LADY JUSTICE THIRLWALL: Ms Langdale.
MS LANGDALE: May Ms Taylor be sworn.
MELANIE TAYLOR (affirmed)
MS LANGDALE: Can you give us your name, please.
TAYLOR: Yes, it is Melanie Taylor.
LANGDALE: You've provided us with a statement dated 16 April 2024. Can you confirm that statement's true and accurate as far as you're concerned?
TAYLOR: Yes.
LANGDALE: Do you have it with you, Ms Taylor?
TAYLOR: Yes.
LANGDALE: You set out at the beginning of the statement your qualifications as a paediatric nurse in September 2010, and we know that you were working at the Countess of Chester in the period 2015 to 2016.
TAYLOR: Yes.
LANGDALE: Can you give us your experience before and since about neonatal care?
TAYLOR: So my career history?
LANGDALE: Yes.
TAYLOR: Yes, so I qualified as a paediatric nurse in 2010 and I went to the neonatal unit at Chester. That
was my first job. I stayed there for a few years and, during that time, I did what's called an induction course, which is learning more about neonatal care, and I also did an intensive care course, which is a course about looking after babies who are in ITU and more sick babies. I left in, I think it was, 2019 and trained as a health visitor, and after my training I did that for about 18 months, and then came back to the neonatal unit. And currently I am doing my advance neonatal nurse practitioner training, so I'm a full time student seconded from the unit, and I hopefully will go back and work as an advanced neonatal nurse practitioner.
LANGDALE: Can you tell us something about that induction course and intensive care course versus something that you're doing now, the advanced neonatal practitioner course, you know, what's the level of experience and qualification across those areas?
TAYLOR: So the induction course is a standard course that I think the majority, definitely in the north-west -- it's -- because neonatal care is specialised it's extra training to learn to care for neonatal and then premature babies, and all staff that start on the neonatal unit, usually within about a year or so, will go on to the induction course.
LANGDALE: How long is the course?
TAYLOR: Oh, gosh, I honestly -- I can't 100% --
LANGDALE: Roughly.
TAYLOR: -- remember. I feel like it's about six months possibly.
LANGDALE: Right.
TAYLOR: But it's part-time, so you're still working on the unit and doing -- so -- but I couldn't tell you that's definitely true. I think it around six months.
LANGDALE: About -- so it's some significant time on an induction. And then the intensive care course, how long is that one?
TAYLOR: Yeah, again, I think it was -- it's a long time ago that I did it. I possibly think again it might be about -- it's either six months or a year. Again, it's part-time while you work in the unit. It -- yes, it just gives you more in detail, in-depth knowledge about looking after babies who are a little bit sicker and a little bit more premature and would be classed as intensive care.
LANGDALE: And can you be any band to do that course --
TAYLOR: Yeah, any band --
LANGDALE: -- Band 4, Band 5 --
TAYLOR: It's usually Band 5 --
LANGDALE: Right.
TAYLOR: -- so there's no time limit -- I think it's not a compulsory course, as far as I'm aware, in terms of units across the country but our hospital we do -- we do get sent on it, so --
LANGDALE: So were you all encouraged to do that Band --
TAYLOR: Yeah, we all do it. So usually, once you've worked on the unit -- maybe once you've done the induction course, maybe a year later or so, you would do the intensive care course, usually. I mean, it can vary depending on timings and things like that. But, yeah, it's something that everybody does if they stay working there.
LANGDALE: And I think it's right that Letby had undertaken that course, hadn't she, and she was a Band 5 was -- were there others that had done that as well, then as a Band 5 or --
TAYLOR: Yeah, it --
LANGDALE: -- Band 6? Is it common or not common?
TAYLOR: So -- yeah, so you do it as a Band 5. You wouldn't progress, on our unit anyway, to a Band 6 level role if you hadn't done that course, so --
LANGDALE: So it wasn't an exceptional qualification it was something of the norm for training that you're describing if you were going to be on the neonatal unit?
TAYLOR: In terms of our unit, yes. I don't -- it's not compulsory in terms of being a neonatal nurse. So I couldn't tell you, for example -- ensure, you know, what units do and don't, but not all units across the country or even in the north-west necessarily will send people on that. But ideally it's a good course to go on, and it's something that we to do on the unit as part of our standard training.
LANGDALE: You are -- since January 200024, you've commenced an MSC in advanced practice neonates. So tell us about that level of specialisation as a nurse.
TAYLOR: Yeah. So that is -- so it's a different job role really. So an advanced practitioner is -- it's a new way of role in terms of we didn't have advanced practitioners on the unit back in 2015/2016 and it's -- it's a slightly different role to the nurses, whereas -- although it is nursing, so you -- you kind of bridge the gap between medical staff and nurses in a way, so you need a lot more knowledge. You need experience to do it. So that course is -- what I'm doing at the moment is a full-time course and it's -- yeah, your role is slightly different, so you will take part in ward rounds and assessing babies and -- rather than the sort of care you would as a nurse, so it's a slightly -- it is a different role.
LANGDALE: We've asked all of the witnesses to the Inquiry in writing to suggest recommendations and one doctor came back to suggest that having Advanced Nurse Practitioners in the way that you are qualified for is really helpful on a ward to have that link between doctors and nurses, continuity and to understand what's going on. Do you have a view about that?
TAYLOR: Yes, so, from my personal perspective, I think they are a really valuable staff member. Like I said, it's something that's fairly new to our unit, sort of the last -- I think Ashleigh was our first practitioner to be trained. I think she's possibly done it for about five years, and -- whereas bigger units have got more established teams of ANPs that work really, really well. What is good about ANPs is they are -- we are specialised in neonates. It's an area that most people have worked in for many years and know really, really well and are really passionate about it, and it -- we are based solely on the neonatal unit, so we can stay there. We are a constant. We don't move hospitals every six months. So we are constant for families, a constant for staff. We are a presence that's always there and we can help support doctors and also provide continual care for the -- for the babies.
LANGDALE: Going to paragraph 3 of your statements and your duties and responsibilities whilst working in 2015 and 2016, you were a shift leader I think at that time. Can you tell us what the shift leader's responsibilities were and particularly in terms of allocating babies to nurses?
TAYLOR: Yes. So the shift leaders -- a shift leader would only be a Band 6 nurse and they -- I mean, the -- the role has evolved slightly over the years, so what it looks like now is slightly different to what it looked back then. But, in theory, they are overseeing the shift, so they should take a lighter workload of babies, and they are a port of call for staff if they need support or they are struggling with anything, and they should have a general oversight of all the babies, what's going on, making sure the staff are supported and, yes, they would allocate, so -- in the morning -- so it -- it varied sometimes. So there was a change in when allocation was made in the nursing staff -- to the babies allocated to nursing staff, and I can't remember when that was. It used to be at one point that the shift leader coming on the day shift would allocate the babies to nurses at the beginning of the shift, and it did then switch to the night -- shift leader on the night shift
that was handing it -- or the day shift, whichever was their shift handing over to the next shift would allocate accordingly because they knew the babies maybe a little bit better because they'd spent that shift with them, so it did change eventually, but, yes -- so it would depend -- but it would have been the shift leader that was allocating.
LANGDALE: And based on your experience before 2015 to 2016 and afterwards, how busy was the unit generally? I mean, we know the NHS is stressed, but how busy was the unit, typical of other years, not typical, typical to what you experience now in places? Describe for us how it was.
TAYLOR: I think what -- the nature of neonatal care is that it can be all or nothing sometimes. So you can have days or periods of time where you are quieter, and then you can have periods of time where you have babies that come through quite quickly because you can't predict -- because they are premature it is not a Planned Care sometimes. So I would say when I started in 2010 it was always fairly busy, constant -- on and off you would have had quieter periods. I would say probably between -- yeah, around the time of this 2015, 2016 I would say that business -- it felt like there was shifts and days where that was very -- it was very busy, but then again there were shifts that were not so busy. I would say it felt like it was a little bit busier around that time. Yeah. But I don't have the official numbers to say, you know, this was --
LANGDALE: No, of course, it's a sense, you were working there.
TAYLOR: Yes.
LANGDALE: Manageably so?
TAYLOR: I think majority of it, yes. I think -- like I said, sometimes you can't predict what comes through the door, so you can have a certain amount of staff on and you could have no admissions from labour ward and manage really well. Whereas you could have a day and it's you -- it's not something you can predict, but you could have a day where you have lots of admissions coming through, and that can sometimes -- I think we always managed really well, because I think as a team we worked really well together, but sometimes that felt like it could be a lot. But I think I could say that honestly would happen anywhere. It's not something you can predict and it's not something you can staff, you know, in advance. You can't, you know, have lots and lots of staff to think the possibility that there might be lots of babies
coming through when you would be over-staffed 90% the time, so -- but, yeah, I would say majority of the time it was busy but manageable.
LANGDALE: And in terms of how well or otherwise the babies were, I'm not asking you about the babies on the indictment, but generally coming through the unit, how was that, what you'd expect in a neonatal unit or -- in your unit or not?
TAYLOR: Say the beginning bit, the how well they were.
LANGDALE: In terms of how well they were or unwell or sick or unsick. Again, just a sense, I know -- I'm not asking you to look at data or numbers, what was your sense, what you would expect coming through a unit or --
TAYLOR: Yeah.
LANGDALE: -- sicker, or what was your sense about it?
TAYLOR: I would say I think what I expected. I think, again like -- it's hard to say, because obviously this is all hindsight and me looking back on lots -- many years ago now. I think I never -- I never had the feeling that I was thinking this baby shouldn't be here. It was always within our realms of knowledge and care. I would say because we had limits on the gestation --
LANGDALE: You were a tier 2, weren't you?
TAYLOR: We were Level 2, yeah.
LANGDALE: So just -- when you say gestation, what did
that mean? What kind of babies were getting?
TAYLOR: So you might -- don't completely take me at what -- I think it was 27 weeks and above we used to take. It's been a long time but I think it was 27 weeks. And we would also -- if we had a baby who maybe was vent -- we managed ventilators as well. The staff that had managed ventilators for years and years and years we would manage generally stable ventilators, babies who were not going to be long-term ventilation. If there was a baby that maybe -- any ITU baby -- I don't know if it was any ITU baby at that time but definitely ones that we were considering were maybe having longer stays on the ventilator or had more intensive care they would be discussed with tertiary units, so a Level 3 unit Consultant. So it would be Consultant-Consultant to manage care and discuss whether they felt that that baby needed to be transferred out or not.
LANGDALE: We asked you about the culture and atmosphere on the unit, and at paragraph 4 -- again you say it's eight or nine years ago now, we do appreciate that Ms Taylor, so doing the best that you can, how did you feel the relationships, first of all, within the unit with the ward manager, deputy ward manager were, how was
it working?
TAYLOR: Yeah, so the ward manager and deputy ward manager I felt were supportive, were approachable and led really well.
LANGDALE: And that's Eirian Powell and Yvonne Griffiths, isn't it?
TAYLOR: Yeah.
LANGDALE: Yeah, go on.
TAYLOR: Yeah, that was my perception at the time. I definitely still agree with that. I feel -- I felt supported and I felt -- yeah, I thought there was a good culture on the unit.
LANGDALE: And when you say supported, how did you feel supported by them? What does that mean in practice?
TAYLOR: Yeah, so they were very visible to us. They were approachable. They would -- so I think the culture on our unit has always been a very supportive one where new members of staff were encouraged to talk to managers, to check in with new staff. I always felt very welcomed by managers, by the -- Eirian and Yvonne. And I felt -- yeah, I -- yeah, just a general feeling of supported-ness, and I -- yeah, I always felt like -- and not just them, I think the whole team because that culture was -- all the nurses were very approachable and always checking in with me especially when I was newer, so yeah.
LANGDALE: And in terms of the relationships between clinicians and managers, first of all with Eirian Powell and Yvonne Griffiths on the unit, you say they were good; yes?
TAYLOR: Yeah.
LANGDALE: And what about more senior managers, would you know what the relationships were like there between doctors and senior managers or not?
TAYLOR: Between doctors and senior managers?
LANGDALE: Yeah?
TAYLOR: Between doctors and managers I -- I don't know. They -- the senior managers as a possibly more junior nurse, not senior or management, they weren't very visible to me, so I couldn't comment on the relationships between the doctors and management.
LANGDALE: Would you have known who they were? Would you know who Mr Harvey was, Mr Chambers, if you'd seen then them in the corridor?
TAYLOR: I would know who Tony Chambers was. Otherwise, I don't think so.
LANGDALE: And the relationship between nurses and senior managers then, you'd say you didn't really have one, didn't really know them, so nothing either way really to comment on?
TAYLOR: No, I would say from my perspective as a Band 5/sort of Band 6 nurse, I -- yeah, there was -- there was just no visibility really that was -- yeah, they were probably around on the unit but they weren't really known -- made known to us. They weren't introduced. They didn't introduce themselves to us. I don't remember them being very visible --
LANGDALE: So your --
TAYLOR: -- as a nurse.
LANGDALE: As a nurse, okay. But your direct managers were Eirian and Yvonne, you say they were relationships with them?
TAYLOR: They were, yeah.
LANGDALE: You comment on the relationship between the NNU nurses and midwives, and you say that that communication by the midwives was poor, which caused strange relationships -- strained relationships, sorry. Could you expand on that for us, please?
TAYLOR: Yeah, I -- again, this is from my perspective. As a more junior nurse, I felt that I was very much overlooked by midwives and not respected in the same way, and that came across in their communication. I felt intimidated by them. I would say now my perception of that is different, and whether that is because things have changed or because I'm more senior,
I don't know. But, yes, I --
LANGDALE: How's it changed? The perception -- when you say a perception changed, your impression of what it was like back then or you've got different relationships with midwives now?
TAYLOR: So I would say I have different relationships with midwives now.
LANGDALE: Mm-hm.
TAYLOR: I don't think it's perfect still, but I think back then there was a notable -- I would say I felt intimidated to go and talk to -- mostly the senior midwives or the Consultant obstetric doctors I would feel intimidated to talk to them.
LANGDALE: We know from parents who have given evidence that they were dependent sometimes on midwives for getting down to see their newborns because there was a process to get through there --
TAYLOR: Yeah.
LANGDALE: -- and they'd had surgery and in some cases needed assistance. If you felt that, do you think it might have been difficult for them to ask for help or assistance, or they may have felt intimidated or not? Do you think it was because you were a nurse?
TAYLOR: Yeah --
LANGDALE: I'm just interested in that communication
generally.
TAYLOR: I mean, I don't feel like I can comment on how they would feel. I think, from feedback that I've had from parents about midwives, the care has always been positive mostly. So I think that probably isn't the case. But I don't -- I don't know if I could comment on that from a different perspective.
LANGDALE: You say the relationships between doctors and nurses on the unit, on the NNU, were good. Can you expand on that?
TAYLOR: Yeah, I -- I think, yeah, they worked -- we worked well together. I think that we had good communication. I think -- yeah, I particularly didn't feel like there was any concerns with the communication at all. I think -- I think as a team we're quite approachable, and I think that reflected in the relationships we had with doctors.
LANGDALE: So you didn't find that the Consultants were dismissive of you or in any way you could speak to them about things?
TAYLOR: No, no.
LANGDALE: Did you find they pushed your views aside in any way and their views were best about things?
TAYLOR: No, quite -- quite the opposite, really. I think I always felt listened to by the Consultants, even as a junior nurse I felt listened to. So, no, I wouldn't agree with that.
LANGDALE: And did you feel you could ask them things if you were worried about anything or raise things?
TAYLOR: Yeah. I did, yeah.
LANGDALE: You answered that swiftly. So, unhesitatingly, there's nothing in your mind -- there's not a gremlin there where you think, "I remember that time or this time"? There's no example you could give us where that wasn't the case?
TAYLOR: No, I've always felt -- even -- I did my nurse training on the neonatal unit and the paediatric unit at the Countess, and I would say as a student they were approachable and kind and friendly to students -- to all members of staff, so I -- yeah, I've always found them -- personally, I've always found them very approachable and I feel like I can ask them questions.
LANGDALE: I'm going to ask you now, Ms Taylor, about [Child A]. And we know from your statement that [Child A] was the first death you had experienced in hospital. We know that you had a handover from Ms Hudson -- with the passage of time you can't really remember now -- from one shift to another, don't you -- didn't you? And then what happened on your shift? We don't need all the medical details but what was your
experience of looking after Baby A [Child A] and what happened subsequently?
TAYLOR: So, I mean, again, my memory is -- is not fully there compared to a few years ago. This was quite a long time ago. I remember him being well or -- I say well, he was obviously needing support, usual care, but he was stable throughout the shift. I remember the shift being busy and struggling with some lines. I had no concerns about him throughout my shift.
LANGDALE: And what happened subsequently?
TAYLOR: So I because -- I handed over to Lucy Letby, I don't remember that, but I know that I've written that in my -- I don't remember the actual handover but I know from reading my statement again that I handed over to Lucy. I -- up to that point, he had still been stable and I had no concerns. I sat at the computer, which was visible, so he was visible to me while I was writing my notes. Technically I think I was either at the end of my shift or I'd just finished my shift, I just needed to finish writing up my notes for the day. I think probably my statement has it in more detail from what I remember a few years ago, but he started to
desaturate. Lucy was standing by the incubator. I can't remember whether I got called over or whether I went over myself because he hadn't been doing that, I think he had a sustained either desat or bradycardia. Yes, and then --
LANGDALE: And an emergency assistance call was put out, wasn't it? Dr Harkness came.
TAYLOR: Yeah.
LANGDALE: And sadly we know what followed.
TAYLOR: Yeah.
LANGDALE: What was your reaction at the time to that death? You've explained that he was stable, you weren't worried about him, and then he died. Was that unexpected to you?
TAYLOR: It was very unexpected.
LANGDALE: The Inquiry has received evidence from all of the people that were there at that resuscitation. Dr Harkness I think took some time off he was so upset by it. How were you feeling about it?
TAYLOR: I -- well, honestly I was devastated. I -- it isn't -- will never be easy, no matter how many times you encounter death of a baby. You -- all you want to do is care for and look after and get these babies home with their parents, and I took it very hard. I was --
yeah, I was really upset. Really, really upset afterwards.
LANGDALE: Who took the lead with dealing with the parents or the mother and addressing memory box and the like?
TAYLOR: I don't know. I wouldn't have been there, because it was the end of my shift, so I -- I stayed for the resuscitation. But once he had passed away, I went home. So it will have been later on in that night shift that a member of staff will have managed that, and I wasn't there at that time.
LANGDALE: He had died, hadn't he, in Nursery 1?
TAYLOR: Mm-hm.
LANGDALE: What was the view about going back to the same nursery after that experience? Had anyone discussed that with you?
TAYLOR: I don't remember anybody discussing that with me.
LANGDALE: Do you know what thoughts you would have had about that, about whether you would go back into the unit?
TAYLOR: Yes.
LANGDALE: What were your -- your what was your thinking having experienced that on that shift in Nursery 1?
TAYLOR: So my personal experience was I found it extremely traumatic and difficult. I found it difficult to go back into work. And I wouldn't have wanted to voluntarily go back into Nursery 1. It would obviously depend on capacity and staffing, but I would have voiced my request not to go in there if possible. Yeah, that -- that was my personal opinion once -- when a traumatic event happened in 1 I wanted, you know, possibly call it a break from more intense unwell babies and wanted to maybe look after some special care babies.
LANGDALE: And to resume later on or at another time going back to that nursery?
TAYLOR: Yeah.
LANGDALE: I'm going to take you, if I may, Ms Taylor, to some text messages between Letby and another nurse on the unit and the reference is INQ0000101, page 6. So and at the bottom it is the last message of that page, going on to page 7. The last message: "I just keep thinking about [Monday]. Feel like I need to be in 1 to overcome it but Nurse W said no ..." So that's Letby texting to say that she wants, after the death of Baby A [Child A], to be back in Nursery 1. Colleague says: "I agree with her [that's Nurse W] [I] don't think
it will help. You need a break from full on ITU. You have to let it go or it will eat you up i know not easy and it will take time ..." And we go to page 7: "Not the vented baby necessarily. I just feel I need to be in 1 to get the image out of my head, Mel said the same and Nurse W let her go. Being in 3 is eating me up, all i can see is him in 1 ... It probably sounds odd but it's how i feel ..." Your colleague says: "Well it's up to you but don't think it's going to help. It sounds very odd and I would be the complete opposite. Can understand Nurse W [she's] trying to look after you all ..." Received from Letby, if we can scroll down a bit, please, Ms Killingback: "Well that's how I feel, from when I've experienced it at women's ..." That's Liverpool Women's Hospital, presumably: "... I've needed to go straight back and have a sick baby otherwise the image of the one you lost never goes. Why send Mel in if she's trying to look after us, she was in bits over it." "Don't expect people to understand but I know how I feel and how I've dealt with it before ..."
Pausing there, this was your first baby death, were you aware from Letby how many baby deaths she had been present at or experienced or not? Did that ever crop up?
TAYLOR: No, not at that time, no.
LANGDALE: So she says: "... I've voiced that so can't do any more but people should respect that ..." Your colleague says: "Ok ..." And your colleague says: "I think They do respect it but also trying to help you. Why don't you go in 1 for a bit ..." "yeah, I've done a couple of meds in 1. I'll be fine ..." "It didn't sound like you would be?" Says your colleague: "Forget I said anything [says Letby], I'll be fine, it's part of the job just don't feel like there is much team spirit tonight ..." If we go down again. Stop there, please. Again from Letby, message 31363: "Unfortunately I've seen my fair share at the women's but you are supported differently & here it's like people want to tell how to think/Feel.
"Anyway. Onwards & upwards. Just shame i'm on with Mel and Nurse W ..." If we go down two more messages: "Women's can be awful but I learnt hard way that you have to speak up to get support. I lost a baby one day. and a few hours later was given another dying baby just born in the same cot space. Girls there said it was important to overcome the image. It was awful but by. the end of the day i realised they were right. It's just different here ... Anyway, forget it. I can talk about it properly with those who knew him and [Mel's] not interested so I'll overcome it myself." When did you -- that can come down now, please -- when did you first see that text exchange?
TAYLOR: I -- I don't know the exact time but it was around the trial.
LANGDALE: Around the time of the criminal trial?
TAYLOR: Yeah, the criminal trial.
LANGDALE: Can you comment on that for us, tell us what you make of all of that?
TAYLOR: Yeah, so as -- the first time I saw it I knew the comments about me wanting to go into -- back into Nursery 1 were not true, because I know my own feelings. The only thing I could take from it was that I had no choice in the fact with the skill mix and the fact that there was a more junior member of staff that needed supporting.
LANGDALE: And you were the Band 6?
TAYLOR: I was the Band 6. I wasn't in charge, but I was the Band 6.
LANGDALE: So you had to go back in that next day?
TAYLOR: In theory, yes. And I think I probably agreed to go in there and say -- and I -- that's -- I can't remember this but this is -- I -- the only thing I can think, reading from these, was I agreed to go in there because that was the most reasonable choice with the staffing and the babies that were on the unit.
LANGDALE: But if you'd your own way and that wasn't required you'd clearly not --
TAYLOR: I wouldn't have.
LANGDALE: -- have done that?
TAYLOR: No. And sometimes -- you know, it can depend on the babies that are in there as well. Sometimes you can get babies that aren't intensive care in there, so that may not have been -- I mean, I think -- but, out of choice, no, I know I definitely wouldn't have expressed a want to go in there.
LANGDALE: And was that anything that Letby had discussed, the suggestion at Liverpool Women's Hospital, that she went straight back to the same cots? Was that
ever discussed with you at the time or subsequently?
TAYLOR: I don't remember that being discussed.
LANGDALE: Have you ever heard of that as a way of getting over or dealing with trauma?
TAYLOR: No.
LANGDALE: If -- if -- I'm not suggesting that was the case, I'm just saying the assertion that that was the way of dealing with it?
TAYLOR: No, I've never heard --
LANGDALE: Have you heard of that since?
TAYLOR: No. I think -- I mean, Liverpool Women's is a very different unit and they have a lot more babies, and they have a lot sicker babies, so it's definitely a -- you know, probably -- well, it definitely happens there a lot more. So I think the staff would be involved in it a lot more. But, I mean, it's still my personal view if you -- that a death is a traumatic event for everybody and really, really upsetting, and I think it's still my view, and I wouldn't change that, that if you go through something like that that actually ideally a break from that situation is the best.
LANGDALE: And standing back from that communication, it is a request to go back to Nursery 1, isn't it --
TAYLOR: (Nods).
LANGDALE: -- which we pick up again later on in relation to Letby? I'll come to that now -- shall we move on to [Child C]?
TAYLOR: Yes.
LANGDALE: So if you look at [Child C], paragraph 18 of your statement, you tell us when you were first called to [Child C]'s cot. What was the situation -- and if you look at your statement there at paragraph 18/19, what did you see, what did you observe with [Child C]?
TAYLOR: Sorry, could you repeat that I didn't quite hear that.
LANGDALE: Yeah, when you -- when you went to [Child C] at the resuscitation, what did you observe? You tell us at paragraphs 18 and 19.
TAYLOR: Yeah, so, there was -- there's a -- I can't remember exactly who was in the room, and I know this was discussed -- this has been discussed previously. What I do remember is Lucy was in the room. What I can't recall is whether -- when I arrived in the room what I can't recall is whether Sophie was already there or came in after me. She was --
LANGDALE: What band was she, Sophie?
TAYLOR: She was a Band 5.
LANGDALE: Right, so the same as Louis you --
TAYLOR: She was the one --
LANGDALE: -- and you're the most senior.
TAYLOR: -- caring for the baby.
LANGDALE: So Sophie's caring for the baby, Letby is there, what do you observe? You described the use of a piece of equipment that you were surprised by.
TAYLOR: Yeah, she -- so, again, my memory of the specific events is, you know, not great any more. I remember -- but I do remember her using a Guedel airway, which is an airway adjunct, which if you are struggling to inflate the chest, inflate the lungs with inflation breaths or ventilation breaths that can help open the airway to assist that.
LANGDALE: So it's a piece of equipment that's usually used, what, had by doctors or --
TAYLOR: It can be used by doctors or nurses. It's something we get training in using, but very rarely get to use.
LANGDALE: Have you ever used it?
TAYLOR: No.
LANGDALE: At that stage you're there more senior than the other two, and is it usual that somebody more junior is using a piece of equipment that you've never used or wouldn't use?
TAYLOR: I mean, not -- I -- I -- no. And I think that's what struck me about that situation was that she seemed quite -- she seemed confident to use this adjunct, and I couldn't personally say that about myself. I definitely had training and I had the knowledge to use it, but I wouldn't say I was confident in using it on a real baby because I'd never actually used it on a real baby at that point.
LANGDALE: Did it strike you odd at the time or is that more in retrospect when you thought about it?
TAYLOR: No, it did strike any as odd at the time.
LANGDALE: Right. Did you mention that to Eirian Powell or anyone?
TAYLOR: No.
LANGDALE: And was that before the doctors arrived to help with the resuscitation that she used that or can't you --
TAYLOR: Yeah.
LANGDALE: So she was using that and the doctors arrived.
TAYLOR: As far as I remember, yes, it was before the doctors arrived because I think they would have taken over at that point.
LANGDALE: So she'd taken the lead when there were just three nurses and then the doctors arrived?
TAYLOR: Yeah.
LANGDALE: We know from Nurse W's statement, which I think you have seen, that on that night she describes
herself as being becoming "a little bit mad" with Letby during the shift because she had wanted her to be looking after her baby, and [Child C] wasn't the baby Letby should be looking after. You nod, so is that your recollection?
TAYLOR: I -- I vague -- vaguely remember the nurse -- was it Nurse W?
LANGDALE: Yes.
TAYLOR: -- nurse W speaking to me and asking me -- that she was frustrated in that Lucy wasn't listening to her and was focusing on supporting me with the family, wanted to be in there rather than looking after the baby she was allocated, and that's about all I remember. But I do remember that conversation because I think she was -- she found that a difficult situation because she had been quite explicit in what she wanted Lucy to do, and that wasn't followed through.
LANGDALE: We'll hear evidence from Nurse W about that, but you remember her saying it to you that evening itself as well. She tells us that she mentioned that to Eirian Powell. Did you have a discussion with Eirian Powell about the use of the Guedel or any of that or not?
TAYLOR: I -- I honestly don't remember. I don't think I discussed the use of the Guedel because it wasn't
something that was necessarily out of our scope. It was just something that I was surprised she was so confident with, but she that hadn't done necessarily -- in my view, at that time, necessarily done anything wrong. I -- I don't remember if I had any conversations with Eirian after that point.
LANGDALE: I'm not going to ask you about the taking of [Child C]'s hand and footprints or any comments. Mr Baker is going to ask you questions about that after my questions --
TAYLOR: Yes.
LANGDALE: -- but you address that in your statement. I'm going to move on if I may to [Child I], who we know, of course, was -- we know now was murdered on 23 October. [Child I] is a child that had had a series of collapses, hadn't she?
TAYLOR: (Nods).
LANGDALE: And you say she was on the unit for a while and you'd got to know the parents and the child.
TAYLOR: Yes.
LANGDALE: Again, how did you respond to this death, was it expected, from your point of view, or not?
TAYLOR: No, I was -- again, I was shocked and really, really upset. As we all were. It's -- yeah, it -- it
never gets any easier. It's always really hard. But yeah, I wasn't expecting -- it was -- it was a shock.
LANGDALE: And I think you spoke with the parents, didn't you? You had some dealings with the parents.
TAYLOR: I think, yeah -- I -- I don't remember fully. I -- I don't know how much. I know I've written in my statement again that I think possibly that I had a few words with them but I -- I couldn't tell you what conversations I had with them.
LANGDALE: You tell us you don't remember if there was a debrief meeting or discussion about the unexpected death of [Child I]. But were you -- would you have expected to have been invited to one if there was, given your involvement with [Child I]?
TAYLOR: Yes.
LANGDALE: And why is that? Tell us about debriefs and why you would or would not expect to attend them.
TAYLOR: So debriefs are basically a meeting, an -- a fairly informal meeting of members of staff who were present at a death or a traumatic event on the unit, such as a resuscitation. It's an opportunity for staff to talk about what's happened, to discuss between themselves -- to talk about things that went well and possibly things that didn't go as well. Yeah -- and it's sort of supposed to be a safe, free space to -- to discuss what happened between staff members.
LANGDALE: When you say a safe space, what's -- what's the purpose in your mind of the debrief?
TAYLOR: The purpose is to be able to process to a certain extent what's happened. I think if you internalise a situation and don't have those conversations sometimes that situation can be a lot harder, and sometimes you can hear things from other members of staff's perspective, which can be helpful. I would say the main purpose of it is support for staff. Yeah, support for staff.
LANGDALE: Had you -- you say in one of your police statements that Baby I [Child I] was only your second death that you'd experienced, you'd the experience earlier and then you'd Baby I [Child I] as well. As you sit here today, how many unexpected deaths have you experienced in neonates?
TAYLOR: A few. I don't know the exact number.
LANGDALE: And in the Countess of Chester that year were the first two.
TAYLOR: Yeah, I'm not 100% sure. I have said in my statement that it was the second, but I'm not sure of the timeline, so I'm not sure whether there was another one because obviously this was a few years later.
But, yeah, there -- there was -- yeah, there was quite a few and it was noticeable to staff that there was a few.
LANGDALE: And in terms of unexpected, when a death was unexpected, did you -- and I'm not saying you should have done, but what did you think was the process or what needed to follow after an unexpected death? You've said the debrief and support staff?
TAYLOR: Yeah.
LANGDALE: Did you think there should be referrals by doctors or other people to other agencies if it was unexpected or not?
TAYLOR: Yeah, I think -- I know there are processes now. I think at the time I -- we had specific bereavement paperwork which had a sort of a checklist to make sure that we had covered at nurse-wise all the areas that we needed to cover in terms of who we needed to let know. In terms of the doctors, I would say at that time I had less awareness of what processes they needed to do. I knew that they had a set of processes they needed to go through, but that was -- at that time it was out of my realm of -- and my scope of practice, so I wasn't as aware then.
LANGDALE: You move on at paragraph 27 of your statement
to [Child O]. Can you tell us about [Child O] -- by all means remind yourself of what you've said in your statement here -- about what nursery he was in, what nursery he was moved to and so on? Do you want to tell us about that?
TAYLOR: What nursery he was moved to?
LANGDALE: Yeah, what nursery he was in, and you describe moving him into another one. Just tell us that now how --
TAYLOR: Yeah, again, I can't remember the specifics. It was -- it was either him or his one of his brothers who was in Nursery 1, and I think, from what I can remember, the other two were in nursery 2. And, yes, one of -- the decision was made, at some point on that shift, that they were all going to go into nursery 2, so whichever sibling was in Nursery 1 got moved into nursery 2 so that they could be together.
LANGDALE: And you describe having a gut feeling about Baby O [Child O].
TAYLOR: Mm-hm.
LANGDALE: Can you tell us about that, when you thought he didn't look so well?
TAYLOR: Yeah. So it's a hard one to quantify because, as far as I can remember, there was no clinical recordable signs that I could have said this baby is
deteriorating. So his observations, such as his heart rate, breathing, stayed the same or stable as he was previously. And so it is a hard thing to explain that gut feeling. Sometimes you look at a baby and notice that they may be have some respiratory distress. But I'm assuming it is not that either. I don't physically remember like I felt that, apart from the gut feeling because, again, that isn't a more quantifiable thing that you can record as a possible deterioration of a baby. However, sometimes it can be their colour or just maybe they're a little bit quieter than normal, and sometimes those things are hard to define or prove that that is a deterioration, and sometimes it is just your experience of working with babies and seeing lots of babies that you maybe notice more subtle things, which are hard to pinpoint to say this is a deterioration or not, but maybe you have -- that's why I've said sort of a gut feeling that maybe something -- but it's -- it's -- I know it really -- it sounds possibly implausible, but I think it's -- yeah, that would have been what it is. I think it is definitely a thing that you can notice as a nurse that's worked with premature babies for a few years.
LANGDALE: And you told the police that at one point you said to Lucy Letby: "He doesn't look as well now as he did earlier. Do you think we should move him back to 1 Nursery 1 to be safe?" And you recalled Lucy saying closer to the time: "No, no, I want to keep him in Nursery 2. I feel like he's okay. We'll just monitor him here for now." And that's where he was with his siblings. So to you, you thought, well, he is with his siblings --
TAYLOR: Yeah, and I think that's -- I think -- I can't remember at that point whether that was my more gut feeling or whether there were some other signs, but there was clearly something that prompted me to think that he wasn't as well and possibly could be moved. And Nursery 1 -- the reason we put them in Nursery 1 is because there's more equipment in there, so it's more easily accessible if a baby deteriorates. But I also understood the rational of -- to a certain extent the rationale of keeping the siblings together because that's also a really important part of family care.
LANGDALE: And what happened subsequently?
TAYLOR: Again, I can't remember the exact details, but he did deteriorate. So I know that he had subsequent desaturations and bradycardias, so that would have been
significant. And the Registrar was called and we moved him into Nursery 1 to be able to keep a closer eye on him. And, yeah, I think he continued to -- to have profound desats and bradys and needed -- subsequently needed resuscitation.
LANGDALE: And you say in your statement you don't recall if Lucy Letby said anything to you after his collapse.
TAYLOR: I don't remember.
LANGDALE: We know, of course, the next day [Child P] died, and there is a statement from another nurse, Nurse Lightfoot, who says she recalls Letby commenting in an excited fashion -- we'll hear from Nurse Lightfoot -- to another nurse who came on to the unit, words to the effect of, "You will never guess what's just happened." Was that you that she said that to? Is that how you learnt of Baby P [Child P]'s death?
TAYLOR: I -- I don't remember if it was me. I do remember an occasion where she came up to me just as I was coming on shift to tell me about a baby that had died in a similar manner. I don't --
LANGDALE: What's a similar manner? You use your words, I've given you Ms Lightfoot's --
TAYLOR: Yeah.
LANGDALE: -- but what would you describe --
TAYLOR: So, yeah --
LANGDALE: -- the manner?
TAYLOR: -- it was almost in a way where she was excited to tell me almost like a gossip -- in a gossipy manner. But I can't remember if that is this time or another time.
LANGDALE: But you have the same -- you do have experience of that "in an excitable manner" saying something.
TAYLOR: Yes.
LANGDALE: At the time -- obviously you know what you know now, but at the time, did it strike you as odd or something unusual or disrespectful in some way?
TAYLOR: Yes, it did.
LANGDALE: It did?
TAYLOR: Yeah. I -- I mean this is -- I -- there were -- I did think she was -- there were parts of her personality that were a little strange to me, so I took that as a personality difference between me and her.
LANGDALE: We asked you about suspicions and concerns. With that hat on, any concerns about a personality or comments like that, what were your concerns? I'm not saying at the time where they would have led you to thinking but please share them with us.
TAYLOR: Yeah, I didn't have any suspicions that she
was -- any of this, this didn't cross my mind. I -- I wouldn't say necessarily I had concerns about her care. There was obviously the incident when Eirian came to speak to me about her not paying attention -- as much attention to the baby that she was looking after on shift with the Baby C [Child C], I think it was. So I was aware of that. I personally didn't have any concerns with her nursing care. I think I had -- I wouldn't say they were -- I wouldn't say they were necessarily concerns but I -- her way of speaking to other members of staff sometimes I didn't like and felt wasn't the most professional. But other than that, I didn't have any concerns about her actual nursing care. She was very intelligent, she appeared to be able to manage babies, as far as I could see, well.
LANGDALE: You describe -- just dealing with the issue of the death of the baby, I'm going to ask for your police statement please to be on the screen INQ0001404, page 7. 0001404_0007. I'm not going to read it out for you, but you see where you begin "As a unit" you set out there no doubt the saddest aspects of your work. And in the third -- sorry, fourth paragraph, you set out movingly and with compassion how you would perform the act that you're describing there where you accompany the Porter, you'd would like to walk with them: "... as I would like to think someone was doing that if it were my baby."
TAYLOR: Yeah.
LANGDALE: So you have described how you feel it is appropriate around infant death.
TAYLOR: (Nods).
LANGDALE: When we see text messages about deaths, now we know murders, what's your comment as a nurse who has that aspect of your work as well to address? What do you make of those comments?
TAYLOR: Which comments --
LANGDALE: The comments --
TAYLOR: -- specifically?
LANGDALE: That I've taken you to wanting to get back to Nursery 1., the comments, "You never guess what", putting them together, which, of course, my Lady will be able to do at the end, I'm not suggesting you can, but when you look at those comments now, and I read how you describe in one of your many police statements how you would conduct this or be involved in this event, what do you make of it?
TAYLOR: I think they're -- it's highly inappropriate. I think -- yeah, like I've said there, when it comes to
the death of a baby, I would always want to be led by parents, and I would always want to put myself in -- as much as I can, I can't wholly, but put myself in their shoes and think what would I want as a parent and how would I want people to, even if they're not there, discuss and talk and what kind of care I want, and that's from my personal values that's really important.
LANGDALE: Compassionate?
TAYLOR: Yeah. And I think that the text messages that I've seen show a complete lack of compassion.
LANGDALE: You tell us in your -- that can go down now, thank you. You tell us in your statement at paragraph 34 you weren't aware of any derogatory comments made by anyone at the time, whether it was nurse (inaudible) whatever the comments were, you didn't hear that kind of conversation. We do know from Dr Lambie that, by September 2015, she had observed a group of nurses in a huddle trying to work out or looking at row rotas, where in effect her evidence was they had begun to think the unthinkable and thinking is there a link between somebody and these unexpected deaths or events and looking at rotas. Do you know anything about that conversations by September 2015 between nurses thinking these events are
happening?
TAYLOR: No. If they were happening -- if they were happening, I was not aware of them. I wasn't aware of any suspicions or concerns.
LANGDALE: Or questions -- I'm not suggesting suspicions -- the questions at that stage thinking, well, who's on shift? What's going on here? That's not necessarily the same as having a --
TAYLOR: Yeah --
LANGDALE: -- concern about an individual.
TAYLOR: I don't -- I don't -- again, I don't recall that. I think I did hear comments, I don't know who specifically, but from staff about -- and I think we all thought that that she was there for a lot. My personal feelings, and from what I heard from other staff, were that it was really unfortunate that she'd been there for so many tragic events.
LANGDALE: Looking back now, what was it either about her or the situation that took you to that place as opposed to thinking, well, it's suspicious so we should get someone in -- not you -- everybody to investigate it. What was it about her that --
TAYLOR: Well, I think that is an unthinkable thing in a way. I think you don't -- you don't ever think that of somebody you work with and you work closely with.
I think nursing is a profession where you put your trust in each other. And, I mean, this is not an event that happens in anybody's lifetime. I think it's -- it's not something -- it's not a conclusion I personally would ever jump to, I think, about anyone unless I'd seen something specific. I think it was so unthinkable it wasn't -- it was -- it almost felt that just wasn't something that crossed my mind. I --
LANGDALE: So you'd needed to have to see something, see a deliberate act. The thought of something being unexpected and unexplained --
TAYLOR: Yeah.
LANGDALE: -- needing more investigation isn't where your thought process would have taken you to --
TAYLOR: Yeah.
LANGDALE: -- you'd need to see someone doing something Wong?
TAYLOR: And I think it is such an unbelievable situation that someone would do that, especially someone you would work with and you had worked closely with, and I -- I personally -- at the time, I would have thought, well, there would be signs of that. And, you know, hindsight there are things that don't match up or -- but actually, at the time, I think your rational brain would never go to that when you work so closely with somebody and it's -- I think your rational brain decides that's what happens to premature babies. When I look back now I think, well, no, that's not what happens, but I think if you thought that about any situation I think you'd have a very difficult view on life, so it's not something that my personal brain would jump to that kind of conclusion because I didn't have any evidence for it.
LANGDALE: As a group premature babies are vulnerable, aren't they, like old people --
TAYLOR: Yeah.
LANGDALE: -- as we get older we are more vulnerable? So do you think it was a false reassurance, well, they're a vulnerable group that's why this has happened, we don't need to --
TAYLOR: Yeah.
LANGDALE: -- think the unthinkable, it seems that this could happen?
TAYLOR: Yeah. I think -- and that's -- and that was my belief at the time. I thought that these babies are vulnerable babies. When I look back now, it -- actually, no, it doesn't add up, but that's -- that was the majority of my career was seeing lots of babies and a large proportion of that was babies unfortunately collapsing and dying, and that made up a lot of my
career --
LANGDALE: At that stage --
TAYLOR: -- and that's what I saw --
LANGDALE: -- yeah.
TAYLOR: So that is -- that was my belief, and I -- yeah, I thought --
LANGDALE: And what's your understanding now? You obviously stayed in the field --
TAYLOR: Yeah.
LANGDALE: -- so when you say that wasn't the case -- and the babies you were involved with, they were stable, weren't they, they were well, that's why you were shocked at the time?
TAYLOR: Yeah. And that's it, I think -- yeah -- I mean, hindsight is -- makes you realise a lot of things, especially when these things are laid out in front of you when you don't necessarily have the whole picture always. But, yeah, I would say actually now I think I would be suspicious of so many babies collapsing, but at the time I genuinely wasn't. I thought that was part and parcel unfortunately of being premature.
LANGDALE: The purpose, of course -- a purpose -- a key purpose of this Inquiry is to consider how this may never happen again. So with that powerful benefit of
hindsight, aside from the fact of the unexpected deaths and deteriorations and their number, what do you know now from either listening to the criminal trial, reading what you have of statements of others about Letby herself that could help with that signpost to how could this be avoided again?
TAYLOR: I don't know because that's -- that is a really hard question, because I think if you took all away -- all this that's happened in the last few years and put me back in that situation, I still don't -- I still think I would probably wouldn't pick it up because -- well, I don't know. I think ...
LANGDALE: It sounds like you would have questioned more the assumption that premature babies die --
TAYLOR: Yeah.
LANGDALE: -- with experience.
TAYLOR: I think I still would find it hard to jump to a conclusion that a member of staff would do that without evidence of that, which I didn't have.
LANGDALE: Would you appreciate, though, going to the police earlier or getting people to investigate unexpected deaths --
TAYLOR: Yeah.
LANGDALE: -- without knowing the answers? How could you know the answers? You don't have all the investigation
tools the police have, do you? You don't get to people's homes or laptops or anything else they look for or at?
TAYLOR: Yeah, I think -- yeah, 100% I think -- and I was not privy to any of this information. I did not know any of this when this was going on in the background at the time. But, yes, 100%, I think that was -- that they should have been involved much sooner.
LANGDALE: On that point, we know, of course, and you must know now, that Letby kept 231 handover sheets stored at her home, and 21 of them related to babies in the indictment. Did you ever see her walk out with handover sheets? What was the position about those for nurses?
TAYLOR: No. We had confidential waste-bins so after -- at the end of a shift you were expected to put your handover in the confidential waste-bin.
LANGDALE: And everyone knew that?
TAYLOR: Yes. But, no, I never saw her take it home -- any -- I mean, it's a little piece of paper that's often folded --
LANGDALE: Sure, easy --
TAYLOR: -- so --
LANGDALE: Exactly.
TAYLOR: -- it's easily --
LANGDALE: No, I understand that. But if you'd seen someone walking out with them, you would have questioned that but you didn't see that, clearly?
TAYLOR: No. And, you know, mistakes do happen sometimes. If -- you -- sometimes you can go, "Oh, I forgot to put this back", and go back and put it in the confidential waste, because we're all human at the end of the day but, I mean, not on so many occasions that is, yeah.
LANGDALE: No. There came a time, didn't there, where the RCPCH were invited to do a review?
TAYLOR: (Nods).
LANGDALE: Can you remember roughly what you were told about that? Did you know who was going on when that was happening?
TAYLOR: Yeah. I -- I don't remember much. I -- I was aware of the fact that they were coming and it was to look into the fact that we'd had quite a few deaths. My understanding at the time, as far as I can remember, was it was to rule out if there was any underlying cause, like if there was any infection on the unit, or anything that could have contributed to these -- I assumed it was sort of -- would have been a routine thing that was undertaken maybe if you had a -- an increased rate that -- I don't know if that was explained to me but
I think that's probably what I felt at the time.
LANGDALE: And you weren't interviewed, I don't think, you weren't --
TAYLOR: I don't think so, no.
LANGDALE: We know at around the same time some emails were coming to all of the nursing staff. Can I ask that we put on the screen please 0002879, page 91. Can you see that, Ms Taylor? So it's 15 July. "Hi everyone." It is an email from Eirian Powell: "In preparation for the external review, it's been decided that all members of staff need to undertake a period of clinical supervision. Due to our staffing issues it's been difficult to determine how we undertake this process. We can only support one member of staff at a time. Therefore, we've decided to that it would be useful to commence with staff who have been involved in many of the acute events facilitating a supportive role to each individual. Therefore, Lucy has agreed to undergo the supervision first commencing on Monday, 18 July 2016. "I appreciate that this process may be an added stress factor in an already emotive environment, but we need to ensure that we can assure a safe environment in addition to safeguarding not only our babies but our
staff. This is not meant to be a blame or a competency issue -- but a way forward to ensure that our practice is safe. It will probably be developed into a competency-based programme to be undertaken every two to three years in line with our mandatory update training." Did you see that at the time?
TAYLOR: I -- I don't remember specifically this email, but I -- I think I probably did see the email.
LANGDALE: What did you make of that?
TAYLOR: I don't remember. I don't remember this specific email. I remember one of the other ones that she sent.
LANGDALE: Shall we go to one of the other ones? Shall we go to 0002879, page 75. Sorry, that one can go down the 15 July. We're looking for 9 August, which is 0002879, page 75. Was that this one?: "Hi all, there are currently opportunities for staff to apply for secondments throughout the Trust. It has therefore come at an opportune time for us and we were able to facilitate this for Lucy. Lucy is currently seconded to the risk and patient office for a period of 3 months ..." Three months, sorry, that's my eyesight.
And so you see the email there.
TAYLOR: (Nods).
LANGDALE: Did you see that one?
TAYLOR: Yes.
LANGDALE: So what did you make of that one?
TAYLOR: I can't really remember. I think at the time it's -- I took it as truth that this -- she was being seconded to another area. And I -- I found it quite believable. I think also, because there was another member of staff going on secondment, it seemed very plausible that that was her decision that she wanted to do and I don't think I, as far as I remember, thought that much more about it.
LANGDALE: Did you have a conversation with Lucy Letby herself about that or not?
TAYLOR: No, not that I remember.
LANGDALE: And then, finally, another email that was sent to everyone, 0058624, page 1. This is from Letby to colleagues: "Dear colleagues, I was redeployed from the Unit in July 2016 following serious and distressing allegations of a personal and professional nature made by some members of the medical team. From then until now I have been unable to visit or contact the Unit whilst these matters were investigated. After a thorough investigation it was established that all the allegations were unfounded and untrue and I have therefore been fully exonerated. I have received a full apology from the Trust but as you can imagine this whole episode has been extremely distressing for me and my family. "I will begin my return to the Unit in the coming weeks. I will need colleagues to be sensitive and supportive at this time." Did you receive that?
TAYLOR: Yes.
LANGDALE: And what did you understand when you received that?
TAYLOR: As far as I can remember, I don't think I was in any conversations about these allegations. I was unaware. So this came as a surprise to me. I think from -- possibly naively -- or what I thought this was probably a clinical competence thing that maybe they had questions around her clinical competence because it doesn't say what the allegations are. I did find it quite surprising, and I don't really know further kind of my thought process on it. She -- she never came back to the unit --
LANGDALE: She didn't come back to --
TAYLOR: -- physically to work.
LANGDALE: -- work, did she?
TAYLOR: No. Yeah.
LANGDALE: I think there was a tea party. One nurse told us about a tea --
TAYLOR: No, I don't think I was present for that --
LANGDALE: No.
TAYLOR: -- as far as I remember.
LANGDALE: Did you see her have any other informal visits at all in this period in 2017 -- from January 2017?
TAYLOR: Not that I can remember.
LANGDALE: So you don't remember her popping in, and you certainly weren't at that little tea party to welcome her or whatever?
TAYLOR: No. I don't -- I don't think I was present for the tea party. I don't know if I knew about it. I don't remember it.
LANGDALE: Did you --
TAYLOR: But, yeah, I don't remember any other occasions that she came on to the unit.
LANGDALE: Did you know if she was doing any observational placements at Alder Hey or anything like that, was that talked about?
TAYLOR: No. That's only since more recently that I found out about that.
LANGDALE: So you were getting on with your own work at
that point and weren't having --
TAYLOR: Yeah.
LANGDALE: Were there discussions generally amongst nurses about what was going on? It seems --
TAYLOR: I mean, there -- there probably was. But what -- I can't remember any specific conversations. I don't -- yeah, I don't remember any specific conversations. I'm assuming probably following that email there probably was some between staff, because I think that's quite a surprising email. But I don't remember. There certainly wasn't any kind of thoughts that she -- of what she had done -- what she had found out to have done at that time from conversations I had.
LANGDALE: The request for support and the need to be sensitive, do you remember that being discussed or whether people were supporting her and being sensitive in the light of that?
TAYLOR: I know that she had a couple of people on the unit that she was close to. I -- so I assumed that they were supporting her through that. But she -- it's -- personally I didn't support her through anything, I didn't see her, and we weren't social outside of work. So --
LANGDALE: Understood.
In terms of reflections, you say about CCTV it would be unlikely -- well, let me put it a different way. What about having a little CCTV camera in the incubator so you can see the baby, for two purposes, one, if the unthinkable, as you have described it, occurs and, two, for mothers who are separated from their newborns can see them if they're on a different part -- in a different part of the hospital, or if they're at home -- whatever the circumstances they can see their own child, do you think that would provide reassurance in the future to people leaving their babies in neonatal units?
TAYLOR: Yeah, possibly. I think that might be quite a personal opinion and maybe that may differ between families to families as to whether that's something that they feel is appropriate for their babies to be -- have CCTV in their incubator, and I think that's something that I probably can't answer. But I think definitely the fact that the CCTV in there -- if the parents were -- say, the mum was on the labour ward or the postnatal ward and wasn't able to visit, and they won't be able to -- weren't able to see each other I think most parents would probably like that aspect of it. I think one of the issues, and, again, it's probably more information and evidence than I have, that in terms of privacy and are these CCTVs being recorded, who has access to them, I think those are possibly issues, and confidentiality, you know -- I don't think it's necessarily a bad thing but I think there's a lot of --
LANGDALE: Checks and balances?
TAYLOR: -- things around it, and I think maybe it might be a personal preference between families as to whether they would like that or not. Yeah, it's a difficult one to answer. I think definitely -- I mean -- and I think another thing would be is that something that would be manned 24/7 because I know that later on there were concerns from some members of staff in this situation, but from my perspective I didn't know that there was any concerns about a member of staff. So, yeah, I think there's -- it brings up a lot of questions, but also it could be beneficial. It's -- I think it's a hard one to answer.
MS LANGDALE: Thank you very much, Ms Taylor. Those are my questions. There's a few from Mr Baker.
TAYLOR: Thank you.
LADY JUSTICE THIRLWALL: Mr Baker.
BAKER: You were taken to your police statement a little while ago and shown a section that deals with the unhappy time when a baby dies and how you would treat that baby. I won't read the statement out but what's said in effect is that you would care for the baby as though it were your own baby, or as though you would want somebody to care for your baby, you wouldn't leave the baby alone, you would accompany the baby to the mortuary and it would be taken there in a pram and shown dignity and respect.
TAYLOR: Yes.
BAKER: Are you somebody who would ever be excited by the death of a baby?
TAYLOR: Definitely not.
BAKER: Are you somebody who would ever be excited or excitable about a collapse in a baby?
TAYLOR: No.
BAKER: You refer to an incident in relation to Mother C's evidence, and I just want to ask you a few questions about that. Now, when Baby C [Child C] -- when [Child C] died -- before, sorry, [Child C] died there was an interval when
resuscitation had stopped but [Child C] was still alive, and [Child C] was being looked after by their parents.
TAYLOR: (Nods).
BAKER: Mother C recalls that you and Nurse Letby either together or separately at various points went into the room to provide support to them or to check on them. Is that something you remember as well?
TAYLOR: Yes.
BAKER: Mother C and Father C describe an incident in their evidence where Lucy Letby went into the room, plugged a cold cot in and said words to Mother and Father C to the effect of, "It's time to say goodbye now and put him in this cot." Were you present when that happened?
TAYLOR: No. The first time I heard about that was during the criminal trial whenever that evidence came up.
BAKER: It's right to say, isn't it, that you weren't always going into the room alongside Lucy Letby?
TAYLOR: No. So it -- I was -- it was my responsibility to look after the baby and the family. Lucy -- and this was -- this is what we discussed before about the nurse in charge having concerns that she wanted to help rather than look after the baby she'd been allocated, I -- I was aware that she wanted to
help, and I don't -- and at that opportunity she must have gone in when I wasn't there.
BAKER: Yes. But it's not your recollection, for example, that you were the person who took the cold cot in or that you were there when Lucy Letby took the cold cot in?
TAYLOR: I definitely -- if -- I definitely hear that comment. I don't know who took the cold cot in but I definitely did not hear that comment.
BAKER: What would you have thought of that comment if you had heard it?
TAYLOR: I would have been horrified. And I was when I read that. I was really sad for the family that that had been said to them in that moment and disgusted that it was a comment that was made, because I think it was really uncompassionate and cold, and not something that us as a team -- our ethos is that's not aligned with our ethos and our -- what we want to care for the baby. Our and my ethos when looking after a baby who is dying is -- or has just recently died is to ensure that we follow along with the parents' wishes about what they want to do, whether that is to spend time with their baby quietly or make memories. The cold cot is -- is there but it's not something that they need to go into straight away. So, yeah.
BAKER: I mean you -- your evidence is you would have found those comments upsetting and deeply inappropriate?
TAYLOR: Yes.
BAKER: You didn't hear them yourself, but you did on other occasions see Letby behaving in what you felt to be an inappropriate way surrounding collapses or deaths?
