- was that there was a remarkable
change between how she was prior to this incident in September and how she was afterwards?
BREAREY: Yes.
BAKER: And you were also shown MRI scans from Arrowe Park?
BREAREY: Mm-hm.
BAKER: Those scans taken after the collapse, again, showed a profound change in the appearance of
Baby G [Child G]'s brain?
BREAREY: Yes.
BAKER: And from that point onwards she appeared to develop evolving signs of cerebral palsy?
BREAREY: Well, obviously, over a longer period of time.
BAKER: Yes, and you say in your witness statement that her mother and father, in effect, said to
you that there was a profound change in her condition. In effect, the progress that she had made to
that point had been lost and they attributed the signs of evolving cerebral palsy to the collapse in
September and you say in your witness statement that you don't regard that as being
unreasonable?
BREAREY: Yes.
BAKER: There will have come a point -- although you initially believed that this collapse was
caused by sepsis -- there will have come a point where you began to us suspect that [Child G] may
have been one of the victims of Lucy Letby?
BREAREY: Mmm.
BAKER: And the reason for that was that her observations prior to the collapse were all normal and
then they changed profoundly with the collapse and from that point onwards; that's correct, isn't
it?
BREAREY: Yes.
BAKER: The signs that you had attributed to sepsis, raising the CRP which rose after the collapse,
the metabolic acidosis which appeared after the collapse, and fact that she needed anatropic drugs
to maintain her blood pressure after the collapse were not concordant with the usual appearance of
sepsis which leads to a which involves the development of prodromal symptoms leading to a collapse;
it was out of the blue?
BREAREY: I wouldn't completely agree with that statement. The CRP test doesn't -- doesn't always
reflect what's happening at the time when the blood's taken.
BAKER: There is a lag with CRP?
BREAREY: There is a lag, isn't there?
BAKER: Yes.
BREAREY: So the fact that the CRP was raised within the 24 hours of her collapsing --
BAKER: If I put it this way --
BREAREY: -- might indicate on its own -- you know, I am not arguing with you in terms of the
neurological sort of outcomes for this, but I think the team in Chester and the team at Arrowe Park
I think where she went to subsequently, felt the blood tests were -- were indicative of infection
but seeing, seeing it with a different perspective now and knowing more about some aspects of her
care which I might not have felt was as important at the time in terms of the quantity of milk that
was vomited, then obviously clearly, you know, we accept now there was a different cause for it. But
at the time I don't think it was unreasonable is given at the time for infection as well as
collapse.
BAKER: Can I just come back to the milk?
BREAREY: Yes.
BAKER: Because there was a very substantial vomit?
BREAREY: Yes.
BAKER: I think it was described by Mother and Father G as "flying across the room"?
BREAREY: Yes.
BAKER: After that vomit, there was an attempt to aspirate fluid and gas --
BREAREY: Yes.
BAKER: -- from [Child G]'s stomach and [Child G] had 100 millilitres still inside her stomach?
BREAREY: Yes.
BAKER: Later that again appeared to you to be odd given the fact that [Child G]'s stomach capacity
as a baby would be relatively small?
BREAREY: Yes.
BAKER: She had had a large vomit and why would she still have 100ml of fluid in her stomach after
such a large vomit?
BREAREY: Yes.
BAKER: That taken with the suddenness of the collapse and the fact that it came out of the blue
later caused you to suspect that there might have been a connection with Lucy Letby?
BREAREY: It was unusual, certainly, and the reason for us to list her as one of the babies that we
had concerned about to the police, I don't -- I don't think our -- my level of forensic knowledge
limited my understanding any further than that and I wouldn't want to step into an area, you know,
that I am not an expert in.
But it would certainly reach the threshold at which we thought it was appropriate to refer to the
police, certainly.
BAKER: Yes. You had a number of consultations with Mother and Father G and [Child G]?
BREAREY: Yes.
BAKER: And Father G recalls at one of those consultations you showed him the observations for
[Child G] and you said to him these were entirely normal up until the point of the collapse and then
there's the collapse and everything changes. Were you trying to tell him something?
BREAREY: I can't remember that specific part of the conversation. But I -- I don't think so, no. No.
BAKER: You described how you had to sit with parents knowing what your suspicions were and not
being able to tell them and how difficult you found that.
BREAREY: Yes.
BAKER: There must have come a time when you were doing that with Family G?
BREAREY: I can't -- I can't recall the dates exactly but -- and obviously I was focused on the
mortality more than morbidities for most of the time after we escalated our concerns. And yes, we
did include Baby G [Child G] in that, but it was a relatively late decision about that and, and --
BAKER: The first Father G found out about that, the inclusion in effect was the arrest?
BREAREY: Right.
BAKER: What concerns him and what he wants to clear the air about --
BREAREY: Yes.
BAKER: -- because you still see each other regularly --
BREAREY: Yes, yes.
BAKER: -- is why couldn't you tell him before then about your suspicions?
BREAREY: Yes. I mean, I can't remember whether my suspicion with Baby G [Child G] was -- was very
high or I really can't remember where I was in my mind process about the concerns for her at the
time. I certainly wouldn't have been in a position to or want to mislead any Family in any way,
certainly not -- not her Family and -- and if -- I ever did, I am sincerely sorry for that, really.
But it didn't remind me of the conversation with the other set of Families where I did feel very
uncomfortable with it and it -- and as I have said before, once you -- once you share a concern like
that with a parent, you are effectively putting your concerns into the public domain before a police
investigation has
even started which is -- is difficult to feel is -- is appropriate, you know, I had never been in
this situation before, I have always tried to be as honest as I can with any set of parents and if I
did mislead them and I was thinking of concerns at that time, I sincerely apologise for that. But
that certainly wasn't anything malicious or intentional.
BAKER: Thank you. Can I move on to a slightly different issue. You were interviewed by The Guardian
for an article that was published in August 2023 and I just want to take a couple of points out of
that and into what you were saying in your evidence. You were quoted in that article as saying that
Executives at the Trust should have contacted the police in February 2016 when concerns were first
raised following the Thematic Review?
BREAREY: Mm-hm.
BAKER: Is it your evidence that a position had been reached following the Thematic Review that the
threshold had been crossed and that the police needed to be called?