TAYLOR: Mmm.
BAKER: Finally, I just want to clarify your evidence you gave a moment ago in relation to [Child O] whose family I also represent. I wonder if we could go back to your police statement, INQ0001404, and it's to page 3, please. So this is an extract from a statement that you provided to the police in 2019. This is the key page, but on the previous page it's referred to the fact that [Child O] was placed -- we don't need to go on to it, yes, thank you -- [Child O] is placed in Nursery 1 because although he seems well there are concerns that he might deteriorate or there are at least worries about his condition. But those worries were felt not to be substantial ones after a time and he appeared stable, didn't he, and well in fact?
TAYLOR: As far as I can remember, yes, he did.
BAKER: And so a decision was made relatively early in
your shift to place him in Nursery 2?
TAYLOR: (Nods).
BAKER: And what you seem to be saying in paragraph 2 of that statement is that it was Letby who prompted the move to Nursery 2. Does that help refresh your memory?
TAYLOR: Yes, and I -- in there I said I believe it was Lucy, and I think my memory has deteriorated again since then, so I can go off -- my memory can only go off what I've written in my witness statement. So in there I've said I believe it is Lucy who asked me.
BAKER: Now, you say: "I am unsure if Lucy was the designated nurse for all [Child O], P and R or just two of them." I think there is other evidence to suggest that Lucy Letby was [Child O]'s designated nurse.
TAYLOR: Mm-hm.
BAKER: Would that be your recollection as well based upon I think what happens next?
TAYLOR: She -- yes. As far as my memory serves, she was looking after [Child O] and, yeah, I can't remember further than that.
BAKER: And then you go on to say: "At one point during the afternoon I recall going into Nursery 2 to have a look at [Child O]."
TAYLOR: Mm-hm.
BAKER: So does that suggest that you were based in Nursery 1 on that occasion or somewhere else if you had to go into Nursery 2 to check?
TAYLOR: I don't know. As far as I'm aware, I was in charge so I would have been shift leader. So as we were discussing before, the shift leader would have a general oversight over the babies. So it may be that I've gone in to offer support, to check charts, to kind of see what was going on, so I don't know. I may have not had -- I may have had a patient or I may not have. It would depend on kind of staffing and what acuity we had on the unit depending on whether the shift leader would take another patient load.
BAKER: Yes. But in any event, you weren't with Letby in Nursery 2, save for those times when you went in?
TAYLOR: Yeah, no, I wasn't.
BAKER: And in the penultimate paragraph, you confirm that when you went into Nursery 2 to see how [Child O] was doing, it was only Letby who was present there.
TAYLOR: And, again, I think if that's -- that's what I've written in my statement, but from my memory now, I -- I don't remember. But I've written that in my statement, so that must have been true.
BAKER: But based upon what you said then, it was Letby who was alone in the room with O, P and R?
TAYLOR: As far as I can remember, yeah. But, yes, I don't remember if she was in the room when I went in.
BAKER: And it's at that point that you became concerned about [Child O]'s condition and you said, "He doesn't look as well now as he did earlier. Do you think we should move him back to 1 to be safe?" --
TAYLOR: (Nods).
BAKER: -- is how you recalled it there. And, again, Ms Langdale took you through the next part and how Letby responded, "No, I'd like him to stay in room 2", or Nursery 2.
TAYLOR: Yeah. So she -- I think I was -- at that time I think -- as I discussed before, I don't know if this point was the point where there was maybe more signs of deterioration or maybe more subtle signs, or whether it was still this gut instinct. I can't remember from this. However, yeah, I do remember she was fairly insistent that she wanted to keep them together in room 2.
BAKER: I mean, from what's written here, it sounds as though this is the sequence of events that [Child O] appears to be doing well, appears to be stable --
TAYLOR: Mm-hm.
BAKER: -- sufficient to be moved out of the high dependency room. He goes into Nursery 2 where he's alone with Letby and then deteriorates.
TAYLOR: Mm-hm.
BAKER: Now, this isn't a criticism of you, obviously. How were you to know? And --
TAYLOR: Yeah, and I think I would not have predicted that. I definitely didn't predict that to happen, and I wouldn't have assumed that that would have happened. So I think me suggesting moving him was probably being very much on the cautious side.
BAKER: Yes.
TAYLOR: Yes, it's -- again it's -- with hindsight, I wish I had pushed that.
BAKER: Well, hindsight's a wonderful thing, Nurse Taylor.
TAYLOR: It is.
BAKER: But with the benefit of hindsight, do you think there might have been another reason why Letby wanted to keep him alone with her in room 2?
TAYLOR: I think that's -- you know, with the trial and what she's been convicted of that is a natural conclusion of -- that you would come to now. Obviously it wasn't at the time.
MR BAKER: No, of course. Thank you, my Lady, and thank you, Nurse Taylor, I have no more questions.
TAYLOR: Thank you.
LADY JUSTICE THIRLWALL: Thank you, Mr Baker. Ms Langdale.
MS LANGDALE: My Lady, that concludes the questions for Ms Taylor.
LADY JUSTICE THIRLWALL: Ms Taylor, thank you very much indeed for coming to give evidence today and giving us a particular insight in some aspects of your evidence in respect of the compassion and kindness that is shown by you and no doubt many of your colleagues.
TAYLOR: Thank you.
LADY JUSTICE THIRLWALL: Thank you very much and we will take the break now.
MS LANGDALE: May I say 11.50, my Lady, ten to 12.
LADY JUSTICE THIRLWALL: Yes, certainly. You are free to go, Ms Taylor. (11.31 am) (A short break) (11.51 am)
MS LANGDALE: Thank you, my Lady, may the next witness be sworn.
ASHLEIGH HUDSON (affirmed)
LADY JUSTICE THIRLWALL: Sorry, Ms Hudson, we are just going to see that the noise is off so that we don't get any more. (Pause). We are ready to go?
MS LANGDALE: Ready to go. Can you give us your name and qualifications, please.
HUDSON: Yes, my name is Ashleigh Hudson. I am a qualified children's nurse but also now an advanced neonatal nurse practitioner.
LANGDALE: You provided the Inquiry with a statement dated 12 April 2024.
HUDSON: Yes.
LANGDALE: Can you confirm that statement's true and accurate, as far as you're concerned?
HUDSON: Yes, I can.
LANGDALE: Can you tell us a bit more about your qualification. We know you were working 2015 to 2016 at the Countess of Chester and where you have come to now with this qualification, can you just explain for us the bands, the expertise, the courses and where you're at now and where you were then?
HUDSON: Yes, of course. So initially I graduate window a degree in children's nursing in 2014, I believe it was, and then started working on the neonatal unit in February 2015. Later that year completed my first neonatal qualification, which was the introduction to neonates, the foundation course, and then I believe --
and at that point I was a Band 5 staff nurse, so much of my responsibility was just patient centred care. I didn't really have any management or admin responsibilities at that point. Probably end of 2017 into the beginning of 2018 I did my QIS, my qualification in speciality, also to do with neonates, a little bit more focused on intensive care. And then in the October of 2018 I began my master's degree in advanced practice, remaining a Band 5 during that time. But when I started my training, my -- my job role changed to that of a trainee advance practitioner. My responsibilities changed, so I went from delivering, like, bedside patient care to being more involved in the medical aspect of care, so the reviewing of patients, the formation of care plans, reviewing medication and making decisions about care as part of the team. I qualified and graduated in I think it was October/November 2020 and at which point I became a Band 7 for a consolidation year. After a year period of consolidating that learning I became a Band 8, and I continue at that now as an advanced practitioner.
LANGDALE: So when we talk about how qualified nurses are with neonates, can you contrast -- or compare and contrast where your level of qualification would have been as a Band 5, you've been on a course, and where you are now as an advanced practitioner who has done the master's?
HUDSON: Sorry, I'm highlight differences?
LANGDALE: Yes, how much more -- how much more expertise do you gain by that advanced course?
HUDSON: A lot more. The way -- you are taught to think about neonates a bit differently, because you're looking at it from a medical perspective and not just a nursing perspective. The -- the goal of the advance practice role is that you almost combine the two. You learn how to think medically but you use your nursing experience and background in that speciality, so you become a bit more of a port of call and a bit more of a constant presence within whatever speciality you're working with. Medics rotate every four to six months as -- qualifying, as wonderful as they might be, it's good to have advanced practitioners who just know the lay of the land, know the guidelines and can help provide that support. In comparison, in -- as a staff nurse, it's much more patient-focused care, so you're at the bedside a lot of the day, you're delivering the personal care, you're supporting parents deliver that care to their babies, you're monitoring their vital signs, you're
looking at their observations, you are escalating when anything's changed or there are concerns, you're responsible for giving medications. It's quite difficult to summarise really. My role now, I'm responsible for reviewing the care of the babies, so I don't deliver the bedside care but I look at where they're up to in terms of diagnoses, gestation, care plan. Every ward round in the morning I'll be part of the team that reviews the care of that baby that's happened so far, looks at what we need to go going forward, is there anything to change that day or do we just continue? And rather than administering medications, I prescribe them now and assess patients and see what medications they require.
LANGDALE: You've explained that really clearly.
HUDSON: Is that enough?
LANGDALE: Very clearly. So when you were at the Countess of Chester, you tell us you were responsible for managing your own workload with support guidance from senior nursing staff --
HUDSON: Yes.
LANGDALE: -- because, as you've explained, it's a patient-facing nursing role, Band 5, even with the course and you need support from senior nursing staff.
HUDSON: Yes.
LANGDALE: If you have concerns you are expected to contact -- you said "escalate", does that mean get someone who knows more really?
HUDSON: Yeah, and that could be to a senior member of staff, or that could just be straight to the medical team. I think it probably depends on your confidence in that role at the time and what you understand. You might speak to your more senior nursing colleague first because they're very experienced, and you might not need to speak to a doctor because it will be a nursing thing not a we're worried about this baby-type thing.
LANGDALE: Did you feel able to speak to doctors? What were the relationships between nurses and doctors -- between yourself and doctors?
HUDSON: I always found them to be quite approachable. I'd done most of my training at Chester. I did placements both on the neonatal and the paediatric ward, and even as a student I found that they were very approachable and you could ask them questions. And I wouldn't often at that point escalate care because I'd be working underneath somebody who was qualified, but certainly as a newly qualified nurse in a Band 5 I always felt that they were approachable and they were either on the unit or at the end of a bleep.
LANGDALE: When you say who was qualified, is that
a Band 6 --
HUDSON: Sorry --
LANGDALE: -- or a Band 7?
HUDSON: -- I think I was -- because I referred a little bit to being a student and working --
LANGDALE: Yes, yeah.
HUDSON: -- so qualified is just from Band 5 onwards.
LANGDALE: Band 5 onwards. And when you're the Band 5 nurse doing that feeding, cares, administering medications, who would you turn to as a Band 5 then for that support or help?
HUDSON: One of the Band 6s or potentially a senior Band 5, because not everybody goes on to be a Band 6 and to be a shift leader. It's not just a natural progression, it's a job that you apply for because you want to have a bit more of a leadership role. So we have a lot of the Band 5 nurses who've been being neonates for so years and have lots of experience. It would depend on -- on the day who was the best person to go to, and then if that person wasn't sure you'd then go above and go to the Band 6 or potentially you would speak directly to the doctor because they would physically be there.
LANGDALE: Were they there on ward rounds regularly enough, from your point of view, or not, the doctors?
HUDSON: Yes, they -- the ward round doesn't happen without them. The ward round doesn't occur without the doctors. The doctors lead the ward round and they come to you.
LANGDALE: And did they happen regularly? Do you know how often?
HUDSON: Yeah, every -- every morning we would have a ward round. I think often it would be junior doctors that did the ward rounds and then I think -- I think -- it's hard to think back now, I think maybe twice a week, on a Wednesday and Sunday, the Consultant would be present as well, because at the time, this time period that we're looking at, they were responsible for both paediatrics and neonates, so there would be a doctor there every morning but who that doctor would be would be different.
LANGDALE: We asked you and you answered at paragraph 4 about the culture and atmosphere on the neonatal unit and you say: "Between June 2015 and June 2016, [you] felt very supported as a junior member of staff. We were as protected as possible as new starters, given opportunities to learn with respect of our limitations and developing knowledge base." Can you expand upon that for us?
HUDSON: Sorry, can you be more specific?
LANGDALE: Yes, in terms of "with respect to our limitations", for example, "in respect of our limitations", what do you mean by that? Are supported to say when you couldn't do something or you didn't know what to do?
HUDSON: Yeah, so experience. So, you know, you come -- you do come into the Band 5 role as qualified, you're a children's nurse, but you -- as any nurse, you learn more on the job. So a really important part of nursing is recognising what you don't know and recognising where your strengths are and where -- you know, if you -- many, many things within any nursing you learn from experience, you don't learn from a textbook, you don't learn from university. So having a really solid foundation of seeing your members of staff who know what they're doing was really reassuring. So I never felt out of my depth, because if I didn't know I would immediately go to somebody else who knew the answer.
LANGDALE: You say you don't recall any animosity. It's your opinion that the nursing and medical terms were not as integrated as they are today. That's more apparent in retrospect. And you also say:
"Regarding relationships between staff at this time, I remember a noticeable divide between nurses and doctors, but at the time I did not understand why." Can you tell us more about that, what are you saying there?
HUDSON: I think -- and I'm sure much of this will have been discussed already -- a lot of what was going on behind the scenes in terms of concerns regarding unexpected deaths and potentially worrying that somebody was responsible, none of that was discussed with us. But I do feel like the divide was a symptom of that, because certainly when I first started I didn't feel that there was a divide. I think as time went on, and probably following Lucy being removed from the unit, there seemed to be this -- a little bit of an atmosphere but I never had any information to know why. I think it happened so slowly, this shift, it's looking at practice now and what the team is like now and how integrated we are that I can compare it to back then and can see that it was different. But what I will say is that I still felt all the staff were really approachable. I still felt the doctors were really approachable. I never had any issues with any of them.
LANGDALE: Yes, you say you found the medical staff to be approachable and witnessed excellent teamwork when
dealing with sick or deteriorating patients, but you thought there was this divide. When did you know there was discussion going on about deaths and unexplained deaths and who may be present or who may have inflicted harm?
HUDSON: Not for many years. I think this is what I've been finding difficult to piece together looking at -- looking back at when -- when did the thinking shift. I think the conversations are going on from a long time before we were informed. I knew that there was an increase in the amount of deaths compared to previous years. I didn't know that there was suspicions about anybody. I didn't know there was massive huge concern about there being unexplained or unexpected. It was all very hush-hush. And I've learnt a lot from the trial and from this Inquiry, information that I didn't know before. So I don't -- I can't pinpoint when I knew. The only thing, you've last night presented me some emails that -- as part of my bundle, in one of them is an email from Lucy.
LANGDALE: Shall we go to that if that helps?
HUDSON: Yeah.
LANGDALE: So if we go to INQ0058624, page 1. This one: "Dear colleagues ..."
HUDSON: Yeah.
LANGDALE: "... I was redeployed from the unit in July 2016 following serious and distressing allegations." That one?
HUDSON: That was the -- from my memory was the first time I had seen in black and white that there been any accusation. She'd been removed from the unit. We had been told it was for her own well-being and it was going to be a short period, that she had a secondment. One of our other nursing staff also had a secondment. So it didn't seem out of the realms of possibility. As time went on, the longer that she was off the unit, it was something that you thought about. You'd think something's not quite adding up and no one's discussing it, no one's saying anything, and it wasn't, from my memory, until this that I saw in black and white that there was allegations and there was concerns.
LANGDALE: And this says this letter "after a thorough investigation", was there a conversation, as you might expect at that point, between nurse: what was the investigation then? You know, even knowing that she says here she's been exonerated, did you all -- did you piece that it must be to do with deaths and deteriorations?
HUDSON: Yeah, just from common sense.
LANGDALE: Yeah. So at that point, in 2017 -- in January 2017, you were aware that she'd been investigated for deaths and deteriorations. Did you -- or she says she had been, I should say -- did you discuss that with any other nurses?
HUDSON: I can't remember. I'm positive that we did, but I cannot remember.
LANGDALE: You're positive --
HUDSON: I'm positive that we must have. We all received --
LANGDALE: Yeah, it's a big letter, isn't it, to get?
HUDSON: -- this email. It's big, it's very emotive --
LANGDALE: Yeah.
HUDSON: -- as well but I can't pinpoint any conversations, unfortunately.
LANGDALE: Were you present -- we know she went back for -- on the expectation that she was going to go back to the unit for a tea party, did you ever go to the unit when she was there --
HUDSON: I don't --
LANGDALE: -- around this time, or can you not remember?
HUDSON: Not that I can remember.
LANGDALE: Mm-hm. Just for completeness, the email that you are referring to, the earlier emails, if we go to INQ0002879, page 91, they pre-date the one you've just
reminded us of from Letby herself to all of you. You see this one, 15 July. Have a read of that again. So that's sent to you. (Pause). It suggested: "Lucy has as agreed to undergo supervision first." Ie others of you are going to follow and she started on Monday, 18 July. When you got that, what did you think that was about? Did you think you were going to be doing some similar role or ask about that?
HUDSON: I mean, I can honestly hardly remember this email.
LANGDALE: I mean, effectively it's telling you she is having supervision, doesn't it, it says she's --
HUDSON: It says she's having supervision. It says that we will all be supervised with our care, which I think is quite reflective of the information that came out at the time, it was all very secretive and there was never any frankness with what was happening. The previous email's talking about secondment and it's -- she's been in.
LANGDALE: Yes, should we go it that one as well? So if we go 0002879, page 75. In fact it follows that one about supervision. Supervision is 15 July and then you've got this one
on 9 August. It will come up in a moment. This one.
HUDSON: Mm-hm.
LANGDALE: As you say, there's suddenly a suggestion opportunities to apply for secondments -- and, again, reference to Lucy having done this first -- to the risk in patient safety office for a period of three months. So you're getting told supervision and then opportunities for secondments --
HUDSON: (Nods).
LANGDALE: -- and Lucy identified for both. So you say there was secrecy. Behind the secrecy, were you all having a bit of a chat, "Well, what's that about. It must be to do with her. It's not really aimed at us", or what? Can you remember?
HUDSON: I can't remember conversations at the time. I can only really think of what I -- was going through my head, and it was very confusing. And now that I know more, I can understand what was happening here. You know, the previous email we just looked at said this isn't -- this isn't about blame or -- that's very clear, no one's being blamed for anything. Okay. So that reply to the whole team, it's part of process, we'll be doing it every two to three years. Strange, but okay, that's what we're being told by senior members of staff. And then in terms of this secondment, if -- in my mind, if Lucy's been accused of harming patients, whether that's on purpose or not, or through incompetence, why is she in risk and in patient safety? None of this information makes sense. And looking back you can -- I, and probably many of my colleagues, have pieced it all together and we can follow a timeline of what was happening. But at the time, it was very murky. And I'm not so naive as to think that somebody isn't capable of doing this. We have previous examples, such as Beverley Allitt, as horrible as it is, to consider. We have a responsibility to think of these things but I'm also not going to accuse someone of something when actually there's no detail about what they're being accused of. So in this time period, I feel it was -- I was very much on the fence and it was all very confusing.
LANGDALE: Well, it's clear, as you say, the first one, the July 15th one, says it's not meant to be a blame or competency issue. So that was stated by your manager, Eirian Powell. So did you think "Well, it's not but it's a bit confusing"? Is that what you're saying?
HUDSON: Yeah.
LANGDALE: Did -- did Eirian Powell or anyone else -- Yvonne Griffiths, anyone else, ever speak to you about
whether you would in fact have supervision?
HUDSON: Not that I recall.
LANGDALE: And did any of you over time say, "Are we having supervision?" Or "Why?" Or did you just leave it lying?
HUDSON: I can't remember.
LANGDALE: That can go down, thanks. Going to the children named on the indictment that you had experience with.
HUDSON: Sorry, I can't quite hear you.
LANGDALE: The children named on the indictment that you had experience with.
HUDSON: Yeah.
LANGDALE: You were involved with [Child A].
HUDSON: Yes.
LANGDALE: And if we go to paragraph 8 -- sorry, paragraph 6 of your statement -- at paragraph 7 you tell us you: "... cared for [Child A] during the night shift of June 7th-8th ... after which he unfortunately died during the following night shift ..." And you tell us you received a text from Lucy Letby informing you of [Child A]'s death. Can we go to those text messages, please, which is INQ0000101, page 1. We're going to start at page 1 and look at page 1
and 2 of that. So we see at the top: "Hi Ashleigh. You may have heard by now but wanted to let you know that we lost little [Child A] on Mon. Know you looked after him when he was born so thought you should know." Scrolling down you say: "I didn't know actually, thanks for letting me know Lucy. That's terrible! How is his sister?" She responds: "It was awful. He died very suddenly & unexpectedly just after handover. Not sure why, it's gone to the Coroner. [Child B] went off Tues night & was intubated but back on cpap now. They are querying a clotting problem. Very sad." Pausing there, that level of detail and this type of information over text messaging, what did you think about that at the time if anything?
HUDSON: I can -- I can actually -- I can vividly remember this because I was devastated. I had only been on the unit a couple of months at this point. This is the first time a patient that I've looked after had then passed away. I was also a bit angry because I didn't think it was appropriate to get this information by text, because what do I do with it? How do I then seek
support? But I didn't feel comfortable saying that on a text message.
LANGDALE: If we go further down, 31274, you say: "Oh god, he was doing really well when I left. I do hope [Child B] continues to improve, have they done bloods to check?" Pausing there, did she know that was the first death that you had witnessed on the unit?
HUDSON: I don't know.
LANGDALE: Okay. Carrying on with the messages: "He had a really good day on [Monday] then I took over [Monday] night & he passed away at 20:58 after 30 min resus. Just collapsed very suddenly. Awful." And so it continues. You can see that. If we go further down. Message 31277. So a bit further up. She says: "I wasn't supposed to be in either, Yvonne swapped my nights as unit busy! But these things happen ... Parents were there during resus. They had them both baptised then spent the night sitting with them both. I took pictures hand/footprints etc. They are beside themselves worried that they will lose [Child B] too." And then the next bundle one message she says: "Yes they had time together & got some nice little mementos when they are ready to take them. Fingers crossed." You will have appreciated this was a mother who lost her baby after 24 hours -- or within 24 hours and had managed to touch him once, once on the tummy in the incubator, and this message comes to you. First of all, you didn't invite that message, did you?
HUDSON: No.
LANGDALE: Are you okay?
HUDSON: Yeah.
LANGDALE: We can stop if you want for a bit.
HUDSON: No, I'd like to continue, please.
LANGDALE: Okay. The messages can go down, thank you. How did you feel, then, and also how do you feel now about a message that says "some nice little mementos", with all that you know?
HUDSON: I think, at the time, I felt like it was too much information. It's -- that process afterwards is a very important and sensitive time. I don't -- didn't feel like I needed that information. And the message after that, that's when I kind of shut the conversation down, deleted the messages off my phone, because I just felt very uncomfortable having them there. I just panicked that what if I lost my phone or it got stolen and someone ... Looking at it now, and knowing what
I know, and that terminology, it's very upsetting. It just makes me feel quite sick to be honest.
LANGDALE: We have heard -- the Inquiry has received evidence from a number of routes about the manner in which Letby spoke about deaths or deteriorations at various times. We've seen that's how you were sent messages. Did you have any other experience of her in the hospital at the time commenting in a way that was inappropriate at least or --
HUDSON: Not that I can recall. And I wasn't present or responsible for much care for many of the other children involved within this time period. So I -- it's not something I ask questions about if I'm not involved. I can provide emotional support. My viewpoint, as a professional, that if I'm not involved in that patient's care that information is not relevant to me unless there is learning that we need to take forward as a team. The rest of it is I don't need to know.
LANGDALE: Paragraph 11, you tell us you were the designated nurse for [Child I] during the night shift 12 to 13 October. Would you like to set out what you tell us there in 11 and 12. Have a look at it.
HUDSON: I'll just find it. (Pause).
LANGDALE: Feel free to read the paragraph if you don't want -- remember events now and add it, however --
HUDSON: Okay, 11 and 12?
LANGDALE: Yes, thanks.
HUDSON: Yeah: "I was the designated nurse for [Child I] during the night shift 12th-13th October 2015, and provided a statement to the police regarding her collapse 23rd March 2018. During the 15 minutes prior to the collapse, I had left [Child I] in Nursery 2 in the care of another member of staff whilst I assisted Senior Practitioner Laura Eagles with a procedure in Nursery 1. Following the procedure, I went to the milk room to fetch milk and took it into Nursery 2. Whilst preparing the milk on the work top in Nursery 2 at approximately 0320 ... Lucy Letby who was standing in the doorway of Nursery 2, alerted me to [Child I] looking quite pale. I turned on light and found [Child I] to be pale, floppy and gasping. Help was summoned, and Senior Practitioner Laura Eagles and senior House Officer ... Dr Katerina Clegg attended initially followed by Registrar Dr Matthew Neame and Consultant Dr Newby. [Child I] was resuscitated successfully and care was handed over from myself to Lucy Letby. "This collapse was unexpected in my opinion,
child I had been stable and very well prior to this."
LANGDALE: You turned on lights. Why did you turn on lights?
HUDSON: Because I couldn't see.
LANGDALE: So if you couldn't see, do you know how she could see from where she was standing?
HUDSON: No.
LANGDALE: And did you think that at the time or subsequently?
HUDSON: I thought it was odd at the time, but I didn't think it was suspicious.
LANGDALE: Did you think of saying to her at the time, "How could you see?" Or you were just focusing on the baby by then?
HUDSON: I think there was no time to ask that question because it was immediately we were into resus.
LANGDALE: Was there any debrief or discussion about that deterioration or event?
HUDSON: Not that I can recall.
LANGDALE: Did any doctor or anyone else ask you about that?
HUDSON: No.
LANGDALE: You say it could have been discussed or would have been during a handover, but you don't remember that now if it was?
HUDSON: I wasn't -- at the time of handover, I was no longer her nurse, it was Lucy, so I would have handed over to Lucy after this arrest, and then Lucy would have handed over care to a member of staff on the day team, so I wouldn't have been part of it.
LANGDALE: You do -- you say at paragraph 17: "In the immediate aftermath of [Child I]'s collapse, as per my statement, I did question how Lucy would have been able to see [Child I]'s colour from the doorway. But I did not think anything beyond that initially." And you found it unusual but you didn't have suspicions about her directly at that time. You say you: "... developed those further down the line as I reflected on the events more and as I gained more experience and as a trained Advance Nurse Practitioner." When did the suspicions develop then, in your mind?
HUDSON: It's difficult to pinpoint. I think it was after her arrest, and not immediately after, because the period immediately after the arrest was awful because she was arrested but we didn't have any other -- we weren't given any more information. In my mind thinking, okay, well, the police have been investigating for a year now --
LANGDALE: Had they taken statements from you before she
was arrested? So you'd been contacted by the police, given statements --
HUDSON: Yeah.
LANGDALE: -- then you learnt she was arrested?
HUDSON: Yeah. So I gave an initial statement about [Child I], she was arrested some time after that, and then I was asked to give further information following Lucy's arrest that asked me more specific questions about Lucy in particular.
LANGDALE: So when you were asked those questions, in your mind, were you thinking then this is all about her?
HUDSON: Yes. I think also having the opportunity for the first time to unpick it forensically and look at how was the room laid out, where were you stood, where was she stood, and having it all laid out in front of me, that's still not proof but that's when my mind was then considering the possibility that Lucy had harmed my patient. And, as you know, time progressed. Like I say, I gained more experience in neonates and I gained more experience as an advanced nurse practitioner. I recognised that how I felt about neonatal care changed. For me, I started my career 2015 when these events occurred. My experience of neonates then was shaped by
those events and I was very much from -- it's from what I have been told as well that this happens --
LANGDALE: They're premature babies, these things happen, yeah.
HUDSON: Very premature, they can be unexpected, there can be no warning, this is what they do. And we had so many that I was, like, that must be the truth. It's not -- it's not the impression I got as a student nurse, but as a qualified nurse that was my impression. The further away I got from that time period and the more experience I had in the neonates, and with sick babies, that's when my suspicions grew. I still had no evidence but just on reflection I just thought, God, that's not normal. I've not had that experience since where so many babies have collapsed or died with no warning. Can neonatal babies be a little bit unpredictable at times? Yes, but that's not common, and they can get very sick very quickly after compensating for a period of time, but there's usually a reason even if you don't know what it is at the time you provide all the support, you give all the care, and then you get blood results back or you get X-rays back and things make sense. It's very rare that you have a baby, neonatal or not, preterm or not, that collapses unexpectedly with no
reason why. But because I was so inexperienced at the time I didn't recognise that.
LANGDALE: Did any of the doctors have a discussion -- or senior nurses -- with you about the fact that that wasn't common and these were stable babies and they were shocked? Did you know that?
HUDSON: No. I can't say that there wasn't, I don't remember any specific conversations.
LANGDALE: But you were aware that it was widely accepted they were unexpected?
HUDSON: (Nods).
LANGDALE: You nod. Sorry, a nod doesn't get picked up --
HUDSON: Yeah. Yes. Yeah, sorry.
LANGDALE: You tell us at paragraph 19 and 20 your involvement with Baby I [Child I] and when the crash call was put out at midnight. Can you tell us a bit more about that?
HUDSON: Is that paragraph 20?
LANGDALE: Yes.
HUDSON: I'll just having a little read.
LANGDALE: You heard the monitor sounding.
HUDSON: Yeah. What specifically would you like to --
LANGDALE: Well, maybe read it in the statement, what did you arrive at? Who called you? What happened?
HUDSON: As per my kind of statement I wasn't within Nursery 1 I was just outside, and I can't recall what alerted me to go into the room, I either heard a cry, I heard the monitor go. I'm not sure which one it was but I knew that I needed to go into the room. She was very unsettled, exhibited a large and relentless cry. I've said that: "I attempted to settle her with a dummy and sucrose; when that didn't work, I repositioned her on to her tummy. Following this, she stopped crying, stopped breathing and became dusky in colour. I shouted for help, and Lucy Letby arrived to provide help. We positioned [Child I] on her back ..." And began resus measures.
LANGDALE: And you were involved in the aftercare, weren't, you for [Child I]? Can you tell us about that, and we know Letby insisted with that because you'd never done before? Did she tell you she had?
HUDSON: And I knew that she had because I knew that she's lost a patient before, more than one, and I knew that she -- I knew that she delivered that because generally whoever is responsible for the care of that baby then delivers the aftercare.
LANGDALE: And you were actually on -- you were designated for that baby --
HUDSON: Yeah.
LANGDALE: -- not her --
HUDSON: Yeah.
LANGDALE: -- but because she had done this before, did she want to do that and assist with that?
HUDSON: Yeah.
LANGDALE: So although you're the designated nurse, she wants to assist she does assist --
HUDSON: (Nods).
LANGDALE: -- with that?
HUDSON: Mm-hm. Yeah.
LANGDALE: Again, looking back, and maybe at the time, what did you think about that, her wishing to assist with that?
HUDSON: I thought she was being helpful. I would expect that from any colleague. I have never -- there is the pastoral side, the emotional support, but there's also a lot of paperwork and things that have to be done when a child dies, and I was just aware that I hadn't done it before, I was really worried about not doing it right, so I just wanted that guidance from somebody. And I didn't specifically ask Lucy, I asked just the staff that were there if somebody could help me. Since then I've -- I think within the trial there was information that she'd gone into the room without me and discussed things with parents that then upset them,
and I had no idea that that was happening at the time, so I didn't have an opinion when it was happening.
LANGDALE: Because you didn't know it was being done like that?
HUDSON: No.
LANGDALE: You thought she was helping you not taking it over really?
HUDSON: Yeah.
LANGDALE: You say at paragraph 22: "[Child I]'s collapses and subsequent death were unexpected events in my opinion. Despite her medical history prior to this point, she presented as a stable baby." You said that you knew that at the time as well and there was a debrief, wasn't there, following on from that?
HUDSON: Yeah.
LANGDALE: If we go to INQ0000429, page 1543. We see here it looks as though it's between yourself, Lucy Letby, Dr Gibbs, who was present at the resuscitation, and the chaplain.
HUDSON: Yeah.
LANGDALE: And we look there we see: "Discussed briefly overall cause of illness since prem delivery."
And then: "Discussed episodes of sudden cardio respiratory deteriorations the week before death, then again at time of death seemed fine and stable prior to the episode of sudden collapse." So right close to the event Dr Gibbs, yourselves acknowledging that came from nowhere, sudden and unexpected collapse.
HUDSON: (Nods).
LANGDALE: At the bottom, it a reference to nursing staff -- quite difficult to read this -- but nursing staff --
HUDSON: Yes.
LANGDALE: -- felt ...
LADY JUSTICE THIRLWALL: "... resuscitations were well run."
MS LANGDALE: Yeah: "... must have been due to ..." Actually let's go to the next paragraph: "Nursing staff felt resuscitations ..."
HUDSON: "... were well run."
LANGDALE: "... were well run." Do you remember that discussion now?
HUDSON: Barely. I knew that we had a debrief. I didn't really get any information from it.
LANGDALE: And it look likes John Kingsley, the reverend has said that: "Someone will come to talk to parents whether or not a child has already been baptised."
HUDSON: Yeah.
LANGDALE: There seemed, amongst all the deaths that we are looking at in the context of the Inquiry, references to baptism --
HUDSON: Mm-hm.
LANGDALE: -- and would they like babies baptised. Was that something you all had training in or discussions about when that should be raised, how that should be raised, if it should be raised?
HUDSON: Yeah, so -- I can't remember the nature of the training at the time but we get regular updates about what support can we provide to parents, and it's -- a big part of that has always been: are they of a religious denomination? Would they appreciate having a baptism? Having a christening? Regardless, even if they are not religious, would they appreciate a blessing? And that comes from parent feedback, from charities -- bereavement charities where parents have said that would have helped to be offered that at the time and be offered that maybe when their child was sick and not after the fact when their child has already
passed.
LANGDALE: If it is a sudden deterioration or a sudden death, I suppose you may not have asked about those preferences in any event at all, mightn't you?
HUDSON: No, I -- no, and that's -- you are so focused -- rightly or wrongly, you're so focused on helping that patient and giving them what they need and the emergency at the time, you don't really think about things like baptism. I know that [Child I] had been baptised and that had been following the initial episode before she was transferred out where I think she was not quite stable but there was a time period where that was thought of by somebody. I think it just didn't cross our minds to offer that again. So John Kingsley very rightly said, "I'm happy to come. I can come again. There is no limit there is no restrictions."
LANGDALE: And dealing with managing bereavement generally, were there other options of support or care or assistance that you were trained about or discussed that people might want in that hour or time of need?
HUDSON: No. I feel the bereavement care in general in neonates was very poor at the time. We -- we did what we could, but we're not -- although you can -- you can attend study days and you can get training, there wasn't
a lot of resource to have somebody specifically who could provide that support. We have it now.
LANGDALE: What do you have now?
HUDSON: We have bereavement links on the unit, nursing staff who help deliver training, help liaise with parent advisory boards. We have a bereavement midwife whose sole -- her job is to provide bereavement support to families, and sometimes she will be involved before the baby is even born if there is knowledge that the baby might not survive or they might have severe health problems. We on the unit now have well-being practitioners that come to the unit twice a week who can deliver counselling whether the baby is in hospital, whether they've gone home, whether they've lost a baby. And they can also assess and signpost and refer parents to further support if necessary. None of that was available at the time.
LANGDALE: And it sounds like the fact that you hadn't dealt with it before and you were unsure of your own position, let alone supporting somebody in a deeply distressing position --
HUDSON: Yeah.
LANGDALE: We've had evidence from at least one parent that they were given a leaflet, and leaflets how
effective can they be in these circumstances compared with a real person, what's your view about that?
HUDSON: I agree. I think things like leaflets and booklets it's very impersonal, and this is a very sensitive and personal subject. There are some fantastic charities such as SANDS that have been set up by grandparents or parents who have been bereaved who provide a lot of that literature from experience. But we cannot just depend on goodwill and charitable causes to provide this support. It should be integral to the healthcare that we provide. It should be a continuation of the neonatal care, and I think only recently has that been properly recognised, and even so it's having the funding. We in neonates work in a certain area where we expect that sometimes outside of this period babies will pass away unfortunately for many reasons. So we're acutely aware of what these families go through. And at the time, not being able to provide that support was so difficult because we would know what they need but we just had no funding and no staff to provide that. I think recently, and publicly, that has been more recognised and there are more conversations about the neonatal period, things like maternity and paternity leave, things like bereavement care because it's a very unique time period and it's very unique to these families. Many, many people will not experience a loss like this. It's very different. I just wish that we could have provided -- the care that we have now I wish that we could have provided it then.
LANGDALE: Were you aware as a nurse at the time what information parents were being given about concerns about Letby or the RCPCH investigation or anything like that? Was that something as nurses --
HUDSON: It's --
LANGDALE: -- you'd consider or was that --
HUDSON: It was not something that was discussed with us. And we had very little information ourselves. It's only through following the trial and also some of the transcripts of this Inquiry that I've recognised that actually parents were kept in the dark for a really long time and not informed that the deaths were felt to be unexpected, and that -- it did very much surprise me.
LANGDALE: You were also involved with Baby M [Child M] and you tell us that you heard Letby shout for help and you attended Nursery 1 to find her and another nurse resuscitating [Child N], and you placed a crash call via the switchboard. You say you don't recall a debrief following [Child M]'s collapse but say when there was a deterioration as opposed to a death that was less
likely that there would be a discussion about a deterioration; is that right?
HUDSON: Yes. I think the debrief process back then was just a little bit sporadic. Compared to now, and what we do now, and what -- a debrief is very -- very much meant to be, like, pastoral support, it's meant to be emotional support. Yes, you might get some information if there has been a post-mortem or something. But a lot of it was that emotional support. And I think the unit was so busy and there was -- we know the doctors were short-staffed, the nurses -- I just think it was an oversight. An unexpected collapse is really difficult to deal with as much as an unexpected death. I just don't think there was that recognition or maybe not the time dedicated to providing a debrief for those episodes.
LANGDALE: Would it happen informally on a ward round if you saw the doctor again and say, "What happened the other day?" Or have a discussion like that or not?
HUDSON: Not -- wouldn't necessarily discuss it on the ward round because that's not a private space, it's not appropriate. There may well have been conversations that were not documented but I wasn't part of them, so I can't be sure.
LANGDALE: You were invited as part of the Royal College
review to go for an interview, weren't you? And you've helpfully set out for us at paragraph 33 of your statement various things you raised and we have also got notes of that. If we can go, please, to INQ0014605, page 1 to 5. You say there were a couple of people interviewing you. I think in fact the note -- the reviewers record -- this interview id recorded as Clare, David and Sue. So were there three people? Does that accord with your recollection or not? Maybe --
HUDSON: Yeah, I think so. I have to apologise, I only received this transcript this morning, so --
LANGDALE: You did --
HUDSON: -- when I answered --
LANGDALE: -- apologies.
HUDSON: -- I think I've gone from memory, but whatever is there is correct.
LANGDALE: Well, it looks like you were with Band 5 nurses together, weren't you --
HUDSON: Yeah.
LANGDALE: -- at this meeting? And you set out various things. If we go to page 1 you're setting out really nice unit, really supported, friendly, tight-knit, all get to know each other and babies, feels like everyone wants to
educate -- things you've set out earlier, but this was obviously fresher in your mind. Everyone pulls you in to see anything interesting, lots of bands on experience with support. If we go over the page it says at the bottom, sorry: "Can be really busy especially if new people are aware and acknowledge it." So can be really busy. So like your colleague earlier, you could have busy parts -- busy times and less busy times. Is that your experience with neonates generally because it's --
HUDSON: Yeah --
LANGDALE: -- not Planned Care, is it?
HUDSON: -- there's no pattern. Yeah, there's no pattern. There's no seasonal difference really that I can recognise. Every day is different.
LANGDALE: It looks as though here: "Normally a positive environment but been very difficult. " "Been very difficult", this is at the time of this review.
HUDSON: Sorry, okay.
LANGDALE: You see at the top of the page 2.
HUDSON: Yeah.
LANGDALE: "Normally a positive environment but been very difficult. Dips in morale when it happened. Uncertainty. Told the review would take place and not sure how going to Level 1 will change it." We know there's been an announcement in the press by now that effectively there's going to be a RCPCH review and the downgrade, so it looks like there was the downgrade being discussed there, the fact there was the downgrade, how are parents going to feel about that, does that make sense?
HUDSON: It's quite difficult to remember, and I'll be honest, I find this really hard to follow.
LANGDALE: Fair enough. Okay. Let's just go over the page on page 4. What we do see: "Experience of death. Overwhelmed first unexpected, felt very supported. Nurse W door always open ? Debrief. Never found out why." Does that bit make sense, given whether you have been saying about --
HUDSON: Yes.
LANGDALE: So it looks like you did raise unexpected deaths, and the short debrief and question mark still didn't know why, was that the position that you didn't have any feedback or know why?
HUDSON: No, I think -- I think the -- the -- from what I can recall, it was almost written off as prematurity verbally, but it just didn't -- it just didn't quite make sense.
LANGDALE: If we look at the bottom of that paragraph 2: "Only thing we need is a unit debrief [underlined]." So it looks like you're flagging up there there's not a unit whole debrief. Does that ring a bell?
HUDSON: Yeah. I've put: "Affects everyone. So would need a local debrief with a resus team". And I've -- I think I've alluded to it a little bit further down, but what -- at the time what we found was is that the nursery nurses, the Band 4s, were never invite today a debrief, and I felt like it should be the whole -- everyone that's on -- everyone that's on that shift, it's a small team, it's only about five or six of us, everyone should be at the debrief, not just the people who were involved in resuscitating at that time. Because although the Band 4s wouldn't have been hands on, giving medications and resuscitating, they would have been running in and out of the room, fetching equipment, they would have been care for other babies on the unit and they would have seen a lot.
And it was my understanding at the time that a debrief was supposed to be largely emotional support, and I just felt like that that wasn't being delivered consistently and it was undervaluing their input on the unit.
LANGDALE: Thank you, the document can go down. There's no time limit for you to have a look at that, Ms Hudson. If you read it in your own time and you think there's anything inaccurate or you don't follow please let us know.
HUDSON: Of course.
LANGDALE: But the parts I've taken you to you've elaborated upon, so thank you from that. In your statement you do say at paragraph 33 you can recall voicing concern, and that won't be a comprehensive note presumably: "I can recall voicing concern at the lack of consultant ward rounds in comparison to the Children's Ward, as I felt that well long-term patients would often get overlooked and lack a proactive plan of care."
HUDSON: Yeah. It just -- it just felt that we had -- we had many wonderful junior doctors, but we also had some junior doctors that didn't have a great deal of experience in neonates and wouldn't want to make decisions on the day, they'd want to -- you'd say. "Oh,
can -- what do you think about, for example, weening the high flow or" -- and they'd go, "We'll wait to when for the grand round. We'll wait for the Consultant". So I just felt that the care of the well babies that maybe had been on the unit for a long time wasn't as proactive as it should be. I feel like every day we should be looking -- assessing that child. Even if nothing's changed, is there anything that we can do to get them closer to going home.
LANGDALE: A management plan --
HUDSON: Yes.
LANGDALE: -- where you're going?
HUDSON: An active management plan rather than "continue".
LANGDALE: You also say: "I ... remember contributing to conversations regarding acuity of the unit and staff levels, the unit was very busy, and staff were taking on bank shifts to help." Is this the part we've gone to that sometimes it was busy, sometimes it was not, you know, it was difficult to plan it could be very busy.
HUDSON: Yes.
LANGDALE: You then summarise your concerns in the statement and say you had been there for the collapse of [Child I] and you were involved in the care of A and M as well. Were you aware of the triplets deaths, O [Child O] and P [Child P], later on?
HUDSON: I was. I didn't -- I was on annual leave at the time.
LANGDALE: Annual leave?
HUDSON: Yes.
LANGDALE: So you didn't feel the atmosphere in the hospital on those days?
HUDSON: No.
LANGDALE: When you did hear of those, were other nurses or doctors expressing real concerns about a person by then or not to you?
HUDSON: Not out loud, and not to me.
LANGDALE: Not out loud. In any other way, was it --
HUDSON: Well, we can see that there was discussions going -- that's what I mean, we can see that there were discussions going on amongst the Consultants and senior members of staff, but there was nothing said to us as a nursing team.
LANGDALE: So nothing was formally shared with any of the nurses?
HUDSON: No.
LANGDALE: Dr Lambie's evidence was to the Inquiry that,
in September 2015, she'd seen: "... a huddle or a small group of nurses at the nurses' station going through rotas thinking the unthinkable, in effect, looking at who might be connected to the same unexpected events." From what you're saying, that wasn't -- you weren't one of those nurses?
HUDSON: No.
LANGDALE: Do you know that some of your colleagues were doing that at the time or not?
HUDSON: No.
LANGDALE: How many nurses, roughly, were -- you had people on bank shifts coming in, was it a very busy nursing group?
HUDSON: You'd have -- because you would have a nursery nurse as well, you could have from four to -- probably four of five nurses on a shift.
LANGDALE: Did you -- did they sit around in groups or huddles at times, if they could, at points of handover or generally?
HUDSON: At points at handover, yes, when the unit was quieter, and there was certainly times where we would have one patient.
LANGDALE: You explain in your statements that after the time of her arrest, you had given statements to the
police and you didn't discuss generally the events as they were confidential. Obviously moving towards that criminal trial, you were all witnesses or potential witnesses, weren't you?
HUDSON: Yes.
LANGDALE: So how did that impact on being able to discuss with others any suspicions or concerns? Presumably, you couldn't at that point.
HUDSON: No, we were told that legally we weren't allowed to discuss what we'd discussed within our statements.
LANGDALE: Now that the trial has happened and with the benefit of hindsight, which is a wonderful thing, what are the concerns or features you could draw together that others might be alert to in the future were they to find themselves in a situation you all were working alongside Letby?
HUDSON: I think things have been -- I think highlighted within this Inquiry already. Very interesting that we get training on safeguarding and what to do when we suspect a parent might be harming a child. We don't have anything that tells us what to do if we think a staff member or what -- or behaviour to look out for. We have training on radicalisation and spotting
people who may have been radicalised into terrorism. But we don't have any training that tells us that there are certain characteristics or things that might cause you to raise concern about a member of staff. I think the information sharing was really poor. For a long time, nobody really said what the accusations were and what was happening. None of that was laid out. It was all very secretive. There was a lot going on behind closed doors. And for us that were working on the shop floor much of our focus was the patients that were there that day and keeping them safe and working, and there was always this background of what is -- what is actually happening? What is going on? So going forward I think just better communication, better identification, like, of trends. So we knew that there was an increase -- a significant increase in deaths and collapses that were marked as "unexpected or unexplained", and be frank about that with the nursing staff.
LANGDALE: And stop just saying "deaths", because there's a reference, isn't there, to lots of neonatal deaths, mortality rates. It was unexpected. It was the unexpected deaths --
HUDSON: Unexpected.
LANGDALE: -- that were significant.
HUDSON: It's not just the increase in the statistics. It's this word "unexpected". What does that actually mean? Because we'd say unexpected, but then there would be narratives about each baby of why they think that happened and this is what happens in neonates. And I just think -- wish that things were more frank and more on the surface. I can see why they weren't, but we're not going to be able to prevent this again unless we are frank and unless you have somebody who can come in with a bird's eye view that has -- who is impartial, who can look at trends, but also look at the patients themselves and the personal characteristics and the care of that patient to identify these things much earlier.
LANGDALE: And Lucy Letby obviously had her friends and allies on the unit, didn't she, with the nurses, people who really liked her? How do you think that impacted -- when you say on impartiality -- impacted on recognising when it needed to be investigated externally by the police?
HUDSON: I think you can't be impartial about somebody. I personally wasn't friends with Lucy, but I think you can't -- it's difficult to be impartial about a friend, and if you haven't seen them do anything people think, well, that's not possible, that can't possibly happen
here. I think it's like a two-thing approach. If we can't imagine that she would do this and we haven't seen anything specific, so it can't possibly be true. For me personally it was the lack of communication, the lack of facts. I wasn't friends with her, so I over time, with my experience, formed an opinion based on my ongoing experience in neonates. That is still my opinion. That's not fact until it's proven, which it has been now. But, how can you form an opinion when you don't have all the information? I don't know.
LANGDALE: All the more reason, when there is any possibility of harm being caused to a baby, to refer externally, whether it's local authorities, the police, for investigation. As you've described, you would know as a nurse, you do if you're suspecting parents of harming children, you don't need proof, you just need the concern, don't you --
HUDSON: Yeah.
LANGDALE: -- that there's a possibility of harm being caused?
HUDSON: Yeah. I feel as though being able to look back at the information that now is available to me and everyone else it was like there's no concrete proof this is happening so, therefore, it can't be happening.
And, like you say, that's not how we conduct care in the community. It's not how we -- if we think a child has been harmed, yes, there's lots of information gathering. But if you see a worrying interaction on the unit you speak to social care and you flag that concern. So why is it different if it's a member of staff?
LANGDALE: Do you think it would be easier if you could do that confidentially in some kind of hospital helpline, "I'm worried about this because the colleagues, this was said, this was said", where effectively whether it's a safeguarding unit in a hospital or an independent unit that that information can be gathered --
HUDSON: Yes.
LANGDALE: -- would that help, do you think, from a nurse perspective?
HUDSON: I think -- I think so, and I think that people are innocent until proven guilty, and I think that it has to be a process which is respectful of both parties and has some protective factors for the person being accused and the person doing the accusing. It needs to be looked at with a fair, impartial point of view. That is the most important thing. Because when emotions and friendships and biases become
involved, if that is what's happened here, I'm sure we will find out, that complicates things and we just can't let that happen.
LANGDALE: When you were training, you mentioned the Beverley Allitt report. That's on the training programme, isn't it, for nurses?
HUDSON: Yes.
LANGDALE: What do you actually learn about the Beverley Allitt case? Do you learn -- well, you tell me first.
HUDSON: I can't -- I can't remember a great deal from university now, I'll be honest. It's a short session.
LANGDALE: Is it -- one of the recommendations from the Inquiry that followed Beverley Allitt's conviction was that there should be heightened awareness of that Grantham case so that within the NHS people like yourselves on wards should know that this can happen, somebody can come to work with the intention of causing deliberate harm.
HUDSON: Yes.
LANGDALE: The unthinkable. That was one of the messages. So was that part of the learning or was it more practical about medication doses? What was it about? If you can't remember say.
HUDSON: I can't remember.
LANGDALE: You just know there was a session. So it does form part of nurses' training?
HUDSON: Yes.
LANGDALE: In your mind, although -- and you recognised she was somebody convicted of killing babies as part of that training --
HUDSON: Yes, yeah.
LANGDALE: -- and yet roll forward to your first experience, not as long after you've had that training than some might, that would still be something really difficult for you to take on board unless you had seen something directly?
HUDSON: Yeah. And it's also -- you know, that recommendation "heightened awareness", what does that actually mean? We're all aware that these things can happen, but people have a really hard time believing it's happening when it's happening. That's why we need that impartiality. That's why we need that outside eye looking in.
LANGDALE: You do say in your statement at paragraph 41: "Due to working on the unit as a student nurse, I knew the average death rate had previously been much lower. I was worried about this increase, especially as they all seemed to be unexpected or sudden -- and there was no explanation ..."
So you were worried, but presumably you didn't know what to do with that worry or what -- or take it to anyone. What do you do with that? You're worried about it.
HUDSON: I think I was just -- I was worried, but I was so junior and I think I just -- over time, I believed that narrative of this is what neonates do, this is what prem babies do, because my frame of reference, even though I had been a student, was just so small.
LANGDALE: Can you remember where you were getting that narrative from?
HUDSON: No, I can't. I can't remember specifics. I think it was just general conversation. I can't remember a person or a time.
LANGDALE: Well, we've heard that. I mean, that's been repeated since, hasn't it, it's what happens. So that was your impression that that was the answer to an increase in sudden and unexpected deaths, that they can happen --
HUDSON: Yes.
LANGDALE: -- a bad run, have a number.
HUDSON: (Nods).
LANGDALE: One final question from me. There's obviously been a wide amount of newspaper reporting, and I think one article referred to a nurse's comments from the
Countess of Chester anonymously made about how night shifts were. You worked night shifts sometimes; right?
HUDSON: Yes.
LANGDALE: So do you recognise this. She described how during night shifts: "... nurses on the ward would pull a name out of a hat and whoever got picked would be able to leave early despite still being in charge of a baby." Do you recognise anything like that?
HUDSON: What I know of that time period is there would be times where staff would have time owing, where they've overworked their hours on different shifts. If the unit was quiet and there was three babies, if a nurse could leave a little bit early and claim that time back they were allowed to do that.
LANGDALE: Right.
HUDSON: There was never a baby left alone. There was never a shortage of staff because we had sent someone home. Nobody would leave the unit if their help was needed, and that's displayed quite often in times of resource where staff would stay hours beyond what they were paid for because they just didn't want to leave. They didn't want to leave the family, the baby, and they didn't want to leave their fellow nursing staff in the lurch.
LANGDALE: This suggestion is: "Instead of carrying out a correct handover they would leave a written note by the infant leaving the baby without oversight for hours at a time."
HUDSON: No. The shift leader knew all the babies on the unit, so if that nurse wasn't available they'd hand over to the shift leader. They might leave bullet points of when things are due, but it's up to that nurse to check that those things are correct times.
LANGDALE: It becomes quite easy, doesn't it, to make comments on the generalities about how the neonatal unit was staffed and run. Can you give your honest, open, candid appraisal of that? How did you feel it was? And just say it how it was. There's no right answer. How was it?
HUDSON: I feel as though it was run relatively well. I feel like the staff -- and it's what I'd experienced as a student, it's where I decided to work, on that unit -- is that everyone just seemed really passionate about neonatal care. They were passionate about learning. They were passionate about improving care. There would be times where we were short-staffed. Staff get sick, staff have personal loss and they have to take time away. I found that many of the staff would do overtime, bank shifts because they had that dedication to the job and to the unit to make sure that the care we provided continued to be consistent and continued to be safe.
LANGDALE: You say finally on reflections: "I don't think the crimes of Letby would have been prevented if there had been CCTV present."
HUDSON: Yes.
LANGDALE: "Many of her crimes were ..." Well, tell us. Tell us, why do you think that?
HUDSON: I think that -- and I would caveat by saying if parents would be more confident with CCTV that's not what I'm questioning. That is if that's going to make them feel safer, by all means. That's not for me to decide.
LANGDALE: And in the incubator a camera so they can see if they're off the ward because they can't get to their babies?
HUDSON: Yeah. Wherever they are, whatever helps parents feel safe and feel that they can see their baby I have no questions over. I just don't want us to fall into the trap of thinking that that might stop somebody from doing this again.
LANGDALE: So not to get a false reassurance from it. Why do you say that, because it's so hard to see the actions?
HUDSON: I think because Lucy attacked these babies under the guise of normal care. Nobody saw her do anything that was -- in a stereotypical way, that was violent or malicious or -- and on CCTV, how do you know what's in a syringe? I don't -- I think it could be part of the process. I don't think it's the answer.
LANGDALE: One other thing if I can ask you, if I may. We have had more than one parent tell us of an experience of expressing breast milk, you know how important that is for a newborn, for the mother and the baby, leaving it in a fridge on the unit and then it's gone with no explanation from anyone. It's just not in the fridge. Did that happen very often and do you think that -- it's an important issue, isn't it?
HUDSON: Yes. It's not something that I'm aware of that it would just be gone. It's not something I've heard before.
LANGDALE: Because there should be systems around that, shouldn't there, where the milk is?
HUDSON: Yes.
LANGDALE: Who has access to it?
HUDSON: Yes, and much of that has changed since then as well.
LANGDALE: How's that changed?