BREAREY: I think that was the most likely outcome of escalating it to the Executives when I did
then. But, you know, we had circumstances shall evidence, worrying really what I felt was quite
convincing circumstantial
evidence and, you know, we needed help with it. So that's -- that's why we -- we asked for that
support and advice.
BAKER: The way you describe things in your witness statement, and in particular it's paragraph 265,
from 265 onwards this is describing the meeting in June 2016. At paragraph 266 you say there were
concerns about the NNU being closed and made a crime scene and the publicity that would follow would
be a disaster for the Trust?
BREAREY: That is what we were told, yes.
BAKER: Did you have a sense that the concerns were being put to one side because of worries about
reputation and reputational harm to the Trust?
BREAREY: Well, that was certainly put to us; that that would be one of the reasons why not to
because of the reputation of the Trust. I -- having lived through all this, I am a little bit
sceptical as to whether that was a true concern or whether it was more on an individual basis, the
people making that decision looking after themselves and trying to protect themselves through this,
particularly if they had not responded to our concerns as early as they should have done.
BAKER: I take it your evidence is that it's as true in June 2016 as it would be earlier in the year
following the Thematic Review, that the appropriate action should have been to call the police to
investigate a potential crime and allow their forensic skills to take over?
BREAREY: Yes.
BAKER: Another thing you say in The Guardian article, or are quoted as saying, that you felt there
was an anti doctor agenda amongst some of the Trust's senior leaders?
BREAREY: Yes.
BAKER: Could you explain first of all if that is something you said, and secondly, expand upon
it?
BREAREY: Well, Mr Chambers made something of him being a nurse and having worked as a nurse and
generally speaking, the Consultant body in the Trust at the time, their morale was low and they
didn't feel particularly listened to, there were a number of sort of issues that contributed to
that. There is a Consultant body within the Trust called the Medical Staff Committee, which
represents all the Consultants in the Trust and the head of the Medical Staff Committee normally had
an advisory role within the Executive board but that I believe Tony Chambers dropped that role, Mr
Chambers dropped that role so that the spokesman for the Consultant body no longer had a voice at
Executive level. And yes, I think generally speaking, the Consultant body's morale was low, you
might have heard it from other -- other Consultants from the Trust, but yes, I think that was a
perception that was shared amongst a number of Consultants.
BAKER: Do you feel it had an impact upon the way that your concerns were received?
BREAREY: I think it allowed the Executive body, particularly Mr Chambers, to give more credibility
to the views of some senior nursing staff, such as Eirian Powell and Anne Murphy and Karen Rees in
preference to the Consultant body's concerns and I think in addition to that, the concerns of
Letby's parents and Letby herself above our concerns.
BAKER: Finally, can I ask you about another issue. Can we go, please, to INQ0012979, please, and to page 23. This is your Facere Melius interview and
your discussion, you are discussing the choice of Mr Medland as a -- to be involved by Stephen Cross
and can you see at the bottom it says Darren Thorne, so it is a distraction, Stephen convinces Tony,
that is Tony Chambers, and there's a rationale written down as to why they shouldn't go to the
police, Stephen has
influenced Tony's thinking, convinced him because we shouldn't go to police as it's not a criminal
investigation, there's no criminality to this and what they do is they go instead to a QC who
Stephen knows and you say: "Has anybody mentioned the Freemasons to you?" Darren Thorne says:
"Nobody has mentioned to me before in terms of [if we go over the page, please] it's all hearsay but
it wouldn't surprise me too that there is a Freemasons connection of a number of high ranking people
in the hospital and elsewhere for this and I am sure that's where his friend is from, that is where
Simon came from, and no one has mentioned it to us yet, and it's useful that you have. But I was
intending to ask a question of one of the other interviewees who has previously been told was
threatened not to do certain things. So yes there will be an undercurrent. Did you have anything
ever said to you?" You say: "It is all rumours and hearsay." Could you expand upon what message you
are trying to get across there?
BREAREY: Well, I mean after Stephen Cross came to the Trust, I understand he -- he rose from quite a
junior
position to a senior position at Executive level quite quickly within six or seven years, I think to
corporate affairs. We were also always given the impression that he was a sort of fixer of problems
within the Executive body and they relied on him a lot like that and it questions whether any
processes were followed by the Trust in terms of fit and proper candidate for Executive roles
because, you know, subsequently I think probably after this interview I found out about Stephen
Cross' demotion to the -- in the police service, which would fit with the rumours and hearsay that I
mentioned here, that maybe some of the conversations he had and some of the people he dealt with had
split loyalties, really I suppose is the word.
BAKER: You had had a sense that there might be some deals going on behind the scenes, some element
perhaps of corrupt behaviour?
BREAREY: People had that impression and certainly there were rumours of that kind, certainly, yes.
MR BAKER: Thank you. Thank you, my Lady, I have no more questions.
LADY JUSTICE THIRLWALL: Thank you very much, Mr Skelton.
MR SKELTON: Dr Brearey, I ask questions on behalf of the Family group. You made a comment earlier
in your answer to some questions from Ms Langdale that on reflection, you thought it's likely that
Lucy Letby didn't start becoming a killer in June 2015. Baby A [Child A] was murdered on 8 June. Is
it your view that she had murdered or assaulted children in your hospital prior to that date?
BREAREY: I think that's -- that's likely, yes.
SKELTON: On reflection now, do you look back and see a number of unexpected collapses or deaths
which with information now available to you appears suspicious?
BREAREY: Yes.
SKELTON: On reflection now, do you recall having any concern about those collapses or deaths at the
time, or did your colleagues?
BREAREY: No. As far as I am aware, neither me or my colleagues had concerns at the time. We just
thought we were going through a busy patch or a particularly difficult patch at times.
SKELTON: So the kind of factual investigation which this Inquiry is conducting from essentially
June 2015 to the police being called a couple of years later, that kind of factual analysis, those
meetings, those reviews, those investigations, was not occurring in the hospital prior to that
date?
BREAREY: Well, those reviews, mainly Mortality Reviews that we talked about and, you know, you have
seen our mortality numbers prior to this, were fairly stable but I -- you know, on reflection I
think events were happening that were unusual and I think the context of why I said it was because,
if you like, we had a thermostat for a level of work and a number of events that we can't quite
understand, you know, I think it was turned up over those years so that our perception of what is
normal for a neonatal unit in terms of the number of collapses that, you know, you might expect in a
week a month or a year had changed and I think that was the case for doctors and nursing staff.
SKELTON: One of the effects of normalising the abnormal is that when abnormalities occur, you don't
react as you should?
BREAREY: Yes.
SKELTON: You don't recognise it and you don't take appropriate action, is that a reflection which
resonates with you?
BREAREY: I think so, yes. I think -- and also people try and rationalise reasons and, you know,
coming out and sort of criticising, you know, there were -- we were working that NHS, it's not
perfect, there's lots of
rational ways of trying to explain it away which at the time really we, you know, looking back on it
wouldn't have made sense, blaming the transport service or, you know, blaming another Trust for
maybe sending babies back when they weren't completely stable, rather than sort of taking a step
back and thinking: well, you know, what's happening here? Certainly, yes, yes.
SKELTON: I will come back to that, if I may, at the end I have only got, I'm afraid, 20
minutes?
BREAREY: Okay.
SKELTON: I have got a quite a few things I need to get through. Can I clarify this before I move
on: did anyone in your hospital suspect Lucy Letby was harming children prior to June 2015?
BREAREY: No.
SKELTON: [Child A]. He had an unusual rash which has been talked about a lot at this Inquiry, and
likewise other children in that cluster of deaths had unusual rashes, his sister did, for example,
as well, as you know. There is an email, I can take you to it if you would like me, where the
Registrars' concerns about those rashes are being voiced by Dr Gibbs; do you remember that?
BREAREY: Yes, yes.
SKELTON: And in your statement you say at paragraph 88 that you weren't aware of the concerns about
the rashes, do you think on reflection having seen that email from 23 June that that was --
BREAREY: Obviously, yes, I mean, I can't remember that email chain but I must have been notified,
yes.
SKELTON: Do you think looking back that it would have been appropriate to have try and done a
serious incident investigation of that cluster of deaths and thereby captured a theme that turned
out to be significant such as the rashes?
BREAREY: I think that's a reasonable thing to say in retrospect, but I still think at the time, you
know, our job is dealing with uncertainty and there is many a time in paediatrics and in neonatology
where you don't have the answer immediately and although [Child C] had a rash and [Child A] had a
rash, and B, obviously who survived -- the [redacted] that mother had for [Child A] and B swayed me
towards a natural cause which we hopefully were going to get an answer from either with
investigations with [Child B] or the postmortem and we were waiting for the postmortem for [Child C]
which we hoped might give us an explanation which is clearly a different case. And I don't think the
description of the rashes in
the case notes when I was reviewing them were did enough to really trigger my concern and clearly
the email as well didn't do that and the perinatal meeting that followed the following day that I
described for the junior doctors to discuss their concerns I -- I found that presentation from Dr
Lambie about [Child A]'s care from that perinatal meeting, I submitted it to Hill Dickinson at the
weekend when I was going through my bundle I had been given on Friday, with the emails in and it's a
six-slide presentation of [Child A]'s care, but it didn't include any mention of the rash in her
presentation. And it might have been mentioned in the presentation, I can't remember everything
about it at the time, but it just adds to the -- my general feeling that I just considered these to
be separate events and natural events and my -- my radar for something harmful was -- was it wasn't
picking up anything at the time.
SKELTON: Mother A would like to have known about the rash because it clearly had caused some
concern to some of the doctors?
BREAREY: Yes.
SKELTON: She wasn't told, do you recognise it's the kind of thing when she was looking and she was
desperate to get an answer for why her son had died that it could have been mentioned to her?
BREAREY: Yes, yes.
SKELTON: Just following forward into the chronology of the investigations, a postmortem took place
and obviously that takes a period of time and was available later in the year and then there is of
course the Inquest and all the way up and including the Inquest, Baby A [Child A]'s death was
unascertained?
BREAREY: (Nods)
SKELTON: That's correct, isn't it?
BREAREY: Yes.
SKELTON: So your initial concern that it might have been something to do with the condition the
mother had was in fact excluded and you couldn't find the medical cause of his death?
BREAREY: Exclusion is different from saying there was a connection, if you know what I mean. You
know, sometimes you don't know and you can't confirm anything, even if the cause is natural. So yes,
I -- I take your point. I understand that it was unascertained.
SKELTON: By the time the Inquest took place the Coroner was relying on a document that you had
produced in part which was a single page analysing the potential causes of death which included the
mother's condition, but in
fact things had moved on, hadn't they, because by that time the Inquest took place, you didn't think
it was necessarily that cause?
BREAREY: Mmm.
SKELTON: Do you recall that?
BREAREY: I don't because after my initial review like that in terms of certainly the Inquest
preparation I wasn't involved with the Inquest preparation, I know Dr Jayaram was and maybe other
Consultants.
SKELTON: Dr Saladi, for example?
BREAREY: Yes, but I didn't have any input prior to the Inquest.
SKELTON: Did you talk to either of those Consultants or indeed anyone else about the Inquest that
was taking place and whether or not your concerns or suspicions about a member of staff needed to be
told to the Coroner?
BREAREY: I can remember Dr Jayaram being very worried about it in terms of what he would what he
could say at the Inquest because obviously we had raised concerns at that stage.
SKELTON: Worried specifically about that concern and whether or not he could say that about
Letby?
BREAREY: Yes, yes. And he was seeking advice from Stephen Cross at the time about that.
SKELTON: Was it your understanding that Stephen Cross advised him not to mention it?
BREAREY: That -- that was my understanding. I can't recall whether that's something that Dr Jayaram
has told me since then or at the time when it happened, but, yes, that was, that's certainly my
understanding now.
SKELTON: Can I turn briefly to [Child I], please. She had a series of collapses and repeatedly left
your hospital and went into care in other NHS hospitals and then returned and then eventually she
had a final and fatal collapse in October 2015. How unusual did you find that pattern of collapses
in your unit: recovery elsewhere, return and collapses again in your unit?