HUDSON: Well, now we have each -- each patient not in ITU, HDU, but in the special care rooms every patient has their own fridge, so milk is kept separate. We have two people checking the milk and signing for it. That can be a parent, two people check the label. I know there was incidents where babies received the wrong milk, but I don't know of any incidents of milk going missing. So I can't comment on that.
MS LANGDALE: Thank you very much, Ms Hudson. Those are my questions. My Lady, nobody else is asking questions of this witness.
LADY JUSTICE THIRLWALL: Well, thank you very much indeed, Ms Hudson, for coming along and giving so much evidence.
HUDSON: Thank you.
LADY JUSTICE THIRLWALL: We are very grateful to you and you are free to go now, but if you would just stay there until everyone else is out of the room.
HUDSON: Thank you very much.
LADY JUSTICE THIRLWALL: We will rise until ten past 2. (1.07 pm) (The luncheon adjournment) (2.10.00 pm)
LADY JUSTICE THIRLWALL: Yes, Ms Lyons.
MS LYONS: My Lady, may Mrs Kathryn Percival-Calderbank be sworn in, please.
LADY JUSTICE THIRLWALL: Yes.
KATHRYN PERCIVAL-CALDERBANK (sworn)
MS LYONS: Can we please begin with your full name.
CALDERBANK: My name is Kathryn Lesley Percival-Calderbank.
LYONS: Mrs Percival-Calderbank, you have provided a witness statement to the Inquiry dated 18 April 2024, are the contents of that statement true to the best of your knowledge and belief?
CALDERBANK: Yes.
LYONS: We're going to begin by going through your career. It's right that you qualified as a nurse in the British army 1988.
CALDERBANK: Yes.
LYONS: And you left the army in 1989, and you commenced employment within the NHS. When did you start working at the Countess of Chester Hospital?
CALDERBANK: I started in I think it was 1991 and I was a student midwife.
LYONS: And you qualified as a midwife in 1992; is that correct?
CALDERBANK: It was probably nearer 1993, at the end. I think I got my dates slightly wrong.
LYONS: Were you aware around the time of your training to become a midwife of the case of Beverley Allitt?
CALDERBANK: Yes.
LYONS: And so you were aware that insulin could be used as a drug to harm babies?
CALDERBANK: Yes.
LYONS: After you qualified as a midwife, in your witness statement at paragraph 5, you say that you took up a position as a midwife on the neonatal ward; is that correct?
CALDERBANK: That's correct, yes.
LYONS: And at some stage you were no longer a midwife on the neonatal ward and you became a nurse --
CALDERBANK: Yes.
LYONS: -- on neonates. So can you just explain that transition?
CALDERBANK: When the NMC decided that you had to keep with dual training, you had to do so many hours in one qualification and the other I couldn't adhere to the full qualification as a midwife because I wasn't practising on a labour ward to fulfil that requirement. So I -- I kept my registration for nursing and not midwifery.
LYONS: And that was in 2013?
CALDERBANK: I can't remember what date that really was.
LYONS: In paragraph 6 of your statement you say you became a senior neonatal practitioner at the Band 6 level in 2013 is what I inferred from your statement, but if you don't remember.
CALDERBANK: Yeah, because I did extra qualifying cases towards it as well, towards getting that -- that qualification. So I'd done my -- what was known as the 405, which was part of the looking after neonates, and then I then did my R23, which is a -- an advanced training to further my position.
LYONS: And are you still employed as a neonatal nurse on the -- at the -- on the neonatal unit at the Countess of Chester Hospital?
CALDERBANK: Yes.
LYONS: I would like to move now to some questions about how the unit was in 2015/2016 and your relationships with your fellow staff members. At paragraphs 26 and 69 of your statement, you describe the working environment on the neonatal unit during the period that we're concerned about, 2015 to 2016, as very busy and particularly stressful for the nursing staff. Can you -- can you tell us why that was? In
your -- in your view why that was?
CALDERBANK: Because we were -- we had a lot of babies -- intensive care babies and there was a lot of work to do for the amount of babies towards the staff. Even though we were BAPM compliant it was still very busy.
LYONS: Busy but manageable?
CALDERBANK: At the time -- most of the time it was manageable but at times it wasn't because of the requirements of taking babies from the maternity unit that were unable -- that mothers weren't able to be transferred out in utero or because the mothers had come in and delivered, and the babies then needed further care with -- with us, so we were indebted to take that -- the care of the baby over for them. The care of the baby to ensure its safe -- it's -- help it -- help the baby out.
LYONS: And what about medical cover, did you feel at the time that there was adequate medical cover, enough doctors -- junior doctors, middle-grade doctors, Consultants on the neonatal unit at that time?
CALDERBANK: Yes. I -- the only difference was that they had to cover an awful lot of -- they weren't just for neonates -- looking after neonates, they were looking after the -- any babies that were born on labour ward and also the paediatric. At times they were also
covering the paediatric ward and -- and A&E at times as well.
LYONS: But if you needed a doctor on the neonatal unit, would they come if you called them?
CALDERBANK: Yes, we would bleep them and they would answer the bleep and come to us.
LYONS: And I'm going to ask you some questions now about Datix reporting. Now, I think by 2015 you would have been employed on the neonatal unit for about I think 22 years or around then.
CALDERBANK: Yeah.
LYONS: So you've probably seen different systems come and go?
CALDERBANK: (Nods).
LYONS: Do you remember when the Datix incident reporting system was introduced?
CALDERBANK: I -- I can't -- can't recall the dates, no.
LYONS: And you explain very helpfully at paragraph 29 of your statement how it was used, and if I understood your evidence correctly, there are two scenarios. I think you say in response to a specific concern, and you give an example, closure of the ward due to acuity or lack of staff or admissions above the allocated number of beds, and the second scenario is if a mistake was made in the clinical care of a baby, for example a drug administration error.
CALDERBANK: Mm-hm.
LYONS: Would you or any of your nursing colleagues complete a Datix form if a baby suddenly and unexpectedly collapsed and died?
CALDERBANK: No, we wouldn't have done that. It would have probably been left to the medical staff to complete that.
LYONS: And would there be a discussion -- so if a baby has to be -- had -- was being resuscitated and the resuscitation was unsuccessful and the baby sadly died and you have the nurses in the room and you have the doctors in the room, how would the conversation go, in terms of who's deciding to fill out the Datix form? In practice, how did it work?
CALDERBANK: It was just understood that the doctors would complete that -- that side of it.
LYONS: Understood, by whom?
CALDERBANK: By -- by the nurses.
LYONS: And what was your understanding about if a baby suddenly collapsed unexpectedly, needed to be resuscitated but did not die, so recovered --
CALDERBANK: Then --
LYONS: -- would a Datix form be --
CALDERBANK: It should have been --
LYONS: -- filled out in that situation?
CALDERBANK: It should have been, yes.
LYONS: And, again, would that be the responsibility of the doctors to do or the nurses --
CALDERBANK: As far as I'm --
LYONS: -- or a joint responsibility?
CALDERBANK: As far as I'm concerned, yes.
LYONS: As far as you're concerned it would be the --
CALDERBANK: The doctors' responsibility.
LYONS: Now, if I can turn now to your roles and responsibilities in the neonatal unit during 2015 to 2016. You set these out at paragraphs 7 to 21 of your witness statement. I would like to ask you some questions about your role as a shift leader.
CALDERBANK: Mm-hm.
LYONS: Now, you were a shift leader between 2015 and 2016, and are you still a shift leader?
CALDERBANK: Yes.
LYONS: And how often would you work as a shift leader? Because it's an additional -- you know, you have additional responsibilities when you work as a shift leader so --
CALDERBANK: It was -- tended to be allocated throughout all the Band 6s who were -- who were working that it was -- that we all covered the shifts and had an equal
opportunity to cover the shifts.
LYONS: So was it monthly, or weekly?
CALDERBANK: I think it was trying to be done -- be done on a monthly basis. But sometimes that might alter depending on staffing and if somebody's not feeling well that they couldn't take the responsibility of being a shift leader, then one of the other Band 6s would take that shift over.
LYONS: And one of your responsibilities as a shift leader, I think you say at paragraph 8 of your statement, was that you were: "... responsible for coordinating shifts and for allocating duties to junior members of the team and ensuring patient safety." Now, can you explain, what was the process between June 2015 and June 2016 for allocating nurses to babies?
CALDERBANK: It tended to be the shift leader who allocated for the next shift on. So if you were on nights you would allocate for the day shift looking at the acuity of the ward and what -- what staff you had on that -- coming on to that day shift or that night shift, and then you would also look at who had been caring for the babies previously, so if they'd worked the day before, then you would -- for continuity of care, then you would then perhaps give that person that baby again so that
there would be continuity for the parents and for the baby.
LYONS: What about -- did you take into consideration any welfare concerns that you may have had for the nurse, for example if the nurse had experienced a bereavement in the previous shift, would you --
CALDERBANK: Yes.
LYONS: Would that play a part in your decision-making?
CALDERBANK: Yes, that would have done as well. I had on occasions moved staff -- staff not to be in an intensive care setting and put them outside in the outside nurseries so that they weren't -- to help with their mental well-being and so that they could not be put in that stressful situation again.
LYONS: And is that something that you would do of your own volition or is that something a nurse might request.
CALDERBANK: Both. I would do both if I -- if I was able to.
LYONS: And by outside nurseries, can you explain what you mean by that, please?
CALDERBANK: The -- we would have intensive care nurseries and then we would have high dependency nurseries, and then there would be -- in the unit, as it was, there were two special care nurseries, and so the intensive care were the babies that might need ventilating or additional support with their breathing. High dependency they didn't need as much support but still needed more specialised care. And then the outside nurseries the special care babies were the babies that were -- had maybe gone past all those intensive and high dependency and were getting ready towards going home, really, so they were -- you were trying to get them to feed and to grow so that they were big enough and well enough to be able to go home with the support of the -- with the parents in being supported as well.
LYONS: And how was the allocation communicated to the nurses?
CALDERBANK: We had a sheet that we would have and the baby -- the nurses' names would be written next to each baby and then that was allocated -- they would have the sheet.
LYONS: So if we -- just if we use an example. We have nurses coming on to a day shift and on your evidence the shift leader for the night shift would have done the allocation.
CALDERBANK: Yes.
LYONS: So when would the nurses coming on to the day shift find out which babies they would be caring for?
CALDERBANK: That morning of the -- they were coming on to the shift.
LYONS: And would that be during the handover?
CALDERBANK: It would just be just -- just beforehand over, yes.
LYONS: So was the sheet given to the nurse or would there be --
CALDERBANK: They were given to each -- each trained nurse had -- would have a handover sheet, yes.
LYONS: Provided by the shift leader?
CALDERBANK: Yes.
LYONS: And did you consider, when you were a shift leader, that you had enough skilled nurses to allocate to the sickest babies, so your nursery -- the babies in Nursery 1 and perhaps the babies in Nursery 2?
CALDERBANK: Most of the time, yes.
LYONS: Or were there times when you allocated babies -- the sicker babies to nurses where you felt maybe they didn't have quite the experience but they could rely on the support of a more senior nurse?
CALDERBANK: Yes, that's -- that's correct, you would -- you would -- so that they were supported by the senior nurses, so that they gained the experience as well.
LYONS: And senior would be a Band 6 nurse?
CALDERBANK: Yes.
LYONS: Turning now to relationships between staff. You've told us that -- in your statement at paragraph 6 that Eirian Powell was your manager.
CALDERBANK: Yes.
LYONS: And it seems that -- I think Eirian Powell says in her statement at paragraph 6 that she returned to work on the neonatal unit in 1993, which is the year I think you joined --
CALDERBANK: Yes.
LYONS: -- the neonatal unit. So by 2015 you'd been working together a long time.
CALDERBANK: Yes.
LYONS: And how was your relationship with her?
CALDERBANK: I had a good working relationship with her. I -- I didn't have any issues with her. She had quite a brash sense of humour, which some people might -- might not like, but -- but generally I -- I worked -- worked well with her and was able to communicate with her both before she was the manager and then after when she became the manager. And if I had any issues I was able to go to her to -- to voice them.
LYONS: And you say at your paragraph 33 of your statement that you were aware that she treated some staff differently from others and the staff she liked more would get certain advantages; is that correct?
CALDERBANK: Yes.
LYONS: And you say it was "subtle but noticed".
CALDERBANK: Yes.
LYONS: Was Letby one of the nurses who Eirian Powell liked more than others?
CALDERBANK: It wasn't just one, it could be -- it was just little, little things that you -- we noticed -- I noticed. It wasn't -- they just -- they seemed to -- if they were able to go into the office they were able to -- to -- if they wanted to go on certain study days or something like that they were able to get it, whereas other people might not have been able to.
LYONS: So just going back to my question, would you say that Letby was one of the nurses that Eirian Powell liked more than some of the other nurses?
CALDERBANK: I know that she did like Nurse Letby, yes.
LYONS: And why do you think that?
CALDERBANK: I don't know. I don't know.
LYONS: Well, what gave you that impression?
CALDERBANK: It was just --
LYONS: Did she say so?
CALDERBANK: She did. She just said that she did like -- she did like her and she was happy -- when she got her position on the unit she was happy that she was working with us and she felt confident that she was a caring and compassionate nurse.
LYONS: Do you think others picked up on what you picked up, that she liked Letby a lot?
CALDERBANK: I don't know.
LYONS: So it wasn't something that was discussed on the unit?
CALDERBANK: No.
LYONS: Looking back, do you think Eirian Powell's positive attitude towards Letby might have affected how she would have responded to any concerns about her?
CALDERBANK: I don't know, it might have done.
LYONS: If you had had any concerns about Letby, would you have felt comfortable raising them with Eirian Powell?
CALDERBANK: Yes, and I did. On an occasion I did raise my concerns because after --
LYONS: Let's talk about that now. So can you tell us about that occasion, please.
CALDERBANK: Yes, it was I had been asked by Eirian Powell to try and not put Lucy Letby into the intensive care nursery --
LYONS: So can you just pause there, can you tell us when that happened?
CALDERBANK: I -- I can't -- I can't know the exact dates. I know it was --
LYONS: No, not the exact date. Can you tell us, was that in June, July, summer of 2015 or by Christmas 2015?
CALDERBANK: I -- I probably -- I don't know to be honest. I don't know what dates it was. I don't know what year it was. It's so many years ago now, I'm afraid.
LYONS: What -- did you have this conversation during the period that this Inquiry has focused on 2015 to 2016?
CALDERBANK: Yes, it was, yes.
LYONS: Okay. Sorry, continue.
CALDERBANK: So because the -- there had been -- I think it must have been probably in the early stages, I don't really know, but that I'd asked -- she'd asked me to try and not let Nurse Letby work in intensive care for her -- for her mental health and well-being after dealing with a death. So I -- I -- she'd asked me as shift leader not to put her into the intensive care nursery, to put her into the outside nurseries for her -- for her own mental health and well-being, which I had -- had put down on one of the -- for the shift, had asked -- asked to put her into one of the outside nurseries, and I was -- nurse Lucy Letby then shouted at me for doing so because she felt she didn't want to be in outside nursery she wanted to be in the intensive care setting because she felt that it was boring looking
after the special care babies where --
LYONS: Do you remember whether this was a night shift or a day shift?
CALDERBANK: It was a night shift.
LYONS: And do you remember if any of the babies on the indictment were in Nursery 1 at that time?
CALDERBANK: Sorry?
LYONS: Do you recall whether any of the babies on the indictment, [Child A] to [Child Q], were in Nursery 1 at that time?
CALDERBANK: I don't know, no.
LYONS: And -- so were you the -- sorry, did you say it was a night of the shift?
CALDERBANK: I believe it was a night shift because I'd had to change --
LYONS: So you were -- you were coming off shift?
CALDERBANK: I was actually coming on shift but I had to swap the off duty -- the -- the shift lead, the shift pattern. I'd gone to the previous shift leader and said, "I need to put Lucy in a different nursery out of -- out of the intensive care into one of the ITU, I've been asked to do it by Eirian."
LYONS: When you informed Letby, what exactly did she say to you?
CALDERBANK: That she was really angry with me for doing
so. She'd felt that it was -- that she -- she needed to be in Nursery 1. She didn't want to be in the outside nursery, it was boring looking after the special care babies, because I tried to say to her about it's sometimes you need to go out in the outside nurseries not to be in that intensive care settings where it's -- you've had a -- an experience with a -- with sick babies, you need to go outside and do some nice things like feeding and cuddling the babies and getting them ready for home, and -- and experiencing that situation rather than that intensive care setting all the time, because it is draining and emotional on you as a person.
LYONS: Were you able to persuade her to work in --
CALDERBANK: I did --
LYONS: -- the outside nurseries?
CALDERBANK: I did, but I did find at times she would then -- find her into the other nurseries at times.
LYONS: During that same shift?
CALDERBANK: Yes.
LYONS: And what would you -- what did you do when you saw her?
CALDERBANK: I just asked her -- I said, "You've got other babies outside, you need to go and look after them."
LYONS: And how did her -- did -- her reaction was -- did it surprise you, were you concerned by it?
CALDERBANK: It did surprise me and it did raise concerns with me, because I felt that that wasn't -- I had done it for her best interests rather than upsetting her for -- you know, it wasn't that I didn't think she was capable of looking after the babies -- the intensive care babies, I was doing it more because I felt that she needed it for her -- herself really emotionally.
LYONS: And what did you do, did you report this conversation to Eirian Powell the next -- the next shift when you saw her?
CALDERBANK: As soon as Eirian -- I was able to speak with Eirian I spoke with her and raised my concerns and said, "I have tried to keep Lucy out Nursery 1 but she still wants to keep moving back in", and told her about the --
LYONS: And what was --
CALDERBANK: -- conversation I'd had with her.
LYONS: What was Eirian Powell's reaction?
CALDERBANK: She said, "Oh, we'll just have to try and stop her -- stop it again when you can."
LYONS: And was that instruction to you to keep her in the outside nurseries just for that shift or was that sort of an ongoing instruction for you and other shift leaders?
CALDERBANK: I don't know whether other -- other people had been asked to do so or not, but I had definitely been
asked to for -- for -- definitely for that week anyway.
LYONS: For that week?
CALDERBANK: Yes.
LYONS: You have described your colleagues -- your nursing colleagues at para 26 of your -- paragraph 26 of your statement as family.
CALDERBANK: Mm-hm.
LYONS: What did you mean by that?
CALDERBANK: Because we spend so much time together we support each other so much. We socialise together at times. It -- and I think because we do -- are so supportive of each other we -- we actually know a great deal about each other because we spend sometimes more hours on the unit together than we do with our own family at times.
LYONS: And what about the relationship with the midwives at the hospital, what was that like in 2015/2016?
CALDERBANK: I didn't -- never had an issue with the midwives on -- on the labour ward. We would go through twice a day to find out what was happening on the labour ward, if there was any concerns that would involve us during the day, and if they had any concerns they would come through and tell us. If they got a lady who was -- they thought was going to go into labour who was not
full term, they would let us know, or any problem -- any babies that they felt there was -- there might be an issue at delivery with them would let us know.
LYONS: So you worked well together --
CALDERBANK: Yes.
LYONS: -- with the midwives?
CALDERBANK: (Nods).
LYONS: And what about your relationships with the doctors, the junior doctors, middle-grade doctors, Consultants, how was that?
CALDERBANK: I didn't -- I found that we had a good working relationship with all the doctors, the Consultants and the doctors, junior doctors.
LYONS: Did you feel able to express your views or challenge them --
CALDERBANK: Yes.
LYONS: -- if you disagreed with the management of a baby?
CALDERBANK: I felt I was able to. And if I had any -- any concerns I would be able to speak to them and say what my concerns were as well.
LYONS: And did you have any involvement with the senior management?
CALDERBANK: We had -- on the ward we had our ward managers and then the next I -- think it was the head of --
I think it was the matron because the -- there were so many changes --
LYONS: Do you mean Ann Murphy? Is that --
CALDERBANK: Yes --
LYONS: Yes.
CALDERBANK: -- yes, she would always come and check that we were okay. But other than that, I wasn't aware of many people coming. We used to have -- the shift co-ordinators on -- at night shift they would always come and check how we were. But other than that, I don't remember many other people coming very often to ask how -- how things were.
LYONS: Now, you say at paragraph 30 of your statement that senior management: "... did not listen to staff who had concerns about how busy the unit was ...
CALDERBANK: Mm-hm.
LYONS: Can you tell us a bit more about that?
CALDERBANK: As we were filling out we felt we were very busy and we were filling out Datixes to -- to put that in so that there was evidence that we were busy and our concerns with it. We just felt that nobody was really listening to us at the time because we were -- there was so -- we were so busy at some times that we felt that we were -- we weren't giving -- we were giving the best care that we could give at the time but it wasn't as good as we could have given I think at times.
LYONS: So what did you think would happen once you completed the Datix form? How did in your mind did you think that would get up to senior management and cause some --
CALDERBANK: I know that --
LYONS: -- sort of response or change?
CALDERBANK: I know at the moment it would -- it goes to a Datix meeting and then it's -- it's looked at there and then it's progressed further, but I don't know what the process was in 2015 and 2016.
LYONS: But you didn't feel the process was working?
CALDERBANK: No.
LYONS: You describe the visibility of senior management before and after Letby was removed from the neonatal unit in your statement. How did senior managers become more visible after Letby had been removed, which is what you say?
CALDERBANK: They would visit every day after -- after Letby was -- was moved. And especially when she was first taken in for questioning, we were aware of them coming to see how we were, but other than that --
LYONS: Who would visit every day?
CALDERBANK: It would depend on who the managers were. At
one point I think it was Karen Rees came. Occasionally the chief exec would come who was --
LYONS: Tony Chambers?
CALDERBANK: -- tony Chambers.
LYONS: Ian Harvey?
CALDERBANK: Sorry?
LYONS: Did Ian Harvey visit the NNU?
CALDERBANK: Very infrequently. But not on a -- not on a very regular basis, though.
LYONS: What about Alison Kelly?
CALDERBANK: And Alison would come on a regular basis as well.
LYONS: Before or after Letby was removed?
CALDERBANK: I felt it was after she was removed.
LYONS: I would like to ask you now some questions about [Child D].
CALDERBANK: Mm-hm.
LYONS: You deal with this in your statement at paragraph 38. You may want to turn it up. Now, we can see from your police statement, which you don't need to look at, that you worked the night shift on 22 of -- well, on 21 to 22 June 2015. And you tell us in your police statement that at around 1.30 in the morning you became aware that [Child D] collapsed. Do you have any independent recollection of the
collapse?
CALDERBANK: Other than what is written in my police statement?
LYONS: So in your police statement you describe that [Child D] had become mottled over her trunk and legs, and you say: "I have seen babies in the past with discolouration from circulation issues or from sepsis but on this occasion it looked unusual and we did not know what was causing it at the time. Discolouration later disappeared and she became a normal colour again." Do you recall any discussions at the time about [Child D]'s skin discolouration with either the nurses or the doctors who attended the resuscitation?
CALDERBANK: Yes. It would have been whoever was there at the time we would be discussing it because it was -- was so unusual because of this mosaic red, mosaic rash that appeared on the baby.
LYONS: So you weren't alone in thinking it was unusual?
CALDERBANK: No.
LYONS: And were you aware that [Child A] and [Child B] had displayed an unusual rash or skin discolouration?
CALDERBANK: No.
LYONS: Now, you tell us at paragraph 42 of your
statement that: "On the NNU we expect babies to survive. Some have increased risk factors ..." And you go through those risk factors: "[Child D] did not appear to fit any of those concerns as far as I was aware." So is it fair to say that [Child D]'s death was a shock for you?
CALDERBANK: Yes.
LYONS: And were there any discussions on the unit about how unexpected [Child D]'s death was?
CALDERBANK: Yes, I think there was at the time of the death. We weren't expecting that to have happened, to have occurred.
LYONS: And earlier in the month of June, we know that [Child A] had died on 8 June and [Child B] had collapsed on 9 and 10 June. Now, you worked the shift -- the night shift I think it was, is that correct, when [Child B] collapsed?
CALDERBANK: I don't know. I can't remember.
LYONS: Okay. And then -- well, were you aware that [Child B] had collapsed and had to be resuscitated?
CALDERBANK: No.
LYONS: Were you aware that [Child C] had collapsed and died?
CALDERBANK: We were aware that there had been a collapse but I -- I wasn't -- I don't think I ever looked after [Child C].
LYONS: So when [Child D] sadly died, you weren't aware that two other babies had died?
CALDERBANK: I was -- we were aware that there had been two other deaths. But not -- not so I wasn't aware that they were so close together.
LYONS: Now, Dr Rachel Lambie gave evidence to this Inquiry in the form of a statement but also in her oral -- she came and gave oral evidence, and what she says in her statement is that a number of junior medical staff and nurses were talking about the collapses of [Child A] and [Child B] following the events that happened on 10 June. I take it you were not involved in those conversations?
CALDERBANK: I can't recollect anything of that, no.
LYONS: And we've -- we've also seen -- the Inquiry has seen minutes of a senior clinicians meeting that took place on 29 June and they heard evidence from Registrars who were worried about the three neonatal deaths of [Child A], [Child C] and [Child D], and they felt nothing was being done. Were you aware that some of the Registrars were
concerned about the three neonatal deaths?
CALDERBANK: No.
LYONS: All three deaths were unexpected and we know, at least in the case of [Child A], [Child B] and [Child D], that there were an unusual rash or skin discolouration.
CALDERBANK: Mm-hm.
LYONS: Do you recall any conversations about these deaths?
CALDERBANK: No.
LYONS: A few weeks after [Child D] died, on 4 August [Child E] died. So by August, so from 8 June to 4 August, four babies had died. Do you recall any conversations in the unit about these deaths?
CALDERBANK: I don't recall any -- any conversations about them, no.
LYONS: Do you recall an atmosphere of worry or concern?
CALDERBANK: I -- I can remember myself because I think I'd had a period of absence and then came on and had enquired after one of the babies where -- had it gone home? Had it been discharged home? Had it gone somewhere else? And then to be told that the baby had actually collapsed and died, that was a surprise. And then to -- then you ask -- you always ask, "Oh, which -- which person was involved when they died, you know, how
are they?" Because you worry about -- about people who've had to deal with it. And then when I was told it was -- that Nurse Letby had been -- had been involved with it, there was thinking -- there was concerns and I can remember saying to one of my colleagues, "If somebody's not careful, they're going to think there's something untoward happening here because it's not" -- you know, because you start worrying about your colleagues' well-being and things like that, but you also start worrying, what are we missing? What's -- what are we not seeing here? Why -- why is this occurring?
LYONS: Do you remember when that conversation was?
CALDERBANK: I don't know when it was, the conversation, and I don't know who I -- I spoke to at the time. But I just remember exclaiming.
LYONS: And what did you mean when you said "something untoward", were you referring to incompetence or deliberate harm or something else?
CALDERBANK: Just because it was -- it -- you know, I'd been there a long time and in the period of the time before this -- these -- these four deaths, I'd never known to have that many deaths in such a short period of time. I'd been there, you know, for -- you know, over -- over 10 years by then, and in that are period of
the 10 years prior I'd not dealt with as many deaths before that.
LYONS: So you -- just based on what you've just said it sounds like maybe you'd this conversation after the three or four deaths, do you think?
CALDERBANK: I -- I think -- I don't know how many deaths it was, I just know that I'd had a period of absence, I'd come back on, and then when I exclaimed that -- you know, finding out that another baby had died, that I was worried -- that there was a worry.
LYONS: Do you remember when your period of absence was?
CALDERBANK: I don't know whether it was -- that I'd had a holiday and then came on -- back after a couple of weeks.
LYONS: But your nursing colleagues were updating you as to what had happened?
CALDERBANK: Yeah, because you would come on and you'd look on the board and say, "Oh, so and so, did that baby go home? Did that one go home?" Because you spent a lot of time with -- with parents or with the babies if they'd been on the unit for a while -- a long time, so you would always sort of like look at -- look at a board and scan where -- and ask -- you know, knowing if the baby was going to be well enough to go home within a short period of time you would ask about it.
LYONS: I want to ask you about an incident which we heard evidence about from Dr Rachel Lambie. She described an occasion when she walked into the neonatal unit, and I think she might have been in the intensive care room, and she found there were some nurses huddled over a computer and they were going through the staff rota, and the reason they were going through the staff rota is because they were trying to enquire, investigate as to who might have been on duty when the recent events had occurred. Now, she thinks this happened before she left the hospital in September 2015, and she remembers a nurse saying words to the effect that, you know, "It would be awful, but we are just checking", something along those lines. Were you, were you part of that conversation?
CALDERBANK: Not as far as I'm aware, no.
LYONS: Were you involved in sort of looking at the staff rota just to try and find out if this was --
CALDERBANK: Was the staff rota on a computer.
LYONS: It was -- that was her recollection.
CALDERBANK: We never -- our staff rotas were not computerised by that period of time. They -- they were all on paper.
LYONS: Right. But you don't know anything about that?
CALDERBANK: No.
LYONS: Okay. So I'm going to ask you now some questions about [Child N].
CALDERBANK: Right.
LYONS: So [Child N] -- you set out your involvement in [Child N]'s care at paragraph 48 of your statement, and on the night shift of 14 to 15 June you say that you were the shift leader. Were you aware -- you don't say so in your statement -- were you aware that [Child N]'s parents were expecting him to be discharged and taken home on 15 June 2016?
CALDERBANK: I think there had been talk about it, yes, as far as I can recollect.
LYONS: And [Child N] was in Nursery 3?
CALDERBANK: Yes.
LYONS: And you've already explained that that's the sort of feed and grow nursery.
CALDERBANK: Mm-hm.
LYONS: And you say in your statement that -- at paragraph 48 -- that Letby arrived about 15 minutes early for her shift.
CALDERBANK: (Nods).
LYONS: For the day shift of 15 June. Had you done
the staff allocation already?
CALDERBANK: Yes.
LYONS: And had you allocated Letby to [Child N]?
CALDERBANK: Yes, because she had had the child the day before and so because they were getting ready for home I thought it would be -- there would be a continuity and all the -- all the talk of the baby going home there would be all the continuity of getting all the discharge papers together ready for the baby to go home so that all the notes and discharge letters would be done by her.
LYONS: So Letby's shift would have started at 7.30; is that correct?
CALDERBANK: Yes.
LYONS: And she arrived at 7.15. Would she have been aware that she had been allocated [Child N] at 7.15?
CALDERBANK: I think she'd -- she'd requested, if she was able to, would she be able to have the baby to the shift before or to the nurse who was looking after her -- after the baby -- or after him.
LYONS: But not to you?
CALDERBANK: I think it had been spoken to me about it as well.
LYONS: So when she arrived 15 minutes early she knew that [Child N] would be her allocated baby for that shift?
CALDERBANK: I don't think she did know at that time.
LYONS: But she had requested it?
CALDERBANK: But she had requested it if she was able to.
LYONS: Now, we -- you say that at around 7.15 -- well, firstly, Jennifer Jones-Key was the designated nurse.
CALDERBANK: Yes.
LYONS: And in her witness statement at paragraphs 9 to 10 she said that Letby came into Nursery 3 at 7.15 am to have a chat with her, and she said [Child N] started to desaturate and was mottled all over and was blue in colour, Letby responded and commenced resuscitation using the Neopuff. Then she called for assistance. Is that when you became involved?
CALDERBANK: Yes.
LYONS: Can you tell us what happened from that point?
CALDERBANK: I -- well, I wasn't -- I don't think I -- I'd been informed because I was at the desk and she shouted for help, but I don't know whether I went in or Belinda Simcock went in to -- to assist because she was around, and the baby was then brought -- the doctors were called and the baby was brought out and put into Nursery 1.
LYONS: And what happened next?
CALDERBANK: And then I was still sorting out ready for the shift for the day -- the day shift coming on, so the baby was in Nursery 1, the doctors and Nurse Letby, Belinda Simcock and Jennifer Jones were -- were in there dealing with the baby.
LYONS: And did [Child N]'s collapse concern you, surprise you?
CALDERBANK: Yes. Well, it -- overnight the baby had -- was not acting as well as he should do. We'd actually called out the doctors in the night and monitored -- put a monitor on the baby of his saturations because Jennifer Jones was concerned about it and had been speaking with Belinda and the course of events, so the doctors had been informed in the night and had come and had -- we put the baby nil by mouth I believe and we'd screened the baby and put IV fluids. So -- and given IV antibiotics --
LYONS: But no decision --
CALDERBANK: -- which is a course of action.
LYONS: Sorry, but no decision had been made during your shift to move [Child N] into --
CALDERBANK: Not at that time --
LYONS: -- another nursery?
CALDERBANK: -- no, we -- because we still had monitor -- were able to monitor the baby and we -- and because Jennifer was staying in the room with the baby we were
happy for the baby to stay there at that -- that moment.
LYONS: Were you aware that Dr Brearey and Eirian Powell were taking a particular interest at this point in time in any sudden and unexpected deteriorations in a baby on the unit?
CALDERBANK: No.
LYONS: Did you speak to Eirian Powell about [Child N]'s collapse and the fact that he had to be moved to Nursery 1 and wouldn't be discharged?
CALDERBANK: Not that I can remember, no.
LYONS: So who within the unit would have informed [Child N]'s parents of what happened?
CALDERBANK: I think it would have been -- I -- because I was in the middle of sorting out the next shift they were coming on, so it I don't know whether one of the team who were looking -- with the baby at the time were going to inform them or -- I don't know whether one of the doctors were going to. I don't know whether it was actually ever mentioned at the time unfortunately.
LYONS: And do you remember Eirian Powell coming to find you to ask you about this incident?
CALDERBANK: No. She might have done but I can't -- I can't remember if she -- if I did.
LYONS: We're going to move now to [Child O]. You talk about your involvement in his care from
paragraph 52 of your witness statement. You were the designated nurse for [Child O] on the night shift of 23 to 24 June 2016 following [Child O]'s death; is that correct?
CALDERBANK: Yes.
LYONS: And how did you feel on learning that [Child O] had died? What was your reaction?
CALDERBANK: I was very surprised because that baby -- because he was -- he was one of three and they were all very well babies, born in good condition, and so it was -- we were -- wasn't expecting the baby to become unwell and to have died.
LYONS: And you returned to work the following night shift.
CALDERBANK: Yes.
LYONS: And you were informed that [Child P] had died, and what was your reaction, and what was the atmosphere like on the unit?
CALDERBANK: I think we were stunned by the -- the react -- by that happening because in the event of the -- the first Baby O [Child O] dying, the baby -- the other two had been -- were screened and started on antibiotics as a precautionary thing because we were -- just to see if there was something that was being missed. And the babies were -- were not acting -- were -- were okay really that -- the night before. There had
been an episode where we'd -- I think it -- where we'd -- one of them we'd stopped the feeds for a short time because he wasn't absorbing the feeds as well, so we just stopped the feeds for a bit and we got him observed by the doctors, and the doctors had checked the baby over, but because we'd already put the anti -- the baby already had antibiotics and had been screened during the day shift, we were not as -- that as concerned as we -- we would have been otherwise.
LYONS: You mention in your statement at paragraph 62 that there were discussions happening between the nursing staff who were working the night shift, so the shift you were on --
CALDERBANK: Yes.
LYONS: -- and the -- and the Consultants involved in the day shift. What were those discussions about? What was being said?
CALDERBANK: I think we were just concerned that we were -- we were missing something, that there were -- that was there something that -- a congenital infection or something that had been -- that was a congenital abnormality that had been missed, or there was something that was causing -- you know, for one of them to be -- to have died and then for the other two -- you know, to be screened and that second triplet being -- having to be screened -- going -- becoming unwell the next day.
LYONS: Did anyone suggest that the deaths might be unnatural?
CALDERBANK: I don't know. I think we were just -- we were just wondering what -- because, as far as we -- we were concerned, we were doing everything that we would have normally done with babies that were -- were acting as if they have got infections.
LYONS: And by this stage, was there any talk on the unit about Letby's involvement in the deaths of [Child O] and [Child P] because she was caring for them and any of the previous -- were people starting to look back and talk and wonder, and speculate?
CALDERBANK: I don't know. I don't know. I think we were just so busy with doing things that we were -- we were just focusing on what we were doing at the time. There might have been thoughts by other members of staff but it wasn't spoken out loud.
LYONS: And having previously thought yourself that maybe -- you know, people might think something untoward was happening, did that thought come back to you with greater intensity?
CALDERBANK: There was a -- I -- I think I did have a niggle, if I'm -- if I'm honest, but I didn't -- but then I thought we were -- because they weren't intensive
care babies, they were special care babies, it somehow didn't -- didn't equate really.
LYONS: So the niggle, is that like a gut feeling?
CALDERBANK: Yeah. Or a concern really.
LYONS: And what was -- what was your -- sort of what was your concern at that point that you wouldn't perhaps tell anyone?
CALDERBANK: That may be, you know -- but then none of us had ever -- most people who go into nursing or to the medical profession are not there to harm. They're there to care and heal and protect and support. They're not there -- so it's completely alien to most nurses to ever think about that you would want to harm, especially a baby.
LYONS: But you had a niggle?
CALDERBANK: There was just -- there was concerns, yes.
LYONS: I'd like to take you now to a document on the screen. The reference is IN0002879, page 81. So we're going to fast-forward now, Mrs Percival-Calderbank, to -- so the -- [Child O] and [Child P] had died on 23 and 24 June 2016, and then on 15 July 2016 this email was sent by Yvonne Griffiths to the nurses in the neonatal unit. Do you recall receiving this email and reading it at the time?
CALDERBANK: No.
LYONS: Do you recall this being discussed?
CALDERBANK: No.
LYONS: The fact that Letby was volunteering to be the first person to undergo clinical supervision within the team?
LADY JUSTICE THIRLWALL: Are we looking at the right document?
CALDERBANK: Actually, I think that's --
MS LYONS: INQ -- I'll read out the reference again INQ0002879, page 91. Sorry about that. There we are. I'll give you a moment to read that. (Pause). Do you remember receiving this email --
CALDERBANK: Yes.
LYONS: -- at the time? Sorry about that. And was there any discussion in the unit about having to undergo clinical supervision?
CALDERBANK: I think at times we -- it was felt that maybe we -- there was a talk about going to a different hospital to get -- look at different things how they do it and how to just keep us updated really and things like that and if there was -- but there had been a talk about it, yes.
LYONS: And was anybody objecting to being -- going -- undergoing clinical supervision?
CALDERBANK: I don't think so, no, not as far as I'm aware.
LYONS: And then it's the same document reference but it's a different page. It's now page 75. So a few weeks later. I'll give you a moment to read it. (Pause). Having received an email a bit earlier about the undergoing --
CALDERBANK: Yes.
LYONS: -- being the first person to undergo clinical supervision and now receiving an email a couple of weeks later about her going on secondment, what did you think at the time? Did you think this was unusual?
CALDERBANK: Because we'd already got a member of staff already -- who'd gone on secondment, so we didn't think it anything --
LYONS: So you didn't question it?
CALDERBANK: No. No.
LYONS: And the last document I would like to take you to -- sorry, before I take you to the last document, paragraph 66 of your statement. If we could go there, please. You say that Tony Chambers told staff at a meeting to be nice to Letby on her return to the unit. Can you tell us a bit more about this meeting?
CALDERBANK: We were all -- a lot of the staff were taken into a room and he took us -- took us by surprise by him saying that we had to be nice to -- to nurse -- to Lucy because none of us had ever been horrible to her, we -- we were unaware that -- we just knew she'd been on secondment, she wasn't communicating with many people, she only communicated with a certain amount of people, So we -- which at times she could -- she could not speak with people, so we didn't think anything. But to be told that we had to be nice to her because she was coming back, well, we wouldn't have been anything else. That's not in our nature -- nobody was ever horrible to her.
LYONS: What did he say the purpose of the meeting was?
CALDERBANK: Just to explain that she was going to be coming back to the unit.
LYONS: Did he mention an investigation, did he mention anything?
CALDERBANK: No, we weren't -- no. Because I think we'd had a -- I think the QCQ had come in and investigated the unit, and they had been happy with what, everything that had gone on, from what I can recollect --
LYONS: I think might that have been the RCPCH.
CALDERBANK: -- but it's just it's -- there's -- there was so much going on at the time and it's -- so --
LYONS: So this meeting happened after they came to --
CALDERBANK: I think so, yeah.
LYONS: -- inspect? And was there any chatter, any discussion after this meeting about what Tony Chambers had said?
CALDERBANK: I think we just -- it was just the fact that, well, why wouldn't we be nice to her? You know, we were -- it wasn't -- we just thought that she'd been on secondment and that she'd come back into the unit because she'd been there for a while that she just needed to gain her confidence and the competence back, and so we just -- I think we were just a bit, well, really?
LYONS: So during the period that she was on secondment, there was no discussion about Letby and the unexpected deaths that had occurred on the unit?
CALDERBANK: No.
LYONS: And no one had made a link at that stage, you say?
CALDERBANK: No, we'd not been -- we'd not -- we'd been kept in the dark completely over everything.
LYONS: Last document. It's INQ0058624, page 1. (Pause). Do you recall receiving this email at the time?
CALDERBANK: I vaguely remember, yes.
LYONS: And what were your thoughts when you received
it? What did you think about it?
CALDERBANK: Because we weren't -- we weren't informed about anything, we -- the fact that we didn't know what these allegations had been and so we were -- and so we were a bit -- a bit stunned by it all really, because we -- we just were still under the impression she'd been on secondment.
LYONS: Had Eirian Powell or Yvonne Griffiths said anything to the team -- the nursing team after this email had been sent?
CALDERBANK: Not as far as I'm aware, no. I don't -- I can't remember being informed about anything.
MS LYONS: My Lady, I have about 10 minutes more of questioning. Should I continue?
LADY JUSTICE THIRLWALL: Yes, please.
MS LYONS: Yes. Were you concerned about Letby returning to the unit after you received that email?
CALDERBANK: I think -- I think we were all -- I think we just -- we thought that she would need some support and supervision for her to be able to -- for her to come back for her own -- for herself really.
LYONS: Had you noticed any change in the unit whilst she'd been away in terms of number of collapses and unexpected deaths?
CALDERBANK: Yeah, that -- I mean there had been -- there had been changes made by the network and things so we -- certain gestational babies were being transferred out, but also that we had noticed that the number of collapses and deaths and things had -- had gone down drastically as well.
LYONS: So when you got that email, did your sort of niggle come back?
CALDERBANK: I think -- I think everybody was concerned that she needed support if she was coming back, yes.
LYONS: Was anyone concerned about the babies on the unit?
CALDERBANK: I don't know. I don't know. Because not long after that, I think things -- everything changed again after that so she never actually returned to the unit.
LYONS: You tell us at paragraph 5 of your statement that you felt that Letby had involved -- had been involved with many of the collapses and deaths. What did that make you think at the time?
CALDERBANK: It was only after -- when the investigation -- the police investigation we had to look back at stuff for our own -- own statements, that it sort of raised concerns and issues that, you know, there was -- that you were becoming more aware that there was a -- there seemed to be a pattern.
LYONS: And I'd like to ask you briefly now -- moving on to another topic -- just about debriefs and what was your recollection of debriefs and support following death of a baby back in 2015/16?
CALDERBANK: I know there were -- there were debriefs but I don't know whether it was actually very often with the nursing team involved. I think it's more that the medical team seemed to have the debrief rather than the nursing team. If it was a scribbled note in the diary saying that there was going to be a team -- a debrief or if a member of the nursing staff had said, "Is there going to be one?" Then it was -- it was then deemed that we were invited. But if you were busy or you couldn't get to them that -- they weren't altered to accommodate anyone, really.
LYONS: And what's the process now, because you still work at the hospital --
CALDERBANK: I do.
LYONS: -- so is it a different debriefing process?
CALDERBANK: Yeah, there's more -- we try and organise now with a -- an email is sent out to the team that were involved and anybody -- and everyone is involved in it from Band 4s up to the Consultant in that, so --
LYONS: Are they compulsory?
CALDERBANK: They're not compulsory, but it's whether -- if you wish to go, but there would be opportunities as well afterwards to speak with -- with other members if you needed to as well. And also we now have -- there's more support with counselling as well.
LYONS: And you say at paragraph 67 of your statement that you had not received any formal training on how to raise suspicions or concerns other than speaking with your manager. Were you aware of any other channel or route for raising concerns about a member of staff at the time?
CALDERBANK: Other than going -- you know, going to your manager or to other managers, matrons and that, not --
LYONS: And what about now?
CALDERBANK: -- not really. There is more -- there is a little bit more concerns and more open -- and that we've -- there's a freedom to speak and there's more being put within the hospital for everybody, so now there is more opportunities to be able to -- to mention these to people.
LYONS: So if you had a concern today about a fellow member of staff that they were harming babies on the unit, would you know where to go?
CALDERBANK: Yes.
LYONS: What to do?
CALDERBANK: Yes.
LYONS: My last question is, what do you think would keep babies safe in hospital from the events that occurred in 2015 and '16?
CALDERBANK: I think we need a more robust way -- policies so that if -- and communications so that if people have these concerns -- without -- without singling out people we need something that's more robust, a policy that can be passed down so that -- to raise these concerns rather than everybody kept in the dark really.
LYONS: Do you think they should be raised internally or externally, anonymously?
CALDERBANK: I suppose it would have -- internally first but then if it needed to, then externally.
LYONS: And anonymously or not?
CALDERBANK: Sorry?
LYONS: Anonymously or not?
CALDERBANK: It would probably have to be anonymously at the start because -- in case -- so nobody is singled out or -- you know, there needs to be a place where somebody needs to be able to say it in a safe space, to -- to mention that, that they have these concerns.
MS LYONS: Thank you, I have no further questions for you. My Lady, do you have any questions?
LADY JUSTICE THIRLWALL: Are there any other questions.
MS LYONS: No, there aren't.
LADY JUSTICE THIRLWALL: No. Thank you. Is the plan to change the layout of the room now?
MS LYONS: Yes. Please can we have a break now and then they're going to reconfigure the room and then we have two more witnesses after Mrs Percival-Calderbank.
LADY JUSTICE THIRLWALL: Thank you. Thank you very much indeed, Mrs Percival-Calderbank. You will be free to go when the room has been sorted out. How long do we need to move the screens?
MS LYONS: 15 minutes, please.
LADY JUSTICE THIRLWALL: Good. We will start just after half past 3. (3.17 pm) (A short break) (3.34 pm)
LADY JUSTICE THIRLWALL: Ms Lyons.
MS LYONS: My Lady, may Kate Bissell be sworn in.
KATE BISSELL (affirmed)
LADY JUSTICE THIRLWALL: Do sit down.
MS LYONS: Can we begin, please, with your full name.
BISSELL: Katie Anne Bissell.
LYONS: Ms Bissell you were sent a questionnaire by the Inquiry which you returned dated 19 March 2024. Do you have it in front of you?
BISSELL: Yes, I do.
LYONS: And are your responses to the questionnaire true to the best of your knowledge and belief?
BISSELL: Yes, they are.
LYONS: Ms Bissell, we're going to go very briefly through your career. You qualified as a children's nurse in 2007; is that correct?
BISSELL: That's right.
LYONS: Between 2007 and 2009 you worked as a Band 5 nurse at Alder Hey Children's Hospital in the paediatric intensive care unit.
BISSELL: (Nods).
LYONS: In 2009 you commenced employment as a Band 5 nurse on the neonatal unit at the Countess of Chester Hospital; is that right?
BISSELL: That's right.
LYONS: In 2014 having obtained further qualifications you were elevated to a Band 6 role.
BISSELL: That's right.
LYONS: Six years later, in 2020, you left the Countess of Chester Hospital to become a health visitor.
BISSELL: (Nods).
LYONS: And this year, 2024, you returned to the neonatal unit.
BISSELL: That's right.
LYONS: And you currently work part-time as a Band 6 nurse on the neonatal unit and part-time as a health visitor; is that right?
BISSELL: That's right.
LYONS: I'd like to focus now on the period that this Inquiry is concerned with, June 2016 to -- June 2015 to June 2016 when you were working on the neonatal unit. We understand from your responses to the questionnaire that this period on the neonatal unit was very busy and stressful for nurses. Can you explain why that was?
BISSELL: We were a Level 2 unit and we were just -- we were busy all the time. We just felt like we were at capacity most shifts. We had -- we were supposed to have sort of two Band 6 nurses and some Band 5 nurses and then nursery nurses on the shift but felt at times we didn't run at full capacity and that we were short-staffed, so there were obviously just a lot of pressure to deliver care during that time.
LYONS: We've heard evidence earlier today that it was busy but manageable. Would you agree with that?
BISSELL: I think some shifts were a lot busier than others. I think often staff would work through break times and lunch times. So I think some shifts it was very busy. We'd often stayed behind after a shift to write up notes that we hadn't had a chance to do in the daytime. And then other shifts were manageable. So I guess that it was sort of peaks and troughs really during that time.
LYONS: And you also -- I think you said -- in your witness statement to the police at page 2, paragraph 2, you said doctors: "Were and still are in short supply, so we couldn't always get the support we needed as soon as we needed it. Like everyone on the NHS they're under immense pressure and cover a number of units, departments within the Countess of Chester Hospital."
BISSELL: (Nods).
LYONS: During 2015 to 2016, were you concerned about the lack of doctor presence on the NNU?
BISSELL: Not -- not the presence. I just think sometimes on a night shift obviously doctors are covering paediatrics, as we say, obstetrics, A&E, so sometimes maybe if they were stuck over in the A&E department and we'd bleeped them for some support then
there would obviously be a little bit of a delay while they were finishing in A&E before they came over to the neonatal unit. That wasn't all the time. In those instances then we might have to go sort of above and maybe ask for a Consultant to come in. Yeah.
LYONS: But if you called them they came -- they came to the unit eventually; is that what you're saying?
BISSELL: Yes, yes.
LYONS: I'd like to turn now to relationships on the neonatal unit starting with the NNU manager, Eirian Powell. In your response to the questionnaire, you said you felt supported by her and you also say that there were staff appraisals, and those staff appraisals you said could have -- you could raise -- you could raise issues outside of your control which may impact on your performance. So did Eirian Powell conduct those staff appraisals with the nurses on the unit?
BISSELL: Eirian -- it wasn't always Eirian, sometimes it's the assistant manager --
LYONS: Yvonne Griffiths?
BISSELL: -- Yvonne Griffiths or the practice nurse, Yvonne Farmer.
LYONS: And what was your understanding as to the purpose of these staff appraisals?
BISSELL: As an annual update just to make sure that we were up to date with our training, for managers to feedback to us how we were performing, whether they felt there was any improvement needed within our practice or any areas that we would need further training in. It would be kind of an open forum for us to discuss whether we would like to do further training. And then also, you know, any issues that you felt sort of impacted on your care as a nurse for the patients.
LYONS: If you had any concerns about patient care, patient safety, would you have used this opportunity to raise those concerns or would you raise them separately?
BISSELL: I think I probably would raise them separately. I wouldn't wait -- because it was an annual review, if you had concerns about care, I wouldn't have waited until the appraisal to raise that. You know, I'd raise that earlier as the concerns arose.
LYONS: And you found the environment within the NNU supportive; is that correct?
BISSELL: I did. I worked there for 11 years before I left to do my health visitor training and I felt during that time -- although it was busy, I felt, you know, there was a lot of opportunities for learning and development and education. I felt I was supported
through that, you know, from the managers and from the practice development nurse. And I just -- yeah, I just felt I'd always -- I was continually sort of training and developing as a nurse, so I felt that it was a good place to work. I felt supported by my colleagues and I enjoyed it. You know, I really enjoyed my job.
LYONS: And how would you describe the relationship between the neonatal nurses and the doctors?
BISSELL: I think generally good. You know, we generally worked well together. I mean, you know, stress -- you have stressful shifts when may be, you know, people are under a lot of pressure or maybe there's the odd sharp word spoken to one another, but, you know, when everyone's under that much pressure that can be expected. But generally most people got on well with each other and were supportive.
LYONS: So when you say at your paragraph 4 of your questionnaire that relationships between the nurses and the doctors could be strained, you meant there may be a cross word in the heat of the moment?
BISSELL: I meant strained as, you know, in a -- yeah, like a resuscitation or, you know, as a situation where it's sort of highly stressful obviously there's a lot of anxiety and a lot of pressure on people. So I meant strained as in now and again people might have --
I don't know, maybe not speak to people as kindly as they -- as they would have done but generally I think, you know, after that people probably apologise or, you know, generally relationships were -- were okay.
LYONS: What about relationships with midwives, how was that?
BISSELL: I think they was a little bit more strained. I do feel there was probably sometimes sort of difficult relationships. It's hard because they -- everyone's got their own agenda, haven't they, when they're dealing with babies and -- and mums, so I feel sometimes they had their agenda and we had our agenda and communication wasn't always as good as it could be maybe.
LYONS: So as a shift leader were there occasions when you'd to communicate with midwives?
BISSELL: Yes.
LYONS: And how would that work?
BISSELL: We'd often have to go on to labour -- on to labour ward and just -- just explain whether we were open or closed as a unit, sort of how many intensive care babies we'd have at that time, and then the midwives would have to sort of explain to us whether they had any impending deliveries, preterm deliveries, and it was just to try and co-ordinate care that day, make sure that we had enough space for babies to come on
to the unit if they needed it, and whether we'd enough staffing and appropriately trained staff to deal with any impending deliveries.
LYONS: And were you usually able to find a resolution?
BISSELL: Generally, yes. And if not, then obviously that would be discussed with -- with the manager or with the doctors at the time and they'd liaise at a higher level with the obstetric team.
LYONS: Did you have much involvement with any of the senior management team at the hospital, so above your ward manager, so above, Eirian Powell?
BISSELL: No.
LYONS: Would they visit the NNU at all?
BISSELL: Not really, no.
LYONS: Would you know what they looked like?
BISSELL: I knew their faces but we didn't often see them on the unit, no.
LYONS: You tell us at page 3 of your -- page 3, paragraph 9 of your response to the questionnaire that initially you were not worried about the increase in the number of baby deaths on the NNU and thought that the unit was simply going through an unfortunate time; is that fair?
BISSELL: Yes.
LYONS: Were you aware at the time of the unexpected deaths of [Child A], C and D in June 2015? So these are three deaths that occurred within a short space of time in the month of June 2015.
BISSELL: I can't remember specifics, sorry.
LYONS: Were you aware of a time in 2015 where there seemed to have been a cluster of unexpected deaths?
BISSELL: Yes, I felt like we -- yeah, I do feel like we'd had an increase to previous years and, as I say, I just felt that we were just having a really awful time.
LYONS: And was there any discussion on the unit about -- about these unexpected deaths, or did they go along the lines of what you just said, it's just an unfortunate time, it will pass?
BISSELL: Yeah, I think it was more of, you know, this is -- this is awful for everybody and it's -- it's an awful time that we're going through hoping that it would -- it would get better, you know.
LYONS: And then we heard evidence from Dr Rachel Lambie about an occasion when she went to the neonatal unit and she said she was walking through the intensive care unit and she came upon nursing staff in a small huddle in the corner, over the computer, and she said she asked them what they were doing, and one of the
nurses replied that they were going through the rota just to make sure there wasn't somebody who was on "for all of them", I think -- I'm not sure what that was a reference to but maybe the recent events, and Dr Lambie gave oral evidence that she recalled the nurse saying something along the lines of "It's an awful thing to think but we're just looking." Were you involved in that huddle around the computer? Does that ring any bells?
BISSELL: No, I wasn't involved in that, and I don't recall that -- looking at an off -- an off-duty on the computer, did she say?
LYONS: Well, I think her evidence is that "They were in a small huddle in the corner over the computer and they said they were looking at the rota", do you know anything about that incident?
BISSELL: No.
LYONS: So by the end of 2015, in addition to the deaths of [Child A], C and D, [Child E] had also died on 4 August, and [Child I] had died in October. Were you aware of those deaths, the latter two, or not specifically?
BISSELL: I would -- I can't remember specifically.
LYONS: Could we, please, have on the screen INQ0017399 [invalid]. Sorry 7339.