BREAREY: Well, it was unusual and it struck me and it increased my level of concern at the time and
triggered things afterwards, particularly in terms of the Thematic Review. But without going through
everything again, I can't say that those -- not exact events happened previously but I know Eirian
Powell felt very strongly that particularly Arrowe Park Hospital were sending some patients back too
early and I can't remember which cases she was referencing to that and whether they are children in
the indictment or not.
But certainly that seemed to be a theme for a while, that concern. Yes.
SKELTON: But specifically in relation to her, she had a pattern of deterioration at the
Countess?
BREAREY: Are you talking "her" as in Child --
SKELTON: [Child I].
BREAREY: [Child I], yes.
SKELTON: Yes. Which was highly unusual, wasn't it?
BREAREY: Yes.
SKELTON: Did that up the index of suspicion or concern, as far as you were concerned?
BREAREY: It did, yes.
SKELTON: I will come back to that at the end.
BREAREY: But the rider on that, as I have said already, was that the -- the consensus amongst
medical professionals in a number of hospitals at the time was that she had some abdominal pathology
going on which was causing her collapses and we didn't have the postmortem result. So it would have
been nice for me to have received the postmortem result in February around about the time of the
Thematic Review and we -- postmortem reports aren't shared with paediatricians directly once they
are produced. They go to the Coroner and I think they go to the GP. So there was some delay in me
seeing that report, it was June before I saw it because that obviously would have informed me more
in February in the Thematic Review, had I known that there is no abdominal pathology going on and
there are these strange events happening --
SKELTON: Is that something that should be improved that you should receive them really as soon as
they are available?
BREAREY: Yes, I don't understand why they are not shared with the paediatricians and neonatologists
in a timely fashion.
SKELTON: Can I turn to [Child M], please.
LADY JUSTICE THIRLWALL: Just before you do, Mr Skelton I'm sorry to interrupt you. There have been
a couple of references to Mother A's medical condition this afternoon.
BREAREY: Sorry.
LADY JUSTICE THIRLWALL: As I said this morning, they must not be reported.
MR SKELTON: Thank you, my Lady. [Child M] had been born in good condition, no concerns again for
him and he suffered a serious collapse on 9 April 2016. You have said previously that you thought
that was very unusual and worrying?
BREAREY: Yes.
SKELTON: The nature of his collapse, and I think Dr Jayaram shared a degree of perplexity too about
that; is that correct?
BREAREY: Yes.
SKELTON: Did either of you think to connect it with your already existing concerns about Lucy
Letby?
BREAREY: No. I have to say and I don't know why, I know I was very focused on mortality and it
looking back on it, it's just one of those moments you think why, why, why didn't we? And it wasn't
something that struck -- clearly, you know, there should have been a link there and it didn't and I
can't go back and tell you what I was doing at the time or what work I was doing or whether I was in
hospital or not in hospital or what conversations went on. But certainly that was a moment I felt
that, you know, there was an opportunity to link some events like that.
SKELTON: Can you explain why you didn't in a bit more -- with a bit more clarity because only a
month later on 16 May, you are writing an email around to the staff saying --
BREAREY: Yes.
SKELTON: -- Eirian and I need no know about these collapses?
BREAREY: Yes.
SKELTON: You could have written that email months before in fact and started to collate the data
about the collapses in order to bring together the information. Why didn't you?
BREAREY: Yes. Because I think the -- it may have been those events in April might have triggered
people's thoughts into thinking -- starting to think along that line, really, as the Consultant
body. I can't remember precisely the dates we started to sort of start to think about the morbidity
cases in addition to mortality cases, but it was certainly around that time. I can't say and
obviously with the volume of work in terms of looking at the mortalities, I accept that it was very
hard to get a grip of the morbidity cases as well and yes, certainly that was a missed opportunity.
SKELTON: Can I ask the similar line of questions in respect of [Child N]?
BREAREY: Mm-hm.
SKELTON: In respect of [Child N]'s deteriorations, he was found -- Lucy Letby was found guilty of
attempting to murder him on 3 June 2016, but in fact the parents weren't aware of that collapse that
was an attempted murder.
Again, that is the sort of thing that they should have been alerted to, shouldn't they?
BREAREY: Yes.
SKELTON: Can you explain why that wouldn't have happened, or didn't happen?
BREAREY: Well, I wasn't the Consultant caring for Baby N [Child N], I was obviously involved in some
of the airway issues that we had. And -- and again, we were blinded a little bit by the medical
issues, the haemophilia and the blood coming up the airway which -- and the difficult airway
problems which distracted me and others from thinking about the cause of the collapse really and the
collapse happened in -- in theatres when people were preparing for intubating [Child N] in the
presence of Letby. So I think a lot of different things were going on all at the same time with that
because you had a team from Alder Hey an ENT surgeon, a PICU anaesthetist, the surgeon prepping for
a surgical airway if needed. There was the issue of getting the correct fact rates for the baby in
view of the haemophilia and I think all those obviously they had to deal with emergency at the time
in terms of intubation and stabilising the baby which clearly takes priority over informing parents
if you have got limited staff available. But I accept that they should have been notified at the
earliest opportunity.
SKELTON: And should his deterioration, the unexpected deterioration that he suffered have been
captured by your own request as one of those cases --
BREAREY: Yes.
SKELTON: -- that needed to be drawn together?
BREAREY: Yes, yes.
SKELTON: And likewise presumably the rash that he demonstrated as well which was recognised to be
unusual could have been captured and linked with the previous children?
BREAREY: So the review for [Child N], the events with [Child O] and P [Child P] meant that those
happened before we got a chance to review [Child N]'s death, you know, appropriately. So those
events didn't get reviewed before [Child O] and P [Child P] died sadly. So -- and then we are on the
rails of escalating the concerns to Executives and everything that went on that week and the
following week. So yes, I am sorry that, you know, I didn't look at [Child N]'s care earlier or in
more depth and I should have done at the time but there was a lot going on.
SKELTON: Do you think the same -- broadly the same conclusion applies to [Child Q], who of course
deteriorated after the death of the first -- the two deaths from the Triplets --
BREAREY: Yes.
SKELTON: -- while Letby was still on the unit just before she was excluded? Again do you think that
needed to have been looked at and the parents spoken to?