So these appear to be notes made by a CQC inspector, Care Quality Commission inspector, during their inspection of the hospital. They're dated 4 March 2016, and if we look at attendees, your name is listed next to Yvonne Griffiths. Do you recall speaking to the CQC in March 2016?
BISSELL: I have -- I have a vague memory of, yeah, chatting with them. I don't remember the details, sorry.
LYONS: Was it just you and Yvonne Griffiths and the inspector, or was anyone else present, do you remember?
BISSELL: I can't remember at the time but I assume, from looking at this, it was just myself and Yvonne and the inspector.
LYONS: The notes are very difficult to read.
BISSELL: Yeah.
LYONS: But if we look at the summary section at the bottom of page 96, it's the last box, it looks like some of the topics that you covered were staffing, parental feedback, complaints, Pseudomonas, news, vision, fluid balance, care, metrics, plan assessment, executive team support, fundraising events. Does any of that ring a bell to you?
BISSELL: I mean, only -- I used to carry out the care metrics, so I used to do audits on the unit relating to
whether pain assessments were carried out, whether paperwork was up to date, hand washing audits and things is like that, so I can assume that that's what that is alluding to.
LYONS: So a number of topics were covered. Do you remember whether either you or Yvonne Griffiths mentioned the unexpected deaths that had occurred in 2015 at this meeting?
BISSELL: I don't -- I didn't -- I don't -- I can't remember whether Yvonne did, no.
LYONS: Did you mention it?
BISSELL: I didn't, no.
LYONS: Do you know why you didn't mention it?
BISSELL: No, I don't, sorry.
LYONS: You were asked in your questionnaire whether you had any concerns or were aware of concerns of others about Letby's conduct, and you responded by describing an incident at page 3, paragraph 7. Do you want to just turn that up. So you've described the incident here, but would you -- would you be able to tell us about it?
BISSELL: So I was working in a non-clinical role on the unit and I heard a shout for help from Nursery 3, so I went to help and, as I entered the nursery, Lisa -- nursery nurse Lisa was on the right-hand side and there was a baby with Lucy Letby on the left-hand side and the baby was desaturating -- I can't recall the name of the baby or who the baby was, sorry, but the baby was desaturating and obviously needed some help, so I aspirated the nasogastric tube that the baby had in situ, and then I gave oxygen via a Neopuff to help increase the saturations, and then another nurse came to help, and then another doctor. And then eventually the baby looked like he or she was recovering. And then the other nurse and the doctor who were actually on shift at the time then took the baby into Nursery 1 and took over the care of that baby.
LYONS: And I don't think you say in your questionnaire, but do you remember which nursery this baby was in?
BISSELL: It was in Nursery 3.
LYONS: It was Nursery 3. So a desaturation of a baby in Nursery 3 and a transfer to Nursery 1 --
BISSELL: Yes.
LYONS: -- would that have been a sort of significant event for a baby in Nursery 3?
BISSELL: I think the baby would -- yeah, would have been moved into Nursery 1 for more closer monitoring just to make sure that that didn't happen again.
LYONS: And after this incident, you were -- I think Lisa Walker came to speak to you, didn't she?
BISSELL: Yeah, it was just -- yeah, just very briefly afterwards she just -- she said was concerned that she'd asked Lucy if she needed some help and Lucy said, no, she was okay. But Lisa -- Lisa couldn't help herself because she was in the middle of a feed, she couldn't leave her baby, so Lisa was obviously concerned that -- she felt the baby needed help but Lucy hadn't actually asked for help herself.
LYONS: And did she say anything about how -- what Lucy said to her after the child had been transferred to Nursery 1? Did she say anything to her about calling for help?
BISSELL: I think I remember she said something about she felt like she'd been told off by her, I think.
LYONS: And at this stage Lucy was a Band 5 nurse; is that correct?
BISSELL: Yes.
LYONS: So would you have expected a Band 5 nurse to call for help if a baby is desaturating or collapsing?
BISSELL: I think any nurse, no matter what band you are, should shout for help if they feel a baby is compromised and needs further assistance.
LYONS: Do you remember whether -- do you have any idea when this incident happened?
BISSELL: I can't remember, I'm sorry.
LYONS: Do you think it happened during the time frame June 2015 to June 2016?
BISSELL: I can't remember, I'm sorry.
LYONS: Do you remember whether you discussed this incident with either Yvonne Griffiths or Eirian Powell afterwards?
BISSELL: No, I didn't.
LYONS: You tell us at paragraph 9, page 3 of your questionnaire, that once you heard that [Child O] and [Child P] had died you were very shocked, and what were you -- did you have any concerns at this stage about either their deaths or the deaths of the unexpected deaths that had been happening, after death of [Child O] and [Child P]?
BISSELL: I was just -- I was very surprised that they had passed away.
LYONS: Did that surprise lead you to be concerned about what was happening?
LADY JUSTICE THIRLWALL: We can take a moment. It's probably best to continue if you can, rather than stopping, but if you want a break just say.
BISSELL: Sorry. Just that I'd attended their delivery and they were -- seemed well, needed some intervention but were seemingly doing really well. So I think I'd attended their delivery but only looked after them for
one shift, and I didn't look after them again, but I was surprised to hear that they'd passed away. I didn't know why, I -- I didn't know how they -- you know, what had happened and why they had passed away but it just struck me as odd that they had been so well and then they passed away.
LYONS: In the questionnaire we asked you whether you had any concerns or suspicions about the conduct of Lucy Letby while you worked on the NNU, and your reply was: "Not until two of the three triplets had died and Lucy was moved off the unit to work in a non-clinical role."
BISSELL: (Nods).
LYONS: So at that stage, after the death of the [Child O] and death of [Child P], what were you thinking? What were your concerns at that stage?
BISSELL: I just wondered what had happened. We were obviously told when -- they gave a reason why Lucy was moved off the unit, and that was to -- to a secondment but it just didn't seem to fit. I don't know, it just didn't seem right.
LYONS: Let's --
BISSELL: It just seemed strange to me that somebody would be moved off clinical -- you know, from a clinical area to move -- and moved to work in a non-clinical area. That ...
LYONS: I'm going to pull up the email about Lucy's move, but prior it that I'm going to pull up another email that hopefully you've seen. Please can INQ0002879, page 91, be brought up. So before Letby was moved from the unit, this email was sent by Yvonne Griffiths about undertaking a period of clinical supervision. Do you recall receiving this, reading it at the time?
BISSELL: I can't remember seeing it at the time.
LYONS: Was there any discussion about the NNU nurses having to undergo clinical supervision? Do you recall that?
BISSELL: I can't remember. I can't remember, it was so long ago.
LYONS: Can I -- it's the same document reference but it's page 75. Can we, please, bring that one up. So this is what you were referring to a moment ago when the staff were informed that Letby would be seconded to the risk and patient safety office. Do you remember receiving that email or hearing this news at the time?
BISSELL: I remember hearing -- I can't remember reading the email but I can remember hearing that that was the
reason that she had been taken off -- away from the clinical area.
LYONS: And what was your feeling at the time? Did you think this was a genuine reason or did you think something else?
BISSELL: It didn't really make sense to me, but I just had to go with what we were told from -- from the management. So ...
LYONS: And when you say it didn't make sense to you, in what way didn't it make sense to you? I know it's really hard to put into words but it would help.
BISSELL: That I know Lucy liked to worked clinically, so I think for her to be to -- move away from the clinical area into a different area I was just quite surprised at that.
LYONS: And were you the only one who was quite surprised by that?
BISSELL: I don't know.
LYONS: Did you have any chats or discussions with your colleagues about this email or about this news that she would be seconded?
BISSELL: I mean, maybe we were wondering if there were other reasons why she'd been moved but I don't -- I can't recall properly.
LYONS: Can you, please, put up INQ0058624, please.
So August you got the email -- or in fact Letby was already on her secondment when that email was sent, and now fast-forward to January 2017, and this email was sent by Letby. Do you -- do you recall receiving this, reading this at the time?
BISSELL: Vaguely, yes, yes.
LYONS: And what were your thoughts on receiving it? What did you think?
BISSELL: Just --
LYONS: Sorry, go ahead.
BISSELL: No. I mean, it's awful. Just I remember thinking it's awful to -- to be -- have allegations like that against you, but then she never back to the unit, so it just all --
LYONS: What did you think the allegations related to?
BISSELL: Related to probably -- they were related to the higher incidence of deaths --
LYONS: Is that what you thought at the time?
BISSELL: -- that were occurring. Possibly, yes.
LYONS: Is that what you were told?
BISSELL: We were never -- we were never told anything, other than -- I felt like the nursing staff were never really told why -- what was happening. We were just told that she was removed from -- from the unit, she went to the risk and safety department, and then
obviously we had this email to say that there were allegations made against her. So it kind of fitted that obviously she was moved at the time and then obviously allegations had been made, so it --
LYONS: Did you have any understanding as to who was making the allegations?
BISSELL: No.
LYONS: Did you have any understanding as to precisely what the allegations were?
BISSELL: No.
LYONS: Were you concerned about Letby coming back on to the unit?
BISSELL: I can't -- I can't remember what I thought at the time. I don't know. She never did come back.
LYONS: Had you been in touch with her while she had been off the unit?
BISSELL: No, I don't -- I was a colleague of Lucy's but I didn't -- I wasn't friends outside of work with her, so I wouldn't have communicated with her outside of work.
LYONS: You say you had no -- in your questionnaire at page 2, paragraph 5 -- that you had no specific training regarding reporting concerns of fellow members of staff. What would you have done in 2015/2016 if you did have concerns that a nurse was harming babies on the unit?
BISSELL: In the first instance, you would go to your manager and speak to her about it and then --
LYONS: Speak to?
BISSELL: The manager. The unit manager, yeah.
LYONS: Would you do anything else?
BISSELL: Well, I think you'd have -- you'd be led -- hopefully, you'd be led by the manager, wouldn't you, then of how -- how you would report it. I mean, I know we've talked about safeguarding before but I think our training for safeguarding is more -- we've always thought of it as safeguarding babies and families on the unit rather than safeguarding staff. But, you know, obviously if I'd have seen think malpractice then I would have reported that to maybe the clinician -- the doctors at the time or definitely the manager and hopefully that would have been escalated.
LYONS: So you returned to the unit this year.
BISSELL: (Nods).
LYONS: And is there a different process that existed before on -- or what is the process for reporting concerns about a fellow member of staff, is there a process?
BISSELL: I don't think there's any other process other than you're encouraged to fill out Datix -- Datixes or -- it depends how serious it, does doesn't it?
Obviously if it's --
LYONS: And when you returned in 2024, did you have any safeguarding training or any additional training that covered this issue of harm from fellow members of staff?
BISSELL: No.
LYONS: And when did you start in 2024?
BISSELL: January 2024.
LYONS: You say that -- at page 3, paragraph 9, you refer to the need for managers to take concerns seriously when they're raised with them and to take appropriate action. And I just want to clarify with you. Did you raise any specific concerns with managers or senior managers at the hospital?
BISSELL: No, but that was talking about what -- on reflection what has happened and, I mean, obviously as nursing staff we didn't know that concerns were being raised from the doctors and above --
LYONS: So you're referring to doctors --
BISSELL: -- so obviously it's -- on reflection it's referring to that, you know, that --
LYONS: To the doctors' concerns?
BISSELL: Yeah.
LYONS: And what do you think -- this is my last
question -- what do you think would keep babies safe in hospital from the events that occurred?
BISSELL: It's really hard -- really hard to say, isn't it? But, you know, obviously training, like you said, about people reporting. I know there's talk of CCTV on units. I don't know whether that would be something that -- that would help. It's a difficult environment, isn't it, to have CCTV in place when you've got mothers and doing kangaroo care and breastfeeding and things like that? But ... I don't know if that's something that made parents feel safer leaving their babies in the care of neonatal unit, then maybe that's something that could be looked at. In Chester we do now encourage, you know, every cot side has a bed for the parents to stay, so we do encourage parents to stay as often -- you know, as often they as they want and -- or as often as they can. So I -- and just encouraging transparency, really, so that people feel they can raise issues and that they'll be listened to.
MS LYONS: Thank you. I have no further questions.
BISSELL: Okay.
MS LYONS: My Lady, there are no other questions unless you have any.
LADY JUSTICE THIRLWALL: Thank you very much indeed, Ms Bissell, you are free to go.
MS LYONS: The next witness is Elizabeth Marshall.
LADY JUSTICE THIRLWALL: Good afternoon, Ms Marshall, you're just about to be asked to take the oath.
ELIZABETH MARSHALL (sworn)
LADY JUSTICE THIRLWALL: Do sit down.
MS LYONS: Can we, please, begin with your full name.
MARSHALL: Elizabeth Marshall.
LYONS: Ms Marshall, you were sent a questionnaire by the Inquiry, which you completed. It's dated 18 April 2024. Are your responses to the questionnaire true to the best of your knowledge and belief?
MARSHALL: Could you speak up a bit, sorry?
LYONS: Sure, yes, I can.
MARSHALL: Thank you.
LYONS: Are your responses to the questionnaire that was sent to you true to the best of your knowledge and belief?
MARSHALL: Yes, they are.
LYONS: You have been employed by the Countess of Chester Hospital since 2004 initially as a healthcare assistant on the postnatal ward and the labour ward; is that correct?
MARSHALL: That's correct.
LYONS: By 2005, you were working as a neonatal assistant on the NNU; is that correct?
MARSHALL: Yes.
LYONS: Can you tell us, please, the difference between a neonatal assistant and a neonatal practitioner or a senior neonatal practitioner?
MARSHALL: A neonatal assistant is Band 4. We're not trained specifically as the trained neonatal nurses are, so we have -- some of us have a base training of what used to be called nursery nurse, and also it's learning on the job, and very much training and -- within the actual neonatal unit and externally as well.
LYONS: And between 2015 and 2016, there was a change to your role; is that correct? Were you now working across the neonatal unit and the transitional care unit?
MARSHALL: Yes, I did work in transitional care as well previously but it sort of varied really dependent upon workload on the neonatal unit.
LYONS: And can you just explain what the transitional care unit is?
MARSHALL: Transitional care is between neonatal unit care and ward care, so for those babies who might need extra support with feeding or be premature, or for some
reason need further support with feeding or -- so it just meant mum and baby could be together, and if they didn't need any respiratory support or monitoring of any sort then we could hopefully accommodate them under that umbrella of transitional care.
LYONS: And where was that unit located?
MARSHALL: Normally on the ward -- in the postnatal ward.
LYONS: Now, I'd like to ask you about relationships within the unit in 2015 to 2016 starting with your managers. How would you describe your relationship with your managers Yvonne Griffiths and Eirian Powell?
MARSHALL: In retrospect, I felt my personal relationship with them was -- was good. I had quite a lot of personal stuff going on and they were very supportive throughout, and it did occur sort of the 2015/2016 time as well.
LYONS: What about with your nursing colleagues, the Band 6 nurses, the Band 5 nurses, the other Band 4 nurses?
MARSHALL: Generally I think our sort of relationships were pretty good. I think there's a -- always a variety of people you feel are colleagues rather than -- or people you're particularly close to and it's that sort of variable with the people you work, so ...
LYONS: And just -- you worked -- can you just tell us
which nurseries you worked in?
MARSHALL: Sorry?
LYONS: Which nurseries on the unit did you tend to work in?
MARSHALL: It tended to be 3 and 4, occasionally Nursery 2. But less -- less so Nursery 1 because that would be ITU and HDU.
LYONS: Did you have much involvement with midwives at the hospital?
MARSHALL: Occasionally. Occasionally sort of going through to labour ward or transferring babies back up to postnatal ward.
LYONS: And how would you describe that relationship?
MARSHALL: I think it's better now than it used to be. Potentially I think it was more them and us, but now I think it's a lot more integrated -- sorry, I'm not answering the question, am I?
LADY JUSTICE THIRLWALL: We can probably guess but (inaudible).
MARSHALL: Yes.
MS LYONS: And what about relationships with doctors, did you have much involvement with the doctors on the unit?
MARSHALL: Not a lot. It would tend -- I mean, we -- we had our own workload, but decisions would tend to go
between the doctors and the trained nurses. So would be around on ward round or if they're there, you know, but --
LYONS: So if you had any concerns about a baby in Nursery 3 or 4, who would you direct those concerns to?
MARSHALL: Initially the shift leader and then if it needed escalating they would do that.
LYONS: At paragraph 6 of your questionnaire you were asked if you had any concerns or suspicions about Letby's conduct while you worked on the unit. And I'd like to ask you about the second paragraph underneath that question, where you said: "After the death of the first five babies, I thought about how Lucy Letby was involved in the care of all those five babies. I know it is circumstantial but that was my recollection at the time. Also, despite having a horrendous shift, Lucy Letby [was] always happy and almost requested to go back to Nursery 1 with Intensive Care babies and wanted to be with all the sicker babies. I recall other members of staff stating that Lucy Letby wanted to be in Nursery 1 and that was what I found odd. I can't recall the names of staff who spoke about this. Surely in my view, after a horrific experience, you would want to be out of the scene to regroup and reflect." I'd like to sort of unpack that response. Can you -- when you say "the first five babies", are you talking about the babies in June that died, the three babies in June that died or -- what is your sort of -- your reference point? What are your first -- I'm not sure what you mean by "first five".
MARSHALL: I think I'm referring to the first five deaths that I was actually on shift for. I struggle --
LYONS: Was this in 2015 or 2016 or some other time?
MARSHALL: I struggle to give a timeline. It was -- it was probably the first five deaths at all -- you know, that -- that were -- sorry, I feel it was the first actual five deaths that occurred.
LYONS: So the unexpected death of [Child A], [Child C], [Child D], [Child E] and [Child I], is that what you think?
MARSHALL: I think so.
LYONS: Given you worked in the outside nurseries or nurseries 3 and 4, and occasionally 2, how did you become aware of Letby's involvement in these unexpected deaths?
MARSHALL: Generally if there was a trauma situation going on, for example in Nursery 1, then the trained staff would move into help with that situation and the Band 4s would be monitoring the outside nurseries ensuring babies are fed and observations are done, so
keeping everything else going, so were -- the actual physical unit then was quite compact, so it was very easy to become aware that there was a major event going on.
LYONS: So if I just understood your response correctly, you became aware by seeing her; is that what you're saying?
MARSHALL: By what, sorry?
LYONS: By seeing Letby there and involved in these deaths?
MARSHALL: Seeing?
LYONS: Letby on shift when these babies died. Is that how you knew she was involved?
MARSHALL: Oh, knew Lucy was involved? It was my impression that she was always in -- yes, she was always involved with what was going on when there was a major collapse.
LYONS: How did you form that impression?
MARSHALL: How did I?
LYONS: How did you come to think that?
MARSHALL: I think it was my observation.
LYONS: Were there any discussions taking place on the unit between the nurses about the unexpected deaths and/or collapses and Letby during this time?
MARSHALL: Not that I recall.
LYONS: Did you share your thoughts with anybody on the unit?
MARSHALL: Initially, no. I think I just kept my thoughts to myself because I was an untrained member of staff and maybe just felt that it wasn't appropriate to say or --
LYONS: How did you know that Letby always wanted to get back into Nursery 1?
MARSHALL: That was something I was aware through -- then through conversations I'd heard at a latter time, not specifically at that time in 2015.
LYONS: Do you know when you became aware of that?
MARSHALL: Not specifically, no.
LYONS: Was there anything about Letby's demeanour, conduct, anything she said that you recall that struck you at the time?
MARSHALL: She was quite a closed individual, maybe quite superior, I think liked being in amongst the higher grade staff.
LYONS: Did you work with her?
MARSHALL: Pardon?
LYONS: Did you sometimes work in the same nursery?
MARSHALL: I don't really recall working -- actually working alongside her. I've worked many shifts with her, but not specifically with her, because it was quite
rare that she was in the outside nurseries.
LYONS: And during this period, you say the first five deaths and -- were you getting concerned?
MARSHALL: Yes. I do recall having that thought of I suppose Lucy was the one common factor who had been on shift, but that was just my thought.
LYONS: Did there ever come a point where you sort of articulated that thought with your manager -- shared your concern --
MARSHALL: No.
LYONS: -- with your manager?
MARSHALL: Regrettably no. But I think it's quite a leap to have a thought about something and then to take that leap to think: what if harm's being done?
LYONS: Did you share it with anyone else on the unit?
MARSHALL: Pardon?
LYONS: Did you share your feeling, your thinking with anyone else on the unit?
MARSHALL: No.
LYONS: I'd like to take you to three emails. The first email the reference is INQ0002879, page 91, please. Do you recall receiving this email?
MARSHALL: I don't recall.
LYONS: Do you recall any discussion about staff undergoing clinical supervision?
MARSHALL: I really struggle to recall any of the -- this -- this email and any sort of discussions that went around that.
LYONS: Do you recall when Letby was taken off the unit?
MARSHALL: Vaguely, yes.
LYONS: And do you recall any discussion either with your nursing colleagues or with your managers about the reason she had been removed from the unit?
MARSHALL: No. I -- I remember that she was placed in a non-clinical role but not really specifically why that was being done.
LYONS: So if we just stay on that document but go to page 75, please, this is another email that you might have received. Do you remember receiving that or having a discussion about that?
MARSHALL: Not really, no. Again, a vague -- a very vague memory, but not -- not specifically, no.
LYONS: So when you got the third email, assuming you got it -- so this is INQ0058624 -- do you recall receiving that email?
MARSHALL: No.
LYONS: Do you recall being told that Letby would be returning to the unit?
MARSHALL: I -- yes, I do remember conversations of the fact that she was due to come back.
LYONS: And do you think it was around this time, January 2017, or it's just hard to --
MARSHALL: Possibly, yes.
LYONS: And what were your feelings about that -- given you had made a correlation in your mind that you hadn't shared, how were you feeling about her return to the unit?
MARSHALL: I really struggle to recall my -- my sort of feelings about it. I think having had that thought initially of the fact that I felt, you know, there was that correlation between Lucy being on the first -- involved with the first five deaths, I don't think I'd gone much beyond that. So, therefore, not necessarily relating harm being done to Lucy.
LYONS: So you had made an association but that's where it ended; is that correct?
MARSHALL: At that time, yes.
LYONS: But you were still concerned about the association?
MARSHALL: Yes.
LYONS: And in 2016, there were further deaths, and we've heard about obviously the death of [Child O] and [Child P]., had you associated her with those deaths as
well, or were you unaware of her involvement?
MARSHALL: I find it hard to remember. Yeah, I just find it very hard to remember.
LYONS: I'd just like to go to something you said earlier. You formed the view that Letby liked being in amongst the higher grade staff, so I guess the Band 6 nurses. What gave you that impression?
MARSHALL: Just from my observations being at work and I know she had a friend or two that were senior nurses, so that's --
LYONS: How did you know these senior nurses were her friends?
MARSHALL: Because they spent time outside of work together and did quite a lot of things together outside of work.
LYONS: And how did you know that?
MARSHALL: Because it was just -- that was just general knowledge.
LYONS: Were you aware about how to raise concerns about a fellow member of staff at this time?
MARSHALL: I think I would have spoken to my manager had I had -- you know had I -- yeah.
LYONS: Did you have a good relationship with her?
MARSHALL: Yes -- yeah, I feel I used to have a good relationship with her.
LYONS: But you still didn't feel you could share what you were feeling back in 2015 with her?
MARSHALL: Possibly. Again, I think as -- as a untrained member of staff I -- I don't know if I'd have felt -- not felt it right to say anything, but felt it appropriate, you know, yeah.
LYONS: And if you were to suspect a member of staff today, someone you were -- a colleague that you worked with was harming babies, what would you do?
MARSHALL: I'd speak to my manager.
LYONS: And are things different now than they were in 2015/2016 --
MARSHALL: Yeah, I think so.
LYONS: -- which would make it easier for you to speak with her?
MARSHALL: I think so. I think there's a lot more -- there's a lot less segregation between, sorry, manager and doctor, and I think it's encouraged -- being encouraged to speak up is --
LYONS: And how are they -- like, how do they -- how are they encouraging staff to speak up? Can you think of an example?
MARSHALL: The managers?
LYONS: Yes.
MARSHALL: Just by their approach and the way they are with the staff. I think they make us feel -- well, make me feel that if I did have any issues, concerns that I could approach them confidentially and speak to them.
LYONS: So this is what they're saying on the unit to staff, so that's why you know you could, is that right? Is that what you're saying?
MARSHALL: Currently?
LYONS: Currently.
MARSHALL: Yeah, I would feel that it would be -- I would feel more able to go and speak to management now if I had concerns.
MS LYONS: Thank you. My Lady, I have no further questions for Ms Marshall and I don't think anyone else does.
LADY JUSTICE THIRLWALL: No other questions. Thank you very much indeed, Ms Lyons. Ms Marshall, thank you very much indeed for coming to give your evidence. You are free to go now. And that concludes the evidence for this afternoon.
MS LANGDALE: That concludes the evidence for today, my Lady.
LADY JUSTICE THIRLWALL: Very good. And for the week. So we will rise now and reconvene on Monday morning at 10 o'clock.
(The Inquiry adjourned until 10.00 am, on Monday, 14 October 2024)
LADY JUSTICE THIRLWALL: I'm sorry to have kept you all waiting, there was a technical glitch which I understand has now been fixed. Yes.
MS LYONS: Good morning, my Lady. May Nurse T be called, please.
LADY JUSTICE THIRLWALL: Nurse T, would you like to come and sit down. I think you have to stand up to take the oath and then sit down.
NURSE T (affirmed )
LADY JUSTICE THIRLWALL: Do sit down. Yes, Ms Lyons.
MS LYONS: Nurse T, you've provided a witness statement for the Inquiry dated 18 April 2024. Are the contents of that statement true to the best of your knowledge and belief?
NURSE-T: They are.
LYONS: The Inquiry understands that you were Letby's mentor on two occasions, is that correct?
NURSE-T: That's correct, yes.
LYONS: The first period of mentorship was during Letby's second year of training and you mentored her during 31 May 2010 until 4th July 2010. What was your impression of Letby during this mentorship?
NURSE-T: So in, in that period of time I found Lucy to be a conscientious, capable nurse. She's obviously quite intelligent -- very intelligent. She had good knowledge and was, was keen to expand that. She was keen to gain and practise the skills that she had. She was always appropriate in her communication. She's quite a quiet person, quite contained, but friendly, approachable, and I found her quite easy to support and mentor during her placement.
LADY JUSTICE THIRLWALL: Can I just ask at what stage was she at then?
NURSE-T: She was coming towards the end of her second year.
LADY JUSTICE THIRLWALL: So she was a student?
NURSE-T: So she was a student. So she started training in September '08, so this was towards the end of her second year. So I felt that for that stage in her place -- in her training and her first placement on the neonatal unit she was, you know, appropriate knowledge and skills.
MS LYONS: And you mentored her again and this would have been in her third year, the first place -- the first placement of her third year and the dates for that placement or mentorship were 25 October 2010 until 19 November 2010, so she's now a third-year nursing student in her final year.
NURSE-T: Yes.
LYONS: And what was your impression of her in this period of mentorship?
NURSE-T: So it was, it was about six months later and I'm not sure what other practical placements she had had in between, but she --
LYONS: If you go to paragraph 16 of your Inquiry witness statement, you comment there on the period of mentoring Letby.
NURSE-T: Yes, I am just sorry I'm just ...
LADY JUSTICE THIRLWALL: Don't worry, just take a few moments. There's no hurry.
NURSE-T: My Inquiry statement.
LADY JUSTICE THIRLWALL: Paragraph 16 she was suggesting you might want to have a look at.
NURSE-T: Yes. Yes. Those are the words I was looking for. She was intelligent and engaged. Her, her skills and knowledge were continuing to increase. She was quite clear that being a neonatal nurse was where she
saw her career going. She, she could seem quite aloof and quiet but she was quite a contained person, but I didn't see, have any issues with her communication. Because we didn't work with our students every single shift necessarily, I always got feedback from other people that had worked with her and nobody else on the unit raised concerns. In fact, the general impression was that she was a good student that, you know, would -- would be a good future member of the team if she got offered a job.
LYONS: And when you look back to that period, when you mentored her in her second and third year, and you look at the --
NURSE-T: Sorry, I'm just struggling to hear you a little bit.
LYONS: Sorry, I'll speak up. When you look back on the period that -- when you were Letby's mentor in her second and third year of study, you obviously had a very positive impression of her and looking back now, does that remain your view of her period as a student?
NURSE-T: Yes, certainly she was -- she always seemed engaged and, and keen and proactive about her learning. She always appeared caring and -- towards the babies and the families and supportive of them in a manner that was appropriate for the stage of training she was at, and certainly nobody else on the unit raised any concerns that they felt differently from that.
LYONS: I'd like to ask you now about something you said in one of your statements to the police. It was your statement to the police dated 2 May 2018 and in that statement, you described the staffing levels on the neonatal unit and what you said there was that: "The staffing levels were: predominantly good." Do you agree with that, that that was applicable for the period that this Inquiry is concerned with, 2015 to 2016?
NURSE-T: Predominantly good? There were times when we were short-staffed in terms of meeting the BAPM recommended levels but it wasn't all the time. So I would agree that most of the time we had adequate staff. At times we were short-staffed but I wouldn't say that was the majority of the time. I would say that majority of the time the staffing levels were okay, yes.
LYONS: And how many nurses were on duty during a shift in the NNU?
NURSE-T: There was often only four nurses on duty. So that would usually be three registered nurses, often two Band 6s and a Band 5 and then a nursery nurse who would
be a Band 4. Sometimes you might have two Band 5s on. Sometimes there might be five -- five on shift and you might have three registered and two nursery nurses, it varied a little bit, but four or five.
LYONS: So in your statement to the police you said: "They would aim for five members of staff on duty during each shift, two members of staff at Band 6."
NURSE-T: Yes.
LYONS: Does that sound right?
NURSE-T: Mm-hm.
LYONS: "If possible", you added, "and three members of staff at QIS." Can you explain what QIS means?
NURSE-T: So QIS is Qualified In Speciality, so those people who have undertaken the neonatal nursing course.
LYONS: And who -- which of the nurses in 2015 to 2016 had that additional qualification?
NURSE-T: So all the Band 6s had it and some of -- quite a lot of the Band 6s had another additional course on top. And then of the Band 5s in that time period, I think we had three Band 5s that had the QIS, one of which was Lucy, but she had only completed the course in the March, I think, of 2015.
LYONS: And are you aware of any other Band 5 nurses? Do you know them by name?
NURSE-T: There were other nurses but they hadn't undertaken the course at that point.
LYONS: Were you aware whether Bernadette Butterworth was a Band 5 nurse with the QIS?
NURSE-T: Yes, she was, and I can't remember whether it was only her and Lucy or whether there was one other person with the --
LYONS: We might --
NURSE-T: -- the band -- with the QIS at that point.
LYONS: -- come back to that. In that same statement to the police, you said, and you were talking about the nursing staff on the NNU, you said: "You could always do with more staff but when it really matters such as when a baby collapses there is sufficient qualified staff to react." When you said that, "sufficient qualified staff to react", were you referring to nursing staff?
NURSE-T: Yes. I -- because I think I believe that's what I was being asked about, nursing staff, not medical staff.
LYONS: You also comment in that statement on some differences between the day and the night shift. Can you tell us what, what was the sort of difference between day and night shifts at that time?
NURSE-T: I can't remember what I said back then.
LYONS: You said that night shifts tended to be a bit quieter.
NURSE-T: They, they are quieter in terms of there is not as many people around so you wouldn't have as many extra people on the unit so parents didn't tend to be there all night. Nursing ratios were -- nursing levels were often very similar day and night though you were more likely just to have four nurses on a night shift, we didn't often have five nurses on a night shift from memory but I'm going back a long time now. Medical staff wise, there was a lot less medical staff around at night so in the day, there would be all the, all the doctors in but at night there was a Consultant on call who would be at home, could be called in if need be, and then there was one Registrar and one SHO covering the neonatal unit, the paediatric ward and anything that any children that came into the A&E department.
LYONS: And during the day shifts, how frequently were the -- how frequently did doctors conduct ward round visits?
NURSE-T: So there would be a ward round daily but that with consist -- that would be led by a Registrar. We only had a Consultant-led ward round on Wednesdays and one day at the weekend. So the Consultant on call for the weekend would do one day of ward round on the paediatric ward and one day a ward round on the neonatal unit but that could vary, but if they did Saturday on the neonates they would do Sunday on paeds, and the other way round. Wednesday was what we called "grand round" day because we had a Consultant there, but otherwise they were conducted by the Registrar that had been allocated to neonates and an SHO usually.
LYONS: At paragraph 20 of your statement, halfway down paragraph 20, you say: "... it was sometimes difficult to contact a doctor when needed."
NURSE-T: Yes.
LYONS: Can you expand on what you meant by that there?
NURSE-T: So I think I'm -- I'm particularly thinking of night shifts because on the day shift there would be enough doctors for there to be doctors on paediatrics and on neonates. But at nights, after the doctors had had handover they invariably went to paediatrics first before they came to the neonatal unit and we often didn't see a doctor for, for many hours.
So yes, you could call them if, if you needed them urgently for something in particular, but they weren't there, you know, they didn't appear just to say, "How is everything?" You know, so unless you had a particular query, you know, so they weren't easily visible if you just wanted to have a discussion about a baby but you maybe weren't actually raising something that needed attending to. Does that make sense?
LADY JUSTICE THIRLWALL: But if there was something that needed --
NURSE-T: Then you would have to bleep them but ...
LADY JUSTICE THIRLWALL: But they weren't generally around?
NURSE-T: Sometimes we could go most of a shift without seeing a doctor.
LADY JUSTICE THIRLWALL: Seeing one. Yes, thank you.
MS LYONS: But if you called for help, called a doctor for help --
NURSE-T: Yeah, but at that point --
LYONS: -- would they come?
NURSE-T: Yes, if you needed them but they weren't visible, you couldn't just have a discussion with them about a baby. It had to be you were raising a particular concern, so you would actually bleep them.
LYONS: I'd like to move now to a different topic. We asked you about the culture and atmosphere on the neonatal unit in 2015 and 2016 and you start to set that out from paragraph 18 of your statement. I'd like to ask you about sort of the relationship between the nurses on the NNU. So in your statement at paragraph 18, you said the nurses worked well together and supported each other?
NURSE-T: Yes.
LYONS: Is that correct?
NURSE-T: Yes.
LYONS: Were you friends with your nursing colleagues?
NURSE-T: I -- I got on -- I felt I got on with all my nursing colleagues. I -- I have a good social group of friends out of work anyway so I maybe didn't socialise with colleagues as much as other people did, but I had one or two friends that I worked with that I did see out of work. But in work, yes, I had a good relationship --
LYONS: And who was that? Who from the NNU did you socialise with outside of work? You should have your cipher list there.
NURSE-T: Yes, so Nurse X.
LYONS: Nurse X.
NURSE-T: And Lucy Letby were really the main two that
I -- I saw out of work. I mean, I would go on a ward night out and, you know, if the whole ward was -- say, a Christmas party or a leaving do, but I didn't routinely meet up with other people.
LYONS: So the Inquiry has heard evidence that Letby had a preference to be allocated babies in Nursery 1?
NURSE-T: Pardon? Sorry?
LYONS: The Inquiry has heard evidence that Letby had a preference?
NURSE-T: Yes.
LYONS: She preferred to be allocated babies in Nursery 1.
NURSE-T: Yes, I agree with that.
LYONS: And did that preference cause any tension or a little bit of upset with the more senior nurses in the unit, so the Band 6 nurses?
NURSE-T: Yes, at times. And I know -- though obviously me and Lucy were friends, I've said that -- I know that on occasion I myself had said to her, you know, "Lucy, other people also need to get experience in Nursery 1." I very much saw her keenness to be in there as her wanting to develop her skills as a neonatal nurse and, you know, she is not the only new neonatal nurse I have worked with that is, is keen to do that. It's quite a natural thing for people wanting to increase their skills, but she could -- she could sort of argue if she felt she should be in there and I know on occasion I did say, you know, sometimes other people need -- want experience too.
LYONS: When you say argue, do you mean argue with the shift leader who was allocating shifts?
NURSE-T: Yes, I know on times she questioned why I hadn't allocated her to a certain baby and that's when I have said, you know, you can't always be in there. I don't know if "argue" is the right word. I was aware that there were times when she felt unhappy with allocation because she wasn't in there.
LYONS: And what gave you that impression?
NURSE-T: She may have told me verbally or via a message or I have picked it up from other people on the unit. I can't, I can't remember exactly.
LYONS: And what did other nurses on the unit say about this?
NURSE-T: I don't remember it being a big topic of discussion. I -- I -- I can't recall exactly it ever being discussed at me -- with me in any great detail. Just that, oh, you know, Lucy wasn't happy she wasn't in there or ...
LYONS: But it was generally known that she preferred to work in Nursery 1?
NURSE-T: It was known that she preferred to be ...
LYONS: The Inquiry has also heard evidence that the relationship between nurses and midwives could be strained at times. Do you agree with that?
NURSE-T: Yes. We -- we didn't have a great deal to do with, with each other. You know, even though they were just through the doors, we didn't see a lot of each other than at deliveries and things.
LYONS: So you operated separately?
NURSE-T: Yes.
LYONS: You tell us at your paragraph 20 that the relationship between nurses and doctors on the unit was generally good.
NURSE-T: Yes.
LYONS: Did you feel able to -- did you feel you could express your views or challenge a doctor if you disagreed with their management of a baby?
NURSE-T: I felt I could but you weren't always listened to. Sometimes you felt you hadn't been listened to.
LYONS: Can you think of an occasion when you did challenge or --
NURSE-T: I can, but it's not a baby --
LYONS: -- and what the response was?
NURSE-T: -- it's not a baby on the indictment.
LYONS: No, but what was the response of the doctor?
NURSE-T: The baby I'm thinking of, it was during --
LYONS: We don't need the details of the baby.
NURSE-T: No, no, it was during the induction period so it was changeover day when the doctors rotate round.
LADY JUSTICE THIRLWALL: So it was a new doctor?
NURSE-T: No, it was -- it was one the Consultants that I was speaking to, but he was like, "Oh, we're busy doing this today", which was showing the new doctors round in the induction so I -- I felt -- and that was a baby that for two days myself and another colleague raised issues about and felt we weren't listened to.
MS LYONS: And in that situation when you felt the doctor wasn't listening to you, what would you do? Would you escalate it to your manager or contact a different doctor?
NURSE-T: I -- yes, I -- yes, if the manager was there to escalate to.
LYONS: Who within this -- the hospital senior management, if anyone, visited the NNU during 2015 and 2016?
NURSE-T: I can't remember any of them particularly visiting, if you are talking -- you're not talking about the --
LYONS: Not the unit manager.
NURSE-T: -- manager, but higher up.
LYONS: Above, yes.
NURSE-T: So there was Ann Murphy who was clinical paediatric nursing lead. So we would see Ann but higher than her, I don't remember anyone particularly visiting the unit before the -- July 16, after the unit was downgraded and then Karen Rees would come daily and she would just walk through the unit quite early on in the shift to see Eirian Powell in the manager's office and then she would leave and she didn't speak to or acknowledge any of the nurses on the -- working.
LYONS: If I understood your evidence correctly, (redacted) from April 2016 --
NURSE-T: Yes.
LYONS: (Redacted); is that correct?
NURSE-T: Yes, yes.
LYONS: So your awareness of Karen Rees visiting the NNU in the summer of 2016, was that what you were told?
NURSE-T: Yes, actually, I'm thinking after that, aren't I -- I'm thinking -- I -- I believe it started when the unit was downgraded but actually I'm talking about when I -- I saw her after (redacted), sorry, that was my mistake.
LYONS: Can you roughly remember what month that was? (Redacted).
NURSE-T: (Redacted). So it would be after that -- from the autumn. But from other colleagues I knew that that's what had been happening for weeks.
LYONS: You were asked to describe the quality of the management, supervision and support of nurses on the NNU between June 2015 and June 2016. Who were your managers?
NURSE-T: Eirian Powell was the unit manager and Yvonne Griffiths was the deputy unit manager.
LYONS: And how would you describe Eirian Powell's management style?
NURSE-T: Quite dictatorial.
LYONS: What do you mean by that?
NURSE-T: What she said she expected to go. She, I didn't feel that she was necessarily that visible on the unit when she was on duty. She never really helped out on the unit if it was busy.
LYONS: Where would she be?
NURSE-T: In the office. She had clear favourites and clear, you know, clearly people that were her favourites and then a -- sort of another small group that were kind of the opposite of that and then the bulk of the staff in the, in the middle. She could generally be supportive of the nurses as a, as a group, you know, if, if there was a criticism or something that affected the whole unit, she could be
supportive. But on an individual level her support of staff would depend where you fell in her range of favourites to not.
LYONS: You believed that Letby was one of Eirian Powell's favourites, is that right?
NURSE-T: Yes.
LYONS: Why did you think so?
NURSE-T: The way Eirian spoke about her to me.
LYONS: Why would she be speaking to you about Letby?
NURSE-T: Just, just generally how she liked her as a student, she was very keen to make sure there was a job for her when she qualified. She would pass comment to me about how good she thought Lucy was. I could see that Lucy got sent on courses she wanted to go on. It's hard to put my finger on exactly.
LYONS: So she was sent on courses that she wanted to go on?
NURSE-T: Just -- yes, I mean, comments that Lucy would go far, that she had a great career, that she had her earmarked for this and, you know, earmarked as being a good nurse. I'm trying to remember -- it's a very long time ago to remember the absolute specifics of what gives me that overall impression.
LYONS: Before you think about the specifics, let's
think about the context. So this is a general chat. Would this general chat be happening on the NNU or outside the NNU?
NURSE-T: It would be when I was in work but whether I was -- whether it was just me and Eirian -- it wouldn't be a general conversation with the whole group of staff on duty.
LYONS: So she was not just sharing these views with you, she was sharing it with other --
NURSE-T: No, no, it wouldn't be. It would just --
LYONS: It would just be you?
NURSE-T: Yes.
LYONS: And why do you think that was?
NURSE-T: She knew we were friends, I don't know. I don't think I was the only person she indicated that she thought Lucy was a particularly good nurse to.
LYONS: And were there other ways in which you saw or heard about Letby being treated more favourably by Eirian Powell?
NURSE-T: Really hard to try and remember examples from 10 years ago -- you know, nearly 10 years ago. I can't.
LYONS: We can come back to it. If anything occurs to you we can come back to it. Did anyone else pick up on the fact that she --
that Letby was in the camp of nurses that she particularly liked?
NURSE-T: I feel that was probably a general feeling throughout the unit.
LYONS: You say at paragraph 19 that had you had any concerns about Letby, when she worked on the unit, you would not have felt able to raise them with anybody.
NURSE-T: No.
LYONS: Can you help us understand why you felt that way?
NURSE-T: So Eirian, Yvonne, and another Yvonne who was a professional development nurse shared an office and I generally felt that anything that you told one person in that office became known to everybody in that office. Myself and Eirian, I don't feel I had a particularly good working relationship with her. I -- she, I think I have put in my statement she was the main reason I left the unit. Knowing that I knew how much she favoured Lucy, I certainly would not have gone to her if I had had concerns. I didn't have concerns but I certainly wouldn't have gone to Eirian to raise them had I had them because I don't think I would have been listened to. And I think maybe more than not listened to, I would have just been told I was wrong.
LYONS: Had you had any concerns about Letby, would you have considered raising those concerns with Karen Rees or Ann Murphy?
NURSE-T: I didn't really know who Karen Rees was. Would I have gone to Ann Murphy? I don't, I don't know because I didn't have concerns so I didn't have to think about -- you know, I have never given that any thought.
LADY JUSTICE THIRLWALL: Understood.
MS LYONS: Do you think Eirian Powell was supportive of Letby after concerns were raised about her?
NURSE-T: Yes.
LYONS: What makes you say that?
NURSE-T: Conversations I had had with her. So my, my understanding at the time, what I was told by Lucy at the time was that after she had been removed from the unit, they told her not to have contact with people from the unit generally, that they recognised that myself and nurse -- sorry, just let me check the letter.
LYONS: Yes, take your time.
NURSE-T: -- Z, yes, Nurse Z because they knew we were good friends out of work with her she was able to talk to us. So Eirian knew that I knew why Lucy wasn't on the unit and I did have some conversations with Eirian
because I, I didn't understand why this was being said. So I -- I did have conversations with Eirian and she was very supportive of her and, and said to me on several occasions that yes, there had been more deaths during that year but if you took out the babies that had sadly been born with congenital abnormalities that were incompatible with life, if you took those out of the equation, that the numbers weren't significantly higher than in previous years and were in line with other units and that Lucy was unfortunate that she did extra shifts so she happened to have been there for more of them. And that was the only thing the doctors had to back up what they were saying. And that was very much what I was told throughout that year and beyond.
LYONS: Do you remember when you were first told that by Eirian Powell?
NURSE-T: I can't remember exact conversations.
LYONS: Were you (redacted) at that time?
NURSE-T: No, it would be after (redacted). I do know that in the late autumn of '15, I saw the -- a chart similar to the one that was presented in court. It was more staff groups with lists of names underneath and I -- I saw that and Eirian said, "Oh, we're having to do a thematic review because the doctors feel our death rate has increased, it's all nonsense." I mean, and
I did see it, and I saw Lucy's name on it, but at the time that was all Eirian said about it and we didn't discuss it further because it probably wasn't appropriate. I just happened to have walked into the office when it was on the desk so.
LYONS: And when do you think you saw that document?
NURSE-T: That would be November '15.
LYONS: November 2015?
NURSE-T: Yes, around there.
LYONS: And it was on the desk?
NURSE-T: Yes, she was obviously working on it. I had gone into the office to talk to her.
LYONS: And what did you think when you saw that document?
NURSE-T: I -- I don't think I thought a lot. I just thought, oh, they just reviewing everything. I suppose it seems logical that you would look at what staff were on duty medically and nursing. I guess, I guess I thought they were looking at, was there a competency issue or was there an interpersonal communication issue that could be contributing, I don't know. It -- it was just lists of names. It didn't ...
LYONS: You say at paragraph 19 that you felt bullied and intimidated --
NURSE-T: Yes.
LYONS: -- by Eirian Powell.
NURSE-T: Yes.
LYONS: Can you tell us -- I know it must be very difficult, but what she did or said that made you feel that way?
NURSE-T: (Pause).
MS LYONS: Would you like to have a break?
LADY JUSTICE THIRLWALL: Would you like to have a break?
NURSE-T: Yes, I just need to gather my thoughts.
LADY JUSTICE THIRLWALL: Yes, all right. We will take 10 minutes. Don't talk about your evidence. So we will rise for 10 minutes. (10.42 am) (A short break) (10.54 am)
LADY JUSTICE THIRLWALL: Are we ready to continue? Good, thank you. Ms Lyons, we don't need to continue with that particular question, we can just move on.
MS LYONS: Yes, my Lady.
NURSE-T: Yes, I can answer it if you want.
LADY JUSTICE THIRLWALL: If you want to answer it, that's fine. I don't want you to get upset.
NURSE-T: No, it was I just couldn't quite find the words.
LADY JUSTICE THIRLWALL: All right.
NURSE-T: Sorry, can you just repeat the question so that --
MS LYONS: I just wanted to understand why you felt bullied by Eirian Powell.
NURSE-T: Okay. So there were certain incidents, certain times where she was very critical, raising concerns about my practice that were unfounded. I don't particularly want to list all the details.
LYONS: You don't need to.
NURSE-T: But there were several, and it got to the point where I wouldn't meet with her alone and Nurse X would actually come with me so that I -- partly for me so that when I was coming out going, "Was that really said?" or, "Did I really -- did I say that?" Because I could have meetings with her about things and describe what had actually happened and it was like she just didn't hear it. She had made her mind up and I was wrong. And it got to the point that coming into work on a day shift when I knew she would be there, I would be anxious and I could feel my anxiety levels rising just turning up for work in the morning. There was one incident where I felt she had
breached my confidentiality and told something -- somebody something about me that she shouldn't have done and at that point I thought I really need to take this further. So I e-mailed Karen Rees. The only upshot of that was a meeting with Karen Rees, myself, and Eirian, no one else present, and all that Karen Rees said was, "Is what she told the person true?" And I said, "Well, yes." And she said, "So, I don't see what your problem is." And I said, "My problem is that was private and that person did not need to know that." "But it is true so what's your problem?" And I just felt completely stonewalled and like I was never going to get anywhere. (Redacted).
LYONS: Okay.
NURSE-T: And --
LYONS: I'll stop you there.
NURSE-T: Yes. (Redacted).
LYONS: Understood. Before we move on to the babies that you were involved with, I have one other question about the working relationship between the NNU managers and the Consultants and what you say at paragraph 20 is that you felt the working relationship between them, the unit manager and the Consultants, was poor.
NURSE-T: Yes.
LYONS: What did you mean by that, that it was a poor working relationship?
NURSE-T: So I -- I feel that there were some very strong personalities in play with the Consultants and with Eirian and that their working relationship was quite adversarial. It would be if one said black, the other would say white, almost, you know, it felt.
LYONS: Which Consultants are you referring to?
NURSE-T: Ravi Jayaram and Steve Brearey, I feel are the two Eirian would make comments about. It being her unit and she would make decisions about things. So I just felt like it wasn't, it didn't feel like a cohesive, co-operative working relationship.
LYONS: And did you form the impression at the time that the difficulties in that working relationship, did you think it had an impact on the quality of care being provided to the babies on the unit?
NURSE-T: Not necessarily, no.
LYONS: I'd like to move on now to some of the babies on the indictment. I'm asking you questions, some of these questions I've been asked to ask you by family, by the family members. If we turn first to [Child A].
NURSE-T: Yes.
LYONS: And if we look at paragraphs 21 to 25 of your
statement to the Inquiry, can you briefly tell us about your involvement in [Child A]'s care on the night shift of 8 to 9 June 2015 when you were working as the shift leader?
NURSE-T: Yes. So we had come on duty at half seven that evening. I was designated as the team leader, the shift leader and I believe I, only from a police interview I have done, that I -- I did actually have a baby I was looking after as well, that night. So I would have taken handover from the off-going team leader. So that would be about all the babies on the unit and then I would have got a specific handover on the baby I had been allocated as well. And I do remember it was shortly after 8 pm. I -- so I had got all my handover, checked my baby was fine, and I went through Nursery 1 because I needed to pop off the unit to go to the loo, so I just wanted to check everyone was okay before I did and that if there were any day staff left they were in the process of finishing off so they could go home. So I remember walking through into Nursery 1 and that Mel was at the computer finishing notes so -- I can't remember exactly but I probably said, "Are you nearly done" and she probably said, "Yes, I'm just finishing this", or whatever. Lucy was standing with her back to where Mel was writing, at Baby A [Child A]'s incubator, so I said, "Are you okay? Do you need anything before I just nip off the unit?" And she was like, "No, no, we just are getting the fluids started", or words to that effect. Dr Harkness and (redacted) Caroline Bennion were at Baby B [Child B]'s cot side, Dr Harkness was inserting lines, central lines access, and they were fine. So I nipped off the unit. As I came out of the door and turned back towards the unit I could see -- so I was, I wasn't long, a few minutes. I could see that they were lifting the lid off the incubator of Baby A [Child A]. So I -- I hurried back in and in the time I had been off the unit he had collapsed, he had no heartbeat, and needed full resuscitation.
LYONS: And you weren't involved in the resuscitation of Child --
NURSE-T: Yes, I was, I was involved.
LYONS: You were involved?
NURSE-T: I -- I gave the chest compressions throughout, so -- and, and I know it was -- the swipe data which I didn't know they had had previous to it being shown to me in trial actually matched up perfectly with my memory of those events and what time I re-entered the unit. So, yes, I -- I gave the chest compressions
throughout.
LYONS: At paragraph 31 of your statement, you describe the skin discolouration that you observed on [Child B] when [Child B] collapsed --
NURSE-T: Yes.
LYONS: -- and you said it was the same colour change you had seen on [Child A].
NURSE-T: Yes.
LYONS: So am I right in thinking that at the time of the resuscitation you had noticed a colour change --
NURSE-T: Yes.
LYONS: -- on [Child A]?
NURSE-T: And we, they had re-intubated, passed a breathing tube down to -- into [Child A] so we had been able to turn him back straight in his incubator so that people could access his right side to give medications and Dr Harkness was on his left, the baby's left side giving breaths via the breathing tube and I was standing at the foot of the incubator reaching through the dropdown door doing the chest compressions, so I was looking up the baby's body so I had a clear view of his colour.
LYONS: And had you seen anything like that before?
NURSE-T: I had never seen anything like that previously and I had been doing neonates for over 15 years at that
point. And I have never seen anything like it since except on his sister.
LYONS: Do you recall how and when Mother A and B and Father A and B became aware of [Child A]'s collapse?
NURSE-T: I can't remember exactly the point they entered the room. But I know that somebody was sent to get them and bring them to the unit soon after the collapse happened. So I don't know exactly the point at which they entered but at some point earlier on in the resuscitation attempt they entered the room.
LYONS: Do you recall making either of them aware of the skin discolouration that you had seen on [Child A]?
NURSE-T: I don't remember specifically talking to them about that.
LYONS: Are you aware whether any of the other nurses or doctors spoke to them about that?
NURSE-T: I don't, I don't know.
LYONS: In Mother A and B's oral evidence to the Inquiry, she said that Father A and B had overheard nurses saying that there was something wrong with [Child A] and discussing whether they should come and get them. Do you know anything about that?
NURSE-T: No.
LYONS: And Mother A and B says that when she was
called to go and see [Child A], she said [Child A] had already crashed and there was nothing more that could be done. What is the practice of informing parents -- what is good practice for informing parents when a child, when a child has either collapsed or it looks like the child might collapse?
NURSE-T: So in this situation, where it was completely unexpected, then I would expect that if I was involved in the resus, that somebody else would go and bring the parents if they weren't already on the unit, whether that involved ringing them at home or going to the postnatal ward, you know, wherever the parents were at that stage. I mean, very few babies in the neonatal unit actually die in a collapsed situation. Most of the deaths I have ever seen is where there is a -- a discussion with the parents that, you know, what we're doing isn't working and it's a compassionate redirection of care rather than a -- in a resus situation. That's actually quite unusual. They are usually much more controlled situations than that.
LYONS: You say at paragraph 22 discussions between the medical and nursing staff about possible causes of [Child A]'s death, that there were such discussions. Do you remember if those discussions included any talk about the unusual skin discolouration or rash on [Child A]?
NURSE-T: I can't recall now.
LYONS: And as far as you're aware, there was no debrief following [Child A]'s collapse and death?
NURSE-T: No. After he had sadly died, after, after we stopped resuscitation and we passed him to his parents for a cuddle, we kind of stepped back to give them some, some time with him, and we went into what we all call the treatment room although it was actually more of a store, a storeroom, I think at some point before that it had been a treatment room, and we were all, all in there talking. At that time the main concern seemed to be was that the line had been in the wrong place or was it something related to Mum's own medical condition?
LYONS: And could I just -- sorry, do you want to continue?
NURSE-T: Sorry, I was going to say also I feel there was a suggestion was it connected to the fluids at that time. But I don't really recall anymore around that than that was maybe mentioned, was there a problem with the fluids.
LYONS: With regard to debriefs you say --
NURSE-T: Yes, so we had kind of that little mini --
LYONS: Yes.
NURSE-T: -- debrief, but it wasn't really a debrief, we were all so shocked at the suddenness of it, it was just and -- and a numbness between us all really, going what, what, you know, we just didn't understand how this baby that was so well had collapsed in such a catastrophic way. There was no formal debrief, there was nothing arranged at a later date where those of us involved could, could get together and, and discuss that when there would be more time to reflect and maybe answers to some of our questions.
LYONS: So with regard to the formal debriefs --
NURSE-T: Yes.
LYONS: -- that don't happen at the time but happen afterwards, at your paragraph 24, we understand that these sorts of formal debriefs were not, I think you said, the norm --
NURSE-T: No.
LYONS: -- and it was not the usual practice to have a debrief after a death, is that correct?