BREAREY: Yes, I mean, we were in so many meetings the following week after [Child Q]'s collapse
that, you know, naturally those events or those reviews were delayed, yes.
SKELTON: Taken in the round, the Families clearly were unaware that there was this growing concern
amongst the doctors that had treated their children over the course of 2015 and 2016, that in fact
their children had been harmed and in some cases killed?
BREAREY: Mmm.
SKELTON: Can you see that asymmetry of knowledge in professionals in whom they must put their Trust
--
BREAREY: Yes.
SKELTON: -- is invidious?
BREAREY: It's -- it's it was really hard for -- for -- it's one the hardest things I have dealt with
through all of this including, you know, the dealing with all the managers, it just goes against the
grain of the way you are trained and -- and supposed to behave and it was
really hard. Really hard. You talked about, you know, existing patients in clinic and [Child G]'s
parents aren't the only ones that, you know, I look after in clinic and even after these events it's
very hard to talk about that in a 10 or 15 minute consultation. But, you know, before we escalated
concerns it was very hard. And there's, there's no guidance for this; you know, you can't look up a
GMC manual and say, you know, well, concerning -- if you are concerned about criminal activity,
that's an unproven concern, you know, is it, is it right that you tell every Family before it's been
appropriately investigated, you know, with the appropriate authorities? And --
SKELTON: Dr Brearey, I have to put to you that it is right that transparency and openness and
simply respect for those Families requires you to tell them?
BREAREY: You know, I -- I accept that, but it was not clear at the time and the consequences of
talking to them about concerns that you had got about circumstantial evidence that's unproven and
putting that in the public domain and the harm that that might incur on parents if those concerns
are incorrect and unfounded is also there. You know, the last thing I wanted to do was, was conceal
anything to anybody. At the same time, you
know, you have to be sensitive to the fact that, you know, if this wasn't correct and this did prove
to be nothing the damage you can do as well. It's really hard and if I got it wrong, I'm sorry.
SKELTON: Can I ask more generally about your response to concerns. As I understood your evidence
this morning to Ms Langdale, the meeting you had on 2 July 2015 in which you made the "not nice
Lucy" comment, was the first time when you had a concern about her causing harm to those babies?
BREAREY: That was the first time it was -- it was raised as a commonality, yes.
SKELTON: And I think you said there was part of your mind thinking the worst. From that time
onwards, 2 July, part of your mind thinks the worst?
BREAREY: It was in the back of my mind, obviously trying to rationalise it and go through all the
thought processes and denial and questioning that my colleagues went through at different times,
yes.
SKELTON: What is the difference between a concern that a member of staff is harming babies and a
suspicion?
BREAREY: To me, you know, a concern is, is something that's on a differential, you know, that you
can, you can have a number of possibilities of cause and you don't know which one it would be or
which is the most probable. And I think a suspicion is a little bit more definite in your thought
processes as to what the cause is.
SKELTON: Not much difference?
BREAREY: Not much, but significant.
SKELTON: Further babies collapsed, as we well know, and further babies died over the course of
2015. By the end of that year, certainly by the time Baby I [Child I] died, you were aware of the
unusual number of deaths, you were aware of that they were unexpected and unexplained in many cases
medically, and there weren't certain causes of death that had been identified. Dr Jayaram also
mentioned in his evidence the fact that babies didn't respond appropriately to resuscitation when
they collapsed. So you piled in and did all the things that you as paediatricians will do to bring a
baby back from a collapse, but they didn't respond to the drugs, to the interventions in the normal
way and you had identified very early on Letby's presence at those collapses and deaths.
BREAREY: (Nods).
SKELTON: And hadn't found, on investigation, an alternative medical explanation, is that fair?
BREAREY: Mm-hm.
SKELTON: You wrote a letter in 2017, a report rather,
with the other Consultants raising the six points I have just mentioned to you. They were in fact in
place in 2015, weren't they, just fewer numbers?
BREAREY: Yes. I mean obviously, as time went on, we consolidated those thoughts, yes. But, yes, the
facts were all there, yes.
SKELTON: All of those facts were in place in 2015?
BREAREY: Yes, yes.
SKELTON: But at that stage there were just fewer deaths and collapses?
BREAREY: Yes. I mean, I think it's worth pointing out that it was quite a lonely place to be as well
because you have got those thoughts going on in your head, but, you know, normally in this line of
work you are bombarded with requests, actions, various things to do on a fairly regular frequent
basis and to respond to in terms of patient safety concerns, national alerts, that sort of thing and
there was nothing. There was no external or internal people alerting us to say, "What are you doing
about this mortality?" and the nursing staff were very adamant that there was no problem, which ends
up with you questioning yourself as well. So, you know, that credibility gap was there and
pushing me in one direction. But weirdly it felt that there was, there was, other than colleague,
Consultant colleagues, there was no other push or request to do anything. I mean it, you know, it,
it -- it felt a bit isolating to be honest.
SKELTON: But shouldn't you have named your concerns and your suspicions when they grew in the
clearest and most explicit terms because what one sees in your emails --
BREAREY: Yes.
SKELTON: -- in your meeting notes, "We need to talk about Lucy", a Thematic Review that doesn't
mention Lucy Letby or the suspicions that she may have murdered children. It's all euphemistic, it's
all implicit and it needed to be clear and explicit and it never was?
BREAREY: Yes. And, you know, if I was writing a guideline for how to do this for future doctors, you
know, I would -- I would be happy to, you know, include that. But, you know, with the environment in
the Trust and the feeling of the nursing staff and the lack of worry from anywhere else in the
organisation then, I felt I had to be categorical in, in -- in naming and being very clear about the
concerns that we had and even when we did raise concerns with even more evidence in June '16 we were
still accused of picking on a nurse
and victimising her and treated in the way that we have described. And, you know, if we had raised
those concerns and been very explicit about her name and naming her earlier, then I sort of suspect
the treatment we had regarding us victimising her would have been even stronger.
MR SKELTON: But the Thematic Review which you judged as being something of a watershed moment --
LADY JUSTICE THIRLWALL: Sorry, Mr Skelton. I'm sorry to interrupt you, Mr Skelton. I certainly will allow to you ask the questions you want to ask, but the shorthand writer has been going now for nearly two hours, so I think we will have a 10-minute break, just for her to recover.