NURSE-T: No, it -- it just wasn't the norm at the time. The only debrief I remember attending in that 12-month period that covers the indictment was for
a baby that wasn't on the indictment that there was a debrief at which there was only myself, Nurse X and Dr Saladi, and that was at our insistence that we wanted to discuss what had happened and the management of that baby further so ...
LYONS: In Eirian Powell's statement to the Inquiry, she says that it was Trust policy to conduct an immediate debrief for the staff directly involved in the incident and for any other staff who wished to attend and a further debrief seven to 10 days following the death. What do you say about that?
NURSE-T: It didn't happen. It did not happen on -- for the babies I was involved in, that did not happen.
LYONS: Looking back, do you think a debrief would have been beneficial?
NURSE-T: I -- I really do and I think that the Inquiry sent me some messages between myself and Lucy actually discussing that after Baby D [Child D] had passed away and there was talk of there being a joint debrief for them all but there was never any, any debrief. And that might have been useful because things like the rashes may have come up, you know.
LYONS: With regards it [Child B] --
NURSE-T: Yes.
LYONS: -- you did -- you detail your involvement in
the care of [Child B] from paragraph 19 of your statement. You were [Child B]'s designated nurse --
NURSE-T: Yes.
LYONS: -- on the night shift of 9 to 10 June 2015 and you say at paragraph 29 that "We were unsure as to why [Child A] had died the night before and we were being extra cautious --
NURSE-T: Yes.
LYONS: -- with [Child B]." Can you expand on that, please?
NURSE-T: So I mean, [Child B] -- [Child A] in what's now 25 years of neonatal nursing experience, I have never witnessed a deterioration in that manner that fast. And we didn't have any explanation for that. So the fact that [Child B] was his twin sister and we weren't sure and the only thing other than it being a problem with the line maybe, one of the things we didn't know was, (redacted). But because we didn't know why he had collapsed so suddenly and they were twins it felt prudent to be extra cautious in case whatever had caused his collapse was also there in, in [Child B]. You know, could, could she have the, if it was, if it was a condition that he had, could she have it, because they were twins.
LYONS: And did you think at the time that [Child B] had collapsed in the same way as [Child A] did, in that it was sudden and unexpected?
NURSE-T: Yes, yes. Yes, it was, it was sudden. She was -- I mean, she was on respiratory support, she was still receiving CPAP at that time, so she was doing all her breathing herself but the CPAP just gives a little bit of pressure which takes some of the work of breathing, some of the effort away for the baby, makes it easier. But they are just little prongs that sit in their noses and, as we know, babies move and things, so the prongs can come out and she did, I think in my statement, police statement that I used for this Inquiry statement, I have described an episode prior to midnight where she had actually knocked her prongs out and her saturation dropped, oxygen saturations dropped a little, I popped the prongs back in and she quickly recovered. I got her checked out because we were being cautious and Dr Lambie was on the unit, so we were all satisfied that it had just been because the prongs had come out. When shortly after that she collapsed again, initially it was because what alerted us was the alarm on the CPAP machine saying that the pressure had been lost, so the prongs had come out. So because I was doing antibiotic, we were drawing up antibiotics and
I had the gloves on and was doing the actual preparation, Lucy said, "Oh, shall I go and pop the prongs back in?" And I said, "Yes, please." But the baby continued to deteriorate quite rapidly and when -- and I think Lucy's words were along the line of --
LYONS: Don't say your own name. Just be careful with your own name.
NURSE-T: Did I say my name?
LYONS: No, no, because in the statement your name is mentioned so I just want you to be careful.
NURSE-T: Right. I think she said, "Nurse T, come over, she's -- she looks like her brother" and I went over and she did have that blotchy rash and had collapsed in a similar manner.
LYONS: And there was a skin discolouration on [Child B] as well?
NURSE-T: Yes, that looked the same, very similar to her brother.
LYONS: And was there any discussion or comment at the time from the doctors or the nurses?
NURSE-T: I think I made a comment about it of --
LYONS: Do you remember what you said about the rash?
NURSE-T: Something along the lines of "Oh, no, not again, she looks like her brother", something like that,
I can't remember my exact words at the time but I do remember feeling that she looked like him and inside I was worrying that we were going to be in a similar situation that we had been in the night before.
LYONS: In your statement to the police, dated 16 July 2018, you set out within that statement a note you had made in [Child B]'s medical records following her sudden collapse.
NURSE-T: Mm-hm.
LYONS: You documented the skin discolouration on [Child B], and you also recorded that: "Parents had been called to the unit as requested by doctors, had been contacted, kept fully informed throughout. At the cot side." Do you recall whether on this occasion Mother and Father A and B were made aware of this unusual skin discolouration on [Child B]?
NURSE-T: I -- I can't remember exactly what we, we said. I have vague recollections of where the incubator was in the nursery and the door they came in and where they were standing and that we were saying to them, "Oh, we've got a heart rate and she's coming round." I can't, I can't recall more specifically what those ...
LYONS: Mother A and B's evidence is that a Consultant was asked, asked that a photograph of [Child B]'s skin
discolouration be taken. Were you present or aware of that being said?
NURSE-T: I -- I can't recall. I -- I have seen it in evidence statements, but it wasn't something that I recalled at the time, you know, that I recall personally.
LYONS: And it's, we understand from paragraph 34 of your statement, that you were concerned about the discolouration you had seen on [Child A] and B [Child B] and you were concerned about the suddenness of their collapses.
NURSE-T: Mm-hm.
LYONS: What consideration, if any, did you give to completing a Datix incident form?
NURSE-T: We'd only routinely complete a Datix form if a child died. We wouldn't complete one for a sudden collapse if the -- for a collapse if the, the child recovered. I don't recall whether I completed the Datix for [Child A] or whether somebody else did it. I have no recollection of that. I presume there was one done, but I can't remember.
LYONS: Do you recall any discussion about whether one should be completed or not?
NURSE-T: I don't recall any discussion. I think it was practice then that we did them for every death but I can't recall because it's so many years and now we routinely do them for every death but I can't remember whether that was the case then.
LYONS: You thought a debrief might have been helpful for [Child A]; am I right in thinking a debrief might have been helpful in the case of [Child B] too?
NURSE-T: Yes, and I think with them happening on concurrent night shifts, that if we had had a debrief for [Child A] then [Child B] would have naturally come up in that discussion because there was a few, there were a few of us that were present at both and that would have been useful.
LYONS: Dr Rachel Lambie recalled in her statement to the Inquiry that a number of junior medical staff and nurses were talking about the collapses of [Child A] and B [Child B] following the events of the morning of 10 June. Were you involved in any of those discussions?
NURSE-T: I can't remember those discussions. I may, I may have been, I may not have been. I mean, it's not unusual for incidents like that to be discussed.
LYONS: How did you become aware of the unexpected death of [Child D]?
NURSE-T: In a message from Lucy, I believe.
LYONS: Please can we have extract A of INQ0000758 on the screen at page 2. So if we -- thank you.
So if we, you see that [Child D] died at 4.21 in the morning?
NURSE-T: Okay, yes.
LYONS: And if we go to line 31765 we see a message from Letby to you at 8.36 in the morning?
NURSE-T: Mm-hm.
LYONS: I'm just going to let you read that.
NURSE-T: Yes.
LYONS: If we go to the next page, page 3.
NURSE-T: Yes.
LYONS: So at line 31768 at the top of the page, your reaction: "What!!!! But she was improving. What happened." Why did you think that [Child C] was improving?
NURSE-T: So I was -- although I wasn't there when [Child D] sadly died, I, I was the admitting nurse, I seem to recall, for [Child D], so I knew her and I knew her history of how she had come to be on the unit and she was -- she had, she had improved. I had seen her and I had seen an improvement in her and she was on her antibiotics and I think my expectation of how she was behaving in herself, you know, how, how she was doing and experience was that she would be fine, that she would continue to improve, finish her course of antibiotics and, and be okay.
LYONS: If we go a bit further down to line 31770.
NURSE-T: Yes.
LYONS: This is where Letby describes what happened. And she says: "... came out in this weird rash looking like overwhelming sepsis". When you read that at the time, did it cross your mind that this might have been similar to the rash that [Child A] and [Child B] had?
NURSE-T: No, it didn't because I was there for [Child A] and [Child B]. That did not look like a sepsis rash to me. I had, by that point in my nursing career, seen sepsis rashes and that's what was so weird about A [Child A] and B [Child B] was they didn't look -- I don't even know if "rashes" is the right word, "discolouration" seems more appropriate to me. But I think we're using "rash" because everyone's being, you know, not knowing what else to call it. She was there for A [Child A] and B [Child B] with me. Had she said "came out in that strange looking rash that A and B had", but because she said "a weird looking -- a weird looking rash -- weird rash looking like sepsis" in my head that's something different.
LYONS: Can we go to the next page, to line 31785, please. So I'll just let you read from the top and then
I'm going to ask you a question about 31785. (Pause)
NURSE-T: Yes.
LYONS: So when you said, "Yes but you've had it all recently", what did you mean there?
NURSE-T: Well, so I knew she was there for A, I knew she was there for B, because she was with me. I knew she was on duty when [Child C] died because she told me, and here we are, what, within a fortnight, and she's there for [Child D] as well. So that's what I meant by that, was she, she had been there for all these difficult, hard, horrible, emotional episodes, and she was a junior member of staff, you know. Just to me it seemed like a lot for her to have -- to be having it deal with.
LYONS: Thank you. Can we please take that down. I'm going to take you to another exchange. Please can extract A of INQ0000101 at page 22 be put on the screen, please. If you could just read that page, please. (Pause)
NURSE-T: Okay.
LYONS: I think we might need to scroll down a little bit.
NURSE-T: Sorry, are these from -- I have lost -- I'm not -- sorry, can we just go back up?
LYONS: And if we go down a bit more.
LADY JUSTICE THIRLWALL: Just pause a minute.
NURSE-T: So am I asking -- is that, is the purple highlight from Lucy --
MS LYONS: That's right.
NURSE-T: -- and the other ones are me?
LYONS: That's right. Purple is Letby and the white are messages that you sent.
NURSE-T: Right. (Pause).
LYONS: Let us know when you get to 32336 and we can scroll up. (Pause).
NURSE-T: Okay.
LYONS: And then -- yes. So my first question about this page is there seems to be some talk about allocation and we've heard evidence from other shift leaders that they allocated nurses to babies?
NURSE-T: Yes.
LYONS: But I'd like to know what you think Letby meant at line 32336 --
NURSE-T: Yes.
LYONS: -- when she said:
"But at least you had a voice in old handover. Chance to say what you want." What is she referring to there?
NURSE-T: So around this time we changed how we gave handover. So the allocation of babies we, we would all go into, like, the resource room and have handover on all the babies from the off-going shift leader and then the on-coming shift leader would allocate who went to each baby, but we switched how we did handover at this time so that we, we got an overview, everybody got an overview and the allocation was done by the off-going shift leader, so you were allocated your babies before you arrived. So you got an overview and then went to the cot side and got a more detailed handover on the babies you had been allocated to. So what Lucy Letby is referring to there is that when it was done the old way, because you were all, the on-coming shift were sitting with the team leader you could say, "Oh, can I have them, please?" You know.
LYONS: You can express a preference for a baby?
NURSE-T: You can express, whereas this way it was pre-allocated. It was to streamline handovers because everybody hearing about every baby could take a very long time and you maybe get -- not everybody needs to know that level of depth on every baby because they
weren't looking after every baby. So it was to see if, if there was a better way of handing over, I guess, more efficient.
LYONS: Do you know why there was a change introduced?
NURSE-T: For that reason I have just said, to make it more efficient.
LYONS: More efficient. Can we please go to line 32359. So you've addressed this in your statement and I'd like to ask you about it. 32359. So you had been a neonatal nurse for many years by this stage.
NURSE-T: 15 --
LYONS: You have given evidence today and in your statement about the unusualness and suddenness of the collapses of [Child A], B, C and D and the unexpectedness of [Child A], C and D's deaths.
NURSE-T: (Nods).
LYONS: And you're reflecting with your friend and you're saying: "There's something odd about that night and the other 3 that went so suddenly." Can you just help us understand what was going through your mind at this stage, what were you thinking was so odd?
NURSE-T: So "there's something odd about that night" is I'm talking about Baby B [Child B] because we've mentioned her in, in the previous couple of, of messages, "and the other 3 that went so suddenly" as in I am referring to A, C and D. By "odd", I am a little bit of a lazy texter so I tend to go for short words, so I mean unusual, rather than odd. Yes. It -- in all my 15 years to then and 25 years to now, I have never seen three babies die so suddenly in such a short space of time. It was highly unusual. I wasn't speculating by the way I used the word "odd" that I thought there was anything suspicious about it. I was just commenting that it, it was highly unusual for me, you know.
LYONS: So --
NURSE-T: It was ...
LYONS: -- Letby responds to you saying -- this is line 32362: "Odd that we lost 3 and in different circumstances?" And your reply was: "I dunno. Were they that different?"
NURSE-T: Yes.
LYONS: So that seems as if you're not even sure whether they were different --
NURSE-T: Were that different.
LYONS: -- and that perhaps they had something in common?
NURSE-T: And that's difficult because I was only there for Baby A [Child A] and B [Child B], not for C [Child C] and D [Child D] when they collapsed, though I -- I had met them both, I had worked whilst they were both on the unit. Were they that different? I knew from what I had been told that C and D were very rapid and somewhat unexpected.
LYONS: So what were you thinking they had in common?
NURSE-T: Just the rapidness, the suddenness, the unexpectedness.
LYONS: Had you worked out that they had all collapsed at nighttime during a night shift?
NURSE-T: I -- I don't think that I had, I don't think I -- I had taken that. I think I was just thinking that it was so unusual to have three deaths so close together and that they were -- seemed to be so sudden in how they happened. I don't think I had really given much thought to them being all on night.
LYONS: If we go further down to the rest of that message exchange -- I'll just give you a moment to read it. So it ends at 31 -- sorry, 32392, I think, and if you just ...
So we -- sorry, it is a bit small. If we go up a bit. Yes. So when you said "Ignore me. I'm speculating", why did you say that?
NURSE-T: Because I didn't really, it was a -- it was a feeling that it was unusual but I didn't have a specific reason for saying it other than it was, they were close together and all appeared to be quite sudden.
LYONS: Is there any reason why you didn't say that to Letby at the time, what you have just told us?
NURSE-T: No. Again, that, yes, it's just ...
LYONS: With regard to post-mortems, were nurses on the NNU allowed to see post-mortem results or did you request them?
NURSE-T: They were -- they were very rarely fed back to us at all. I don't ever remember having a debrief meeting or a meeting, you know, where post-mortem results were, were given to us so that we knew what a definitive cause was if there had been a post-mortem carried out.
LYONS: Can you please take the document off the screen, please. Thank you. We have seen -- the Inquiry has seen minutes of a senior clinicians meeting on 29 June 2016 and heard evidence that the Registrars were worried about the
three neonatal deaths and felt nothing was being done. Were you concerned about these events? How were you feeling at the time?
NURSE-T: I -- I felt that it was unusual. I -- I know that case notes are reviewed by the Consultants when there is a death so I guess I just presumed that they would be looked into.
LYONS: At your paragraph 46, you say: "There was something not sitting comfortably with me, but I couldn't work out what was going on." So was that your feeling after these deaths and [Child B]'s collapse?
NURSE-T: Yes, I -- I -- was there something underlying? And I guess there was that thematic review carried out that I mentioned earlier. Yes, I -- I never suspected there was anything sinister. I never suspected that there was somebody causing deliberate harm that had caused these four incidents.
LYONS: Did it occur to you at the time that the deaths might be due to some sort of incompetence on the part of the medical or nursing staff?
NURSE-T: No. I think I was more thinking had we -- could it be down to some -- a particular batch of fluids or an equipment problem or, you know, something more physical in, in the unit. I, you know, that sort of
thing.
LYONS: You know, you say you didn't -- you didn't suspect anything sinister. But something was not sitting comfortably with you about these events. Were you aware of the Allitt case, for example? Were you aware that there were occasions when nurses have caused harm to babies that they were caring for? Did that cross your mind at all?
NURSE-T: I -- I am aware, I am aware of Beverley Allitt. She actually carried out her crimes towards the end of my nurse training, my initial nurse training, and was convicted shortly after I had qualified by which time I was working in paediatrics, not in neonates but in paediatrics. So I -- I was very aware of her and I was also very aware that changes were made to training and mentorship, you know, sort of, and I always, I always took that very seriously and I -- if I felt I had concerns about a student would raise them because I was aware that that was one of the things that was highlighted from the Inquiry after Beverley Allitt. But no, it never crossed my mind that that could be happening on my unit because it's just ...
LYONS: So Kathryn Percival --
NURSE-T: Pardon?
LYONS: Kathryn Percival-Calderbank gave evidence last Thursday.
NURSE-T: Yes.
LYONS: And she said she can remember that after finding out that Letby's name kept coming, kept being mentioned as being involved in some of the deaths, she said at the time that people would start to think that there was something untoward occurring. She said she didn't know who was present when she said that, and she wasn't quite sure when she said it. But, were you present or aware that Mrs Percival-Calderbank had said that?
NURSE-T: No.
LYONS: Dr Lambie, in her evidence to the Inquiry, she said she left the hospital in September, around September 2015, and she described an incident when she was walking through the intensive care unit, she came upon nursing staff in a small huddle in the corner over the computer. She said she asked them what they were doing and one of the nurses replied that they were going through the rota just to make sure there wasn't somebody who was on for all of them. Dr Lambie recalled the nurse saying something along the lines of "It's an awful thing to think but we're
just looking." Were you involved in that incident?
NURSE-T: No.
LYONS: Were you aware of it?
NURSE-T: No.
LYONS: I'd like to ask you now a question about [Child I].
NURSE-T: Okay.
LYONS: Please can extract A of INQ0000424 at page 59 be put on the screen and if you can look from the last line, 39387. That's a message from Letby to you: "I'm awake. How are things?" Do you see that?
NURSE-T: That's not to me, is it? That's to Ashleigh.
LYONS: It's -- no. "I am awake. How are things?" 39387. The last purple --
NURSE-T: Oh, okay, sorry, yes.
LYONS: -- box there.
NURSE-T: Okay, yes.
LYONS: From Letby to you.
NURSE-T: Yes, got it.
LYONS: So this is 14 October 2015, and then if we turn and go to the next page, I'll give you a moment to read it. The first message is from you.
(Pause)
NURSE-T: Okay.
LYONS: And if we could just go to the bottom of the document, so the last line is 39414.
NURSE-T: Yes.
LYONS: And Letby's response to this message is on the next page. So you were on duty at the time these messages were being exchanged, is that right?
NURSE-T: Yes.
LYONS: Can you tell us why and who asked you to reallocate [Child I]'s care?
NURSE-T: I think it was Yvonne Griffiths, deputy manager. So I had -- I was the shift -- I must have been the shift leader for, for that day shift. We often if, if a nurse was on for more than one shift, we often allocated them the same babies for continuity. So I -- I think I had done that which was Lucy for Baby I [Child I], and then I think it was Yvonne and not Eirian, it was definitely one of them and my feeling is it was Yvonne, just came to me when she was leaving and, and said that because Baby I [Child I] had had recurring episodes of being unwell that we weren't going to allocate her to anybody for more than one shift so that it wasn't too much for anybody.
LYONS: In that conversation, did Yvonne Griffiths mention Letby?
NURSE-T: Not that I recall. Only in, in that I allocated Lucy to that baby. So she asked me to change the allocation.
LYONS: When she, did you take what she said at face value or did you think there was more to it?
NURSE-T: I kind of took it at face value. I mean, I was aware, me and Lucy were friends, I was aware she had been present at those incidents in the summer, and this, this baby had, had been backwards and forwards a few times between us and other hospitals with a distended abdomen and not tolerating feeds. So I -- I didn't really think more deeply about it than that was the decision that they had made in the office.
LYONS: Can we take that document down, please. Thank you. So that, that message exchange was 14 October and I think you gave evidence earlier this morning that it was in November that you saw a version of the thematic review?
NURSE-T: (Nods).
LYONS: Do you remember which babies from the indictment you had seen on that document or --
NURSE-T: There were no babies's names on it. It was just lists of -- so there was, like, the different groups, so like Band 4, Band 5, Band 6, Consultant, Registrar, SHO, and just lists of names. And I can't remember if there were numbers by the sides of them but it was in descending order, so at the top of the list was who had been at more of the incidents. So I didn't see it for long, I didn't take a lot of notice of it because I didn't feel like it was -- I wasn't sure how, how private and confidential it was so I -- I had inadvertently seen it so I didn't study it in detail.
LYONS: (Redacted)?
NURSE-T: (Nods).
LYONS: Did you and Letby stay in touch during the period (redacted)?
NURSE-T: Yes.
LYONS: Did you continue to see each other outside of work?
NURSE-T: Well, yes, because I was, I wasn't in work so I did see her. She did come and visit me (redacted).
LYONS: Were you aware that she had been moved to the Risk and Patient Safety Office in the summer of 2016?
NURSE-T: Yes, I was made aware of that.
LYONS: And how did you become aware of that?
NURSE-T: So I became aware that something had, had gone
on and the unit had been downgraded when I -- via a message from somebody else.
LYONS: Was that Yvonne Griffiths?
NURSE-T: Pardon?
LYONS: Was that message from Yvonne Griffiths?
NURSE-T: No, no. But then Yvonne Griffiths (redacted) she came back to my house. And then when she was leaving we were standing outside and I can't remember the exact words and how it came about, how Lucy came up, but I remember it, she was the person that told me Lucy had been moved off the unit and that she only named Ravi Jayaram had made accusations that she was harming babies and that was how I became aware of it. I was, I was very concerned about that. I knew, I knew the unit had been dropped down a level because of the increase in baby deaths, but that was the first time I had heard that. I do think Yvonne probably thought that I already know -- that I already knew from Lucy but I didn't and I was so concerned that I had been told this that I rang the RCN for advice about did I need to flag it to Lucy that I had been told this? How did I handle it? So I actually had a conversation with the RCN about it.
LYONS: So if we just unpack that. Yvonne Griffiths told you about the allegations that Dr Jayaram had made about Letby?
NURSE-T: Mm-hm.
LYONS: What did you say to Yvonne Griffiths when she told you that?
NURSE-T: I can't remember the exact words. But I did say something along the lines of: I don't know anything about that. Should you be telling me, kind of, something along those lines? And we, we ended the conversation.
LYONS: So you said, "Should you really be telling me about this?"
NURSE-T: Yes.
LYONS: And what was her reaction?
NURSE-T: She, I think, very much that she thought I probably knew. So after Lucy was removed because I -- (redacted) I saw Lucy soon after I had come back and she did indeed tell me all about it and she told me that she wasn't allowed to contact anyone on the ward but because Nurse Z and myself were friends that she saw out of work that she had been told she could tell us what was going on for support.
LYONS: And what did Letby tell you was going on?
NURSE-T: That some of the doctors were accusing her of
murdering and harming babies and she had been moved to the office job because of that.
LYONS: Did she say which doctors?
NURSE-T: I think she named Dr Jayaram and Dr Brearey.
LYONS: And when she told you this, what was your reaction?
NURSE-T: Well, so I had had a little bit of time to think about that because I had heard that from Yvonne. I -- I was shocked.
LYONS: Did you tell her you already knew?
NURSE-T: I -- I did at that point tell her and she was okay about it. She -- I do think Yvonne said that to me because she thought I had probably already had a conversation with Lucy. So ...
LYONS: And sorry, if you can just go back to what you said earlier in your evidence. Why did you feel you needed to -- who did you ring for support?
NURSE-T: The RCN.
LYONS: And why did you feel you needed to do that?
NURSE-T: Because that was, I mean, I felt it was a breach of confidentiality, wasn't it? I didn't know whether Yvonne should really be telling me that. I didn't know what to do about that. And just it was such a, a big, big thing to hear and it wasn't something I wanted to go and discuss with a friend or a colleague because of the nature of what I had been told. So the RCN seemed like a good place to get some confidential advice about what I should do.
LYONS: And did they help you?
NURSE-T: They just advised me that at that point it sounded like Lucy Letby had enough on her plate and maybe not to tell her there and then that I had been told that.
LYONS: Sorry --
LADY JUSTICE THIRLWALL: Sorry, are you --
MS LYONS: Yes, I have one more question about this, sorry. Are you okay?
NURSE-T: Yes.
LYONS: Just -- I know it's a long time ago. But did Letby use the word "murdering" when she described what the allegations were?
NURSE-T: I think so. I can't be 100%.
LYONS: You were asked in your Rule 9 request about a comment that had been attributed to you in minutes of a grievance meeting with Eirian Powell on 28 October 2016.
NURSE-T: Yes.
LYONS: It was recorded in those minutes that Eirian Powell said, and I'm just going to read it out
for you: "Ravi Jayaram was heard by a nurse, (Nurse T) in outpatients, when asked if anything had come from the review to say 'somebody is causing these deaths on the unit'. Nurse T is now anxious to return to the unit after RJ's statement. EP [Eirian Powell] escalated to KR [Karen Rees]." Now, you tell us at paragraph 58 of your statement that you did not hear Dr Jayaram say this, so can you tell us what was the conversation you had with Dr Jayaram?
NURSE-T: (Redacted) I always felt I had a good working relationship with the Consultants and I -- whilst I was there the preliminary report from the Royal College of Paediatrics and Child Health came back with its findings and I was just having a conversation with Dr Jayaram. I said, "Oh, I believe the preliminary report didn't find anything particularly untoward, you know, that was causing the rise in deaths." I can't remember my exact words, but along those lines, and his reply was along the lines -- well, his reply was "Just because they didn't find something doesn't mean there isn't something to find." That -- and it was a direct conversation with me and at that point that was the end of that conversation
and I can't remember whether I left the room or whether we changed subject but we didn't discuss it further.
LYONS: Was anyone else present for this conversation?
NURSE-T: I can't remember whether Dr Za was there or not.
LYONS: So did you agree or disagree with what he said or said nothing?
NURSE-T: I don't, I don't think because --
LADY JUSTICE THIRLWALL: That name shouldn't be reported, the one that was just mentioned.
NURSE-T: Oh sorry, sorry.
LADY JUSTICE THIRLWALL: Don't worry about it, it mustn't be reported.
NURSE-T: I completely forgot. Sorry, I lost my train of thought.
MS LYONS: When Dr Jayaram said what he said, did you say, "No, that's not right"?
NURSE-T: I don't think we discussed it any further because obviously I knew at the time I -- I knew what Lucy and Eirian had said. So I don't think I discussed it further because I wanted to maintain a professional working relationship with Dr Jayaram and it didn't feel appropriate to push that further.
LYONS: At paragraph 60 you say you spoke with Letby about what Dr Jayaram had said.
NURSE-T: Yes, I think I did, yes.
LYONS: You told her?
NURSE-T: Yes.
LYONS: And what was Letby's reaction to what Dr Jayaram had said?
NURSE-T: I can't remember exactly. Probably, "Oh, he's ..."
LYONS: Were you aware of any other comments being made about the possibility of babies on the neonatal unit being deliberately harmed?
NURSE-T: No. And I think that's in my statement when I have said about what Eirian said I had overheard it -- he, he didn't allude that -- when he said it doesn't mean there is something to find, he didn't -- he wasn't -- he didn't say to me that there was, you know, that there was something to find that was deliberate, he just said, "It doesn't mean there wasn't something to find." It was a very open --
LYONS: But how did you interpret that statement? What do you think -- what did you think he was talking about given the background that you were aware of?
NURSE-T: Well, I did wonder if he was alluding to -- to Lucy Letby. But I didn't know.
LYONS: You state at paragraph 60 that (redacted) in September 2016 you recall there was a sign in the NNU after the police were involved stating that any death was to be reported to the Coroner and to the police under Operation Hummingbird. Are you sure about the dates, because the evidence before the Inquiry is that the police were not contacted until May --
NURSE-T: Yeah, no, I got the dates wrong.
LYONS: -- 2017.
NURSE-T: I've got my dates wrong there.
LYONS: You weren't given, you say at paragraph 63, any training on how to report any concerns about a fellow member of staff. You say you cannot recall any policy or process on speaking up. What was your understanding in 2015/2016 on reporting concerns about patient care or patient safety?
NURSE-T: Well, that your first line would be to raise it with your manager.
LYONS: But we heard earlier that you wouldn't have felt comfortable doing that. So what might you have done instead, if anything?
NURSE-T: I guess I would have probably gone to Ann Murphy.
LYONS: Can you have a read of your paragraph 70, please. (Pause).
NURSE-T: Yes.
LYONS: You have already mentioned some of this in your evidence today but can you just expand on what you mean by what you set out there at paragraph 70.
NURSE-T: So --
LYONS: How do you think --
NURSE-T: -- I'm just trying to think how to word it. So I think that they were very strong personalities and that -- it was -- I felt like it was quite a, it wasn't a cooperative, cohesive working relationship necessarily. That was the impression I had as a ward -- my experience of working on the ward, so I just feel that, especially as it was one of Eirian's favoured, you know, favourite nurses that they were raising concerns about, that it could quite -- could have quite quickly come into an adversarial state, almost, nurses against doctors.
LYONS: What do you think should be done to keep babies safe in hospital from the events that occurred here?
NURSE-T: So it's hard to know. Like I said in my statement, I don't think the answer is CCTV. Even had that been in place on every baby in the Countess, how long is that going to be stored for because I know (redacted) we have it on the corridors but it's sort of
a continuous loop so it's not kept long term and stored. You know, you've got to keep it safe, there's got to be somebody available to monitor it and for a lot of the time neonatal units are dimly lit with covers over incubators, you wouldn't able to see, see the babies. So I don't know how much practical use that could be. I do wonder if insulin should be a controlled drug in hospital. This isn't the first case we have seen where insulin has been used to attack patients. We mentioned Beverley Allitt before, she used insulin, the case in Stepping Hill Hospital used insulin and, yet, insulin is still held on units without any stock balance. So I do wonder whether that should be more controlled. I think, I think we don't get any specific training. We get annual safeguarding updates, mandatory updates, but they don't cover who or how to raise concerns about a fellow member of staff. It's a rare event but we know it happens, sadly. We get lots of training on how to spot if a child's being abused at home or domestic violence and things like that, but never had training specifically on if you have concerns about a member of staff.
I don't, I don't know and, and maybe some sort of guidance on the procedures to follow if, if that becomes necessary because obviously when these concerns were first raised it could have been that -- we know in this situation it wasn't, but you don't want a situation like did happen in the Stepping Hill case where the wrong person was initially charged. You know, suspicions were initially against her. So it has to be careful so that if someone's got some suspicions about somebody that person is protected until those are investigated further. So there needs to be some guidance, some protocol steps to follow so that it's done appropriately. I mean, I don't know that there was that for the Trust to follow. I -- I don't know because I wasn't at that level.
LYONS: Looking back, do you have any reflections that you want to share with us?
NURSE-T: I mean behind, hindsight is great. When I -- I look back and I look back at the statements that I made prior to me starting to have doubts about her guilt, whether it could be true, I wouldn't have given different statements. They are factual and truthful. The only difference was at the time I believed that they would show that it was an unfortunate period rather than deliberately done by somebody. I don't know how things could have been more open, but things that have come to light since I think would have maybe flagged things up quicker, sooner. But I don't know how that could have been managed differently.
MS LYONS: My Lady, those are my questions.
LADY JUSTICE THIRLWALL: Thank you very much indeed, Ms Lyons. May I just ask two questions, if I may. You told us about, I think Yvonne Griffiths coming to see you and then telling you about Lucy Letby and you think she probably thought that you knew already and you said, "I phoned the RCN to see if I should inform Lucy." And then you came back to that a little while later. Can I just ask you, what was it that you were asking you should inform Lucy about?
NURSE-T: What Yvonne had told me.
LADY JUSTICE THIRLWALL: Yes, but what were you thinking? Were you asking whether you should say, "Well, Yvonne has said this in a breach of confidentiality and so what should I do about that" or should I say, "Do you know what's being said about you?"
NURSE-T: I think, I think both.
LADY JUSTICE THIRLWALL: Both?
NURSE-T: Yes.
LADY JUSTICE THIRLWALL: And the reason that you did that was what?
NURSE-T: Just because it was such a shocking thing to have heard.
LADY JUSTICE THIRLWALL: Yes.
NURSE-T: And I didn't know what -- what to do with it. You know, it was really to have someone to talk to that could maybe give me advice where I knew it was confidential and safe. I didn't want to talk to another colleague. I didn't want to talk to a random friend. So yes, it seemed like the RCN as my Union was a safe --
LADY JUSTICE THIRLWALL: A good place to go.
NURSE-T: A good place to go.
LADY JUSTICE THIRLWALL: Understood. I think you said that they did say not -- that you shouldn't tell Lucy about it.
NURSE-T: Yes.
LADY JUSTICE THIRLWALL: I wasn't sure I had heard that correctly.
NURSE-T: Yes.
LADY JUSTICE THIRLWALL: Thank you. And then related, possibly related to your response to what you had heard, you were asked a question about
whether you had any suspicions and you said, "Well, it couldn't be happening on my unit because it's just", and then in fact you were asked another question. I just wondered what was it you wanted to communicate?
NURSE-T: It's just so unbelievable. It's so out of my sphere of understanding, you know, I find it so difficult to comprehend that anyone could do that, that anyone would deliberately harm or kill somebody else, another person, never mind a baby that you are charged with caring for. I have always looked at my, my role as one that I am, I am part of a multi-disciplinary team and our aim is to send these babies home with their families, with as little long-term ongoing needs as possible from whatever brought them into our care in the, in the first place. And that, that was -- we can't do our jobs without trust and we can't do our jobs -- I think if you asked any of my colleagues, medical or nursing, they would describe that in a similar way, that you are part of this team with a common goal to send these babies home with their families, and I -- I still now sometimes wake up going, "How can it be true?" I know it is. But it -- and there's things that
have come out in the trial and the Inquiry that reaffirm that for me because I couldn't understand how I was so blind to any of it. But I now know that she told me there was only me and Nurse Z that she talked to. I now know that's not true. There's things, considering that she told me that I was one of her closest friends, there's things I have heard from the Inquiry like her trips to Alder Hey I knew nothing about. Her friendship with, relationship, whatever, with Dr U I knew nothing about. So she -- it -- I am learning how in hindsight I didn't see what was, was going on. (Redacted). And she didn't, there was only her and Nurse X that I was in touch with and saw regularly during that year and neither of them discussed work with me (redacted).
LADY JUSTICE THIRLWALL: Yes, understood.
NURSE-T: So, yes, I think that's what I -- I just left hanging in the air, was it's that -- it's that -- it's that disbelief and I go into work now and I trust my colleagues. I -- you can't do your job unless you trust each other and I still find it really incomprehensible that we are in this position.
LADY JUSTICE THIRLWALL: Thank you. Do you want to ask anything else, Ms Lyons?
MS LYONS: No, my Lady. May we have 15 minutes to reconfigure the room, please.
LADY JUSTICE THIRLWALL: Yes. So thank you very much indeed. That concludes your evidence, you are free to go.
NURSE-T: Thank you.
LADY JUSTICE THIRLWALL: We are just going to adjourn for 15 minutes so the room can be sorted out for the next witness. 15 minutes. (12.14 pm) (A short break) (12.30 pm)
MS LANGDALE: My Lady, may I call Nurse W.
LADY JUSTICE THIRLWALL: Indeed and you are in position. Would you like to take the oath?
NURSE W (sworn)
MS LANGDALE: Nurse W, you have provided a statement to the Inquiry dated 7 August 2024. Can you confirm the contents are true and accurate as far as you are concerned.
NURSE-W: Yes.
LANGDALE: I am going to take you through that statement, if I may, if you have it in front of you. You tell us that in 2015 and 2016, at paragraph 8,
you were working as a Band 6 nurse and shift leader on the neonatal unit?
NURSE-W: That's correct.
LANGDALE: Can you just tell us what the role of the shift leader was and in particular how shifts were allocated and whether that changed or not in the period round June 2015?
NURSE-W: Okay. So the role of the shift leader was ideally to be supernumerary which was as BAPM standards --
LANGDALE: Can you just say what BAPM is?
NURSE-W: British Association for Perinatal Medicine. That wasn't always able to happen but that was, that was the ultimate aim on the unit, and the shift leader was responsible for all the nurses and the nursery nurses working on that shift, the Band 6s, the Band 5s, and the Band 4s, to try and ensure the smooth running of the unit.
LANGDALE: In your time when you were a shift leader, were you ever worried about that skill mix or numbers of nurses in the unit under your shift or generally did it work?
NURSE-W: I think it worked, there were certainly busy days but the work was certainly completed. If it took longer -- if it missed -- if it meant missing breaks,
the work was certainly completed but there was definitely busy days within that time period.
LANGDALE: And the Inquiry heard from Ms Hudson last week that if there were quieter periods occasionally you might be able to, one of you, leave a bit earlier and reclaim some of that time back but generally you worked shifts when the babies required it and you had to stay late; is that the position?
NURSE-W: That's correct. As a Band 6 you could never leave early. Occasionally the Band 4s and Band 5s may get out half an hour early if they could, but there was only ever two Band 6s working a shift so, as one of those, I was there to the end, if not longer.
LANGDALE: How many of you were Band 6s, do you know?
NURSE-W: Not at the time, I'm sorry, no.
LANGDALE: Were there more Band 6s than Band 5s, do you know?
NURSE-W: Yes.
LANGDALE: So the majority, the most skilled, Band 6s and then the 5s, did many of them do this extra course or qualification in intensive care training?
NURSE-W: Yes. So the -- the unit was very supportive of that, so the first course you did was within six to 12 months of starting on the unit. At the time it was called the North-West induction course but now it is
called the Foundation in Neonatal course, or the acronym is FIN. And then after one to two years of consolidating that course you then went on to do your qualification in speciality, which is the QIS, which you are referring to, and that was very much encouraged by the managerial team and the in-house managerial team, and then that would then -- you would be then qualified in speciality so you were technically a neonatal nurse once you had those two courses.
LANGDALE: And trying to understand Letby's level of expertise within the organisation or the structure you have described, she was a Band 5 who had done that course. Did that leave her highly experienced, well qualified, moderately qualified, within the nursing group, if you like, with the Band 6s as you were?
NURSE-W: So she was qualified in speciality which meant she had done the two postgraduate, two neonatal postgraduate courses. She had also done her mentorship course which meant she was allocated students on a frequent basis. But she hadn't completed the QIS by too long. However, she did work full time and she did pick up extra shifts. So when you are working full time and working extra shifts you can become more senior quicker than if you were working part time.
LANGDALE: Is there a limit to how many hours you could all work a week, or not? Is it around 37, 38? Is it more than that?
NURSE-W: I think full-time contracted hours as a nurse is 37 and a half hours a week but certainly if you did bank shifts you could work over that time.
LANGDALE: The culture and atmosphere on the NNU in 2015 to 2016, you say at paragraph 9: "In 2015/2016 the NNU was very busy with a high mortality rate ..." And you go on to say how that affected you and I'll come to that in a moment, but very busy with a high mortality rate. What did you understand about previous years' mortality rates, that year's mortality rates, or, indeed, was there any discussion at the time about mortality rates?
NURSE-W: So in the previous years to that -- so (redacted). In the previous years to that there was no more than five deaths a year and that would be the higher number of five. And in 2015 to 2016, the frequency appeared to increase. However, I just want to make it clear at the time when you are working shifts you can have a week off, you can have two weeks off on annual leave, and if I give the instance of Baby K [Child K], as she was only there for such
a short period on the unit, you may not have known as a nurse that actually a baby had died, so if you hadn't have been on the night shift when Baby K [Child K] was born or the day shift where she was transferred out, actually a death could go through the unit and the whole of the nursing team wouldn't be -- wouldn't have that information. It was the overarching team that would be reviewing these deaths that would know the amount that was happening, but certainly I did notice there were more.
LANGDALE: And that's not because you sat and looked at the figures, from what you say, or reviewed a document with numbers; it is just how it felt, was it?
NURSE-W: It's how it felt, yes.
LANGDALE: Was there much discussion between you as nurses or with managers or anyone else about that feeling?
NURSE-W: Not for -- with the nursing team, no.
LANGDALE: You say that rate ultimately affected morale through fatigue, trauma and bereavement -- those words speak for themselves, but can you expand on that for us when we are talking about the culture of that year?
NURSE-W: Yes. So I believe it was a very supportive peer support that I refer to. So nurse to nurse. My managers at the time, Eirian and Yvonne,
definitely had an open-door policy. I could go in there if I felt overwhelmed, if I was upset, if I needed any personal support, if I had any questions. They very much had an open-door policy. But ultimately it was an extremely busy year and there was more bereavement than, than previous. So ultimately it's going to take a toll on you. I don't think there is -- there is no words to describe that feeling but as a team we stuck together and we carried on, we turned in every shift and did the best we could.
LANGDALE: You indeed say that, Nurse W, that you "prided" yourself on your work and: "As nurses we turned up for each shift, on time upholding all the Nursing Medical Council's professional values."
NURSE-W: Yes.
LANGDALE: Did you discuss between you how it felt differently at that time? You have said you were working much earlier, in earlier years you hadn't had that level of bereavement to deal with on the unit. Was that something you discussed with the more established nurses at the time, or not?
NURSE-W: I don't think so. It was just so busy we, we carried on, I guess, is what you would say.
LANGDALE: And you say: "... nurses often went above and beyond, from baking ... cakes, celebrating parent birthdays, baby milestones, key calendar dates, Christmas, [et cetera], to entertaining siblings so the parents could have a few minutes peace and quiet with their baby." You are describing compassionate care to families?
NURSE-W: Very much. Yes. Now it's called Family Integrated Care, or FiCare. Chester have always been exceedingly good at it. (Redacted), it was already embedded in the culture at Chester, but now it's labelled as FiCare.
LANGDALE: In an article reported in a newspaper somebody apparently who worked on the unit anonymously described how during night shifts nurses on the ward would pull a name out of a hat and whoever got picked would be able to leave early despite still being in charge of a baby and instead of carrying out correct handover they would leave a written note by the infant leaving the baby without oversight for hours at a time. Do you recognise that?
NURSE-W: No, I never witnessed that at all.
LANGDALE: No one discuss anything like that amongst themselves or say anything like that?
NURSE-W: No. If someone was going to leave early it would be a Band 4 or a Band 5 and definitely not a shift leader and that would be on a very, very rare basis that there was low acuity on the ward.
LANGDALE: So the more junior nursery nurses or nurses might be able to leave early if the safety of the babies meant that that wasn't going to be a problem?
NURSE-W: Very rarely, but literally, I can't even tell you the last time that it happened. It's so infrequent and it's very much done by the safety of the unit.
LANGDALE: You say in your statement you had always described the neonatal nursing team like your second family, hugely supportive of each other, shoulder to cry on, a person to debrief to, friends not just colleagues; is that how you felt at the time in 2015 to 2016, broadly?
NURSE-W: By the majority of the team, yes, I did.
LANGDALE: You have already told us that Eirian Powell and Yvonne Griffiths were approachable, kind, and you wouldn't have had any hesitation in approaching them about any -- any professional issues. Does that include if you had concerns about others?
NURSE-W: Yes, I could have gone and spoken to them, yes.
LANGDALE: You tell us that you had an experience working some non-clinical days in the office which was shared by
Eirian Powell, Yvonne Griffiths and Yvonne Farmer. What did you learn about those -- from those days and that experience?
NURSE-W: Yes. So at that time I was shadowing Yvonne Farmer's role and -- but as my statement says, I would, Yvonne shared the office with Yvonne Griffiths, the deputy manager, and Eirian, the manager at the time, and Eirian was showing me reports one day around staffing levels. So she was showing me the data that she was submitting, who that was submitted to, how frequently that data was submitted.
LANGDALE: At that time, in 2015 to 2016, did you ever see any of the Executives on the unit come down to see you?
NURSE-W: Very, very infrequently.
LANGDALE: Would you have known them, would you have recognised them?
NURSE-W: I think I would have recognised the Chief Executive because his face would appear on emails occasionally that were sent to the rest of the Trust, but no, I wouldn't have recognised them. I think at that time they wore their own clothes as well, so it would be very hard to distinguish someone.
LANGDALE: I think you describe one New Year's Eve day shift when Mr Chambers and another executive came down
to the ward. Can you tell us about that?
NURSE-W: Yes, so it was a New Year's Day shift, and it was around about lunchtime from recollection, maybe early afternoon, and he came -- I had never met him before in person, came with an older gentleman, he was part of the Exec team but I can't recall who he was. I had not met him before, not seen him before. And they said Happy New Year to us and they said, "Are there any New Year babies been -- here been born here today?" But then they said a really strange comment around: had we been out, did we celebrate New Year, basically had we been significantly out partying, and we were quite shocked by the comment, we felt it was very inappropriate and we politely said no, we hadn't, we were in bed by 10 o'clock as any nurse would be before a 12-hour shift the next day. They just didn't seem to be on the same level of understanding of what we were doing at the time.
LANGDALE: You say that the support on the unit was provided all in house, neonatal nurse to neonatal nurse, and there were no clinical psychologists available.
NURSE-W: That's correct. Yes.
LANGDALE: What's the role, as far as you're aware, a clinical psychologist can play in terms of support for neonatal nursing?
NURSE-W: So in the past two years, they have been of a great service to us as the neonatal team, they have been brought into the unit to support the staff through group sessions, one to ones, and I don't think we would be standing as strong as a team today without them. They are, they are very much there on an emotional level to hear us. They have offered kind of talking therapies and more kind of in-depth therapies to people, to nursing teams that have needed it over the past couple of years. But they were only brought in to support us from 2022 which is obviously a few years after the first arrest. So we wish, as a team, that they had been brought in sooner to us.
LANGDALE: At the time, 2015 to 2016, did you have visits or support from Occupational Health? Did they come down and support staff around bereavements or anything?
NURSE-W: I occasionally remember them calling by, but I don't remember any significance that occupational health played.
LANGDALE: We heard from Kathryn de Berger that she made visits to the neonatal unit to support nurses but you are not aware of that?
NURSE-W: She could have done but she didn't leave a lasting impression.
LANGDALE: You say that Yvonne Farmer provided a lot of the supervision and support to nurses and she would ensure compliance of mandatory training, e-learning and equipment competencies. How did she facilitate the education and training opportunities? How did that work in practice for you all?
NURSE-W: So she ran study days. She did cot side teaching with students, newly-qualified nurses, new members of the team, she ensured that everyone's competencies were up to date, she was a really valued member of the team.
LANGDALE: In terms of relationships between nurses and doctors, you say they were professional, from your point of view; would you like to elaborate on how they were generally at that time?
NURSE-W: Do you mean Consultants or junior doctors or all?
LANGDALE: Separate them as you will or not, however you see fit to describe the relationships.
NURSE-W: Yes. So I think on all counts they were professional. The junior doctors, like on any -- on any unit rotated through, some of them you may have met previously because they would come through the unit at least once within their training. The Consultants at that time were quite an established team and I would say they were respectful
to the nurses, the nurses were respectful to them and at that time there wasn't a neonatal Consultant of the week (redacted), so they were shared with the children's ward as well, so they had a bigger workload, so they weren't quite as visible. But certainly if you had any concerns about a baby on the ward round, they, they would listen to you as a nurse and respect your opinion.
LANGDALE: So you didn't think you were shut down or put off from saying what you were worried about if you were worried about a baby in any way?
NURSE-W: No.
LANGDALE: Did you feel that whatever they said went or not?
NURSE-W: I didn't have that impression.
LANGDALE: What about the relationship between neonatal nurses and midwives? You say in your opinion that was poor at this time, that's 2015 to 2016. Why do you say it was poor?
NURSE-W: So I kind of -- I think I divided them in my statement into two groups of the midwives. The senior midwives I didn't feel were very approachable. Would you mind if I just referred to my statement for the exact words?
LANGDALE: Of course, please do. I am. It is 19b.
NURSE-W: Thank you.
So if I could just read, if that's okay. So I have written: "There were some very senior midwives that did not make the neonatal nurses feel very welcome when attending central labour suite or the antenatal/postnatal ward. Some of the midwifery leadership teams were against change. They were patronising and belittling and it made you feel very uncomfortable and inferior. I would avoid these senior midwives wherever I could." So that was the senior midwives. But I have definitely gone on to say: "However, there were many midwives that were helpful, kind, approachable and trying their best. It is these midwives who we called upon several times to provide parental support and scribing in emergency situations. I will be forever grateful to them".
LANGDALE: We have heard from parents of the babies named on the indictment that sometimes they were dependent on those midwives to facilitate their visits to their own children in the neonatal unit, they had to be taken down, it wasn't easy and they had to request assistance. Given what you say, it sounds entirely at one with that, that sometimes they felt they were making difficulties for people to ask for that assistance, or
for midwives if they needed that assistance, I'm not saying in every case, there is other examples, but they may well have, as they have described, felt as you did that you were interrupting something or perhaps an unwelcome request is being made; would that be fair, that's at one with what you are saying sometimes?
NURSE-W: I would agree. As you say, it is not in every case but parents have definitely reported that to the neonatal team since I began in the Trust. I think it (redacted) improved over time. But parents have certainly told us, "Oh, we have had, we have had to wait an hour to come down this morning to come and see my baby" or "I have missed the ward round because there was no one to bring me." (Redacted). That's exactly it.
LANGDALE: Moving on, please, if I may, to your involvement with some of the babies. You tell us at paragraph 21 you were involved in the care of [Child C] at the time of his death on 14 June and we know [Child C] died six days after the death of [Child A] and four days after the collapse of [Child B]. When you were on that shift, were you aware of the death of A and the collapse of B a few days earlier, can you remember?
NURSE-W: I can't recall at this time, I'm sorry.
LANGDALE: You were the designated shift leader on the night of 13 and 14th, can you tell us, as you've set out from paragraph 24 onwards, what the difficulties were for you as a shift leader in terms of allocating Letby that night and where she was supposed to be?
NURSE-W: Yes. So I am not sure the -- in terms of allocation, I have said this within my statement and at the trial, that allocation, I don't know happened -- if it happened by the previous day shift and the allocation was already in place for the night shift or if I allocated the babies because it was around that time where we changed that criteria.
LANGDALE: Just pausing there actually because --
NURSE-W: Yes.
LANGDALE: -- the previous witness, Nurse T, dealt with that. So around June it became the nurse who had completed the shift role to allocate the babies and a proper handover happened at the cot between the new nurse and the one leaving the shift; is that the position?
NURSE-W: Sorry, when did Nurse T say that happened?
LANGDALE: Around the same time, around the time of that -- June 2015, I think she said. Is that your understanding, it was changed around then as well?
NURSE-W: Yes, and I think I am actually adding in an
extra little part to that. So around this time, as you say, what happened was everyone met in the handover room for shift coming on and the nurse in charge from the previous shift came into that room and gave a full handover to all of the team coming on to that shift. What changed was that everyone had then a safety huddle, a no more than five-minute safety huddle kind of at the desk, and then everyone went to the cot side and received their individual handover. So that's part of it. But I think what I am trying to say is at some point as well it changed that the nurse coming on duty, the nurse in charge coming on duty, allocated there and then based on what the handover was.
LANGDALE: Right.
NURSE-W: So there was the change of where you received your handover but also of who allocated the babies. But I can say that at any point, as the shift leader coming on to shift, you could change that allocation anyway but who allocated the nurses Mel, Lucy, and Sophie that night to those designated babies, I don't recall.
LANGDALE: You can't be sure now, but what's clear is who was allocated to which baby so perhaps you can pick it up from there.
NURSE-W: I remember distinctly this night shift.
LANGDALE: So tell us now what happened.
NURSE-W: Yes. So at the beginning of the shift, the only baby that I was concerned about was in Nursery 3. So that was not Baby C [Child C]. Letby -- I refer to her as Letby.
LANGDALE: However you want to.
NURSE-W: Yes. Letby was that baby's allocated nurse and I had some concerns about this baby. I had met him previously. He was showing some signs of respiratory distress which was not normal for this baby and I made that clear to her and asked her to get this baby reviewed by the Registrar and increase the frequency of the baby's observations. I believe she did listen and get the baby reviewed, I remember the baby being reviewed but I don't recall whether she increased his observations. So my concern at the start of the shift was for a baby that is not part of the trial. The shift was busy. Mel had a ventilated baby in Nursery 1, so that baby was one to one with Mel as the other Band 6, and Baby C [Child C] was next to that baby with Nurse Sophie and so Sophie was a newer member of the team and my former student so I knew her competence level, so Mel was very much supporting Sophie if she needed it and I was supernumerary this shift as well.
So I didn't have so much input in Nursery 1 to begin with because I had no concerns. Although those were the two ITU babies on the unit, they were stable from a distance and --
LANGDALE: You say that, indeed, at paragraph 29 in relation to Baby C [Child C]. You were aware Baby C [Child C] "was receiving ITU care, that he was small for his gestation and that he was clinically stable." So you were comfortable with the allocation that had been made?
NURSE-W: That's correct.
LANGDALE: Sorry, continue.
NURSE-W: So then further into the night, [Child C] has full resuscitation. I believe it was unexpected. It was a highly traumatic event. However, the rest of the unit was still very busy. So once Baby C [Child C] had gone into the family room with his parents and grandparents, as a shift leader I had to still consider the safety of the rest the unit which was incredibly challenging in such a high emotive environment. Sorry.
LANGDALE: Not at all.
LADY JUSTICE THIRLWALL: You don't need to apologise. Just take a moment.
NURSE-W: Thank you.
MS LANGDALE: Have you got a drink there? So once Baby C [Child C] had moved to palliative care, you, what did you ask Letby to do?
NURSE-W: I asked her to return to the baby in Nursery 3 because I was still really concerned about this baby in Nursery 3. I had a quick chat with Mel, a private chat with Mel, and I said, "I'm not sure why -- she's not listening, I am really concerned about this baby in Nursery 3." I'm not a loud person, I'm not a confrontational person. I was simply just asking her some really basic-level things and she, she just appeared really consumed with Baby C [Child C] and wanting to be in the family room with Baby C [Child C] and that family even though I distinctly asked her to not be in there.
LANGDALE: You say -- sorry, go on.
NURSE-W: So, so I just carried on making sure the baby in Nursery 3 was supervised whilst Letby was not there and ensuring the safety of the rest of the unit.
LANGDALE: You say: "After asking Letby more than once I felt some anger towards her as she was being incredibly selfish, this was a challenging shift and I needed her to listen and follow instructions. I did not outwardly display this anger. That is not [your] personality, and it
certainly would not have been within my nursing professional conduct." Incredibly selfish. Why did you think it was incredibly selfish what she was doing?
NURSE-W: Because she just wasn't being fair to myself or the rest of the unit. I know they are really strong words and they are really strong words that I have written there and they are not words that I have written lightly but that's, that's the truth. Baby C [Child C] was with his family and extended family and Mel was allocated with that family now. We reallocated from Sophie to Mel, which was a very reasonable reallocation, and so Mel could come to me for support, Dr Gibbs was still on the unit from in terms of a medical support and the pain relief that Baby C [Child C] required. So it didn't then need Lucy as well because the rest of the busy -- the rest of the unit was still so busy. That night, actually, one of the children's ward nurses came round to help me do some of the IV infusions because of the busyness of the ward.
LANGDALE: And we know, we took Melanie Taylor last week to them, that Letby was also messaging Jennifer Jones-Key about:
"I just keep thinking about Monday, feel like I need to be in 1 to overcome it but Nurse W said no." And there is an exchange between them. "I just feel I need to be in 1 to get the image out of my head, Mel said the same and Nurse W let her go." Melanie Taylor had no recollection at all of saying to you she wanted to be in Nursery 1 but that she, having been allocated there as a Band 6 accepted she should be there and got on with it.
NURSE-W: (Nods).
LANGDALE: Which is right as far as you are concerned, did Mel, Melanie Taylor ask to be there, was she there?