MR SKELTON: Certainly, my Lady.
LADY JUSTICE THIRLWALL: We will take 10 minutes and come back in just before five to. (5.42 pm) (A short break) (5.50 pm)
LADY JUSTICE THIRLWALL: Mr Skelton.
MR SKELTON: Earlier you explained to Ms Langdale the Thematic Review you reviewed as being a key
moment where the Executives might understand that the police needed to be called, is that
correct?
BREAREY: Yes.
SKELTON: Why is it though that within that Thematic Review, you don't make clear Lucy Letby's --
your suspicions about Lucy Letby or the view, which was shared I think by the Consultants, that the
police needed to be called? Why didn't you make those things explicit?
BREAREY: The evidence was circumstantial, but concerning and significant, I -- as I said to Ms
Langdale before I regret not putting her as a commonality in the theme. But at the time we had to
agree a draft before it was finalised and I didn't think that the nursing staff would be happy with
me doing that particularly when they had criticised me already for not including all the doctors
being present for all the events. And it was the intention to meet with Executives as early as
possible to discuss the report with them, in which case it would have been mentioned explicitly in
that meeting and we could have discussed the appropriate action. It was never my intention that that
meeting was delayed until May 11th that I asked for in February. So it was really to -- probably a
feeling of appeasing some
of the members of the group which undertook the Thematic Review so that we could agree the final
report and get it out and request the meeting, not to do that. And as I say, you know, in retrospect
now knowing what followed I regret doing it --
SKELTON: But also --
BREAREY: -- or omitting to do it.
SKELTON: -- knowing what you knew at the time because the situation was actually rather urgent,
wasn't it?
BREAREY: Yes.
SKELTON: Lucy Letby had been actively harming children for seven, eight months by this stage?
BREAREY: Yes.
SKELTON: And there was no action being taken to stop her?
BREAREY: Yes.
SKELTON: At all?
BREAREY: And --
SKELTON: And so you couldn't actually guarantee the safety of the patients on the unit unless
urgent action was taken and it wasn't?
BREAREY: And again I was, I was looking for guidance from an external neonatologist as well and
certainly if he'd told me, "Go to the police" or go -- you know, anything, you know, I would have
followed his advice for
that. But I didn't get anything explicit from him at that meeting to suggest that I should do so.
SKELTON: This is?
BREAREY: Dr Subhedar.
SKELTON: Who's giving evidence tomorrow.
BREAREY: Yes.
SKELTON: You had at least three options open to you. One was to raise a safeguarding concern?
BREAREY: Yes.
SKELTON: One was to contact the police yourself or insist that someone did so?
BREAREY: Mm-hm.
SKELTON: And the third was to tell the Coroner the concerns or to insist someone did so. Those
really are the three urgent and immediate options, aren't they, that needed to be implemented by
someone?
BREAREY: Yes.
SKELTON: And you talked about the sort of index of concern, the spectrum perhaps?
BREAREY: Yes.
SKELTON: Bearing in mind what you were thinking by the time Baby I [Child I] died, which is when
you and Eirian Powell put together the table which identified Lucy Letby, and you were already aware
of her from July?
BREAREY: Yes.
SKELTON: So this is several months afterwards, so we are talking October, November 2015; that was
the time to take those steps, wasn't it?
BREAREY: As I say it was, it was -- it was a relatively lonely place and with every -- after every
death there was, you know, obviously excepting the Triplets, there was a pause in, in the -- in the
death rate, well, you know, I think some of my emails surmise as much when I put the draft of the
Thematic Review out, "Well, you know, here's hoping for a better year this year." I was, I was, you
know -- it was always a little bit in your head thinking, you know, I am being paranoid here and,
you know, and that was supported by some people, that view, and, you know, things might get better
and there was always a period of time where you thought, well, that might be the case. Obviously
now, you know, I would have liked to act earlier certainly.
SKELTON: Sorry, I didn't catch -- obviously now... I'm sorry, I didn't catch that very last bit you
said.
BREAREY: Obviously now I, you know, accept that I should have acted earlier.
SKELTON: Or someone else should have done. Really --
BREAREY: Yes.
SKELTON: -- from the moment Lucy Letby was suspected of harming and killing babies --
BREAREY: Yes.
SKELTON: -- action needed to be taken, not further internal investigations, meetings, notes and
reviews, but actual action involving external help?
BREAREY: Yes, and, and clearly, you know, we asked for -- I asked for advice about that with an
external doctor and, and again there was no advice pushing me that way and, yes, there was no ... To
give you an example of, you know, the -- the Executive body, they weren't problem sensing and they
were comfort finding and the previous Medical Director to Mr Harvey was Virginia Clough, and a very
good Medical Director, and I can remember her calling me in to ask me about an episode where some of
our babies were colonised with MRSA, which is a bacteria that was, was passed on to them either
through the mother or from infection in another Trust before they came to us. Those babies didn't
have an MRSA infection as such that needed antibiotic treatment. They were colonised with it on the
screening swabs we do when the babies arrive on the unit. So we felt that we had things covered. But
she, she politely and firmly approached me as the neonatal lead and Eirian, the unit manager, to
enquire about why we had three cases of MRSA on our
unit. She didn't ask for me to volunteer that information. She, she came to us about it because
she's the Medical Director and she was -- she was problem sensing as Executives ought to be and, you
know, I -- I didn't feel offended by her challenge. You know, it was a reasonable question and, and
we assured her that we were taking the appropriate steps and did some actions that she recommended
as well. But that's that -- that problem sensing behaviour was never there at Executive level and
when, when the lines of escalation are blurred, you know, we chose to skip most of them and go
direct to the Executive because we knew that the, you know, the process of going through various
things within the Trust was -- would only sort of delay things further. You know, I've -- I was just
limited by what I could do at the time. As I say, I was trying to do my best in very difficult and
unusual circumstances and naturally looking back at the end result there are times when I could have
been more explicit with the concerns that we had and there are times when I feel that we could have
pushed a little harder. You know, but that's in retrospect and, you know, I was just doing what I
could at the time, really.
SKELTON: Just finally in respect of the Executives who you've mentioned a number of times.
BREAREY: Yes.