NURSE-W: I don't recall any conversation that I had with Mel but the allocation seemed completely correct because Sophie was a junior Band 5 and Mel was a Band 6. So it would be more unusual for someone to have allocated two Band 5s for the two ITU babies. It makes a lot more sense for one Band 6 and one Band 5 to have the two ITU babies next to each other for that, that support.
LANGDALE: Melanie Taylor also told the Inquiry how it was in the resuscitation that Letby suggested using a Guedel to open [Child C]'s airway. Melanie Taylor, of course, was a Band 6. Do you have any observation on that, that it was Letby who was
using that?
NURSE-W: I don't remember anything about the Guedel. I've been asked about the Guedel for the first time in my Rule 9. I don't remember anything about the Guedel. But I was also asked, "Would this be an unusual thing for a Band 5 to suggest so early in a resuscitation?" and I have said -- let me make sure I get my correct wording.
LANGDALE: It is paragraph 32a.
NURSE-W: I have put: "... so for Letby to think of using it at a very early stage in the resuscitation would be unusual." But I do not recall it being used.
LANGDALE: We also told you or you became aware, perhaps at the criminal trial, what [Child C]'s father stated that had been said to them as parents, "You've said your goodbyes now. Do you want to put him in here?" referring to a basket. When did you first become aware that had been said to the parents of [Child C]?
NURSE-W: When I got my Rule 9.
LANGDALE: How would you describe that comment?
NURSE-W: I was absolutely horrified. Absolutely horrified. I was deeply upset by that comment. It was no part of mine or Mel's or Dr Gibbs' palliative care for Baby C [Child C] and in very, very I'm very, very sorry that these words were used.
LANGDALE: You obviously weren't there when they were and you have just learnt about them.
NURSE-W: Yes.
LANGDALE: Had you known that at the time, and spoken or someone had taken feedback or comments from Baby C [Child C]'s parents, would that have raised a red flag for you or concern that that was said or not?
NURSE-W: It, they would not have been appropriate comments, no. They absolutely would not have been appropriate comments and I would have taken them to Eirian, my manager, the next time I saw her, and I would have asked her for advice. It wouldn't have been the right time to have, kind of, dealt with that situation at the time.
LANGDALE: Of course.
NURSE-W: But I would -- there's always a nurse on-call within the hospital as well, a bed coordinator, their role is, so that's kind of the highest nurse that's available on-call during the night shift. So could I have taken it to them? Possibly. But I don't know because I wasn't aware at the time. But certainly if I had been aware I would not have kept that information to myself.
LANGDALE: But it's clear you didn't keep the information to yourself about Letby repeatedly not following instructions. You tell us at paragraph 37 that you indeed reported that to Eirian Powell at the next available opportunity and informing her that the babies' care in Nursery 3 was compromised as a result. You didn't, of course, know what had happened to Baby C [Child C].
NURSE-W: (Nods).
LANGDALE: What was Eirian Powell's response to that? What did she ask you to do?
NURSE-W: I -- I don't remember her kind of emotional response to it. I remember that she asked me to put in a Datix, a clinical incident form particularly around the delayed care for the baby I mentioned that was in Nursery 3 and to speak to Lucy directly about that as well, which I completed.
LANGDALE: Did you tell Eirian Powell in the way you have today that it was selfish and compromised another baby as far as you were concerned?
NURSE-W: I did.
LANGDALE: It is a real criticism, isn't it?
NURSE-W: Yes.
LANGDALE: It's not --
NURSE-W: And I don't speak lightly, I don't speak that
way about my colleagues, it is just not in my nature at all. So Eirian will have known for me to come to her and speak about a colleague in that way that I was, I was angry with Lucy on that night.
LANGDALE: And you say you weren't regularly angry with her, that was, I think you say the only time you were angry with her, but did you expect Eirian Powell was going to speak to Lucy Letby about that?
NURSE-W: I would have presumed so.
LANGDALE: Did you ever get any feedback or her coming back to you, you having raised that concern, with the conclusion or her conclusion having investigated it further or asked Letby about it?
NURSE-W: Not that I recall.
LANGDALE: Did you ever want to ask, "Did you speak about it" or did you think that was a question ...
NURSE-W: With hindsight, I should have done.
LADY JUSTICE THIRLWALL: Perhaps you will just choose a convenient moment.
MS LANGDALE: I think that's it, my Lady.
LADY JUSTICE THIRLWALL: We choose the same one. Thank you. So we will take a break now and if you would be back, please, ready to start at ten past 2.
NURSE-W: Okay, thank you.
LADY JUSTICE THIRLWALL: We will rise. (1.09 pm) (The luncheon adjournment) (2.09 pm)
MS LANGDALE: We will continue where we left off. At the top of the statement you refer to your feeling strongly a debrief should be held.
LADY JUSTICE THIRLWALL: I just noticed that I think your microphone wasn't working and suddenly you have become very loud, so that's a much better state of affairs. Sorry, would you ask the question again.
MS LANGDALE: Yes. So you have at the top of the page, paragraph 11 (sic), you say you always felt strongly that a debrief should be held at the closest possible time to the significant event witnessed by neonatal staff.
NURSE-W: Correct.
LANGDALE: Why's that?
NURSE-W: That's what the research suggests. I think the common term for it now is a "hot debrief". There is a hot debrief and a cold debrief. So with people working shift patterns the chances of that exact team being back together within the vicinity the next few weeks would be highly, highly unlikely. So it is better to gather as a group together there and then on the shift where it occurs for everyone to kind of come together just to ensure everyone's well-being really before they go home because it's really difficult to go home with those, that high emotional state.
LANGDALE: As far as you were aware, was anyone at that debrief present when [Child A] had died and [Child B] had collapsed? Less than a week before, both of them?
NURSE-W: I don't know whether I knew at the time. But I do now.
LANGDALE: So nobody said anything at the time, as far as you remember, about the deaths earlier -- the death earlier on in the week and the collapse of Baby B [Child B]?
NURSE-W: I don't remember, sorry.
LANGDALE: Do you think you would have remembered if somebody had said, "There's two in close succession" or any other such comment?
NURSE-W: I probably did at the time but it, it was such, I think you can tell by my emotions and my earlier evidence it was a really, really difficult night and by that time in the morning, this was just beforehand over, I was completely drained so I could well have done at the time but I'm sorry, I don't remember now.
LANGDALE: You say attendance at such debriefs was not compulsory in 2015 and 2016. Even when it was still
within the shift if you like, it wasn't compulsory, or do you mean if they were booked at another time they weren't compulsory?
NURSE-W: Yes, either. No one had to attend a debrief and they still don't now, it's still not mandatory now to attend a debrief, whether that's the hot debrief or the cold debrief, it's an elective thing to come along.
LANGDALE: Why is it an elective thing?
NURSE-W: I don't know the answer, I'm sorry. I have always believed that debriefing is, is a good way to come together. Any debrief that is offered to myself I'll always try and attend.
LANGDALE: And roughly, do you think they are well attended or, you know, or not?
NURSE-W: I think it depends on the person, some people think they are of use to them, some people think otherwise, so I think it depends on the individual.
LANGDALE: In terms of the matters this Inquiry is investigating, a debrief which might collate concerns that of their own don't seem significant but when you put them together are more significant, do you think it's important where those rare cases where it's abuse on the part of a member of staff is concerned that debriefs can be very productive to see wider issues, behaviour, broader context, and the like?
NURSE-W: I don't think that would be discussed at a debrief. I think a debrief is about the team coming together to talk about the events. But I think concerns, if you are talking about suspicions, anything along those lines would be at their -- the reviews held by the Consultants following the death of a baby on the back of the clinical incident form that would go in about that. That's where you would look to see if there is any other matters of concern. That's not what I see as a debrief.
LANGDALE: So you wouldn't necessarily expect a nurse to raise any concerns about another nurse's conduct or comments or behaviour in that hot debrief when you are all together; there would be a different route for raising those afterwards, do you think?
NURSE-W: That's what I would believe, yes.
LANGDALE: What would be that route? What is it and do you think it could be improved upon whatever that route is?
NURSE-W: To raise concerns?
LANGDALE: Mm-hm.
NURSE-W: So I think your first line would be your manager. That would be always your first line but then the matron would be the person above the manager and now within the Trust, there is a big Speak Up campaign but
only since the -- maybe the past two years since the criminal trial. So we do now have a Speak Up representative on, on the ward, a nurse representative. So if you didn't want to approach it with your manager or someone in a senior position, you could go to her. Yes.
LANGDALE: Do you think an anonymous confidential line into a safeguarding unit if you had concerns about the way someone was behaving around children would be a useful tool for people to report items that they were concerned about?
NURSE-W: I think it would be. I think anonymity gives you courage.
LANGDALE: It may seem obvious, but why does it?
NURSE-W: Because people say that they won't judge but unfortunately that is society today; that they will. And so you will approach the situation differently, I think.
LANGDALE: And would it be different as well if it was someone independent from a manager or in the unit, so someone who didn't know the personalities involved, reporting a concern about -- it could be a member of staff's absurd comment or a comment that was so off that it raised real concerns?
NURSE-W: Yes. Someone that's not part of the team I think will be best placed for that because naturally within a working environment there are different groups of friends within a team and ideally all those different groups get on. But if you had someone independent then they wouldn't be there to judge the personality or the kind hair, the little, you know, tittle tattles that go on naturally within any working environment. They would go in as, I would probably describe it as fresh eyes, that they wouldn't know any of the previous events or anything along that line so --
LANGDALE: A new perspective?
NURSE-W: Yes, I think the term would be "fresh eyes", I think I have heard that term used around where there may be, I think like on ward rounds on different units, I know they do it on labour ward where a senior midwife will go and have fresh eyes over a situation around maybe a baby's monitoring inside the mum -- I know it's not along the same lines of debriefing whatsoever but the "fresh eyes" term is used within the NHS. So it's that independent person with the fresh perspective, perspective that's the word I am looking for, a fresh perspective on something without any kind of bias.
LANGDALE: You say going back to your statement at
paragraph e on page 11, you say: "... there will have been informal discussions about [Child C]'s collapse and death." And that would be very normal, you say, for nurses coming in on the shift over the next few days to enquire after [Child C] if they had previously met him and his family.
NURSE-W: Yes, that that would be correct because that's your natural feeling as a nurse; is ultimately you want to care and if that baby wasn't then there you would naturally enquire as to where that baby was. You don't necessarily think the worst. You think maybe they have been moved to another hospital, maybe they needed surgery. Your first thought wouldn't be that baby has sadly died. So you would do it at an appropriate time and in a private space as to where that baby had been, and I'm sorry, I don't remember how many days Baby C [Child C] was before he passed away. So whoever had met him on those previous shifts would naturally be: Where is he now?
LANGDALE: So a professional and caring curiosity generally you would say --
NURSE-W: Yes.
LANGDALE: -- if babies died? Would that be the same if they deteriorated or collapsed or when they have
recovered, or appear to have recovered, is that closure on that event as far as routes of enquiry are concerned?
NURSE-W: Sorry, where's the question within that, sorry?
LANGDALE: When a baby deteriorates or collapses --
NURSE-W: Yes.
LANGDALE: -- would there be the same informal conversations between people about that or if the baby's recovered does that not trigger the same enquiry that you have described for a baby who's died?
NURSE-W: I think it depends on what you mean by "collapse". In some of the statements I have provided over the years, a collapse to maybe the police is a different way that I would use the termination "collapse". So a baby starting to vomit, in my mind isn't a collapse, but it may have been within the criminal proceedings. In my mind a collapse is a baby that's needed resuscitation or it's a baby that's become critically unwell whether that's in special high dependency or intensive care and possibly if they were in special care and they had had a collapse and then in ITU you would definitely be curious around that, "Oh, gosh, what events led to that?" So that's where some questions may be considered.
LANGDALE: And again informally, was there a nurses' room where you could eat lunch on the occasions you got time for it, or have breaks?
NURSE-W: Yes.
LANGDALE: Where did you manage to speak together?
NURSE-W: Yes, there is a break room.
LANGDALE: And how many people can sit in the break room?
NURSE-W: I would say -- it doesn't exist anymore -- probably four, four to five.
LANGDALE: Four to five. So you could ask each other in breaks or informally. And was that kind of conversation taking place about different babies or patients?
NURSE-W: I think naturally on breaks you try not to speak about the patients to be honest because that's your time to breathe and enquire about other people's personal lives and try to just have that little breathing space. But you may enquire at that time.
LANGDALE: You tell us on page 13 of your statement about [Child E] and you met him on the night of 29 July?
NURSE-W: Yes.
LANGDALE: Also on 3 August when you say -- well, how was he when you saw him on 3 August?
NURSE-W: How was he when I saw him?
LANGDALE: Yes, the -- at page 12, b --
NURSE-W: Yes.
LANGDALE: -- on the night shift.
NURSE-W: So I don't remember now, from recall, but this is -- "the night of the 29th" was from my statement provided to the police a few years ago. But the day of the 3rd I do remember. He was still in Nursery 1 in an incubator and he was clinically stable. He had a lot of skin to skin that day with his mum and the only concern I had that day was that he recommenced his, his insulin in the afternoon.
LANGDALE: And when you came in the next day, what was the news that you were given about Baby E [Child E]?
NURSE-W: That he had died.
LANGDALE: And who gave you that news?
NURSE-W: I believe it was Lucy.
LANGDALE: And you say at paragraph d on page 13 where she was and what she told you. Can you tell us that?
NURSE-W: Yes. So in the old unit, as you came in on the left-hand side, that's where the kitchen was where you put your bags and your food in the fridge, so that was naturally the first place you walked in when you entered the unit. And I believe she came in here to tell me. I'm not 100% certain that it was Baby E [Child E] but I am highly, you know, a high number that it was.
She appeared. She couldn't wait to tell me and it was not easy news to walk into first thing in the morning.
LANGDALE: And the way that that was imparted to you, did you think that was appropriate at the time?
NURSE-W: No, I didn't think it was appropriate at all.
LANGDALE: In what way wasn't it?
NURSE-W: Obviously when I had left only 12 hours previously the baby was clinically well. I should have been allowed to have come into work, received the handover with the rest of the support of the team around me, but I was bombarded with that information in the kitchen within a minute of walking on the unit. It wasn't professional. It wasn't conducted in a fair manner to myself.
LANGDALE: Did you mention that to anyone at the time? Any of your managers?
NURSE-W: I don't recall, I'm sorry.
LANGDALE: Did you or any other nurse suggest talking to Mother E about this? About events, or not?
NURSE-W: About how Lucy gave me the information?
LANGDALE: No, not how Lucy had given you the information but about -- about the death, did any nurse discuss that with Mother E, do you know?
NURSE-W: Sorry, I'm not quite sure what you are saying
to me.
LANGDALE: Did anyone discuss with the parents, with Mother E and F about the death?
NURSE-W: So the death had occurred in the night shift.
LANGDALE: Yes.
NURSE-W: So they will have done but I was on the day shift before and the day shift afterwards. Yes, I did meet with the family that next day though because I was allocated to his brother Baby F [Child F].
LANGDALE: And was there any discussion at that point with her about what she had seen or observed the day before or anything, or not?
NURSE-W: I don't recall, sorry.
LANGDALE: Baby M [Child M], if you go to page 17 of your statement, which is at page 18, paragraph e. What do you remember now about Baby M [Child M]?
NURSE-W: I remember the situation fairly clearly. He was one of a twin, he was in Nursery 1 in the right-hand corner. He was next to his brother, who was in an incubator alongside him. He was stable in terms of his observations on that day. He did have some bile in his NG, which is an abnormal finding, but I did not think what happened on that day would happen for the morning.
LANGDALE: You say Letby walked over to his incubator to
check him -- to check on him as the type of monitor being used was quite sensitive and the alert could have been explained by something as simple as him kicking the probe off himself. When Lucy got to the incubator she immediately said that he wasn't breathing.
NURSE-W: (Nods).
LANGDALE: So from what you have just said, that's nothing you expected to happen to him?
NURSE-W: It's not what I expected at all.
LANGDALE: You say on page 19 that: "Dr Jayaram arrived very quickly." And during the resuscitation you remember thinking it wasn't looking hopeful because you had given him quite a lot of drugs. And then you say and you told the police, at the bottom the page: "... we had given him quite a lot of drugs but he wasn't responding until, and I don't really know why, I don't really know what made the difference, but he did respond and we managed to bring him back." Can you expand upon that?
NURSE-W: Yes. So we are following something here called the newborn life-support algorithm in terms of the management of the situation and the resuscitation and we'd got to the stage where we were administering drugs and that being adrenaline, sodium bicarb, glucose, everything that is involved within the algorithm and we had given multiple doses of adrenaline. So when you are at that stage, with experience, if they don't respond to the first or the second adrenaline, normally that baby will go on to die because in effect that baby is dead at that moment in time, they have got no heartbeat and they're not breathing, so if you were to stop the resuscitation that baby would not survive. So you generally can carry on the resuscitation until the clinical team come to the conclusion that we all agree to stop the resuscitation and we were very close to doing that in this case with [Child M], and then his heart started beating again. The -- after every 30 seconds you listen in with a stethoscope, you'll auscultate and there was a heartbeat. So when I say he came back, that's what I mean; that his heartbeat was himself and not the compressions anymore.
LANGDALE: You tell us you remember talking generally to Dr Brearey when he was completing an echo scan on [Child M] within the next few days to see if there was an underlying cardiac condition that caused the collapse. What were you asking Dr Brearey about it?
NURSE-W: So Dr Brearey is our cardiac link within the neonatal unit and that's why he was performing the echo and I guess it was just inquisitive. I was trying to find an answer because it, it was unexpected and I almost needed an answer for what had happened and the fact that he was scanning the baby's heart made it suggest that there may be an underlying cardiac issue within this baby. When babies collapse, when neonates collapse, the most common finding is that it's a respiratory cause because the majority of babies have a perfectly formed heart when they are born. Most cardiac conditions are picked up antenatally on scan. So I was really intrigued to know was there going to be something found on, on this echo scan. So I was asking appropriate questions within the situation.
LANGDALE: Can you remember what Dr Brearey said to you?
NURSE-W: I remember him reporting the scan as normal to me.
LANGDALE: And then you tell us you remember Eirian Powell calling you into the office and asking what you had said to Dr Brearey about [Child M]'s collapse. When did she do that, after she had seen you speaking with him presumably, or not?
NURSE-W: I don't know whether she witnessed me speaking
with him or whether he went to her and said, "Nurse W has asked this question of me." The recollection I have is that I was asked to come into the office to speak to her and she asked me, "What did you say to Dr Brearey?" and I just said exactly what I have said to you now.
LANGDALE: You weren't involved in any further conversations about [Child M]?
NURSE-W: No.
LANGDALE: You have no memory of [Child N] or dealing with [Child N] at this point. Were you aware that medical staff were being requested at that time to let either Dr Brearey or Eirian Powell know about any serious deteriorations or collapses, sudden deteriorations, at the time of [Child N], not [Child M]?
NURSE-W: I don't recall.
LANGDALE: You don't recall anyone saying that: tell us now if you have got any concerns --
NURSE-W: No.
LANGDALE: -- about it?
NURSE-W: The only thing along that lines would have been the police were definitely involved. Whether it was before the first arrest or after the second arrest, I'm sorry I don't know the time order, but we had to let Cheshire Police know of any deaths on the unit within
a certain time frame. That's the only thing in relation to that question that I remember.
LANGDALE: The CQC visit to the hospital you deal with at paragraph 21 (sic), between 16 and 19 February. You weren't interviewed as part of that, were you?
NURSE-W: No.
LANGDALE: Was there any preparation as far as you were concerned within the hospital or the unit for that inspection? Were you all asked to prepare any documents or anything or?
NURSE-W: Not that I can recall.
LANGDALE: Do you know how it is that some people were interviewed or not? Was that something that was ever shared with you, or not?
NURSE-W: Nothing was shared.
LANGDALE: You say at paragraph 61 of your statement: "As time passed I was aware of the increased number of deaths on the unit." Were you aware how many of those deaths were unexpected? You have obviously given your own evidence in relation to C and E. But in relation to A, D and I, for example, were you aware how many deaths were unexpected over this period of time?
NURSE-W: I don't think they were ever labelled as that to us, no.
LANGDALE: So were all deaths labelled as deaths in this period between 2015 and 2016, whether they were sudden and unexpected or not?
NURSE-W: To myself as a nurse member, that's what I remember as a nurse.
LANGDALE: So conversations about the mortality rate, the increased number of deaths, nothing specific --
NURSE-W: I wasn't a part of those conversations.
LANGDALE: You then say: "Naively, I believed that due to the increased acuity, and the more complex the patients were with significant risk factors, the mortality rate could logically increase."
NURSE-W: Yes.
LANGDALE: Can you unpack that for us? What you thought then and when you say "naively" what you mean about that.
NURSE-W: Yes. Naively because my opinion is obviously very different now. But at the time, and I think I mentioned it earlier, was -- as you are working shifts and if a baby dies at only maybe a couple of days old you may never find out about that baby's death. So I don't think I knew the number of deaths on the unit, the complete total. I definitely didn't know any form of any shift patterns that were being examined on
who was on shift, who was not on shift. I wasn't aware of that being looked into and the unit was extremely busy. We had babies that appeared with more complex -- complex needs during that year.
LANGDALE: How do you know that? What was your evidence base for that?
NURSE-W: I think just the, the amount of infusions that these babies need -- that they needed. We had more ITU days on the unit. So I have got no statistics but from -- from my personal memory these babies appeared to require more from the nursing and medical teams during that year. So "naively" is the word that I have, I have used because it's -- I am looking at everything that I am saying now with very different eyes and you don't think the unthinkable. I didn't think the unthinkable.
LANGDALE: How is -- how is it so unthinkable? You were, like your colleagues in the middle of this situation, what made it so unthinkable, given the babies were dying and were unexpected?
NURSE-W: It's everything -- sorry.
LANGDALE: Not at all. Have you got some water there?
NURSE-W: (Nods). It's everything as a nurse that you will never believe will happen. You know what your duties are as
a nurse and you believe everyone has that same duty. And when it's some people like this, it's easier to see but at the time I didn't see it. I didn't see it at all. As a nurse on shift, we weren't aware of everything above. We didn't see any reports. We didn't see any staffing statistics. We didn't see any insulin results. We didn't have that bigger picture. And I think the police said it to me that: you have just got a few pieces of the jigsaw puzzle when you go to court. All I went with was my statements and then since the trial I have read some of the evidence. When I then received the Rule 9 I was presented with more evidence that I had never seen before. So when you have only got your awareness, you can't see the bigger picture and I can't speak for the whole team, that's not fair to them, but I can speak as a shift leader and I wasn't informed of, of any concerns around the bigger picture. What I knew was what I knew. So ...
LANGDALE: When you were trained, did you get training on the Beverley Allitt case?
NURSE-W: I definitely was aware of her, yes.
LANGDALE: And one of the recommendations from an Inquiry that followed that case was that there should be increased awareness, heightened awareness of her crimes
and the potential for those crimes, and the NHS, presumably in charge with communicating that message, be aware. Do you think there was, as far as you are concerned, or is communication of that message?
NURSE-W: Did I receive that message as a student?
LANGDALE: Yes, and subsequently when you are actually working in a hospital -- I mean, it is one thing to say heighten awareness but how would that be done? Did you have an awareness of that?
NURSE-W: I had an awareness of it from my training. I don't think I received any further training on it from the Trust. But what has come to light is the people with all this extra information, with the Consultants, and they were the ones to -- to raise the concerns and suspicions with more pieces of this jigsaw puzzle, as the police put it. And yes, you will hear from, I'm sure you have heard from some and you will hear from some further down the line as to what, what happened with them. But they were the ones raising the, the concerns.
LANGDALE: You set out at paragraph 62 of your statements that you were on duty when the triplets were born, O, P and R, and you were allocated one of the triplets once admitted to the NNU, and you remember being very shocked and worried when you came into work a few days later to find two of the triplets had died and the surviving triplet had been transferred out to another hospital and you say you began to think there might be something more going on. So something in the environment, is that what you were worried about?
NURSE-W: It went through my mind because at this stage with two in such quick succession, and brothers, and the fact that the remaining (redacted), the remaining child was removed from the unit and went into a different unit, I guess I started to think --
LANGDALE: Started to think it's about the unit?
NURSE-W: I started to think is there something more but, again, I had no concerns or suspicions. I thought was there something wrong with the water? I know the Inquiry know that there were filters on the taps in the unit. Was there a contaminated batch of medication? I was starting to think of other things, but not the unthinkable.
LANGDALE: You tell us Letby was taken off the unit in June 2016 but you don't recall if you were informed the reasons for this.
NURSE-W: No. I do not recall. Certainly I wasn't aware of the -- the kind of the content of what the Consultants had been saying or the extent of any, any
concerns.
LANGDALE: I am going to ask you to look at some general emails and also a press release just to see if this helps you in any way to remember events at the time. The first is INQ0004914. And Nurse W, this is a press release, Information from the Countess of Chester Hospital, Thursday, 7 July at 2 pm. You may not have seen it at the time, you may have done.
NURSE-W: Sorry, there is nothing on the --
LADY JUSTICE THIRLWALL: We've got it now.
MS LANGDALE: Have a look at that and tell us if you have seen that before. (Pause).
NURSE-W: I -- I don't remember seeing it at the time, but it's highly likely that I did see it and if I can just point out the fourth paragraph, I think this is what we were being told as a nursing team; that these reviews were taking place, these independent reviews, and subsequently we were told that nothing was found on, on those reviews.
LANGDALE: Did you know what the Royal College of Paediatrics and Child Health and the Royal College of Nursing review was looking at?
NURSE-W: No.
LANGDALE: But you were subsequently told?
NURSE-W: Well, we knew they were looking at the mortality rates but we didn't know what they were looking at within that.
LANGDALE: And who communicated to you the results of those reviews, can you remember now?
NURSE-W: No.
LANGDALE: Well, from what you said earlier you had no contact with senior managers, did you?
NURSE-W: Executive level, no.
LANGDALE: So would it have been doctors or nurses, senior nurses?
NURSE-W: I wouldn't want to say because I can't recall, sorry.
LANGDALE: Okay. The next document, if we may, INQ0002879, page 91. So this is from Yvonne Griffiths to neonatal unit staff, 15 July 2016. Have a read of that, please. (Pause)
NURSE-W: Yes, so I think at this stage (redacted).
LANGDALE: (Redacted).
NURSE-W: (Redacted).
LANGDALE: Okay, so you won't have had emails July and August?
NURSE-W: (Nods).
LANGDALE: And I won't take you to the other ones as well. So do you remember any discussion before you went off about what was being examined or investigated or potential secondments or anything like that?
NURSE-W: Not that I recall.
LANGDALE: Moving to paragraph 65 of your statement. You say there's been a big campaign in the hospital around Speak Up. At the time, 2015 to 2016, were you aware of the Trust policy on Speak Out Safely by way of reporting a fellow professional, or not?
NURSE-W: I -- I couldn't quote it. I think as part of when I received my Rule 9, they, they asked me did I have anything to contribute kind of in terms of documentation and I searched back within my emails and I provided this Trust Executive blog which was dated July 2018. And it said within there "we have always supported a culture", I can't comment because I never used the Speak Out Safely line myself, so you will have to use others within the team, ask others within the team that have tried to use the Speak Out system. But, yes, you are quite right in saying they have mentioned there, it's only been in the past two years since the criminal trial and the CQC inspection this year that has -- there's been a big campaign within the Trust about Speak Up.
LANGDALE: Paragraph 72 under "Reflections", you suggest recommendations this Inquiry should make to keep babies safe from any criminal actions of staff. The first one, and of course you do work at the Trust now, so perhaps you can help us with the implementation of these as far as you are concerned. The first one, you say: "Zero separation from the parent/guardian."
NURSE-W: So, so what I am meaning there is that it's 24 hours open access to parents or guardians. I believe still on some neonatal units during the handover times, nursing medical handover, cot side handovers, that parents aren't allowed on to the unit during that time for patient confidentiality and that did exist at Chester during this time period but it doesn't anymore.
LANGDALE: So how do you get round that issue where --
NURSE-W: You seek an area of privacy and quite often you will actually handover in front of the family if there's no other familiar within the room so they can be part of the handover processes, part of the Family Integrated Care that I mentioned earlier.
LANGDALE: And you say: "24-hour unlimited access to parents/guardians. "... Parent/Guardian bed at each cot side ..." We know that some of the mothers on the indictment themselves were still in need of care post surgery, so in those situations, can you still be next to the baby when needing --
NURSE-W: So they need to be -- so the mum needs to be medically well after delivery but what is quite common practice at the moment is the mum remains on the postnatal ward and the dad or the supportive partner can be on the cot -- on the bed next to the cot side.
LANGDALE: So a family member or close friend?
NURSE-W: I'm not sure close friend, but it would be a supportive partner in terms of a same sex relationship, I mean by that.
LANGDALE: Okay. You say at d: "Restrict 'traffic' on NNU, minimise swipe access to core staff, sign in/sign out for all non-core staff ..." Should that be feasible electronically? Do you have that now?
NURSE-W: So that's around our swipe access. So although the nurses are really good at kind of stopping people and asking them, please can you provide,
you know, show us your swipe card with your photograph on to say, like, who are you, what's your purpose for your visit for safeguarding of the babies. There's a lot of people coming in and out, not necessarily into the nurseries but around the rest of the unit in terms of topping up pharmacy supplies, for instance, or linen supplies, getting rid of waste, kind of the extra things that go on within the unit, not directed necessarily to patient care. There's a lot of people that can come on to the unit with the swipe of a card.
LANGDALE: You also say at f: "When there is a patient death, document at the time all staff present the shift before and current shift. This will highlight any trends, including student nurses/midwives/doctors, allied health professionals ..."
NURSE-W: Yes, so I would never have thought of this before the trial but it's clear to see now that was one of the first things that they looked at within the reviews, which I have only seen since I've been given my Rule 9, is staff who were present around the time. So I have specifically said also around students and allied health professionals because they are not on our clinical nursing roster, so you would have to go
elsewhere to find out who was on shift from their perspective.
LANGDALE: And you say, your final suggestion: "Staff to think the unthinkable." How does that message -- how could that message be communicated?
NURSE-W: I honestly don't know. I wish I knew the answer. But I will always personally think it from now on.
LANGDALE: You say in relation to documents you: "... kept a copy of the email in my NHS email from Letby which outlined her intention to return to practice and the 'apology' from the paediatricians. I have searched for this email but cannot locate it." Did you delete it or are you suggesting in some way that's been removed from the emails?
NURSE-W: I don't remember deleting it. So I think it's possibly been removed from my emails.
LANGDALE: So you kept it purposefully, or didn't delete it? You tell us in your own words.
NURSE-W: I have got a folder within my NHS mail secure email called "Investigation" and within there are copies of emails that come from the Trust, the email from Lucy was within that police statement, so in there. Anything that I believe that I may need to refer to again in terms of investigation is within that folder.
LANGDALE: And when did you discover that wasn't there then?
NURSE-W: When I went to look for it when I got given my Rule 9 to ask if I had any other documentation.
LANGDALE: You say the support you had around the criminal trial, what was that like, within the Trust?
NURSE-W: Can I read this because it took me a long time just to -- to write it? Is that okay so I can get the words --
LANGDALE: Of course.
NURSE-W: -- correct?
LANGDALE: Of course.
NURSE-W: Yes. (Pause). Sorry. I don't know whether I can read it. Can someone read it on my behalf?
LANGDALE: I can read it. Is this paragraph 75?
NURSE-W: Yes, please.
LANGDALE: "I would like to make it known that the Trust's initial handling and support around the criminal trial to the staff on the NNU was abysmal ... I found out that a nurse had been arrested from a phone call ... Other units of the hospital found out before the staff working in the NNU. As a team we had to ask repeatedly
for information and updates. The Trust were neither forthcoming nor willing. There were endless broken promises to our team. The Trust were more concerned about protecting their public reputation than providing even a basic level of support to their neonatal team in crisis. The unit became even more isolated."
NURSE-W: Yes. So when it says phone call that was a phone call from a family member, that wasn't a phone call from, from the Trust (redacted), so I received a phone call whilst I was at home.
LANGDALE: (Redacted), a phone call from a family member, no support or preparation --
NURSE-W: Exactly.
LANGDALE: -- from the unit you were working in?
NURSE-W: But would it be the unit --
LANGDALE: The hospital.
NURSE-W: -- that give this information? I would believe this would be an executive level that our team who were in crisis, and had been for a little while, I think we deserved better as a team.
LANGDALE: In terms of bereavements and supporting parents with bereavement and palliative care, how would you describe the difference in 2015 to 2016 to what is available now in the Trust?
NURSE-W: Yes. So in 2015, 2016 there was a bereavement
link nurse on neonatal. There was -- I don't even think necessarily there was in maternity but there was a midwife with an interest and who did her best. Now there are two link nurses on the neonatal unit with an interest in bereavement, one with a hospice background, so she brings that perspective, and in maternity there is a designated midwife called the Lavender midwife and she is employed and so she will support antenatal losses, stillbirths, and neonatal deaths, and the two bereavement link nurses on the neonatal unit work well with the Lavender midwife.
LANGDALE: And you say there is a remembrance service led by the Spiritual Care team?
NURSE-W: Yes.
LANGDALE: You see in paragraph 77. What's that about?
NURSE-W: So here I am criticising the Trust Executives. I have said that: "I feel that since 2018 some Executives have become involved where I think they did not need to be, which has created unnecessary obstacles to neonatal bereavement and palliative care projects that we have wanted to take forward. I understand and sincerely respect ..."
LANGDALE: "... sensitivity must be shown to the families involved with the trial, but this appeared more to
protect the Trust's reputation and not draw any more attention from the media. An example of this would be each year there is a remembrance service led by the Spiritual Care team. Neonatal and maternity bereavement services have wanted for many years to be included within this but also highlighted separately, this has been forbidden by the Executive team."
NURSE-W: Yes. So what I am saying here is with absolutely the most respect to these bereaved families during 2015 and 2016, is neonatal/maternity services have strived to continue to improve their services and the executives have put some form of obstructions within that because they haven't wanted to appear insensitive to the families, is what their stance was. But I believe there is more of a -- that they don't want to have any more media attention brought upon them.
LANGDALE: You say finally that you: "... feel the neonatal team has been failed by the Royal College of Nursing. They have been noticeably absent throughout all aspects of the criminal processes, from the first arrest in 2018 until present." What's your criticism there of the Royal College of Nursing? What do you think they should have been doing?
NURSE-W: They should have been there from the, from the very beginning. They may not have known about anything until the first arrest. But from the first arrest they should have reached out to all of their members within their, their body of nursing for any support that they may offer. We have very much been as a nursing team on our own providing peer support to -- to one another without any regulatory body there to represent us and support us. And I have not written this to take anything away from the families because the families are at the heart of everything that I do but as a nursing team we needed more.
LANGDALE: While you were all giving statements to the police, it may have been more difficult to have group conversations, presumably you couldn't have those, could you, about the events being investigated? Was that the case? Is that what you were told?
NURSE-W: There were numerous excuses as to why we weren't allowed things. But then over time things did get put in place, so they needed to just consider what could happen rather than what wasn't allowed to happen and I do know that -- I think it was the mid-Staffordshire Hospital reached out to our hospital after their investigations a few years ago and said: let us know how we can support you. Because they had already been through a similar event, not the same but
similar in terms of the nature of the incidents and so that Trust were offering to help the Countess. So they knew what they could and couldn't do for their staff already. I don't know whether that help was declined but I never saw any evidence of it.
MS LANGDALE: Thank you. Those are my questions. Mr Baker has some questions, my Lady.
LADY JUSTICE THIRLWALL: Thank you, Ms Langdale. Mr Baker.
MR BAKER: Thank you, my Lady. Hello, Nurse W, I ask questions on behalf of some of the families.
NURSE-W: Hi.
BAKER: I begin by saying if I say anything that upsets you, or you want a break, just say.
NURSE-W: Many thanks.
BAKER: I also want to say at the outset I'm not here to suggest that you personally should have put all the pieces of the jigsaw together and identified Letby.
NURSE-W: Yes.
BAKER: So please understand that when I am asking these questions.
NURSE-W: Okay.
BAKER: Do you have a copy of your witness statement
in front of you?
NURSE-W: I do.
BAKER: So if we could begin at around paragraph 25, please. This is in relation to [Child C] whose family I represent. And it's describing the events on the night when [Child C] was attacked and there had been a discussion at some point that led to Letby being allocated to Nursery 3 as opposed to Nursery 1. How far away is Nursery 3 from Nursery 1?
NURSE-W: Not very. About five metres.
BAKER: Okay. But it deals with children who are perhaps far less vulnerable than the children in Nursery 1.
NURSE-W: So a baby in Nursery 1 is more likely to be receiving intensive care or high dependency support. However, as I said earlier, there was a baby in Nursery 3 that I was concerned about on that evening, so even a baby out in special care can become poorly and so nurses and the nursery nurses need to be observing those babies accordingly to look out for any signs of decline in their, in their well-being.
BAKER: Yes. And we know that on 13 June, because you refer to it, it's in your witness statement, there is a text message or an instant message from Letby to another person, where she says:
"I just keep thinking about Monday. Feel like I need to be in 1 to overcome it but Nurse W said no." Do you recall seeing that text message?
NURSE-W: I've seen the text message. Yes, I didn't know anything of any text messages until the criminal trial.
BAKER: Do you think based upon that it may have been your decision to allocate Letby to Nursery 3?
NURSE-W: It could be read in that manner. Even with everything that has happened through the trial and now the Inquiry, irrespective of everything, I would still stand by the allocation, that if a nurse had recently dealt with a bereavement that they shouldn't then go back into ITU, that they should go out into special care as a well-being protection for that staff member.
BAKER: Have you ever --
NURSE-W: I would always have the interests of the staff member at heart.
BAKER: Thank you, and sorry for interrupting you, but have you ever come across an ideal or practice that a nurse should be put straight back into ITU having suffered a bereavement?
NURSE-W: I haven't seen that practice at Chester.
BAKER: Now, your evidence in your witness statement is -- you refer to your police statement. You say: "I got the impression at the start of a shift that Letby would have preferred to be in Nursery 1 as opposed to Nursery 3 as she was above Sophie in the ranks." And Sophie is another level 5 nurse, the same level as Letby.
NURSE-W: Yes. So with that, I mean that Lucy had her qualification in speciality and Sophie didn't. Lucy would quite outrightly tell you that she preferred being in intensive care and high dependency, and different nurses work in different ways. Some prefer the ITU work, some prefer the special care work, and she would, she would say that she preferred ITU or HDU, and she wouldn't have liked the fact that Sophie was being given the chance to have some intensive care experience with support.
BAKER: The way it's phrased in your police statement which you quote at 25 is that she's above Sophie in the ranks, and in the following paragraph, paragraph 26, you say: "Letby did not appear to like that Sophie, who was a recently qualified Band 5, was allocated to an ITU baby and she had been allocated to special care babies as a senior Band 5." Now, one interpretation of what you have written there is that it had pricked Letby's ego that she had
been sent to Nursery 3 and a more junior nurse had been sent to the intensive care unit. Is that a fair interpretation?
NURSE-W: I think it's a fair interpretation.
BAKER: As a neonatal nurse and you yourself are a Band 6 nurse, would you see it as being beneath you to go into room 3?
NURSE-W: Absolutely not. No.
BAKER: Why not?
NURSE-W: Because every baby irrespective of dependency level requires the care that we are there to provide. It doesn't matter what level of care, they are someone's baby, and they deserve the utmost best care that you can give them to get them home safely.
BAKER: Do you think in your interactions with Letby on 13 June that she recognised that?
NURSE-W: Sorry, please may you repeat the question?
BAKER: Do you think in your interactions with Letby on 13 June that she recognised the concept of what you just described?
NURSE-W: No.
BAKER: In fact, you had allocated Letby to room 3 because you were concerned about the safety or health of the baby who was in there, hadn't you?
NURSE-W: I'm not sure I did the allocation but whoever
did the allocation --
BAKER: Forgive me.
NURSE-W: -- knew that -- actually, no. Let me go back a step. I do not recall if the baby in Nursery 3 had those increased work of breathing signs on the day shift. I certainly noted them on the beginning of the night shift and asked for the doctor to review. So whoever allocated that baby may have been unaware of that but, as I say, irrespective of whether the baby required that extra level of observation, Lucy was allocated that workload to -- to care for those babies and it doesn't matter what level they need, they need some form of level and that's why they are in the neonatal unit and not at home.
BAKER: You say that: "Letby appeared [to be] quiet with me, and she appeared not to be happy with the allocation." Another witness described her as being angry at being allocated to room 3. Again, is that a description that you would agree with?
NURSE-W: I don't recall her being outwardly angry. I remember her being quiet. But then I think in terms of I have described that I was angry with her, within my statement I'm not an angry person on the outside, it's
on the, on the inside.
BAKER: Do you think she was being moody with you, sulky?
NURSE-W: Yes.
BAKER: Now, the child who Letby was looking after in Nursery 3, you were concerned about that child, and I don't need to know any more details whether it was a him or her or anything else, but you were worried about that child?
NURSE-W: That's correct. My worries were brought to reality, unfortunately, just after handover that next morning. That baby was given the care that I had -- or had received the investigations that I had requested 12 hours previously, that baby had a very high CRP level which showed he had overwhelming sepsis and he actually was self-ventilating in air at the start of the night shift and he ended up on respiratory support. So my concerns were correct.
BAKER: Yes. And you say at paragraph 30 -- you describe what Nurse Sophie Ellis has said in her witness statement, her recollection of [Child C]'s collapse, and she, I think, had popped out of the room for a little while when [Child C] collapsed.
NURSE-W: That's what I have written in my statement. My recall is when I was called to help that Sophie hadn't been there initially.
BAKER: And Letby, however, was in the room, was in Nursery 1 at the time of the collapse, it appeared?
NURSE-W: No, that's not my recollection.
BAKER: So you say: "I do not remember if I was informed at the time by Nurse Ellis or anyone else about Letby's presence in Nursery 1 [at the time of [Child C]'s collapse]."
NURSE-W: Yes.
BAKER: So the answer is --
NURSE-W: I was shown my transcript of the court because I was saying that I couldn't 100% recall so they showed me the transcript.
BAKER: Yes.
NURSE-W: And I think the judge -- how do I word this -- the judge agreed that I said I couldn't 100% recall -- my memory wasn't that she was there at the time of the collapse, but I said I couldn't 100% confirm that.
BAKER: Yes, so the answer then is you don't know whether she was in the room or not?
NURSE-W: Correct.
BAKER: Yes. But you are aware that Nurse Ellis had been out of the room?
NURSE-W: Correct.
BAKER: Now, you go on to say at 32a, you talk about
the use of the Guedel for -- the Guedel airway. I mean, I just want to be clear about this. Are you aware of any other occasions when a Band 5 nurse has used a Guedel airway?
NURSE-W: Not that I can recall. We are all trained to do it though as part of our NLS, which is a mandatory course that all neonatal nurses within two years of qualification must attend every four years externally, and we have a yearly update on the ward also. So it is part of NLS training but I can't recall another Band 5 using it so soon within a resuscitation.
BAKER: And then moving on to the period following the cessation of resuscitation, you're, from paragraph 33 onwards, describing events after [Child C] had moved on to palliative care.
NURSE-W: Mm-hm.
BAKER: So you could understand why Letby would be present at a resuscitation because it's all hands to the pump --
NURSE-W: Correct.
BAKER: -- at that point. But following that point, there is no good reason at all for her to be in Nursery 1, is there?
NURSE-W: I could see no reason for her to be there anymore.
BAKER: In fact, she really needed to be in Nursery 3 where she was supposed to be caring for a sick baby?
NURSE-W: Correct.
BAKER: You go on to say: "I was surprised, shocked and frustrated that Letby had refused to comply with my instruction to return to care for another baby." Why, why did that shock you?
NURSE-W: I think I said it earlier; it appeared very selfish. She wasn't working as a team. She seemed to be working for herself, the -- the babies on this night shift still required the help. I have said within my police statement and it got mentioned in court that Sophie had become upset around the resuscitation of Baby C [Child C], we needed to protect her. The other baby in Nursery 1 was on a ventilator. That baby remained one to one, that baby was originally allocated to Mel so I took on that baby as well as trying to ensure the safety of the rest of the unit. So it shocked me and I became frustrated by it because she was not playing as a team.
BAKER: And also you are a Band 6 nurse and her direct supervisor in that situation and you told her to go and look after a baby in Nursery 3 and she had ignored it.
NURSE-W: She did ignore it, yes.
BAKER: And it was proven to be detrimental to the baby in Nursery 3 who then deteriorated; that was your impression?
NURSE-W: So the baby didn't get any sicker but the baby also didn't get any better. He didn't acutely collapse. He didn't need resuscitation but should those antibiotics -- should that baby have had a septic screen on that night? Yes, he, he should. And he should have received the antibiotics much, much sooner than he did. There was a delay in the caring treatment for that baby, and ultimately that is the nurse's responsibility. They are the one performing the observations and reporting any escalated concerns on to the shift leader and the medical team and she did not do that.
BAKER: Instead, Letby was inserting herself into [Child C]'s family's grief, wasn't she, she was going in and checking on them asking them things, offering to do things for them?
NURSE-W: She was going into the family room, I don't know what was said until I read it in my Rule 9. But I do know she was going into the family room, yes.
BAKER: I mean, it might be suggested, and it certainly would be suggested by the family of [Child C] that this was ghoulish behaviour, that she was inserting herself into, into their private space?
NURSE-W: She didn't need to be there. Mel was more than competent to be there at that family support. They didn't need any more people than, than they had. Too many people in that situation can be overwhelming for the family. So they only needed Mel and Mel was coming back to me for support and extra direction if she needed it. Lucy did not need to be there.
BAKER: Indeed the appropriate thing in that situation is to be of light touch, to offer help when it's needed or asked for, but not to overwhelm the family?
NURSE-W: I agree. The health professional didn't need to be there at all times. The parent needed their, their private space.
BAKER: You obviously considered this to be very serious at the time because you reported it to Eirian Powell and also then completed a Datix about it.
NURSE-W: Correct.
BAKER: Is that -- is that because you considered it to be inappropriate behaviour or because you considered it to put the other baby at harm or a combination of the two?
NURSE-W: I think the Datix went through in as a delay in treatment for the baby in Nursery 3. That's the way the context of the Datix went and the delay in treatment came by her going to care for Baby C [Child C] when she didn't
need to be.
BAKER: Thank you. I am going to move on if I can just to briefly ask you some questions about [Child E]. You have said to counsel to the Inquiry that [Child E] was making good progress as far as you were concerned before the collapse.
NURSE-W: That's right.
BAKER: You have also said that it was Letby who came to talk to you to tell you that [Child E] had died. Melanie Taylor in her evidence described her as inappropriately gossipy and excited when she gave her that news. Would you -- would that have been your impression as well?
NURSE-W: "Excited" wouldn't be the word that I would describe. I would say eager; eager to tell me that this situation had happened and -- sorry, my mind's gone blank -- what's -- highly inappropriate.
BAKER: Highly inappropriate, did you say?
NURSE-W: Yes.
BAKER: Indeed I think you also felt that [Child E]'s passing was so unexpected to you that you felt it necessary to go and review the records because you were concerned that you might have missed something?
NURSE-W: That's correct because I had helped care for this baby for 12 hours previously, so I wanted to have
a look at the order of events that had led to Baby E [Child E]'s death during that night. My first reaction was blame on myself. Had I missed something? Had there been a sign there that I had missed?
BAKER: But you found nothing?
NURSE-W: I found nothing.
BAKER: No. If you had discovered that Mother E had encountered Letby stood by [Child E], who was bleeding from the mouth, had told her that she had contacted the Registrar but then discovered that the Registrar had not in fact been contacted for approximately an hour and that the notes had been recorded inaccurately thereafter, what would you have done in response to that?
NURSE-W: If -- can I just clarify what you are asking of me? So had I found that the notes had been written incorrectly?
BAKER: Yes, to -- to describe an inappropriately short interval of time between the Registrar being called and the onset of symptoms?
NURSE-W: I would report it to the manager.
BAKER: Do you think sometimes a debrief with parents as to what they recall happening and sequence of events might be useful? I appreciate it wasn't necessarily the
practice at the time, but might it have been useful if you were able to find out that mum disagreed with what had been written in the notes?
NURSE-W: So in terms of debrief for parents, it's not something I have ever considered for with that terminology around it. What I do know was in practice then, and is still now, is every set of bereaved parents have the opportunity to meet back with their, their named Consultant at a later opportunity and I believe that is once any results are back from post-mortem, any other air tests that were done at that time and would that be the correct time to offer that service? It probably would and it probably is done to some extent too. But I don't know whether they look at case notes and things like that together. I have never been a part of that conversation.
BAKER: Just two very brief questions or two very brief topics, one is in relation to [Child J]. There was a meeting between [Child J]'s parents, Dr Saladi and a nurse where they were complaining that [Child J] had been left with their nappy off and their stoma leaking and wrapped in a towel. Do you recall if you were the nurse at that meeting?
NURSE-W: I don't recall. I have never been questioned with anything with regard to Baby G [Child G], I'm sorry.
BAKER: J.
NURSE-W: Baby J [Child J], I'm sorry.
BAKER: Obviously [Child J] had a Broviac line in place --
NURSE-W: Yes.
BAKER: -- and so you would understand that allowing a baby to be covered in faeces that has a Broviac line in place would be dangerous?
NURSE-W: Correct.
BAKER: And should be taken very seriously?
NURSE-W: Yes.
BAKER: And should be the subject of a Datix report?
NURSE-W: Yes.
BAKER: Finally then in relation to [Child K]. You make some comments about finding the endotracheal tube had been displaced and it had moved. Now, [Child K] was a small premature baby.
NURSE-W: Yes.
BAKER: Intubated babies are sedated so that they can't move around or risk pulling their own tubes out.
NURSE-W: Not sedated in terms they couldn't move completely, no. That would be a paralysis and sometimes that happens and I do actually think just before Baby K [Child K] was transferred they, they were given the paralysis
medication. But during the incident where you are talking at 20 past 7 in the morning, I believe she had some morphine being infused, but that would not be enough to not make that baby move by themselves.
BAKER: But it would be extremely unusual for a tiny premature baby to pull out its own endotracheal tube or push it in?
NURSE-W: If the tube was secured correctly, it would be highly unlikely.
BAKER: Yes. And your account at paragraph 51c records that the tube had previously been secured?
NURSE-W: Had it been just recently resecured? Sorry, was that the question?
BAKER: Yes. So you had noted that it had previously been secured before it became dislodged?
NURSE-W: Yes, that's what was handed over to me, yes. I wasn't there at that time but yes, that's what I'd been told.
BAKER: You say you cannot recall whether any enquiries were made at the time regarding the displacement of the endotracheal tube. Do you think with the benefit of hindsight some form of enquiry as to how this tube moved might have been appropriate?
NURSE-W: So I know at the Liverpool Women's Hospital
they do an audit, I don't know how frequently that happens, and that looks into displacement of ET tubes, so that would -- may be something that could be translated across all units and then that, that may be discussed there.
BAKER: So as to understand how it happened and perhaps how it might be prevented in the future?
NURSE-W: To see if there was a reoccurring theme.
MR BAKER: Yes, thank you. Thank you, my Lady. I have no more questions, Nurse W.
MS LANGDALE: No more questions from me, my Lady.
LADY JUSTICE THIRLWALL: Nurse W, I don't have any questions either so thank you very much indeed for coming this morning and being here with us this morning and this afternoon. You are free to go now.
NURSE-W: Thank you.
LADY JUSTICE THIRLWALL: Thank you.
MS LANGDALE: My Lady, resume at 3.45?
LADY JUSTICE THIRLWALL: We will rise until 3.45. (3.28 pm) (A short break) (3.45 pm)
LADY JUSTICE THIRLWALL: Good afternoon. Sorry, Ms Langdale, I'm just waiting for the pen I have left downstairs but we can start.
MS LANGDALE: I think we might need someone to swear the witness in. May I call Nurse ZC.
LADY JUSTICE THIRLWALL: Thank you, Nurse ZC. I'm sorry for the slight pause, it's because my clerk has very kindly gone to find the pen I left behind and she is meant to be administering the oath. So perhaps if you would -- are you affirming or are you taking the oath?
NURSE-ZC: Affirming.
LADY JUSTICE THIRLWALL: Affirming. Well, if you would like to just pick up the card which is just in front of you.
NURSE ZC (affirmed)
LADY JUSTICE THIRLWALL: Thank you very much. Ms Langdale.
MS LANGDALE: Thank you. Nurse ZC, you have provided a statement dated 23 May 2024 for the Inquiry. Can you confirm whether the contents are true and accurate as far as you are concerned.
NURSE-ZC: Yes.
LANGDALE: Do you have the statement in front of you?
NURSE-ZC: Yes.
LANGDALE: So we see from the beginning of the statement, Nurse ZC, that you completed a Diploma in Children's Nursing at the University of Chester in September 2010. You -- moving to your first Band 5 nursing opportunity, that arose within a temporary placement within the neonatal unit at the Countess of Chester which you joined in 2012, is that right, for that role?
NURSE-ZC: Yes.
LANGDALE: You have done other roles before, I'm just focusing on that one.
NURSE-ZC: Yes.
LANGDALE: Can you tell us what that role was under the temporary contract --
NURSE-ZC: Yes, so it was a Band 5 children's nurse on the neonatal unit.
LANGDALE: You then took employment in children's emergency departments in other hospitals and worked briefly in a hospice and you returned to the Countess of Chester in 2015, is that right?
NURSE-ZC: Yes.
LANGDALE: 2015 to 2017?
NURSE-ZC: Yes.
LANGDALE: And you were working in the children's unit then not the neonatal unit?
NURSE-ZC: Yes, the children's ward.
LANGDALE: Children's ward. So what were your responsibilities then?
NURSE-ZC: So I was, again, a Band 5 children's nurse on the children's unit, predominantly working night shifts, it was a rotation -- it was meant to be a rotational post between the children's ward hospital at home and the children's assessment unit which I think I just did one short rotation to the assessment unit and then was back on the ward, as I say, predominantly working nights. And that's looking after acutely unwell children on the children's ward.
LANGDALE: And when you were working in that time, 2015 doing the nights, what was the overlap between doctors between neonatal unit and the children's ward? Was there any?
NURSE-ZC: Do you mean on how the doctors rotated?
LANGDALE: Yes, how the doctors rotated, yes.
NURSE-ZC: So I think it was -- I think they rotated every six months from different areas and the children's ward and the neonatal unit would share the doctor -- not share them as such, but they would be the same doctors, they didn't have specific doctors based on the neonatal unit and the children's ward; they both worked across the different units and over to the emergency department
when they were required over there.
LANGDALE: And in terms of the nurses' break rooms or anything similar, were they separate from the children's unit and the neonatal unit or did nurses frequent both or interact much?
NURSE-ZC: There was a break room that was on the corridor in between both of the units that was accessible to the children's ward, the neonatal unit and often some of the other wards within that building would use that ward. The children's unit did have sort of a resource room that sometimes people might stay in there if the ward was particularly busy and, equally, when I was on the neonatal unit, they also had sort of a little room within the unit there that you could access for a break room.
LANGDALE: So would you know many nurses from that unit and vice versa or not really?
NURSE-ZC: I think I knew the nurses because a lot of them were still the nurses that were there when I worked on the neonatal unit previously.
LANGDALE: Yes.
NURSE-ZC: But with me working predominantly night shifts it was very rare that I would access the break rooms anyway.
LANGDALE: As a generality on your ward, were night
shifts quieter than day shifts or how did it work?
NURSE-ZC: No, I would say, if anything, the night shift probably seemed busier because you had less staff of a night, so in the day you would have more nurses around, more healthcare support workers, and there would be more doctors and Consultants around whereas of a nighttime you would only have the three nurses and one healthcare and then it would be two doctors working between the different units of a night. So even though it might not have seemed as busy as such, with the workload and less staff it sometimes, I don't think it was ever quieter of a night time.
LANGDALE: Paragraph 14, you say in your statement: "Letby and I commenced our employment on the NNU together on the same day in January 2012. While we had no prior acquaintance, our simultaneous start led to frequent interactions during the initial weeks." And you go on to tell us about something Letby said to you at that early stage that you say caught you off guard. Can you tell us what that was?
NURSE-ZC: Yes, we had been on a mandatory training -- I can't recall what it was specifically -- and obviously, so during that time we did spend our days together, I think the mandatory training was sort of Monday to Friday, 9 to 5, and she did make a comment that she'd said that she can't -- something along the lines of she can't wait for her first death to get it out the way with, which -- it took me back because, for me, the thought of having to experience that, it was something that actually even though, you know, I was a trained nurse, it's not something that you actively want to happen. But at the time I just took that as she was trying to make conversation with someone that she didn't know. It wasn't something that I instantly thought "that's alarming", I just thought it was a little bit strange that that was the sort of conversation that she was having with me.
LANGDALE: You say you didn't perceive any sinister intent behind her statement deeming it rather peculiar rather than necessitating formal reporting?
NURSE-ZC: Yes. It was sort of said offhand. It wasn't an in-depth conversation, it was just part of a normal conversation that then moved on. So it wasn't like it went any further that made me think, oh, it's something that she's really, you know, thinking about.
LANGDALE: You then tell us about a baby, and I won't ask you much of the details, in early 2012.
NURSE-ZC: Yes.
LANGDALE: A baby that was ready for a step down care in preparation for discharge had been admitted to the
Countess from somewhere else and she was in a process of, you describe it as feeding and growing. What was that, what was expected when she was at the Countess of Chester?
NURSE-ZC: So with that, it's -- this specific baby had been to a higher-level unit and they had sort of come back and it's kind of a way of the parents adapting really of having a lower-level unit because the runnings are different and it kind of the baby wasn't quite ready for discharge because they need, I think, if I remember rightly they needed to be a certain weight before they could be discharged. So it was sort of a step down from this higher level to monitor the feed and growing and to give the family support and during that time as well the parents would sort of stay on the unit and they would be provided with sort of basic life-support before they were discharged home with the child.
LANGDALE: And you explain that you had been on the long day shift and the baby had collapsed unexpectedly during the night shift.
NURSE-ZC: Yes.
LANGDALE: And then when you came in the next day, you are looking for the patient on the patient allocation board, is that right?
NURSE-ZC: Yes.
LANGDALE: And what do you find out?
NURSE-ZC: So as I said in my statement, it wasn't unusual that there wouldn't be anyone around at that point because, you know, they would be feeding babies and doing cares and preparing for handover. So I was kind of looking at the allocation board and the baby's name wasn't there. So obviously I was wondering where she had gone, had they forgot to put the name on, and not long after I had been there Lucy had then sort of presented quite animated and told me everything that had happened with the baby, that she had been involved with resuscitation attempts and, again, it was something that took me -- it took me by surprise because obviously the baby had been so well when she came, came back and equally, I guess I didn't feel that I would be as confident in that situation as Lucy was sort of portraying during that conversation telling me about what had happened.
LANGDALE: You say you: "... specifically remember Letby informing me about the blood during intubation and how the doctor had struggled to get the tube down. She expressed the parents' anguish ..." How was this information communicated to you? What
was the tone of it?
NURSE-ZC: Throughout the whole conversation, I would say in my statement, she was animated with it. It was kind of like it was an excited -- she was excited to tell me about it but reflecting on it, when I -- at the time, for me it was kind of, was that still the adrenaline, everything that she's experienced that she just needed to offload it to somebody? But it definitely was -- she was animated in telling me about it. It wasn't as if she, she didn't seem upset or that she, it had traumatised her in any way.
LANGDALE: You tell us that you had a conversation with Yvonne Farmer --
NURSE-ZC: Yes.
LANGDALE: -- about it. She was the practice educator, Band 6 nurse --
NURSE-ZC: Yes.
LANGDALE: -- and a link for new nurses, as you were, on the NNU, and students. So what was the basis of your concerns with Yvonne, what were you raising with her?
NURSE-ZC: I think the conversation that I had had with Yvonne, obviously, you know, she was sort of our link that we would go to with us being newly qualified perceptors and new to the neonatal unit. My concern around that was that I had actually missed something. I didn't go to Yvonne escalating concerns about how Lucy had conducted herself to me telling me, it was more my concern as a newly qualified nurse that actually had I have picked something up the day before, had -- before my shift, would things have been different? So that was sort of the basis that I had had a conversation with her, that -- wanting reassurance, really, that, you know, it hadn't been something that I had missed.
LANGDALE: And you tell us she reassured you you had not missed anything, and: "... this is something I will experience on neonates." You were a newly qualified nurse at this stage.
NURSE-ZC: Mm-hm.
LANGDALE: Did you accept that they can be unpredictable?
NURSE-ZC: Yes, so I think, again, there was other nurses on shift, I don't recall who they were, and they had equally told me the same that, you know, premature babies, they can be unpredictable, that this was a baby that had spent time on another high level unit and sometimes, you know, they can deteriorate without any sort of signs.
LANGDALE: You weren't approaching Yvonne Farmer about
apprehensions about Letby. Do you think you did tell her, as you have described, the animated conversation, or not? Were you more focused on the baby themselves?
NURSE-ZC: I was more focused on the baby but I know further along I think that my concern -- not my concerns as such but I think maybe I felt a little bit intimidated that I wasn't as confident as Lucy had come across in that situation, that we had both started together and my thoughts were if that had have happened to me at that point, and I was experiencing a baby arresting in the manner that I had been told, that I wouldn't have been as confident dealing with it as she portrayed. And I think that's sort of where, you know, it was sort of, well no, you know, this was the first Band 5 job that came up and I didn't actually have an interest in pursuing a career in neonates and I think that's sort of what was deemed the difference between myself and Lucy, that actually that's always something she wanted to do and I was just there as a -- to get myself into my career really.
LANGDALE: You also tell us at paragraph 27 about a time when during Letby's placement at Liverpool Women's Hospital she frequently mentioned a particular baby -- obviously we don't want the names or details -- but what
did she tell you that concerned you or made you question whether she was excessively familiar with particular parents of patients?
NURSE-ZC: Again, at that time, it didn't make me -- well, looking back on it now it isn't -- it is odd that she did have that sort of relationship. But she would be in touch and come back onto the unit and let us know of sort of events that had happened, what she had experienced, and to me at that time, I had just put that down to that, you know, she was living in an area that she had no family and that was her sort of way of debriefing. You know, if something bad had happened on my shift, I was able to go home and, you know, speak with my parents and, you know, I would have a support network whereas, actually, she was living on her own and, you know, her job became sort of everything. So, you know, at the time that's what I saw it as. But, you know, on reflection, there was that over-familiarity with that family and, you know, it doesn't sit right now.
LANGDALE: So she would come into the unit, you say, at the neonatal unit at the Countess of Chester and engage in detailed discussions about experiences and you interpreted those visits as a form of debriefing and trying to seek companionship to share.
NURSE-ZC: Yes, and equally we were both doing the induction to -- induction to neonates together. So, again, maybe it was a case of me thinking that because we were both doing the same course, we were both up to the same level but she had gone to her placement first, it was her way of sort of letting me know what to expect as well.
LANGDALE: You have just expressed that you weren't confident you wanted to be a neonatal nurse in any event but how did her descriptions of her placement there, and particularly describing to you resuscitations, impact you?
NURSE-ZC: It terrified me. I did not want to go on that placement at all. I had -- my contract was initially a six-month contract which was then made to a one-year contract and I was sort of hoping that I would have found a job before I had to go on that placement. Because my thoughts were it's not something I've got an interest in and I don't actually want to experience what she's experienced there.
LANGDALE: You in fact did have a brief period, didn't you?
NURSE-ZC: Yes.
LANGDALE: Just a matter of four weeks on that placement and how was that for you?
NURSE-ZC: It was no different to what I had experienced in the Countess of Chester. I wouldn't say in those four weeks that I was there I particularly learned anything more than I did when I was at the Countess. I didn't look after any high level babies, I didn't observe any cardiac arrests or any sort of complex cases whilst I was there.
LANGDALE: You say you left the Countess in March 2013 and your connection with Lucy Letby "stemmed solely from us starting our nursing jobs together." Beyond that, you didn't stay in touch, you didn't have shared interests and the like?
NURSE-ZC: No, I mean, we stayed in touch probably for a couple of months after, but we didn't, like I say, we didn't have any shared interests, we weren't really friends apart from the fact that we had started together on, on the unit.
LANGDALE: You say at paragraph 34 of your statement -- this is when you are back at the Countess of Chester, 2015 to 2017.
NURSE-ZC: Yes.
LANGDALE: You say: "During a period of night shifts, there appeared to be a notable increase in collapses on the NNU."
NURSE-ZC: Yes.
LANGDALE: "Although exact dates escape my memory due to the passage of time, I distinctly recall a stretch where nurses found themselves managing the ward and unwell patients for prolonged durations due to doctors being occupied in the NNU overnight". So that was the impact for you on the children's unit that you are describing there --
NURSE-ZC: Yes.
LANGDALE: -- or children's ward?
NURSE-ZC: Yes. Especially of a night shift as well, we didn't have any of the Band 6 nurses so it would be reliant on the Band 5 nurses running the shifts and we would be made aware of the collapses that were happening because obviously we were left without a doctor's presence on the ward whilst they were on the other unit. So, you know, we would be trying to contact doctors for patient reviews, you know, admissions that had come in that they would need to come round and do the clerking in. So we had become made aware that, you know, there were babies unwell because the doctors would be letting us know that we're stuck over on the neonatal unit, there's a baby that's collapsed or deteriorated so you will just have to managed as you are.
LANGDALE: Do you remember when that was, roughly, that timing? You say you find it difficult to be precise,
but when was this?
NURSE-ZC: I think based on what I've put in my statement it would have been around the February to the April 2016 time, that's all I can ...
LANGDALE: And you can't timeline that by anything in particular, so it may or may not be right, you just remember that?
NURSE-ZC: Yes.
LANGDALE: You say to us that you recall two occasions with two different doctors making comments about Lucy being on shift. Can you tell us, it's Dr Chang, I think, and Dr Neame, what you remember both of them saying, and what you did and did not think they were saying by that at the time?
NURSE-ZC: Yes, I remember it being -- these were on some of the night shifts again, and nothing was said in a sinister way or that they thought that there was any malice. It was said more of a, you know, it was Lucy on again, as if they kind of felt sorry that she was experiencing all of these deteriorations or that she had to take over the care and, you know, when they were saying that, knowing sort of her interest previous in neonates and the additional courses that I knew that they had to go on, you know, for me it was a case of, you know, is she -- has she got these babies because
she's the one that's qualified in looking after the higher acuity babies.
LANGDALE: You say: "... Dr Chang returning to the ward after a particularly challenging series of shifts, expressing feeling deflated and exhausted. She mentioned, 'It's always Lucy too' which [you say] might have stemmed from the concern for Letby experiencing similarly difficult shifts." That's how you took that at the time.
NURSE-ZC: Yes.
LANGDALE: And you say Dr Neame had also said: "... he made a comment that he's used more adrenaline during these night shifts than he did in six months at the LWF." We know he had shifts 13, 14, 15 October like that relating to Baby I [Child I]. So that seems a bit later than your -- sorry, a bit earlier than your February to April 2016?
NURSE-ZC: Yes, like I say, it's difficult to recall the exact timelines when, when it was because, like I say, it was a good few years ago. But I do specifically remember those night shifts with, with Matt Neame on and Rachel Chang.
LANGDALE: And Matt Neame certainly in 2015?
NURSE-ZC: Yes.
LANGDALE: So you say at paragraph 37: "I suspected that many staff members had also noticed this correlation, but like others, hesitated to assume anyone was causing harm to vulnerable patients." So people recognising that Letby was present at these unexpected deteriorations or collapses but not making any assumption around causing vulnerable causing harm rather?
NURSE-ZC: Yes. I think, you know, as children's nurses, as medical professionals, you never want to think that an individual wants to cause harm. That's not what we go into the job to do. So I think, you know, there was -- people were making a link but, again, it was a case of, you know, knowing that they have specific training in different areas on, on neonates. It's not -- it's very different to paediatrics where, you know, we cover a range of things. On neonates they are trained to look after certain levels. And, you know, the higher levels it is, you know, I think they used to do the ITU course that some of the nurses would have done and others wouldn't and it was a case of, well, actually, she's probably the one that was on shift that was qualified to look after them and that's sort of where your thought process is because you never want to
think that someone wants to intentionally harm any of the patients.
LANGDALE: You have commented on junior doctors making the links. Were you aware of nurses, other nurses making such a link or Consultant doctors making such a link?
NURSE-ZC: Not the Consultants because, like I say, I would have -- working nights I didn't really see as much of the Consultants as you would on a day shift. Again, I think some of the nurses made links that, you know, she was on shift but again it was probably the same viewpoint as, as, you know, myself, that we don't want to think that anyone would harm a child and is it because she's trained in looking after that level of baby. And, equally, even though we would know things that were going on on the neonatal unit, you know, we didn't know the back story of, actually, was it a case of she had different patients and, you know, on the children's ward if we had a patient that would deteriorate we wouldn't let -- we wouldn't have a less qualified nurse looking after them, we would say, okay, let's look at jigging around our patient allocation so someone more senior can look after that, that child or baby that's deteriorating. So, you know, we didn't know the back story of the
run-up to that, had she have, you know, was it case of she had taken over from somebody? We didn't know that.
LANGDALE: You say: "The link for me was following the event of the death of the triplets that made we concerned. This was potentially more than an experienced nurse always being allocated the unwell babies."
NURSE-ZC: Mm-hm.
LANGDALE: And: "This was during a week I was doing a rotation to days and was on shift on the children's ward when the doctors crash bleep went off for the neonates."
NURSE-ZC: (Nods).
LANGDALE: So tell us what you thought then. Paragraph 39 of your statement sets it out.
NURSE-ZC: Yes, so that -- I did have to do with the odd rotation of days, you know, with -- for service demand. Initially the, you know, the first day I didn't think anything, you know, I didn't think to myself: oh, you know, this is something awful. It was more the second day and realising that actually she was on -- had chose to look after those babies again. For myself, personally, you know, it's, as I say, we don't -- we go into nursing to make people, make people better. We are fortunate enough that, you know,
children dying isn't a regular occurrence. So even as nurses, I think when you do have a child that dies, you know, it's nothing in comparison to what the parents go through, but it's really hard going as you are a nurse, you know, it's mentally and physically exhausting, you will look after a patient and, you know, see to all the clinical needs and unfortunately when they do pass away you're then providing the emotional support to the families afterwards. You would hope that after that shift you've got a day off the next day so you can compartmentalise what's happened because, you know, when you witness a child dying it's awful, it's not normal, it's not something that you should experience. So for me to go back the next day on shift, if -- you know, if it was me going back on shift, I would want the lowest acuity patient. So, for me, I found it quite strange that she chose to go back. Again, I don't know if she chose to or whether it was allocated but to then look after the siblings of the child that had died on her watch.
LANGDALE: So to have O and then go back for P?
NURSE-ZC: Because I couldn't think of anything worse of -- after -- already having one child die to then go back and have to ...
LANGDALE: You said you also found it distressing, quite distressing, observing a very skilled doctor appear completely confused regarding one the deaths.
NURSE-ZC: Yes, and I think we saw that with a lot of the -- the, you know, especially with the triplets, I think they had seen them improve and, you know, they had come in and used the resource room and there would be conversations. So I think when there was the death it took them back a little bit because they didn't expect it and I guess in the back of my mind as well that was something that was maybe sat there, along with me thinking she's gone back the next day and looked after a sibling -- the sibling.
LANGDALE: You say at paragraph 40, and then I am going to take you to 45, you say at paragraph 40, you went and saw Nicola Lightfoot who was on one of the computers documenting and you recall saying to her, this is after the triplets, "Is it not concerning that she is involved and she is always there?" "Nicola just shrugged her shoulders and didn't say anything in response." What did it require to say that to Nicola Lightfoot, from your perspective, speaking up about that link and being concerned about it?
NURSE-ZC: It was really difficult for me because I had
already had an experience on the ward a few months before where I had escalated concerns about a clinical assessment completely unrelated to the neonatal unit.
LANGDALE: You don't need to give us the details.
NURSE-ZC: No, no. And sort of my working life there was made really difficult then by senior managers and the advance nurse practitioners because I had escalated concerns and it had been deemed that as a junior nurse I had sort of undermined someone who was more qualified than me. So it was difficult anyway that I didn't have sort of a relationship with any of the managers apart from Nicky that I felt that I could say, you know, is there no concerns, which unfortunately from reading her statement, she deemed that as me gossipping although it is only myself and her in the room at the time.
LANGDALE: You say -- so she literally shrugged her shoulders. Did you raise it with anybody else in response?
NURSE-ZC: No, I didn't because of what I had been through previously and what I had been subject to, it was kind of like this smear campaign against me on the ward, that actually it was only Nicky that I had felt comfortable going to and even sort of the lead nurse at the time had condoned some of the behaviour towards me from the previous issues.
So obviously when I had said that to Nicky and nothing -- there was sort of no validation at all or any sort of, okay, let's have a bit more of a conversation about that, it was kind of like, you know, I don't want to put myself in that position again and actually my voice isn't being heard anyway.
LANGDALE: You say at paragraph 45: "Following my conversation with Nicola Lightfoot, I distinctly recall staff were informally advised in shift safety huddles ..."
NURSE-ZC: Yes.
LANGDALE: ... (which I do not recall them formally documented) that if anyone discussed the NNU, Letby, or the infant deaths disciplinary measures may be considered."
NURSE-ZC: Yes.
LANGDALE: Were you present for any of those safety huddles or discussions?
NURSE-ZC: I remember being there for one of them which I don't think it was long after when I discussed it with Nicky and it was kind of we -- we were told that there was a potential infection on the unit and that's why we couldn't access it. So it wasn't long after that that that was the conversations that were had, but it was very brief in what was said that, you know, we are not
discussing it, there is no more conversations to be had and, like I say, disciplinary measures would be considered if you were found talking about it.
LANGDALE: And which of the nurse managers did you hear that from directly yourself, those messages, or did you hear them from others?
NURSE-ZC: I don't recall exactly which one it was. I do remember Ann Murphy being round at the time but I couldn't specifically say which one it was on shift because sometimes, you know, you would come in and out of a safety brief. You wouldn't be there for the whole of it. So I can't recall exactly which manager that was.
LANGDALE: Did you see -- I am going to ask for a press release to go on the screen and see if you have seen this. It is INQ0004914. And this, Nurse ZC, was communicated externally 7 July, so after the death of the two triplets and the time you are talking about. Did you see that?
NURSE-ZC: No.
LANGDALE: So you obviously weren't on the neonatal unit staff list so I'm not going to take you to emails. We know they were sent about what was happening. But did you know there was this Royal College of Paediatrics and Child Health and Royal College of Nursing review being done?
NURSE-ZC: No.
LANGDALE: No one discussed that with you?
NURSE-ZC: No. I knew that later on, that it had been, the acuity level had dropped but I never saw this.
LANGDALE: You mean when they downgraded the unit?
NURSE-ZC: Yes.
LANGDALE: So babies would come in of later weeks gestation than they had previously?
NURSE-ZC: Yes. But I'm not sure if that was later on. Like I say, I hadn't seen this.
LANGDALE: Okay, that can go down, thanks. You tell us in your statement that there was a time when you were expecting a Care Quality Commission visit and I think that, in fact, was in February 2016 time.
NURSE-ZC: Mm-hm.
LANGDALE: And you say -- well, let me ask you this. Were there any instructions about how to respond to that CQC inspection given to you, or to other staff, as far as you are aware?
NURSE-ZC: Not specifically to myself. But with a CQC visit it's kind of they want to get everything in line and obviously, you know, you would be told of specific individuals that you need to know names of.
But I didn't have any direct briefing prior to the CQC coming in terms of, you know, if things -- what to say to them if I was questioned but I think, again, you know, I was predominantly on nights so I wouldn't really see them.
LANGDALE: Were you questioned? Were you --
NURSE-ZC: No, not that I recall.
LANGDALE: So you didn't attend for an interview.
NURSE-ZC: No.
LANGDALE: And it looks -- this was earlier than the triplets. It looks like you thought it was later than it was. It was February 2016, I think.
NURSE-ZC: (Nods).
LANGDALE: You say something about you were required to fill in appraisal documentation and sign them?
NURSE-ZC: Yes.
LANGDALE: What was that about?
NURSE-ZC: So obviously as nurses you are meant to have annual appraisals or, I guess, they are called different things in different Trusts, appraisals, PADRs, which was never something that I had had whilst working at the Countess. I can't say that I was aware of other people having them either. But obviously it, it's -- it was something that was mandatory that you had to be compliant with and during that time when CQC were due to
visit we were asked to start filling in our appraisal forms and sign them.
LANGDALE: So was that something you should have been doing anyway or did you think it was just being done to create an impression for CQC? What are you saying there? What did you think this process involved?
NURSE-ZC: I thought it was a way of them looking like they were compliant and that they had either started or we had had our appraisals but, like I said, in the two years that I was there, I never received a one-to-one or appraisal or had one booked in.
LANGDALE: But you weren't backdating or signing with an earlier date or anything like that, were you?
NURSE-ZC: No.
LANGDALE: So did you date the documents as to --
NURSE-ZC: I can't recall.
LANGDALE: No, okay. You know that I think it was Nurse Lightfoot suggesting that Dr Barrett had said to you or used the term "Nurse Death" about Letby speaking to you. In fact, Dr Barrett says she didn't say that to you and you say the same, Dr Barrett didn't say that to you. Dr Barrett does say she said it to Nurse Lightfoot. So were you party to any discussion with anyone with names like that, Nurse Death or --
NURSE-ZC: No. That was sort of the first I had become
aware of that when I read the statement.
LANGDALE: You refer, when you are talking about management generally, to a "circle of trust"?
NURSE-ZC: Yes.
LANGDALE: What did you mean by the "circle of trust" and how did that operate?
NURSE-ZC: So the ward, it was very much based -- it was, you know, the hierarchy you had the managers, the senior managers, and the APMP, and it was commonly known that there was a WhatsApp group from them and they kind of referred themselves to the "circle of trust".
LANGDALE: What level of management are you talking about here?
NURSE-ZC: The ward manager, the deputy ward manager.
LANGDALE: So who are the names of those?
NURSE-ZC: So it was Anne Martyn, Nicky Lightfoot, Catherine Pollit, some of the Advanced Nurse Practitioners.
LANGDALE: And is that the group that you wouldn't have felt comfortable raising concerns with?
NURSE-ZC: No, I wouldn't have felt comfortable going to any of them.
LANGDALE: Okay. Do you think a confidential helpline would have assisted if you did have concerns about somebody or, as you had done, were making links certainly after the triplets between Letby and unexpected deaths, would it have helped to be able to leave that concern with somebody independent from the hospital --
NURSE-ZC: Yes.
LANGDALE: -- who may be getting similar concerns from others and gathering the picture?
NURSE-ZC: Yes, I think in other Trusts that I've been in there's been sort of a Freedom to Speak Up Guardian that you could go to, an individual that had nothing to do with the area and speak to them and, you know, they would signpost you or, you know, escalate that further whereas there wasn't anyone that I was aware of at that time in the Trust that I could have gone to and addressed those concerns.
LANGDALE: So you weren't aware of such a thing there to --
NURSE-ZC: No.
LANGDALE: -- separate from --
NURSE-ZC: And as far as I am aware, it's only more recently that they have brought in a Freedom to Speak Up Guardian.
LANGDALE: In terms of reflections now if I may.
NURSE-ZC: Yes.
LANGDALE: At paragraph 55, what do you set out there?
What do you think, reflecting on what happened, events here, is required to avoid similar events in the future?
NURSE-ZC: Sorry, could you repeat that question again.
LANGDALE: Yes. At paragraph 55 you are reflecting --
NURSE-ZC: Yes.
LANGDALE: -- on how you think babies could be kept safe in hospital.
NURSE-ZC: Yes. It's difficult for me to say in terms of, you know, neonates and what happened during that time because I wasn't on that unit to know what their processes were. But I think, you know, there should be a higher level of review. I think, you know, a lot of the time it may be put to that, you know, they were premature. I don't know what that was, but, you know, I think moving forwards having, you know, an outside agency looking at things and, you know, reviews being a little bit more in-depth.
LANGDALE: You say analyses, including examination of test results, information, standardised procedures to enable identification of patterns and investigations into deaths and collapses should be carried out by impartial agents not directly involved in the processes. Would you add to that "or with the people involved"?
NURSE-ZC: I think where it would be appropriate, yes, especially if -- and I think sometimes because you are working so closely with staff on the ward, with doctors, I think, you know, like a lot of us probably did we didn't want to think anything bad or that individual was doing anything sinister. So I think when you are working with the people like that, it would be beneficial to have someone that's not involved and that doesn't, don't -- doesn't know the staff to be able to look at things from a different perspective.
LANGDALE: The Inquiry has heard evidence from Dr Lambie that as early as September 2015 some nurses were sitting together and talking about who could be connected and looking at rotas to events -- untoward, unexpected events, she wasn't sure precisely -- but looking for who might be on shift on occasions. You have given evidence that Dr Neame and others still in 2015 are making the association. What you are also saying is no one wanted to think anything bad and I want to just ask you more about that. You make an association, in some cases you know it's an unexpected, an unexpected event without a medical explanation. What is it you would say means people don't want to think anything bad? And it's
a clear option, isn't it, if you don't know what a medical cause is?
NURSE-ZC: Yes. I think, you know, like I have said previously, you know on the children's ward we would know things were happening but we didn't know the back stories. We didn't know the run-up to the collapses. We would just know that it was that nurse that was on and like I said that could have been due to her being the experienced one. I think what I mean by you don't want to think, you know, anything bad it's like I said we don't go into this profession -- you like to think we don't go into this profession to do things like that. You know, we want to see people get better, we want to help patients and that's -- it's just not something that you want to even think anybody would do.
LANGDALE: Did you have training on the Beverley Allitt case in your nursing?
NURSE-ZC: As a student nurse I think we probably had discussions around Beverley Allitt and why we do things that we do for, I think, you know, us doublechecking drugs came off the back of what happened with Beverley Allitt. But there wasn't a specific, you know, in-depth module about it, we were just, you know, made aware because that was something significant to children's nursing.
LANGDALE: And moving forwards, your awareness after being involved in the events at the Countess is no doubt heightened now.
NURSE-ZC: Mm-hm.
LANGDALE: How do you think the importance of that message being heightened can be communicated to others, so that they don't not want to think anything bad when something like this is confronting them?
NURSE-ZC: I think it's having a culture where staff feel that they can have those conversations. You know, we can all sit and say, you know, we don't want to think anything bad is happening but, equally, when we have thought there might be more to this and we have gone to managers to have that discussion, it's -- it's completely shut off and it's not supported and actually it's then flipped, I guess, as: you are the problem, you are the gossip. And that doesn't make anyone feel comfortable in going forward and saying, actually, I've got concerns here. And I think it's having a more even culture that we can have those difficult conversations even if it is, you know, that, you know, managers are having to deal with uncomfortable situations to be able to speak openly and be listened to. I think that's really important
moving forwards.
MS LANGDALE: Yes, thank you, Nurse ZC, no further questions from me. (Redacted).
LADY JUSTICE THIRLWALL: (Redacted). Thank you very much indeed, Nurse ZC. You are free to go but just remain there while the room is cleared and I'll also leave the room.
NURSE-ZC: Thank you.
LADY JUSTICE THIRLWALL: Thank you very much for coming. 10 o'clock tomorrow morning -- Ms Langdale, 10 o'clock?
MS LANGDALE: Yes, 10 o'clock, thank you, my Lady.
(4.31 pm) (The Inquiry adjourned until 10.00 am, on Tuesday, 15 October 2024)
LADY JUSTICE THIRLWALL: Good morning. Ms Langdale.
MS LANGDALE: Good morning. May I call, please, Nicola Lightfoot.
MS NICOLA LIGHTFOOT (affirmed)
LADY JUSTICE THIRLWALL: Do sit down.
LIGHTFOOT: Thank you.
MS LANGDALE: Ms Lightfoot, you have prepared a statement for the Inquiry dated 31 March 2024. Can you confirm the contents are true and accurate as far as you are concerned?
LIGHTFOOT: Yes, that's correct.
LANGDALE: Have you got it with you?
LIGHTFOOT: I have, yes.
LANGDALE: So if I refer you to paragraphs you have it there?
LIGHTFOOT: Yes.
LANGDALE: You tell us that you worked as a Band 6 deputy ward manager during 2011 to 2015 on the children's unit. Can you tell us what that role entailed and also set out, as much as you would like to, your experience before taking that role; how long you had been a nurse
and your experience?
LIGHTFOOT: Okay. So I completed my nurse training '93 to '96. It was specific in paediatrics. I started my role on the children's ward at Chester in January '97 as a junior staff nurse at that point. After a few years I took on a role as senior staff nurse and then after that, I also took on the deputy ward manager role which was classed as a sort of Sister role. I have been an acting manager on the unit for a short period of time as well. I have worked on that unit ever since. My role involves day-to-day clinical management of my own patient workload at times. I am responsible for running the unit which is across three areas. I have management responsibilities on day-to-day runnings of the ward, managing patient flow from the admissions that we have in, supporting my colleagues and junior staff. Part of my deputy ward manager role is also completing appraisals, sickness reviews, any disciplinaries with any staff, dealing with parent complaints. So it's two-fold really. There is some management of the staff and then the day-to-day runnings of clinical duties as well.
LANGDALE: So in 2011 how long had you been working as a nurse or practising?
LIGHTFOOT: So I qualified in -- the end of '96 and started, sort of, '97', so nearly 20 years is that? Get my fingers you out.
LANGDALE: A considerable time.
LIGHTFOOT: Yes, yes.
LANGDALE: So you have a lot of experience. Did you overlap in your role as a deputy manager on the children's unit with the managers on the neonatal unit?
LIGHTFOOT: No. We have always worked quite independently. Although we are logistically next to each other, they have always run very separately, separate areas and specialties. So I may have been involved in some of the contact with managers during meetings and such but the day-to-day runnings of the neonatal unit, we had no involvement of. Very little awareness even in a management role, even as deputy manager, as to any day-to-day issues or things that are happening within the neonatal unit.
LANGDALE: What about the managers there, which ones did you overlap with in management meetings?
LIGHTFOOT: So I might have been to meetings with
Eirian Powell. Usually, if I was representing the manager -- the manager would usually go to these meetings; obviously I would stand in as deputy manager in their absence.
LANGDALE: Right.
LIGHTFOOT: So it wasn't a regular thing but that's where I might have come across --
LANGDALE: Her.
LIGHTFOOT: -- the management.
LANGDALE: And what about Yvonne Griffiths or Yvonne Farmer, dealings with any of them?
LIGHTFOOT: Similar. I might have just sat, sat in the same meeting but no other interaction other than sort of friendly "hellos", you know, when passing. If we had gone to the unit to borrow equipment or vice versa if they'd have come over.
LANGDALE: We know, and I am going to come on to the specifics, that you were Letby's mentor during her final placement in 2011. But can you tell us first of all, as you do at paragraph 5 onwards, what the Mentorship Module (Teaching and Assessment Module) was about in 2011? How did the scheme work? What was it supposed to achieve?
LIGHTFOOT: Okay. So, so my mentorship training was, actually, a module. I had to complete a piece of work and a number of assessments. It was an official qualification at that time. It's since changed since. There isn't actually the formal training and qualification now. So I completed that. That was something that was routine for senior nurses at a certain point into their career. It was a sort of natural progression as you became a senior staff nurse that you would complete that course to enable you to support and mentor students.
LANGDALE: And support and mentor students, was that their way of achieving qualification, you were helping them to achieve their qualification and develop into independent nurse practitioners?
LIGHTFOOT: Absolutely. So throughout, obviously, the nurse training at that point was a three-year course and students would have various placements across different specialties, some community placements, some hospital placements. Towards the end of their third year we expected a bit more autonomy, them to be able to work a little bit more independently, and in the placement that I was mentor to Lucy, and it was her final placement, so that is the placement prior to becoming a qualified nurse. So it's quite pivotal and particularly important to ensure that that student is ready to qualify because as
a student, you do obviously have your own responsibility, however you are supported and the main responsibility lies with your mentor and the qualified staff you are working with. Obviously that transition to go from that to an independent worker although albeit under still supervision we have a sort of preceptorship programme that we support newly-qualified staff in is really quite a change. So you have to be absolutely sure that that person is at that point ready to qualify and take on that responsibility.
LANGDALE: So in the first year, then, so first year students you say need basic orientation to the role and you teach basic skills like ward routeing, observations, and completing documentation but by the time of the third year, they are about to qualify so expectations are different, as you have just said.
LIGHTFOOT: Absolutely, absolutely, and you work almost more remotely, you allow that independence. They -- in the first and second year often they are on your shoulder, they are behind you, they are observing a lot. Obviously we would try and encourage participation in those skills and that is how you learn, you know, often, you know, watching what is done and
then, under support, completing that task yourself. By the time they are in the third year, we would allocate our third year students their own patient workload of two or three patients. They would independently plan that care, with your supervision, based on their nursing assessments, the condition of the child, you are observing their interaction with the family and other members of the multi-disciplinary team. But we are expecting them, as I said before, to work more autonomously, come back, touching base every so often, but I would expect a third year to be able to go and plan their own care for their patients, recognising their priorities, delivering that care and assessing and evaluating how that care has impacted on the condition the child.
LANGDALE: And what kind of mentor were you, certainly in final placements? Had you mentored many third year students?
LIGHTFOOT: Yes, so at that point, I -- I had been qualified sort of almost 15 years. We have -- we all have had a number of students over, over every year. I had mentored an awful lot of students, first years, second years, third years. I think I personally in the first year perhaps the expectations I would have are not quite so high because
they have got time to develop. By the time they get to third year, my professional responsibility and my duty of care as a nurse is to ensure that that student qualifies and is safe, can deliver effective care; that I am happy that that protects them as a practitioner. I am happy that that protects their colleagues as a safe practitioner and, more importantly, the children and the families that they are looking after and that's is my primary focus. It doesn't always make you very popular especially I have found in my experience that students that have been weaker or I have felt were lacking in some areas are often quite defensive. Often may have said, "Oh, I find, I find you difficult" or "I find you intimidating", but my primary responsibility is to ensure that that person is safe for all of those reasons I have just, I have just said.
LANGDALE: And how many had you failed? When you are asked about this with the police in 2018, how many third year students had you failed at that time, would you say, roughly?
LIGHTFOOT: Yes, I couldn't, I couldn't put a number on it but I have, I have failed a few. And as you probably have seen and for anybody that isn't aware, any student that is failed in that final placement has the opportunity to repeat that placement to try and achieve the competencies that they have not met. So the student training and the placements have a number of competencies that we expect the nurse to achieve. If, as we go through the time of that placement, we are finding that that member of staff is struggling to meet some of those objectives, at that point we will action plan for it, we will raise issues as we go along -- it's unfair to put them all at the end and that student have no awareness of what areas that they need further work and support in.
LANGDALE: And you do the marking, don't you? As a mentor you mark --
LIGHTFOOT: Yes.
LANGDALE: -- it is fed back to the University of Chester and then they pass or fail or they give them feedback as appropriate?
LIGHTFOOT: Absolutely. So at that point there was what we called an OSCE, which was a practical test, and basically it was to assess that student's ability to co-ordinate care for a number of patients. It included a medication ward round, which obviously has to work within the -- the Nursing and Midwifery Council guidance for administration of medicine. So there is right and wrong ways of completing it;
that's not a subjective assessment. The competency-based assessment is a little bit more subjective. But I would say that in my experience I have seen sufficient students in practice to know what students perhaps need additional support.
LANGDALE: You tell us at paragraph 15 that you were Letby's mentor during her final placement 23 May to 31 July and you say: "... it became apparent to me that Lucy didn't have overall characteristics to be a successful registered nurse." What did you mean by that?
LIGHTFOOT: So obviously students have to have a certain academic ability which is assessed by the university. They have assignments that they have to pass and they also obviously have their ward assessments to pass as well. We see students that actually are extremely academic but actually from a personality and characteristic point of view they don't seem to blend into the role of being a children's nurse, which includes characteristics of empathy, being kind, being friendly, being able to establish good relationships with our families. This is a position of trust. It is an honoured
position to provide care to sick children and their families and they come as a whole. We expect our students and our staff to be able to establish a working relationship with that family. They need to be able to trust that you know what you are doing, that you are going to provide the best care possible for their child in a very distressing and anxious situation. They want to feel supported in that they feel that you know what they are doing. So, actually, those kind of traits are really vital in becoming a competent practitioner.
LANGDALE: What were your concerns about those traits as far as Lucy Letby was concerned?
LIGHTFOOT: So, as I said, I have mentored a number of students over the years. I am well aware that actually when you are under assessment, it can feel intimidating so I very much tried to stand back and allow Lucy to perform without feeling I was over her shoulder putting that pressure on, that perceived pressure that she had, and I would allow her to go and establish these relationships and perform the duties that we have talked about previously and then I would just touch base and reassess. Sorry, could you just repeat the question again?
LANGDALE: No, you have answered it, I think.
LIGHTFOOT: Okay.
LANGDALE: If you answer this question, please. Did you discuss any concerns you had with her directly about her communication with patients or families?
LIGHTFOOT: Yes, absolutely. So as I say, we address things that we -- we do -- at that point we have an initial interview, we class it, and that's where we would say to the student: this is what we expect you to have achieved by the end of this placement. What would you like to achieve? What areas do you feel you haven't had opportunity to experience yet? We then do a halfway interview and we will assess where they are with those competencies: is there anything flagging up that we need to do further work on that we need to put additional support in with, and at that point if we feel there are things that need working on we will liaise with the university which is what we did. We also had our practice facilitators who worked within the hospital and they would also provide support to you as the mentor to complete an action plan, if necessary, at that point for that student to achieve the competencies they were lacking in.
LANGDALE: If we go to your final report, we see what you said at the time. So it's INQ0014042, page 163. So 0014042_0163?
LIGHTFOOT: I think I have from 0164 onwards, sorry.
LANGDALE: That's fine. It will come on the screen anyway so everyone can see it. We see the front page, the final outcome for you of that placement in the third year was a fail, "has not provided sufficient evidence to demonstrate the common foundation programme outcomes". If we go over the page, beginning 164, your final report, you start by saying: "Since the mid-point interview Lucy worked hard to address the areas of concern highlighted by myself." Had you failed her at the midpoint of the placement?
LIGHTFOOT: There was some -- so it's not classed as a fail.
LANGDALE: Right.
LIGHTFOOT: There was some competencies that you could say at that point "you haven't achieved these yet".
LANGDALE: Right.
LIGHTFOOT: Sometimes it's because of lack of opportunity, but the things -- one of the things that I felt she wasn't achieving at that point was under the very broad banner of "professionalism". And the things that I have
documented in this report and that I have said in my previous statements that I was concerned about was her interaction, how she communicated. I felt it was lacking, it wasn't where it should be. I felt her clinical knowledge was not where it should be.
LANGDALE: If we look at paragraph 3 on that page --
LIGHTFOOT: Yes.
LANGDALE: -- you say she: "... needs more experience at observing and picking up on non-verbal signs of anxiety/distress from parents and recognising when to change her approach."
LIGHTFOOT: I found -- I found Lucy to be quite cold, I didn't find a natural warmth exuding from her that I expect from a children's nurse. I appreciate as a student you feel like you are being assessed all the time. But I didn't feel it was a natural characteristic that she showed. Non-verbal signs are absolutely crucial as a nurse. The verbal signs are obviously clear as they are verbalised to you from parents or children. But a lot of our job is interpreting those non-verbal signs that a child is distressed that -- and it perhaps might not be as obvious as crying, it could involve looking at their body language, assessing how that parent is
responding to you, how they are feeling, you know, understanding and empathising with their anxieties and responding appropriately to reassure them, as I said earlier, as part of that building a trusting relationship.
LANGDALE: Page 165, please. If we go to that. And the fifth paragraph, go further down if we can.
LIGHTFOOT: Yes.
LANGDALE: Page 165, we are still not there. "Lucy does demonstrate drug calculations" -- there we are, it is the penultimate paragraph on the one that's there now. She "does demonstrate drug calculations on a regular basis", did that mean how to calculate the amount of drugs, she knew -- she was competent at that?
LIGHTFOOT: Absolutely. So within children's nursing we would always have two registered nurses to sign medications. Children's medications are often very different, they are weight-based, they are often very variable, sometimes the doses are very complex to work out, hence we would always have two people to check that that dose is correct, that that dose is appropriate, that it's been given at the right time and that there's no drug interactions or, sort of, allergic responses the child has previously had that would affect how you are
administering drugs. We would ask the third -- the student to be the third checker. They would take no legal responsibility, obviously, for signing those medications but we would expect them to be able to calculate the volume of drug that they needed, to check that the dose is appropriate for that child's age or weight, and a lot of the drugs we regularly do, the students very quickly have awareness for because we are giving them all the time such as paracetamol.
LANGDALE: Just pausing there, the checker, is the checker checking that the infusion or the drugs being administered at the right rate? In other words, so one person puts the infusion on or sets it up and the checker comes to check the calculation and it looks the right amount?
LIGHTFOOT: So both of the people will go to complete that drugs round. We would ideally take the medication to the child's bedside. We would, as I say, ascertain that it's the right dose, that it is the right time and it's not being given too early and that it's due, and actually that it's been prescribed correctly because obviously there are occasions where human error occurs and prescriptions are incorrectly prescribed. So our responsibility is to check against our recommended medication guidance that that is the correct dose for that child as well. When we are then administering that, so we are independently checking even though we are alongside each other, we are independently checking all of those things. We are then ascertaining that we are giving it to the correct patient, so we are checking their name band, we are confirming verbally with the parents, asking them to confirm the name and the date of birth and any allergies, we would confirm with the child, if appropriate, and then only if we were happy with all of those things we would administer that medication and the two registered nurses would sign the drug chart which was paper at that time. So we didn't expect Lucy to sign any drugs. But we would ask her to independently try and check to ascertain that she gets the correct dose and volume and I found that even doing the same kind of medication that she struggled to retain that information and we had to do a lot of repeating and asking her to look up and clarify for herself, which we would always recommend anyway, if you are unsure, you would check it, you know, that's where mistakes happen. But she did struggle to retain that information.
LANGDALE: You say there -- sorry, just to go back, she
struggled to retain the information about side-effects and drug usage for common drugs given. Is that a different struggling to retention rather than calculations; do you see how you have set it out there that's what you say -- (overspeaking) --
LIGHTFOOT: So calculations -- so we have a certain drug calculation to work out the volume and that is based on how many milligrams or micrograms of that drug there are in a certain volume. So that is one part of it. So there is a calculation to ascertain the correct volume that you are going to give and that the strength of the drug you are giving is correct because many drugs come in various strengths, so you have to ascertain because 5 millilitres of one drug would be a different strength than 5 millilitres of another drug. As I say, there are, there are a number of very basic medications we give all the time in paediatrics, such as paracetamol, ibuprofen, basic antibiotics, stuff that, actually, after you have given a couple of times I would expect you to remember the side-effects because actually they are fairly generic and the same and actually when we would ask Lucy to verbalise during any practices, and including her official OSCE practice, to clarify some of those side-effects she couldn't verbalise them.
LANGDALE: Can we go over the page, please, to 166. You in that second paragraph highlight the -- what you said already, I don't need you to go back on that about the non-verbal cues. We heard from Nurse T yesterday, who had Lucy for the first period in that third year, that she felt her communication skills were very positive, and something that was raised by Letby was that at the midpoint she found it -- was anxious -- you made her feel anxious. Do you want to just comment on that, the impact of different people and the assessment of things like communication skills by different people?
LIGHTFOOT: Yes, I mean, obviously, we are all individuals, we all have various amounts of experience. We all -- we -- I would say my professional manner has always been trying to keep safety at the forefront of what I am doing, in a kind way, I would try to be encouraging. There were a number of positives that I mentioned throughout this report that I felt Lucy had shown improvement in and there were areas that I felt didn't naturally come to her. When I was -- when you are trying to ascertain people's knowledge base, that involves having to ask questions. On occasions, as I say, I would sort of stand back and allow Lucy to go and provide care for
a group of patients. When I had then reconvened with her a few hours later to say, "Tell me about this", she actually couldn't verbalise what conditions they were, what signs of deterioration she would be looking out for. So I had deliberately tried to stand back so I didn't -- so she didn't feel I was putting any pressure on her, but even in that situation I found she struggled to provide me with that information. I know in Ruth Sadik, her link lecturers, one of her statements, she had also found that Lucy struggled to verbalise some, some of the questions that she had and that's very difficult to determine that person's level of knowledge. If they can't verbalise it and can't show it, then in essence it's not happening.
LANGDALE: Look at the last paragraph. You say: "At the moment Lucy is requiring much more support, prompting and supervision than I would expect at this stage to allow her to qualify as a competent practitioner. However, I strongly feel if Lucy continues to take on board feedback and continues to work on her weaker areas and develop her practice accordingly then this is achievable in the future." We know -- that can be taken down from the screen now. In terms of achievable, what did you think should happen next and we know there was discussion between yourself, Ruth Sadik and others about next steps and, indeed, Ruth Sadik spoke with Letby about the next steps as well, didn't she?
LIGHTFOOT: Yes.
LANGDALE: If you go to paragraph 19 of your statement, you set out there the options that were documented by Ruth Sadik which were for Lucy to repeat her practical OSCE assessment at a later date, for Lucy to see her GP and get signed off sick for four weeks or for an interruption of her studies and go back and repeat a portion of her training. What actually happened? There was a discussion between all of you, wasn't there, about next steps?
LIGHTFOOT: Yes.
LANGDALE: And it looks as though there was a retrieval placement put in place; is that right?
LIGHTFOOT: Absolutely.
LANGDALE: Let me take you to a document so you can see it, because I think it is signed by both you and Ms Sadik, INQ0014042_0171.
LIGHTFOOT: Yes.
LANGDALE: So that should come on the screen. So an action plan agreed, obviously with Letby's input too,
and decisions. There we are. This is the note on 7 August, it's actually the same date as your report, setting out she's made great progress in clinical practice and retrieved five proficiencies. However, still has three outstanding. What are AI, DI, and JI?
LIGHTFOOT: So each of the proficiencies or the competencies that I mentioned before are alphabetically ordered and in each section the A, the B, the C, the D section there is a number of competencies within each section. Some of them are practical things, practical skills that we would expect them to achieve but from my recollection, A1, as I say, was a broader competency, proficiency, based on professionalism and that was one of my main concerns, that I still felt that she had some way to go. All students develop, we all learn at different rates, you know, and we do take that into consideration. But by the third year, most of these should be achievable. From their first year it's very much filtered from university and from us on the ward that, actually, professionalism is, is key and how you build those professional working relationships.
LANGDALE: We know that Letby went on to do a retrieval, four-week placement, with Sarah Jayne Murphy and we will read that in, my Lady, after this evidence. Were you aware that she then subsequently achieved the competencies and passed?
LIGHTFOOT: Yes, absolutely. As I said before, I stand by the decision I made at the time based on my experience and, actually, when you are a mentor you are not the only person making an assessment on this person. Often you do have to consider, is there a personality clash, we don't all get on with everybody we work with, we have to form professional working relationships. So I had sought other colleagues' opinions of Lucy just to reinforce to myself that I was happy I was making a non-judgmental assessment of her skills and how she was as a nurse.
LANGDALE: Did you feel criticised by her in that process?
LIGHTFOOT: No. I think at one point during a conversation Ruth had said, "Oh, she says she finds you intimidating", you know, but I think that was because I was professionally challenging her knowledge and her skills. Often, I think I said earlier, students that are lacking in where they should be often you find provide
negative feedback almost to try and get their side in first. So I wasn't surprised she found that approach, in her words, intimidating. But I was trying to ascertain her level of knowledge and skills to ensure that she was safe, partly for her benefit as a practitioner.
LANGDALE: And Sarah Jayne Murphy, in her statement, refers to she thought that Letby had initiated an appeal process -- I don't think there was an -- we can't see any evidence of an appeal process.
LIGHTFOOT: No.
LANGDALE: It was more the comments appealing to the fact that she felt intimidated by you, or something similar.
LIGHTFOOT: So all students, if they failed a placement, had the opportunity to do a retrieval placement. It is only a very short placement. It is -- at that point it was only a further four weeks. I also verbalised that I felt I couldn't objectively continue as Lucy's mentor, she felt the same, because I genuinely didn't think that in four weeks she would be at a level that I would be happy to sign her off. That previous document that you showed me where you -- where I had circled the fail and I had signed it, that is my professional responsibility as well. That is my professional registration. I have to be sure that I am saying that this person is ready and safe to practise and I wasn't prepared to put my professional reputation and my professional registration on the line at that point.
LANGDALE: It looks like the second document I showed you written by Ruth Sadik but signed by you both, I think, so you were on board with the discussions about what happened next?
LIGHTFOOT: Absolutely.
LANGDALE: But she went to different nurses and different experiences?
LIGHTFOOT: Okay.
LANGDALE: Moving on then to the deaths of [Child O] and P, the -- two of the triplets. You tell us that you heard Letby say something. Can you set that out for us, please?
LIGHTFOOT: Yes. So as I said earlier, actually we work really as two independent units from a nursing perspective. We do help each other out when we need to but we are predominantly fairly independent. The medics cross between the two. So we have -- I personally had quite limited information as to what had been happening. I couldn't say that I had any awareness as to what their normal level of mortality was on the unit. I didn't have
enough experience in working that neonatal unit to know that. And the first triplet sadly passed away on one day, and on the second day, I heard that the second triplet had also passed away and as I was coming out of the break room I passed Lucy, who didn't see me, she was coming out of her unit and greeting a member of the night staff that was coming on and I heard her say something along the lines of, "You never guess what just happened". And I felt, I felt -- I felt it was inappropriate in light of what had happened. The way she had said it seemed like she was talking about some exciting event or something, you know, that she had witnessed or seen on the unit. It wasn't an appropriate response to the death of a child. The death of a child is distressing for everybody involved whether it's expected or not. And it has a profound effect on the whole team looking after that child, and I have never, and I have never since seen a response like that to a nurse involved in a patient's passing.
LANGDALE: And Melanie Taylor who you thought she said it to confirms that was said, she described in an excited manner. Did you take that up with anyone at the time or
mention it to Eirian Powell or somebody who was responsible in the workplace for Letby?
LIGHTFOOT: At that point, when I had heard about that second triplet, I thought, oh gosh, that's strange because there was a passing yesterday and I think that was my -- a moment where I thought perhaps there was something significant happening that I hadn't been aware of. I didn't realistically think anything more about this response other than it was inappropriate. I think I probably will have mentioned it to somebody when I came back on the ward, another colleague, because I was quite shocked. But in hindsight, you know, perhaps I -- I could have escalated it but I -- there was nothing substantiated. There was just an inappropriate response and I didn't have the full awareness of what had been happening on the unit and their mortality rate for me to put two and two together.
LANGDALE: Nurse ZC, who has a cipher so remember that, says that in the resource room after the death of the triplets, and it was after an afternoon safety brief, you were working at one of the computers, and you were somebody she felt able to talk to at that time, and she said, "Is it not concerning that she is involved and she is always there?"
And she describes you as shrugging your shoulders and not saying anything in response. Can you remember that, her saying that to you?
LIGHTFOOT: I don't recall those specific words and that conversation. The resource room, for some clarity, is a public area where the medics and the nurses work.
LANGDALE: Do you have safety briefs in there sometimes?
LIGHTFOOT: Yes, yes, we do.
LANGDALE: Which is what she is describing, so maybe not the public there after a safety brief.
LIGHTFOOT: Yes, but it's not the privacy of the office that I would expect any concerns to be escalated. That is not the first time that I have heard Nurse ZC comment about Lucy. I had heard her and a couple of medical colleagues on a number of occasions discussing that Lucy must be involved. I felt it was quite malicious, it was gossip. It was, at that point as far as I was aware, unsubstantiated.
LANGDALE: Did you think that even after the triplets when you yourself had heard her say that, when another nurse says to you, "She seems to be around a lot"? Did you still think it was malicious then?
LIGHTFOOT: If a member of staff had come to me with a professional concern, it is -- it would be my professional practice, and it has been previously, to escalate that concern appropriately. At that point, I thought it was nothing more, still, than a member of staff that disliked Lucy making ongoing unprofessional comments and judgments and supposition. I am aware that there was also a separate complaint about Nurse ZC.
LANGDALE: Well, let's just pause there. I am focusing on Letby. We know that you said, for example, Dr Barrett and Nurse ZC had used a derogatory term about Letby, both of them say that conversation didn't happen although Dr Barrett accepts she did say "Nurse Death", she said, "I didn't have that conversation with Dr ZC". So who else, apart from Dr ZC, when you say you were aware of people --
LADY JUSTICE THIRLWALL: Nurse ZC.
MS LANGDALE: Nurse ZC, sorry. Who else, apart from her, were you aware was talking about Letby when you say you were aware and thought people were gossiping or it was malicious?
LIGHTFOOT: May I just clarify. In my statement I didn't hear a conversation between Nurse ZC --
LANGDALE: Right.
LIGHTFOOT: -- and Dr Barrett talking about Nurse Death. The comment was made after the second triplet passed
away by Dr Barrett on the corridor to myself --
LANGDALE: Right.
LIGHTFOOT: -- when she passed me and she said, "I see Nurse Death's on again."
LANGDALE: Right.
LIGHTFOOT: So I didn't hear a conversation per se.
LANGDALE: So you had had Dr Barrett say to you "Nurse Death" and you had had Nurse ZC saying the comment "Isn't it concerning she's involved and she's always there?", or something similar. So you had had two people raise with you concerns about Letby at that point. But you thought they may still be gossip or malicious or what is your evidence? I don't know what you thought.
LIGHTFOOT: I did, I did, because Nurse ZC and Dr Barrett and Dr Mayberry, who I had also mentioned in my statement, were very friendly, they were often together, they were often sending text messages between each other. So the conversations that I am aware other staff had also witnessed were between those three. So I didn't feel they were independent concerns.
LANGDALE: Did you speak to Dr Mayberry about them at all? Did you tell him that she didn't seem engaged as a student or anything like that, or not?
LIGHTFOOT: I don't recall saying that to him. I didn't have that kind of relationship with him.
LANGDALE: Nurse ZC tells us that there were briefings at this point that staff were told they shouldn't be discussing deaths on the neonatal unit, infant deaths, or Letby, or disciplinary measures might be considered. Was that the case because there was concern that this was malicious gossip --
LIGHTFOOT: So the malicious gossip, as I said, was witnessed by a number of colleagues, as well as myself, and it was --
LANGDALE: Which colleagues?
LIGHTFOOT: So there were colleagues that I am aware of made a formal complaint.
LANGDALE: Yes, who were they? Tell us who they were.
LIGHTFOOT: (Redacted).
LANGDALE: (Redacted)?
LIGHTFOOT: (Redacted).
LANGDALE: Yes, about -- in support of Letby, malicious comments about Letby?
LIGHTFOOT: Yes, part of the complaint was about Nurse ZC's general professional behaviour.
LANGDALE: I'm not asking about her, I want to move on and ask about --
LIGHTFOOT: But part of it was about Lucy Letby and
allegations that they had heard her make that she would be -- she would be involved.
LANGDALE: So would you have been part of the briefings to staff to say: do not discuss her otherwise disciplinary measures would follow?
LIGHTFOOT: Absolutely, because at that point it was, it was -- there was nothing substantiated from our perspective on the children's unit that we had awareness of.
LANGDALE: But you had concerns yourself about her communication and you had heard something that you thought was inappropriate, didn't that ring --
LIGHTFOOT: Absolutely.
LANGDALE: Didn't that ring bells for you that it might be concerning?