SKELTON: I have asked you about that report, which you and your fellow Consultants wrote in May
2017, which had that summary of six points, which I put to you earlier, the unexpected nature of the
collapses, the failure to respond normally to resuscitation and so on?
BREAREY: Yes.
SKELTON: At what point in time do you think the Executives were aware of those points? Was it --
are you clear in your mind that it was prior to the deaths of the first two, the two Triplets?
BREAREY: Yes. That -- they were -- that was -- most of that information was in the Thematic Review.
All of it was given to them when we escalated to them at the end of June 2016. You know, the, you
know -- the myth that we were bashed with during the grievance procedure, that we are somehow
withholding information, was literally that; it was just a myth and, you know, we were in a
grievance procedure where we were made to feel as though we were on trial and we weren't -- I was
keen not to sort of hypothesise about mechanisms for, for injury because I thought the evidence that
we had in terms of
everything that you have described was enough to escalate and I thought hypothesising about air
embolus or whatever would actually just be outside my area of expertise and distract from the
significant -- we had concerns with evidence we had already albeit circumstantial.
SKELTON: So as far as you are concerned, if you try and get the timing pinned down from the time of
the Thematic Review --
BREAREY: Yes.
SKELTON: -- from your perspective, the Executives had sufficient information to take immediate
action should they have chosen to do so?
BREAREY: Yes.
MR SKELTON: Thank you.
LADY JUSTICE THIRLWALL: Mr Kennedy.
MR KENNEDY: My Lady, can I just indicate before I ask any questions that the PowerPoint presentation of Dr Lambie on [Child A] has been provided to the Inquiry?
LADY JUSTICE THIRLWALL: I think it already has been.
MR KENNEDY: It has been, yes.
LADY JUSTICE THIRLWALL: Yes.
MR KENNEDY: But I don't think it's made its way any further than that.
LADY JUSTICE THIRLWALL: I made an enquiry about it during the hearing. Thank you.
MR KENNEDY: Very well. I am behind the pace. Dr Brearey, I just want to deal with three brief
matters and depending on how we are doing for time I may just trim that to two. The first is you
have been asked a lot of questions about the nature of your concerns and the timing of your
concerns. You have been asked by both Ms Blackwell and by Mr Skelton about 2 July. I am not going to
ask you about that again. You were asked a question by Counsel to the Inquiry about 23 October 2015,
so immediately after [Child I]'s death, and the preparation by Eirian Powell of the table?
BREAREY: Mm-hm.
KENNEDY: She asked you a question about which was premised on what Dr Jayaram was thinking at that
time. I just want to ask you to consider what he said in evidence and just assist the Inquiry with
what your -- what was the state of play as far as you were concerned. So he was asked a question and
my Lady it's on page 35 of his at line 16. He was -- he gave an answer having said that there were
informal conversations and
informal conversations which included you. He also said that he thinks that or thought that Dr Newby
had been involved and Dr Gibbs had been involved. These were what he referred to as corridor
conversations. To start with, does that accord with your recollection that there were at that stage
four of you or does that not accord with your recollection?
BREAREY: That's seems a reasonable thing. I mean I haven't got, any you, know explicit memory as
such. But, you know, certainly we were talking about things round about that time, yes.
KENNEDY: Okay. So this is as I say 23 October. He then said this: that he couldn't remember
specific conversations, but his impression was that all of us had begun to consider whether her [so
that's Letby] Letby's presence was a significant -- was of significance rather than just
coincidental and bad luck. So dealing with that. Where were you in terms of your thought process
using that perhaps as a guide?
BREAREY: Again, it was, it was a significant step up in concern. But in the back of my mind, I was
thinking, well, if this is, we need to ensure that we haven't overlooked anything significant here,
hence the reason for the tabletop review of the transport service issues and the other hospitals
and, and the need to see the PM
results that were sort of critical in -- in sort of validating those concerns really because, you
know, if there had been an abdominal issue then we could step down from those concerns a little at
that stage.
KENNEDY: Very well. He went on to say this. He said: "I don't know whether all of us had genuinely
begun to consider: could she be potentially be causing deliberate harm?" So he went on to consider
that, to say that?
BREAREY: Yes.
KENNEDY: Again, where were you in relation to that proposition in late October 2015?
BREAREY: Well, I suppose it's implicit if you have excluded all the other possibilities and there's
this one association that you are worried that she might be harming those babies.
KENNEDY: All right. So if one looks at a range from simple association --
BREAREY: Yes.
KENNEDY: -- perhaps through a competence question to deliberate harm, where on that, if that's a
legitimate range, tell me if it's not, but where on that range were you?
BREAREY: I think that it's too simplistic because --
KENNEDY: All right.
BREAREY: -- again, you know, it's -- it's the natural cause of death exclusion that would push you
further along past halfway in your scale before I could come to that conclusion really. So -- and
obviously if you are going to be in a position where you are presenting your concerns to Executives,
police, whoever, you need to be sure that your own house is in order and that, you know, natural
causes of death have been excluded to have that level of concern. And so that's where I was at. I
mean, yes, worrying. But then still in my head there was a feeling that we needed the PM and the
other things sorted for this baby first.
KENNEDY: Okay. So association, yes?
BREAREY: Yes.
KENNEDY: Whether I need to be worried?
BREAREY: Yes.
KENNEDY: Whether that is for competence reasons or more sinister reasons, I'm still uncertain?
BREAREY: Well, I don't think we were ever concerned about competency issues.
KENNEDY: Very well.
BREAREY: Which is obviously a concern in the other direction. So it was really just natural causes
or and -- you know, I think by the time we had finished the Thematic Review, you know, most of the
other things that you might want to consider I felt had been excluded and, you know, in medicine
we'd call it a diagnosis of exclusion. You know, that you've ruled out everything else and you are
just left with this, this one probable even though, you know, in legal terms it was still
circumstantial.
KENNEDY: Okay. So as at October, we have association?
BREAREY: Yes.
KENNEDY: But you are still on the route to where you get to at the Thematic Review?
BREAREY: Yes, yes.
KENNEDY: Okay. In relation to the Thematic Review, you explained that it was Dr Subhedar's
intervention that caused you to add "sudden deterioration" to your list of themes?
BREAREY: Mmm, I think he actually emailed after the meeting actually.
KENNEDY: Very well.
BREAREY: I think there might be a copy of that email somewhere in the pack, but when I sent the
draft out and obviously after the discussion we had had about her association at the end of the
meeting he emailed back and suggested putting in "sudden and unexpected" as a theme.
KENNEDY: You put in "sudden deterioration" into the final draft?
BREAREY: Yes, yes. Yes.
KENNEDY: We can bring it up if -- we can bring the two versions up if we need to, but I anticipate
everybody has them well in mind now. But one of the other differences between version 1 and version
2 is the timing of events comes up in the list of themes?
BREAREY: Yes.
KENNEDY: Was there any significance to that, question one?
BREAREY: Well, yes, because, you know, again that balance that I had in terms of the members of the
-- in the meeting and accepting the draft and getting it out and, you know, we have talked already
about why I didn't put the staff association in, but one thing I could do if I wasn't putting that
in is put what I felt to be the most important factors and common themes at the top of the list,
hence both of those going to the top.
KENNEDY: All right, so that was conscious?
BREAREY: Yes.
KENNEDY: That was my first question?
BREAREY: Yes.
KENNEDY: I think you have answered my second question
which was: why or whose decision was it?
BREAREY: It was my --
KENNEDY: I take from your answer it was your decision?
BREAREY: My decision, yes.
KENNEDY: Okay. The action that was to be taken in relation to the question of timing of events was
the same, so it read the same, so that you and Eirian Powell to review these cases focusing on the
nursing observations in the four hours before the arrests and then you say: "... aim to identify if
unwell babies could have been identified earlier." And then you say this: "... identify any medical
or nursing staff association with these cases."
BREAREY: Mm-hm.
KENNEDY: And that was the --
BREAREY: Inclusion of the medical staff in the staffing analysis that Eirian had created yes.
KENNEDY: Okay but appended to both version 1 and version 2 was Eirian Powell's analysis which set
out the association in fact of Letby with all of the -- well, with the cases?
BREAREY: Yes.
KENNEDY: Okay.
The third point I just wanted to ask you about was, was this: you have said on a number of occasions
that you were -- and this is my expression, that you were hampered by the volume of work that you
had to do in terms of -- in terms of working on the mortality cases to the detriment of the
morbidity cases in the 2015/2016 period?
BREAREY: Yes.
KENNEDY: Do you recall that?
BREAREY: Yes.
KENNEDY: I think you explain that of the 40 hours that you were due to work each week 75%, so 30
hours, was allocated to clinical tasks?
BREAREY: Mm-hm.
KENNEDY: Was the balance your function as neonatal lead?
BREAREY: Well, no, I mean the -- in the job plan -- I mean, the job plan didn't really resemble what
I was doing anyway because I was doing way over 40 hours of clinical work anyway. But the
two-and-a-half sessions which is 10 hours a week that was allocated to non-clinical work, four hours
of that was allocated to the neonatal lead work, and the other time was allocated to other
non-clinical work that I was doing in terms of work with the College supervision of trainee doctors,
appraisals, that sort of thing.
KENNEDY: So just so we understand. The work that you did reviewing deaths, did that fall within the
--
BREAREY: Neonatal lead role.
KENNEDY: It fell within the neonatal lead role?
BREAREY: Yes, yes.
KENNEDY: All right.
BREAREY: I mean, nobody was counting, you know, it just needed doing and I just did it. Yes.
KENNEDY: You also explained and I am not quite clear in terms of timing, but you explained that
there was -- a Risk Management Consultant was allocated some time and I am not clear whether that
was relevant to the issues that the Inquiry is looking into.
BREAREY: Well, only relevant in so much that it sort of emphasised the workload that was on me and
other neonatal leads at the time --
KENNEDY: Okay.
BREAREY: -- really.
KENNEDY: Did it take any of the work off your shoulders?
BREAREY: Absolutely, because obviously risk was a huge part of my neonatal lead role so the
Consultant -- I think she started doing this in 2017 -- would have four hours allocated --
KENNEDY: All right. So for the 2015/2016 period --
BREAREY: Yes.
KENNEDY: -- you were on your own?
BREAREY: It was just me, yes.
KENNEDY: Okay. Where I wanted to get to was this, you are no longer the neonatal lead, I think
that's now Dr McGuigan?
BREAREY: No, he was the paediatric lead equivalent to Dr Jayaram at the time.
KENNEDY: Forgive me --
BREAREY: The neonatal lead at the moment is Dr Guratsky.
KENNEDY: Okay. Is the allocation of time as far as you are aware any better than it was in 2015
between clinical responsibilities and the time -- the time that the neonatal lead has to has
available to devote to tasks such as Mortality and Morbidity Meetings?
BREAREY: Yes. You know, you always look back on what you are doing and think that the people at the
moment have got it slightly easier but actually they are working very hard and they are still
stretched in their role, requirements always evolve and increase in terms of risk management and the
Trust is -- the Trust Risk Department has obviously developed a lot since then as well.
But I still see colleagues who are working very hard trying to fulfil risk and governance roles
probably beyond the scope of the hours they are given for those, those roles. It's still a demanding
job, despite the extra resource.
KENNEDY: So there's extra resource which assists the neonatal lead?
BREAREY: Yes.
KENNEDY: My question was more to do is more time carved out of the neonatal lead's hours to allow
him or her to commit to this type of work? If you don't know the answer, please say so?
BREAREY: No, it would still fall on the Risk Lead Consultant's --
KENNEDY: Very well, all right --
BREAREY: -- workload for doing this.
MR KENNEDY: Thank you. My Lady, thank you, those are my questions.
LADY JUSTICE THIRLWALL: Thank you very much indeed, Mr Kennedy. Dr Brearey, I have no additional questions. They have all been dealt with. Thank you very much indeed for coming today, I know it's been a very long session but it does mean that you don't have to come back tomorrow, so thank you very much. And we will rise now until 10 o'clock tomorrow morning. I'm sorry, Ms Langdale, I didn't ask you?
MS LANGDALE: No further questions.
LADY JUSTICE THIRLWALL: We will rise now.
(6.19 pm) (The Inquiry adjourned until 10.00am on Wednesday, 20 November 2024)