LIGHTFOOT: No, I didn't have any other evidence other than concern about an inappropriate response. The briefings were not to silence anybody, the briefings were: this is damaging unsubstantiated, from our perspective, discussions about a neonatal colleague that were very damaging. So please do not gossip and discuss anything that we have no involvement in, that we know nothing about.
LANGDALE: Were you curious after hearing the comment about the triplets to know more about it? Did you have any curiosity yourself about how they died, was it unexpected, was it expected, what were the circumstances, or did you think that wasn't any of your business on the children's unit?
LIGHTFOOT: I didn't recall how I felt. As I say, I feel like that was the first point I actually had some understanding of actually this seemed unusual to have two deaths in two days. But that was based on, as I say, my lack of knowledge and awareness of what is usual on the neonatal unit.
LANGDALE: So when did you first start to think the unthinkable, as some nurses have described it, that someone, or Letby, might be harming babies on the unit?
LIGHTFOOT: I imagine it will have been when I heard she had been redeployed to another department.
LANGDALE: When she went to the risk department?
LIGHTFOOT: Absolutely.
LANGDALE: What did you think was going on then?
LIGHTFOOT: I assumed that she had been removed because there was concern that she was involved in what had been happening.
LANGDALE: In what way did you think she was involved or may have been involved in what was happening?
LIGHTFOOT: As I say, my limited information that I had at the time was that there had been this unexpected number
of deaths. So I presumed at that point she must have had some kind of involvement. I would have said, and I think I have said in my police statement, that I perhaps wouldn't have been surprised to hear that her lack of knowledge or her lack of skills may have led to a failure to recognise deterioration. But I absolutely would not have thought, knowing her as I did, that that would have been a deliberate act.
LANGDALE: You spoke, did you, with Eirian Powell much about Letby at the time? Were you aware Eirian Powell was describing her as a competent nurse?
LIGHTFOOT: Sorry, could you repeat.
LANGDALE: Were you aware that Eirian Powell was describing her as a competent nurse at this time?
LIGHTFOOT: Not that I recall.
LANGDALE: We know she moved to the risk department in July 2016. That must have been a matter of conversation for lots of people in the hospital, mustn't it? It is a significant event. You had made a link by then that there must be something that associated her with deaths on the neonatal unit at least; yes?
LIGHTFOOT: (Nods).
LANGDALE: So were there still instructions that people shouldn't discuss this at all? Did that continue,
concerns that people shouldn't be discussing it and it would be a disciplinary matter if they did?
LIGHTFOOT: I don't recall specifics but I would imagine that absolutely would have been the message to -- to not discuss it.
LANGDALE: How do you think that sits by policies such as Freedom to Speak Up and speaking up about concerns when all these people who may have different pieces in the jigsaw aren't supposed to speak up or talk about it or talk about it with each other? Do you think there was a conflict there?
LIGHTFOOT: I think there's obviously always room to professionally challenge. I think if we have concerns we should escalate them and we have and I have been involved in escalating concerns previously, as I did when I had concerns about Lucy as a student. However, these have to be in a professional manner and the gossip and tittle-tattle and unsubstantiated talk such as that, is not usually part of a formal professional response to concerns.
LANGDALE: Sometimes it's in the most informal settings that people tell us, when you are in a management role or a senior role, what's really troubling them. It's a big deal to make a formal complaint or come in and make -- to a meeting, and you use the term "escalate"
it, take it forwards through a process. Actually, a trusted colleague where you can just say, "I am worried about this", isn't that a very valuable way of hearing concerns and complaints? It's not simply gossip because it is done informally, it may weigh heavily with the person that tells you something.
LIGHTFOOT: And I think that if that had been brought to me in a professional manner, in a professional -- as a professional complaint, I would have dealt with it as a professional complaint. We were -- our usual practice and my usual practice to anything like that would be to have a conversation with that person in a private room, I would document that conversation I would document that person's concerns. And I would have escalated it to my manager or my head of service at that point. This colleague ZC, ZC, I -- it was not a colleague that I --
LANGDALE: I'm not asking for comments --
LIGHTFOOT: I thought you asked me --
LANGDALE: No, no --
LIGHTFOOT: -- if a trusted colleague came to you, I thought that's what you meant.
LANGDALE: Yes, that's what -- well, you -- any colleague, I am talking about the principle now of --
LIGHTFOOT: Okay.
LANGDALE: -- freedom to speak up generally. How does it work for you that someone might tell you in an informal setting, not just that one? You indeed tell us you went back to the children's unit and would have probably said to somebody what you'd heard Letby say because it shocked you.
LIGHTFOOT: (Nods).
LANGDALE: Again, that would be natural for you to go back and say, "I have just heard someone say this." Do you think if you said it in an informal way like that, there wouldn't be a responsibility on the receiver of that comment to take it forward if they thought "Actually, that's really troubling"?
LIGHTFOOT: Yes.
LANGDALE: If they knew something else, another piece?
LIGHTFOOT: I think obviously, as you said before, this was a small piece of a puzzle that in hindsight --
LANGDALE: Yes.
LIGHTFOOT: -- perhaps I -- I could have escalated it. But with the limited information I had at that point, I didn't feel professionally I had a need to raise it further. We have -- we encourage all of our staff to speak out, to bring any concerns, as you say, professionally
or personally to us as managers. I felt I had a good relationship with all of our members of staff and that they could do that and I, as I say, it is my professional practice to raise concerns if I feel it appropriate. But at that point, I didn't have all of the information that I am now aware of.
LANGDALE: Understood. You also refer to an internal investigation being conducted, I think. Do you know what investigations were being done? Whether it was the RCPCH or internally, what did you think was happening?
LIGHTFOOT: I didn't really have much information about that. I knew that the Trust was looking at the mortality rate and the collapses on the neonatal unit. I really knew very little about it as I say, because we are a separate unit.
LANGDALE: Do you think you should have known? Someone should have told you, you are working in a children's unit.
LIGHTFOOT: I suppose we -- we are separate units. We are separate teams of nursing staff. Again, I imagine if it was our unit that it would be dealt with within our unit and escalated appropriately within our management hierarchy. I wouldn't necessarily expect it to be shared with the neonatal unit or midwifery or any of the
other units if it was an internal issue.
LANGDALE: And so by the time she had moved to the risk patient safety unit, did you think that was a matter that shouldn't be discussed because it obviously affected an employee and she was moved to another unit; is that broadly where you were at with that?
LIGHTFOOT: Absolutely. Absolutely. Obviously, you know, personal thoughts aside, you know, it's my job to try and maintain professionalism and set an example of as a role model, as a deputy manager, so we would discourage as much as we could general gossip about a colleague that, as I say, at that point was unsubstantiated.
LANGDALE: We know that nurses on the neonatal unit were all e-mailed with information about secondments or being able to move around the hospital for secondments. Was there any conversation like that on the children's unit about people wondering about those opportunities or generally talking about secondments at that time?
LIGHTFOOT: Not that I can recall.
MS LANGDALE: Just give me one moment. Thank you, I have got no further questions.
LIGHTFOOT: Okay. Thank you.
MS LANGDALE: My Lady, there are no further questions from the Bar.
LADY JUSTICE THIRLWALL: Thank you very much indeed. No, I have no questions either. Thank you very much indeed, Nurse Lightfoot, you are free to go.
MS LANGDALE: My Lady, I am going to ask Ms Bennett to read in sections of Sarah Jayne Murphy's statement to complete the mentoring.
LADY JUSTICE THIRLWALL: Thank you very much. Ms Bennett.
Statement of SARAH JAYNE MURPHY
MS BENNETT: My Lady, the Inquiry has received a statement from Sarah Jayne Murphy, nurse practitioner, which reads as follows:
My full name is Sarah Jayne Murphy. After studying at Chester University for a diploma in higher educational nursing studies, I qualified as a registered children's nurse in February 2004. A few week after I qualified, I went to work on the Children's Unit at the Countess of Chester Hospital where I worked until September 2013. Whilst working at the Trust I completed the Teaching and Assessing in Practice module enabling me to become a mentor and an assessor for student nurses. As part of the mentoring and assessing role, I became a sign-off mentor, meaning that I could work with students during their final placement and their OSCEs, the Observed Structured Clinical Examination. My day-to-day duties on the ward included managing the care of a small group of patients, assessment of patients' needs, planning, implementing, and evaluating care delivery according to changing health needs. I worked collaboratively with the wider multi-disciplinary team to ensure health needs were met and contributed to the development of services for children and young people, supervision of others including being a shift leader, development and education of student nurses.
In September 2013 I left the Trust to work as part of a nurse-led community continence team with the Wirral Community NHS Foundation Trust where I worked for a further five years as a Band 6 children's bladder and bowel nurse. During this time, I completed a Bachelor of Science professional practice degree and the V300 independent non-medical prescribing modules. I left Wirral Community Trust in September 2018 and came to work for the Wirral Teaching University Hospital NHS Foundation Trust at Arrowe Park Hospital with the epilepsy team.
Currently, I am a Band 7 children's epilepsy specialist nurse. I am the lead nurse in a small team of nurses working closely with two paediatricians who specialise in epilepsy. I am an independent nurse prescriber, run nurse-led first seizure and teenage clinics, gather clinical data for national epilepsy audit and work to develop epilepsy services for children and young people locally and regionally. I continue to work at Arrowe Park Hospital in the same role.
Mentorship of nursing students. During the last year or so that I worked on the children's ward at the Countess of Chester Hospital, I became the link nurse for students. The role included planning student off-day rotas allocating each student with a named mentor, liaising with the university lecturers to ensure effective learning experiences for students. The Nursing and Midwifery Council state that a mentor is a mandatory requirement for pre-registration nursing students. All student nurses were assigned a mentor and a back-up mentor and expected to work 40% of their placement time with their mentor. It was a responsibility of the mentor to get feedback from other nurses and professionals who had worked with their allocated student.
I do not have complete recollection of assessment and grading of students during placement, students had a large amount of paperwork to complete and were expected to arrange an initial meeting with their mentor to think about how their learning needs could be facilitated during the placement and to make a plan to achieve set placement outcomes. At the midway point, a second meeting would look at progress so far and what might still need to be achieved in the second half of the placement and where the student might need further support and learning to achieve outstanding outcomes. At the final meeting, the mentor and student would complete outstanding paperwork. The mentor would write a small report and if the outcomes were achieved then sign off the placement as complete. There was also a section of this documentation for the student to complete. During the student's placement their mentor would be expected to gather feedback from other nursing staff and nursing support staff that their allocated student had worked with. This might be done informally, for example if your student had worked a night shift with a colleague you might ask them for feedback at handover.
As registered nurses and mentors, we had support from Practice Education Facilitators, PEFs, and could speak to them for advice and support. This included if a student was failing to meet learning outcomes for their placement. Students would have support from their mentor from their peers and from university lecturers who would make visits to the ward during the placement. As a sign-off mentor I worked with third year students in their final placement.
A big part of the final placement, and always stressed to the student and mentor, was a final placement of the Observed Structured Clinical Examination. On this day, the student would be given a small group of patients to manage and would be expected to be involved in patient allocation, arranging of staff breaks, asking for updates from their colleagues about their allocated patients. A drug round was also part of the assessment where the student would be expected to calculate the dose, prepare, administer medications.
I worked with a very capable third-year student who during her OSCE, made a drug calculation error and failed. We arranged for this examination to be redone the following week and made use of lots of opportunities for drug calculation practice. On her second attempt the student passed and was signed off. This was an experience of failing the student that stands out for me. I can't recall failing other students during my time as a mentor.
I believe I was nurturing and encouraging -- and an encouraging mentor. I believe that I am approachable and friendly but always maintain a professional relationship with the students. I tried to maintain a mix of working closely with my students whilst facilitating and encouraging them to arrange their own learning opportunities, practice and improve clinical and interpersonal skills. I cannot be certain, however, having now reviewed the Royal College of Nursing's guidance for mentors, nursing students and midwives, I cannot say for certain whether this was the toolkit that I would have used. However, having said that, I might have used a toolkit that the university directed the students to use. I would have used Nursing and Midwifery Council standards to support learning and assessment in practice.
Mentorship of Letby. I mentored Letby in her first year as a student nurse. I believe it was her first ward placement. I cannot recall the year. The nurse in charge of student allocation would have allocated Letby as my student. I cannot recall who that was but this was the usual process. I did not mentor Letby again during her training until I was asked to work with her at the end of her third year when she had failed her final placement and still had three elements of practice proficiencies to complete. I monitored and assessed her over a four-week period. During her first placement I remember Letby being quiet and, I thought, shy. She did not show good interpersonal skills with children, parents, nurses or the wider team. I believe this to be Letby's lack of confidence and experience as she was very young and an only child away from home. There was a tendency among some students to hang around the nurses station and the desk area. Letby was one of these students and often had quiet [sic] an expressionless look. I and other staff members found it awkward and quiet. I think she felt comfortable working with me but she remained quiet and never appeared particularly animated or to be enjoying herself. At the end of the first placement I remember telling Letby that although she had passed the placement, it was important that she develop her communication skills, especially with the children and families. I presumed that this would come with practice and experience.
I cannot recall Letby's reaction to my feedback. My conversation with Letby would have been documented in her student paperwork which I presume is held by the university. In terms of my role as a mentor when working with Letby, I was responsible for ensuring that she had available to her the necessary learning opportunities and to ensure that she was able to achieve the required competencies and learning outcomes as part of the placement. Also, my role was to make sure that her off-duty rota allowed her to work at least 40% of her time with me. During the time that she was working with other members of the team I would keep track of her progress by asking for feedback from those members of staff at handover or other times.
In terms of Letby's responsibilities she was required to make sure and take the initiative to facilitate her own learning. For example, if a student nurse felt that they would benefit from observing a ward round then it would be their duty to ask for this to be arranged for them. In addition, it was Letby's responsibility to ensure that she proactively arrange the initial, midpoint, and final assessment interview dates and times. Although the assessment date and times were often agreed between students and mentors, the student was required to communicate their schedule and availability with their mentors so that the arrangements could be agreed upon.
Letby did not work with me again until the end of her third year after she had failed her final placement with Nurse Nicola Lightfoot. As Letby had requested to work with me I had concerns that she might not work equally as well and with confidence if asked to work with another member of staff. I do understand that we can't get along with everyone but it is important professionally to be able to do this. I discussed this with one of the PEFs, I think it was Anita Hargreaves, we agreed that Letby would work a shift with each of two other colleagues Anne Murphy and Azra Eccles.
Documentation from when Letby worked with me will be in her student paperwork which will be held by the university. This will include my comments in the first year about her need to develop her communication skills and from when we agreed that she would work alongside two of my colleagues as part of her retrieval process. This was at the end of her first year. However, I do not have the documentation in my possession now. There would have been documents in relation to Letby's final assessment as well but, again, I do not have access to these documents.
Nurse Lightfoot was already a very experienced and senior member of the nursing team when I joined the Trust in 2004. In her statement, university lecturer Ruth Sadik states that in her mentorship of Letby Nurse Lightfoot was "very supportive but very forthright". I would agree with this statement and whilst it is important to have high standards and expectations from students, especially in their third year, I think that, unintentionally, Nurse Lightfoot may have been a little overwhelming or intimidating at times. This would not have been with Letby in particular.
I do not have a good recollection of the proficiencies passed and failed but looking at the documentation provided in Letby's student file, Letby had eight proficiencies still outstanding. Five of these had been and progress made over the previous weeks but three were still outstanding when Letby began the retrieval process with me.
I have set out the relevant proficiencies and what they mean.
A1: demonstrating professional integrity, working with patients and families to review and monitor progress in care, timely documentation of care outcomes to ensure continuity of care.
D1: development of therapeutic relationships with children and family showing an appropriate level of communication, employing interpersonal skills of effective listening and communication, demonstrate evidence of being able to interpret verbally and non-verbal signs from patients and families, able to reflect on performance.
J1: evaluate and document outcomes of nursing and other interventions, working with the child and family to review and evaluate progress, ensure continuity of care for the patient, documentation actions, outcomes and progress.
The above is what was meant by the comments "Has made great progress in clinical practice and achieved five proficiencies. However, still has three outstanding AI, DI and JI". I note my comments in the police statement where I stated: "I believe that Lucy appealed Nicky's decision to fail her reasoning that there was a clash of personalities between them. I felt awful as I had been approached due to Lucy requesting me to be her mentor for her final placement and she felt that we had a good relationship during her first year placement."
I have no recollection of the actual shift when Nurse Lightfoot failed Letby but I was fully aware that this had happened and at some point was made aware that Letby had asked for me to be her mentor for the retrieval of the final three competencies. I do not know how the appeal process works and I do not know if it is normal practice for students to be able to request a mentor. I cannot recall who approached me about being a mentor for Letby's retrieval placement. On reflection of events, I do not think I would have been given a choice to refuse. I do not recall Letby herself discussing anything with me directly about being her mentor during her retrieval placement.
In terms of my police statement where I stated I felt awful, I do remember being worried about this, as the general feeling on the ward was that if Nurse Lightfoot, who is very experienced, had failed Letby, then that decision should stand. I think at the time I personally also believed that if Nurse Lightfoot had failed a student that decision should stand.
I cannot specifically recall the individuals who believed Nurse Lightfoot's decision should prevail. However, I do think it was reasonable to hold that view. This is because Nurse Lightfoot was an experienced and professional nurse and regardless of her direct approach to dealing with certain matters, she would never fail a student without good reason. I only have vague recollection of my discussion of Anita Hargreaves about postponing the retrieval process as I thought Letby may need time to process the events of recent days, ie failing her final assessment. However, from the documentation provided I can see that it was agreed with the university that the retrieval process would start the next day.
I cannot remember whether Letby spoke to me at all before this final few weeks that we worked together. I do not think it was common for students to fail in their final year. The student I mentioned earlier that failed with me had achieved all her competencies, it was just that the final OSCE placement was extremely stressful for students and sometimes mentors too. We were able to repeat that after a few days with some drug calculation practice.
I do not remember conversations with Nurse Lightfoot and/or Ruth Sadik with regards to concerns about Letby. I do not remember the exact nature of conversations with the PEFs, but I do remember feeling very supported by them. Due to the lapse of time, I cannot recall a conversation with Nurse Lightfoot or anyone else stating that Letby would not be ready to qualify as a nurse in four weeks' time, which was the length of the retrieval placement.
My concerns about Letby during her retrieval placement were whether she would be able to demonstrate the ability to work with other members of the nursing team, not just with me and so I arranged for her to work with Anne Murphy, who was a ward manager at the time, and with Azra Eccles, who was working as a Band 6 nurse in the children's assessment unit. I believe it is documented that I received positive feedback from them but I cannot remember what the feedback was. Letby worked with me and with other nurses when I was not on shift to achieve the three proficiencies documented above. I cannot remember the actions planned -- made for how these competencies might be achieved, but I do know that I would have monitored Letby very carefully and asked for feedback both from her and from other nurses that she worked with.
It would be usual for the retrieval placement to be documented but I cannot remember exactly where or how. I would imagine the school of nursing would have a record of the documentation. During her police interview Ruth Sadik discussed her thoughts about Lucy passing these final proficiencies and her comments relate to a conversation that she had with me. She stated: "I spoke to Jayne to ask why she was passing her and Jayne had a lot of -- a lot of soul searching. It wasn't something she did easily but she felt that it was right to do. Now, my personal thoughts at that time were that Jayne was conflicted but that bit is because Nicky is quite a powerful person. She wanted to please Nicky but also that she -- her conscience wouldn't allow her to, and she had seen what she saw." I cannot remember the conversation above with Ruth Sadik but I did feel conflicted at the time as Nurse Lightfoot had felt that Letby was not competent to pass the final placement. But after observing and working with Letby for a number of weeks, I had felt that she had achieved the three outstanding proficiencies.
I cannot recall a conversation with Ruth Sadik, but from my perspective, I was asked to assess Letby based on the three proficiencies and whether she had met those. From what I had observed during my assessment I could not say that she did not meet those three proficiencies. Also, I would like to reiterate that I sought feedback from other members of staff that she worked with and so I had no reason to believe that she was performing well only just during my assessments. If, however, the feedback I received was negative and raised concerns about Letby, this would have of course impacted my assessment on whether or not she had passed those proficiencies. I cannot recall what was meant by the quote, "she had seen what she saw."
Friendship. I don't recall that Ruth Sadik and Letby were friends and I am not aware that they socialised together. My relationship with Letby was purely professional. I would not count her as a friend or someone that I would socialise with. Louise Newman(?) in her statement talked about friendships on Facebook which I do not use so I would not be aware of a friendship between Ruth and Letby.
Concerns or suspicions. I left the Trust in 2013. I was never made aware of any suspicions or concerns about the conduct of Letby at any time.
My Lady, that concludes the statement.
LADY JUSTICE THIRLWALL: Thank you very much indeed, Ms Bennett. Is that a convenient moment for the break.
MS LANGDALE: It is, my Lady, 11.30?
LADY JUSTICE THIRLWALL: So we will rise now and start again at half past 11. (11.13 am) (A short break) (11.30 am)
LADY JUSTICE THIRLWALL: Ms Brown.
MS BROWN: If we could call the witness, please.
JULIE CAROLE FOGARTY (sworn)
LADY JUSTICE THIRLWALL: Do sit down.
FOGARTY: Thank you.
MS BROWN: Could you please give your full name.
FOGARTY: I am Julie Carole Fogarty.
BROWN: Mrs Fogarty, you provided a witness statement to the Inquiry dated 30 May 2024. Is that statement true to the best of your knowledge and belief?
FOGARTY: Yes, it is.
BROWN: And turning to your qualifications, it is correct, is it, that you qualified as a registered general nurse in 1985, as a registered midwife in 1988, and as a supervisor of midwives in 1996?
FOGARTY: That's correct.
BROWN: And you also have a degree in midwifery and a postgraduate certificate in leadership behaviours.
FOGARTY: That's correct.
BROWN: And turning to your career history, when did you first start working at the Countess of Chester Hospital?
FOGARTY: So in 1987 I commenced my midwifery training as a student midwife.
BROWN: And when was your first role as a midwife?
FOGARTY: So that would be in 1988, upon qualification as midwife.
BROWN: And that was at the Countess of Chester?
FOGARTY: Yes.
BROWN: And I think approximately 12 years later, you were appointed Head of Midwifery in July 2010?
FOGARTY: Yes, that's correct.
BROWN: And in that intervening period you worked solely at the Countess of Chester Hospital, did you?
FOGARTY: Yes.
BROWN: And you moved, I think, from your role of Head of Midwifery to that of Associate Director of Risk and Safety in April 2017, is that correct?
FOGARTY: That's correct, yes.
BROWN: And having worked in midwifery for all of your career up to that point, why did you make that move?
FOGARTY: I was asked by the Director of Nursing at the time to go and oversee that department because the previous postholder had left.
BROWN: And who was the previous postholder?
FOGARTY: Ruth Millward.
BROWN: And I think it is correct that you retired from the NHS in April 2020?
FOGARTY: Yes, that's correct.
BROWN: So that was after three years of Director of Risk and Safety but how long in total did you work at the Countess of Chester Hospital?
FOGARTY: So from 1987 to 2020, so 33 years.
BROWN: And how did you find the Countess of Chester as a place to work?
FOGARTY: It was a happy place to work, people were proud to work within maternity services which is where was the bulk of my career.
BROWN: And in your role as Head of Midwifery -- you set out in your statement at paragraphs 8, 9 and 10 what your role involved. But it's correct that included in your responsibilities was ensuring midwifery care was delivered by competent midwives and best practice was followed?
FOGARTY: That's correct, yes.
BROWN: And you also say that within your area of responsibility, was the quality of the patient experience. Can you just expand a little on what you mean by that phrase?
FOGARTY: So it's making sure that women had a voice and their views were listened to and that the care they received was to the best of the ability of the staff and the services available, and that it moved in time with new initiatives as they developed within midwifery.
BROWN: And you say in paragraph 9 of your statement: "I had lead responsibility for co-ordinating clinical risk activities with maternity services." In practical terms, what does that mean?
FOGARTY: So it's making sure that the midwives were trained, so they knew how to report incidents using the Datix system; that any reports that were produced were received at the Women & Children's Care Governance Board and that as a, as maternity services we reviewed any new guidance that came out, issue -- and things like the NICE guidance, that if anything new came out that they were reviewed within a timely manner and that anything that needed changes in practice that they were implemented.
BROWN: And your role as Head of Midwifery, did that
ever involve actually working on the ward as a midwife if -- filling in if the ward was short-staffed?
FOGARTY: No, not clinically no.
BROWN: So there was no -- from when you took over as Head of Midwifery, there was no clinical aspect to your role?
FOGARTY: No.
BROWN: And you say in your statement as well at paragraph 9 that you participated in the Trust managers on-call rota?
FOGARTY: Yes.
BROWN: Can you explain what that was?
FOGARTY: So out of hours there was always someone on duty for the clinical psych ward, who managed the Trust, to contact someone if there were issues with ambulance delay, staffing. So it was making decisions to try and keep the Trust safe out of hours and we reported directly to the -- there was always an executive on-call that we would escalate if we had concerns.
BROWN: So the on-call rota would be the most senior person on site subject to access to an executive director, is that --
FOGARTY: We wouldn't be on site, we would be at home, as would the executive but we would attend if we needed to.
BROWN: And how often would you be asked to be on that call rota?
FOGARTY: Probably a couple of times a month.
BROWN: And in terms of your physical presence on the ward, how often would you, you said you didn't have a clinical role, but how often would you be physically present on the maternity ward, walking around?
FOGARTY: Probably three, four times a week.
BROWN: And where was your office in relation to the maternity ward?
FOGARTY: It was in the Long House Building, which was the building virtually next door to the maternity unit.
BROWN: So did you have to leave one building and go into another or did you just --
FOGARTY: There was a corridor, so it, it was just a corridor but I did have to leave one building, so I was based in what was known as the Long House, but it was literally next door.
BROWN: And in terms of the neonatal ward, would you ever have cause to visit the neonatal ward to actually walk on to that ward?
FOGARTY: No, no, it wasn't in my remit, so no.
BROWN: And just looking at where the Head of Midwifery fitted into the divisional structure. Midwifery was part of the Planned Care Division?
FOGARTY: Yes.
BROWN: And then at the top of the Planned Care Division there was a divisional director of Planned Care, who was that?
FOGARTY: Linda Fellowes.
BROWN: And then again, looking at Planned Care, there would be a Head of Nursing for Planned Care and that was Carmel Healey?
FOGARTY: That's correct, yes.
BROWN: There was your role, obviously, as Head of Midwifery, and then there would be a Medical Director for Planned Care and that was David Semple, I believe?
FOGARTY: Yes.
BROWN: And what was his specialty as a doctor?
FOGARTY: So he was an obstetrician.
BROWN: And in terms of that management structure of the Planned Care Division, David Semple and Carmel Healey, did they continue in practice or were those full-time management roles?
FOGARTY: So Mr Semple continued clinical practice. Carmel Healey was like myself; it was a management role.
BROWN: And who did you report to?
FOGARTY: So I reported directly to Alison Kelly, the Director of Nursing, and Linda Fellowes, the divisional director.
BROWN: And did you feel that this management structure, with those three -- well with your -- four posts sitting at the top of the Planned Care Division was that a management structure that worked effectively?
FOGARTY: It appeared to work for me because the -- the divisional directorate, that was more the business planning side and the Director of Nursing that was the professional aspects.
BROWN: And to understand how it worked in practice, if you had concerns, for example with mortality rates, would you be raising those issues with the divisional director, the Medical Director of Planned Care or would you be going straight to Alison Kelly with those sort of issues?
FOGARTY: I would raise them with both people.
BROWN: And just staying with the divisional structure for a moment. Midwifery, as you have explained, was part of the Planned Care Division, but the neonatal unit was part of the Urgent Care Division.
FOGARTY: That's correct, yes.
BROWN: And you say in your statement at paragraph 21 that you felt that it was not good practice to have the mother in one division and her baby in another, so you are referring there to the fact that the mother when on a maternity unit would obviously be in the Planned Care
and if her baby had cause to be admitted to the neonatal unit, the baby would then be under the Urgent Care Division?
FOGARTY: Yes.
BROWN: And what were the problems that you saw with that structure?
FOGARTY: I just felt that if the two areas of care had been within the same division, there would have been more joint working, there would have been better communication and we would have been on the same journey together at the start of projects.
BROWN: And Dr Brearey raised this issue and you refer in fact to 20 July 2015 in your statement, at paragraph 21 as well, that the divisional structure with Urgent and Planned Care split, obstetrics, gynaecology and midwifery on one side, paediatrics and neonatal within Urgent, and that was discussed at the Quality, Safety, and patient Experience Committee that you sat on, I think, as well?
FOGARTY: Yes, I did.
BROWN: And Dr Brearey said at that meeting that he considered the split would hinder the improvement of maternity, neonatal and paediatric services. Did you agree with that view?
FOGARTY: I did, yes.
BROWN: And I think you have explained, but did you -- what did you understand was Dr Brearey's concern and objections to the structure?
FOGARTY: It was similar to mine. The fact that we were both reporting through two different divisional lines instead of through one joint divisional line. So methods of communication sometimes were delayed.
BROWN: And just staying on communication there. You say that you felt that being, as you have explained now, you say in your statement that if you had been in the same division you felt there would be improved communication. Just so I am clear. You are talking there, I think, about communication in terms of the management structures, or are you also talking about communication at a nursing and doctor level?
FOGARTY: More as --
BROWN: Nursing and midwives, I should say.
FOGARTY: More as the management structure.
BROWN: And in terms of this Inquiry, do you feel if there had been one Women's and Children's division, as I think there was before --
FOGARTY: Yes.
BROWN: -- and I think as there is now, do you think that you and your colleagues in the midwifery obstetrics and gynaecology might have been alerted at an earlier
stage to the concerns that we know there were in the neonatal unit?
FOGARTY: Yes.
BROWN: And related to that, and maybe if you can just expand on that -- it might seem obvious to you, but why do you say that you think you would have been alerted to those issues earlier?
FOGARTY: We would have been at meetings where they would have been potentially discussed.
BROWN: And related to that question, do you think that divisional split also had an effect on how the management responded to the issues because they had two chains of command going to them?
FOGARTY: I don't -- I don't feel that I can comment on how the management responded.
BROWN: I'm just staying with communication then for a moment. In terms of the practical aspects of communication, you have explained that at management level the two units meant that you were in different meetings, but you say that the labour and neonatal units were positioned next door to one another. Can you just explain the geography as to where the labour ward and the neonatal unit was?
FOGARTY: So from a clinical position of wards, it was literally through a door. So the labour ward, you
literally went through a door and that's where the neonatal was. And also from the Consultants' point of view they were based in the same building as myself. So that eased communication as well.
BROWN: So just to be completely clear, the labour ward and the neonatal units weren't on different floors?
FOGARTY: No.
BROWN: They were on the same floor. And when you said about offices, did that mean that on a daily basis you would be walking past colleagues who worked on the neonatal unit?
FOGARTY: No. No. So the Consultants were in the same building but not the, not the neonatal nurses.
BROWN: So you worked in a different building to the Consultants?
FOGARTY: No, my office was in the same building as the paediatricians, obstetricians and myself, we were all based in the Long House Building.
BROWN: I see, thank you. And the Inquiry has heard some characterisations of there being hostile relationships between midwives and those working on the neonatal unit, doctors not feeling welcome on the maternity ward, tensions between nurses and midwives. Is that something you recognise?
FOGARTY: It's not something that was ever escalated to
me and not something that I recognised from my time clinically working.
BROWN: And what was your view, your personal view of relations between midwives and nurses? You obviously worked as a midwife for a long period before you went into a management role.
FOGARTY: Yes. So there -- there never seemed to be a problem, you know, there was always good communications so the minute somebody came into the labour ward and there was a potential that they may need neonatal services, you would go through as a shift leader and alert the neonatal unit to that fact so they could start to prepare.
BROWN: So that's at the level of midwives and nurses.
FOGARTY: Nurses.
BROWN: At your level, at the management level, if you wanted to speak to someone on the neonatal unit about a common issue, who would be your point of contact?
FOGARTY: So I would go to see the manager at the time so that was Eirian Powell.
BROWN: And what sort of working relationship did you have with Eirian Powell?
FOGARTY: We didn't have a problem. We didn't see each other very much but if I needed to speak to her she was -- she always made herself available and we always agreed on a plan going forward.
BROWN: And in practice, how would that take place, would you walk to her office, call her on the phone, just a feel of how often you would be in communication with Eirian Powell?
FOGARTY: So it would be very, very infrequent. But normally I would email her to see if she's free.
BROWN: And in relation to Dr Brearey who was the clinical lead of the neonatal unit, what was the extent of your contact with him?
FOGARTY: So, again, I would see him very infrequently because he wasn't working in the same sphere of practice as myself.
BROWN: And how would you describe your working relationship with Dr Brearey, or was it minimal?
FOGARTY: Very -- if ever I needed to engage with him there was no issues whatsoever.
BROWN: And presumably you would have a great deal more contact with the Consultant obstetricians?
FOGARTY: Daily.
BROWN: Just staying with the culture of the hospital for a moment. Generally the relationship with doctors and nurses, how would you have observed that, how would you characterise that?
FOGARTY: I can only comment on the relationship between
doctors and midwives.
BROWN: Of course.
FOGARTY: And I felt there was excellent teamworking.
BROWN: And relationships between staff and senior management, again, you will be dealing with staff within your unit, but what were the relationships like between staff and senior management?
FOGARTY: I mean, I can -- again, I can only really comment for within maternity services and there didn't appear to be a problem. It wasn't anything that was ever escalated to me or anything that came out through any incident reporting or -- there were lots of different channels that people could go to if they needed to and they were never, they were never used.
BROWN: Why was that? Why were these channels never used?
FOGARTY: Because obviously people didn't feel there was a need to escalate. They felt that if they wanted to speak to managers they had access.
BROWN: And in relation to access to managers, your relationship with Alison Kelly as the person who you reported to, or one of the people you reported to, how often would you see her?
FOGARTY: So I had a monthly one-to-one with her but I would also see her at meetings and I may bump into her
on the corridor if I went to the execs' office to escalate or to drop a report off, then I may see her there.
BROWN: And what could you or -- could you comment about Alison Kelly's level of engagement with the issues on the maternity ward and the issues that you were dealing with?
FOGARTY: So she was always engaging, if ever I had anything I need today escalate I always had access and she listened.
BROWN: And in relation to Tony Chambers and Ian Harvey would you have cause to have much contact with either of those?
FOGARTY: I didn't see them on a regular basis but there would be meetings that they would be present at that I would also be present at.
BROWN: And members of the board, Sir Duncan Nichol would you come into contact with him?
FOGARTY: So again, I didn't see him on a regular basis, but he may be there in the execs' office. He came to visit maternity unit when we won an award. So he was aware of what was happening but I didn't see him on a regular basis at all.
BROWN: And the non-executive board members, would you have known who they were?
FOGARTY: Yes.
BROWN: Did they ever visit?
FOGARTY: Yes, I mean, some of them were -- some of them were on QSPEC and there were a number of meetings that I attended that they represented -- you know, represented the non-execs on.
BROWN: Just one final point looking at the divisional structure, you gave an interview, I think you'll recall, to Facere Melius in -- on 14 July 2020. You recall that interview?
FOGARTY: Pardon? Sorry?
BROWN: You had an interview --
FOGARTY: Yes, yes.
BROWN: -- on 14 July? And one of the points you made in that interview was you felt the fact that neonatal unit being in Urgent Care and the fact that A&E also clearly was part of Urgent Care with the four-hour target that they work to, meant that the neonatal unit was swamped, what did you mean by that?
FOGARTY: Well, the fact that that was a big division with a lot of competing priorities.
BROWN: And you also say --
LADY JUSTICE THIRLWALL: Sorry, I wonder, could you just -- I am sorry, Ms Brown. But the neonatal unit was swamped, do you mean sort of overlooked or do you mean too much to do? I wasn't ...
FOGARTY: Yes, the fact that there was a lot of competing, so A&E had the four-hour target and I, mean that may have not been the fact, that was just my personal opinion.
LADY JUSTICE THIRLWALL: Yes, and that's what you are being asked about.
FOGARTY: That that, you know, potentially because that division was very big and had a lot of competing pressures, because of the nature of the work, then the neonatal unit potentially suffered because of that.
MS BROWN: And you go on to say in that interview, which I think is what you are explaining now, that you felt it wasn't given the attention it deserves and people weren't aware of the issues in the neonatal unit. Who are you referring to there as -- who are the people who weren't aware of the issues?
FOGARTY: So the -- the Urgent Care management. But that, that may have not been correct. That was just an assumption I was making but that may not have been correct. I didn't have any hard facts. It was just a feeling.
BROWN: And when you are saying there people weren't aware of the issues in the neonatal unit, what issues
are you referring to there, are you talking about the issues of increased mortality or --
FOGARTY: Yes.
BROWN: -- more generally?
FOGARTY: Yes, because obviously I was interviewed in 2020 and I was aware then of the mortality issues.
BROWN: If we can look now at some of the committees that you sat on. We are looking first at the Women's & Children's Care Governance Board, and if I can call up INQ0015325. My Lady, this is tab 13 of your bundle.
LADY JUSTICE THIRLWALL: Thank you.
MS BROWN: This is going to show up the Terms of Reference, I hope. So this is a document that's the Terms of Reference. This document, Ms Fogarty, was actually -- is dated February 2016 but it appears they were updated on a, on a sort of annual basis, the Terms of Reference --
FOGARTY: Yes.
BROWN: -- so would it be right to say that this, this document would be reflective of the year before and probably the year after?
FOGARTY: Yes.
BROWN: And we can see there in terms of the
Women's & Children's Care Governance Board that the chair was Dr McCormack who was a consultant obstetrician and gynaecologist. How would you describe your relationship with him?
FOGARTY: I would say I had an excellent working relationship with Mr McCormack.
BROWN: And you were the deputy chair?
FOGARTY: That's correct, yes.
BROWN: And what did the role of deputy chair of the Women's & Children's Care Governance Board involve?
FOGARTY: So if Mr McCormack was on leave, so unable to attend the meeting, then I would chair the meeting.
BROWN: And did you have an input into, for example, what would go on to the agenda?
FOGARTY: Not, not unless I was actually going to chair the meeting.
BROWN: Would you discuss the agenda with Mr McCormack?
FOGARTY: Not before the meeting, no.
BROWN: But presumably if you had something you felt would be on it you would be able to raise that with him?
FOGARTY: Yes, we had a standard agenda item but any items you wanted to be received, you referred them to the risk and safety lead and she put the agenda together.
BROWN: And if we just look down that list, we can see, as one would expect, there are representatives from the Planned Care Division, from Midwifery, so you, Mr McCormack, the Head of Nursing for Planned Care, and then also there's representatives from the Urgent Care, Dr Jayaram, Dr Brearey, the Head of Nursing of Urgent Care. So this was a committee that brought together -- whereas there was a division in management structures, this was the committee that brought both units together in terms of the care of women and children?
FOGARTY: Yes.
BROWN: And if you can just in overview, what would you say the primary role was of the Women & Children's Care Governance Board?
FOGARTY: So we were monitoring, so from a midwifery aspect I was there to ensure that reports that had been received in the Trust were reviewed and then received in the board. Any serious incidents that had action plans, that they were monitored until they were completed. If we had had an inspection by the CQC and there were action plans, that they were received at this board and then they were monitored until actions were completed.
BROWN: And presumably as deputy chair, whilst you obviously came to it with a midwifery perspective, your position on the committee, as with everyone on the committee, was to see that this looked at things holistically, that the committee looked at both midwifery and the neonatal care?
FOGARTY: Yes.
BROWN: That was the purpose of the board presumably?
FOGARTY: So we were responsible so the -- everybody who was a member was responsible for bringing documents to the meeting and at that meeting, we all would review and challenge. However, we were aware that because it is such specialised work, we were dependent on the specialist to provide the overview.
BROWN: And I think if we could go over the page to page 2, we will just see the duties and responsibilities there. And we see the second bullet point down, that one of those was to: "Provide assurance to the board lead executive of effective risk management". Again, what does that mean in practice?
FOGARTY: So if we had any concerns that were identified or any gaps or risks that we then made sure that we escalated them through this meeting.
BROWN: So if you had a concern, for example, about increased mortality rates, this would -- that would be the sort of thing that should be escalated through this
meeting?
FOGARTY: If, if that information was brought to the meeting, yes.
BROWN: And going down the next bullet point, so the third bullet point: "Review and monitor the risk registers, escalate risks to the divisional and organisational risk registers". Again, just can you explain in simple terms what that actually in practice meant?
FOGARTY: So every area had a risk register and if a new risk was identified, they would be discussed at a divisional level and then brought to this meeting for noting and escalating further.
BROWN: And then finally, not quite finally, the next but one down says: "Review and monitoring ..." And one of the things you were reviewing and monitoring was incident trends.
FOGARTY: Yes.
BROWN: And obviously the trend that this Inquiry is concerned with is the trend of increased mortality, so that would fall -- should that be the trend that would fall within the remit of this?
FOGARTY: Yes, we would be looking at the data.
BROWN: When you say you are looking at the data, what data would you be looking at on a regular basis?
FOGARTY: So, so every month we would be looking at any new Level 1, 2 or 3 investigations, progress of action plans and any trends that were being identified that were being flagged up to us.
BROWN: And then just the last one that has particular relevance, three from the bottom: "Also duties and responsibilities to ensure that clinical performance, quality monitoring and reporting mechanisms are working effectively". So that would be one of the responsibilities of this board.
FOGARTY: Yes. Yes.
BROWN: So in terms of -- I think you have accepted that this would be an appropriate forum to discuss concerns about increased rates in mortality, more babies dying; this would be something that would fall --
FOGARTY: Yes.
BROWN: If there were concerns about this, this would be the place to discuss it?
FOGARTY: Yes.
BROWN: And this would be the place that you would bring, you would expect people to bring those concerns to you?
FOGARTY: You would expect them to bring those concerns, yes.
BROWN: And what about concerns about some commonality in terms of a member of staff being connected to deaths or collapses, would that be something that you would consider could be raised in this forum?
FOGARTY: It could be, yes.
BROWN: So turning now to another committee that you sat on, and if I could go to INQ0002639. So this is the Quality, Safety & Patient Experience Committee and this, we can see there at the top, was a committee that reported to the Board of Directors?
FOGARTY: Yes.
BROWN: So there was a hierarchy here, correct me if I have this wrong, Mrs Fogarty, where the Women's & Children's Care Governance Board would take the views from the neonatal and the midwifery and look at things from the perspective of women and children and babies and then their concerns would be escalated to QSPEC?
FOGARTY: Yes.
BROWN: And we see, just picking out some of what they say the purpose was in the Terms of Reference there, four bullet points down: "To monitor serious untoward incidents". How would the committee do that?
FOGARTY: So the -- Ruth Millward would produce a report for that committee on numbers and progress, et cetera.
BROWN: So if there was a serious incident on the neonatal unit, you would expect that to come up to QSPEC?
FOGARTY: So if it meets the STEIS Level 2 or 3 reporting then, yes.
BROWN: And it says there as well, the next bullet point: "To review the risk register." There seems to be some overlap here with who is looking at risk registers. Can you just explain that, was there an overlap or was this forming a different function?
FOGARTY: So the review of the risk registers is when the divisions have escalated a risk that cannot be managed at divisional level and the executives need to be aware of.
BROWN: And it says then, three bullet points up, under the section 1 on purpose: "To gain assurance from divisions in all matters to do with risk governance, quality, and patient experience." How, in practice, did QSPEC gain assurance from the
divisions?
FOGARTY: So if there was something that was a concern they would invite the lead Consultant or manager to QSPEC to present assurance.
BROWN: And if I could just turn to paragraph 33, then of your statement, where you at the end of that you refer to one other board you sat on and that was the Trust Safeguarding Board, and you say that met four times a year. What dates were you a member of this board?
FOGARTY: Throughout my time as Head of Midwifery.
BROWN: And who chaired that board?
FOGARTY: That was chaired by Alison Kelly.
BROWN: And if you can recall, other than yourself and Ms Kelly, who else sat on that board?
FOGARTY: So Karen Milne sat on there, she was the lead midwife for Safeguarding, her deputy, there were members from external agencies.
BROWN: So approximately how many members on that board, from recollection, sitting at the table?
FOGARTY: About 20, if I recall.
BROWN: And who did that board report to?
FOGARTY: I can't, I don't know that answer.
BROWN: And you say in your statement there were quarterly meetings to support effective delivery of
Trust Safeguarding agenda. What was the Trust's Safeguarding agenda?
FOGARTY: I don't know that in detail. So I can't answer.
LADY JUSTICE THIRLWALL: So what did you think was the purpose of the board?
FOGARTY: So the purpose of the board was to make sure --
LADY JUSTICE THIRLWALL: In practical terms.
FOGARTY: In practical terms, they monitored things like mandatory training for safeguard to make sure that staff were getting the training. If there had been a serious case review that the Trust had looked at it and looked at the implications for the Countess and addressed any action. That there was --
LADY JUSTICE THIRLWALL: Let's take that example.
FOGARTY: Yes.
LADY JUSTICE THIRLWALL: Where would the outcome of the review have been sent?
FOGARTY: So, so an example being so Victoria Climbié, when that report came out, I met with Karen Milne from a midwifery perspective to look if there were any, any actions we needed to take, but that report would come at that meeting.
LADY JUSTICE THIRLWALL: To the Safeguarding Board?
FOGARTY: To the Safeguarding Board, yes.
LADY JUSTICE THIRLWALL: Then does that mean -- just reflecting on what the practicalities were, does that help you remember who the board was accountable to?
FOGARTY: It, it sorry, it doesn't.
LADY JUSTICE THIRLWALL: Where would we be able to find that out?
FOGARTY: It should be in the Terms of Reference of the Safeguarding -- because they had Terms of Reference so it should be in that.
LADY JUSTICE THIRLWALL: It may be that we have them but you can't remember --
FOGARTY: I can't remember, no.
LADY JUSTICE THIRLWALL: All right.
MS BROWN: And you speak there, and you have spoken in response to a question there about the mandatory training you are referring to. Did the Safeguarding Board, did they look at the content of that mandatory training, was that something that you would consider whether the content of the training was adequate?
FOGARTY: I don't recall us -- it ever being an agenda item to actually look at the contents of the training. It only looked at the delivery, ie percentage of staff that had attended.
BROWN: And in terms of turning to that, if you are unable to -- so what I was intending to ask is whether you were aware whether the training made clear who Safeguarding issues should be raised with and what the level of concern was needed before a concern was raised with the Safeguarding Board -- are you able to help with that?
FOGARTY: Yes, I mean I attended the same mandatory training as my clinical midwives and we were always told that you could go to the Safeguarding team if you had a concern and it was better to escalate and it be found not to be a concern than to not escalate at all.
BROWN: And you said just earlier about the list of people who were trained. The Inquiry has heard evidence that there were a large number of doctors training with their six-month placement. How did you, as a hospital, approach Safeguarding training for those doctors who were rotating through the system being --
FOGARTY: I -- I wasn't responsible for any, any part of doctor training. I only know from the Consultant obstetricians' point of view they attended the midwifery training alongside the midwives for Safeguarding. But I am unable to provide information about the rotational doctors.
BROWN: But I am asking you here not in relation to your Head of Midwifery role but as sitting on the
Safeguarding role, how did you assure yourself as a member of a board that the doctors working there, part of the staff, were properly trained? Was there a system for seeing --
FOGARTY: They were part of the statistics and it, it demonstrated that there was compliance for all members of staff. They were broken down into staff groups, the report, so you knew that doctors were getting the training.
BROWN: So as far as you were aware --
FOGARTY: So as far as I was concerned, everybody had access to Safeguarding training.
BROWN: Having access is not quite the same as doing Safeguarding training. Were you looking at who had actually completed their Safeguarding training?
FOGARTY: Sorry, can you repeat?
BROWN: Were you looking at who had actually completed Safeguarding training as opposed to simply had access to it?
FOGARTY: No, it is who has completed.
BROWN: Mrs Fogarty, it appears that the suspicions about Letby harming babies were not in fact treated as a Safeguarding concern and it was not raised through Safeguarding channels. Given your role on the Safeguarding Board, have you got any reflections as to
why that was?
FOGARTY: No. I, you know, I have never been asked as to why that was.
BROWN: Well, sitting on the Safeguarding Board, you have told us about your training, that you understood if there was any suspicion, even if you weren't sure, to raise it. Why, why do you think no one took that view about the concerns they had about Lucy Letby?
FOGARTY: I can't answer why colleagues didn't, didn't escalate through those channels.
BROWN: At what point did you have suspicions, Mrs Fogarty?
FOGARTY: So I became aware -- so, obviously, I was aware of three neonatal deaths in July of 2015 because I attended a Trust Serious Incident Panel but I then next became aware in June 2016.
BROWN: And at that point, in June 2016, you were aware of suspicions about -- a member of staff about Letby?
FOGARTY: I didn't know the name but I knew there was suspicions following the death of the triplets.
BROWN: So whilst you may not be able to answer on behalf of other people, why, why did you not raise that as a Safeguarding concern at that point?
FOGARTY: Because I didn't have enough data. I didn't
have the information, I didn't have the clinical information that was required. And I was also aware from the workstreams by the executives that there were, there were people who were appropriately trained reviewing the clinical care of the babies.
BROWN: You did go on, and we shall come to this in due course, but there was a point where you were the day-to-day manager of Letby -- (overspeaking) --
FOGARTY: That is correct.
BROWN: At that point, clearly you knew exactly the person involved and the suspicions that were being raised. At that point did you not think this should be raised as a Safeguarding concern?
FOGARTY: So I wasn't Lucy's direct line manager until 2018 when the police were already involved.
BROWN: Prior to the police being involved, did you not -- you were aware at that point that Lucy had been moved -- Letby had been moved off the unit?
FOGARTY: No.
BROWN: Did you --
FOGARTY: No, I wasn't aware that she had been moved off the unit until the -- July, July '16.
BROWN: And at that point, why did you not raise a Safeguarding issue at that point?
FOGARTY: Because I didn't have any further information to back up.
BROWN: And you are aware, were you, Mrs Fogarty, that the guidance on Working Together is that Safeguarding is everybody's responsibility?
FOGARTY: Yes.
LADY JUSTICE THIRLWALL: Sorry, Ms Brown. So did you think of raising it?
FOGARTY: No, because --
LADY JUSTICE THIRLWALL: You have given a lot of reasons why you might not have done it. But I just want to see whether you actually thought of it in the first place.
FOGARTY: I didn't think of it in the first place.
LADY JUSTICE THIRLWALL: And I just wonder if you might reflect now and think I wonder why that was that you didn't think of it as a Safeguarding issue.
FOGARTY: I think at the time I felt that the Executive Board had initiated actions to try and review the whole situation and I didn't have the clinical component. So my work with Sian Williams had demonstrated that Lucy was a common denominator though not involved in every collapse, but I didn't have the clinical situation because I have not got the clinical expertise to interrogate neonatal data.
LADY JUSTICE THIRLWALL: No, you have explained
that. I just wondered why you didn't think it was a Safeguarding issue. You didn't get as far as thinking of the other things, I understand that.
FOGARTY: Yes.
LADY JUSTICE THIRLWALL: But it just didn't occur to you.
FOGARTY: It didn't occur to me.
LADY JUSTICE THIRLWALL: Do you think, on reflection, that this is something that ought to be considered a Safeguarding issue?
FOGARTY: Definitely, definitely, on reflection it is something that I would have done.
MS BROWN: And turning now, then, Mrs Fogarty to the involvement that you had with reviewing the deaths of some of the babies on the indictment from a maternity aspect, you were involved in obstetric secondary reviews, and I think you confirm in your statement that you were involved in a number of the indictment babies, certainly you were involved in the obstetric secondary reviews of [Child A], [Child C] and [Child D]. Can you just explain, assist with what an obstetric secondary review was?
FOGARTY: So it is a review purely of the obstetric and midwifery care provided to a mother and it involves a comprehensive critical analysis of all care provided
from the first point of contact with maternity services to delivery or to the postnatal period, if there's a complication with the mum. So what we are trying to do is make sure that the correct pathways were followed, the correct escalation, correct documentation, and that care met our pathways and what was expected.
BROWN: And in what circumstances would there be a OSR, obstetric secondary review, what would trigger one?
FOGARTY: Anything where there was a poor outcome or concerns about care.
BROWN: And when you say poor outcome, that would be poor maternal outcome or maternal complications?
FOGARTY: Maternal or neonatal outcome.
BROWN: And what was the procedure that you followed to conduct an obstetric secondary review? So one assumes you would examine the notes, but what else would go on? In terms of speaking to the midwives or doctors, what was the process of the review?
FOGARTY: So it was purely a review of the, the case notes and the handheld record that the mum and electronic notes, if required, for the obstetric, for the OSR, the obstetric secondary review. If we decided that it needed a further deeper
comprehensive review then obviously that would be then notifiable and it would be a root cause analysis and that would involve interviewing staff.
BROWN: So this was an initial paper exercise?
FOGARTY: Definitely, yes.
BROWN: And who would generally make up the review panel?
FOGARTY: So there would always be an obstetrician, a senior midwife and a risk and safety lead as a minimum.
BROWN: And how would you reach conclusions about whether the standards of care had been set?
FOGARTY: Benchmark it against practice and get clinical guidelines.
BROWN: And what was the system to ensure that any issues you did identify were followed up, followed up?
FOGARTY: So if we found an issue with an individual they would be spoken to. If we found a theme that would be included in the mandatory training, it would be escalated at handover so that all staff received that information. Also we had a resource room on the labour ward where anything that we had identified from reviews, there was a poster presentation and the staff used to go in there and read those so that they were familiar with the findings. But the most important things was that if an individual had not followed policy or their documentation wasn't accurate, that they were informed, because otherwise you are never going to improve practice if the individual wasn't aware.
BROWN: So as I understand it, you were looking at any individual poor practice but that the method of doing these obstetric secondary reviews would or should have picked up if there was a trend of a problem?
FOGARTY: In maternity, yes.
BROWN: And would families be involved if an obstetric secondary review had been triggered?
FOGARTY: No.
BROWN: And in terms of the notification of the deaths, Mrs Fogarty, in your role as Head of Midwifery, would you always be informed if a baby had died either on the maternity unit or after transfer to the neonatal unit?
FOGARTY: No.
BROWN: Why was that? It was not something as Head of Midwifery you would need to be made aware of if there was a death on the unit?
FOGARTY: It would be good practice but if a baby died in the neonatal unit it, it wasn't within my remit, the service didn't belong to me.
So I didn't always get notified of neonatal deaths.
BROWN: But as I understand it, if there was a poor outcome of the child, or of the mother, that would trigger an obstetric secondary review, so didn't you need to know if there was a baby that had died to trigger the review?
FOGARTY: So we would know from Datix that, that -- from the Datix incident, and that would initiate our review. But I wasn't -- there wasn't a formal process where I was informed of every review.
BROWN: But you would always come to know, is that correct, because you would always need to do an obstetric secondary review if a baby had died?
FOGARTY: Yes, providing we were aware.
BROWN: And in fact that clearly did happen in the case of [Child A], [Child C] and [Child D]?
FOGARTY: Yes.
BROWN: You became aware that they had died because you were involved in all three of those obstetric secondary level reviews?
FOGARTY: Yes.
BROWN: And you say in your -- you accept in your statement, this is paragraph 69, that it was unusual to have three deaths on the NNU within two weeks.
FOGARTY: Yes.
BROWN: And how were you able to say that, that it was unusual to have three deaths?
FOGARTY: Because you -- we wouldn't be doing that number of obstetric secondary reviews in such a short period of time in relation to neonatal deaths.
BROWN: And you have talked at the outset a little bit about the communication and there would be, because of the geography you would see people who worked in the other units. Did you, did you go and speak to your colleagues in the NNU, did you raise it and say, "This seems very unusual"?
FOGARTY: No, no.
BROWN: Why was that?
FOGARTY: Because we had gone to a -- there had been a paediatrician present at the Serious Incident Panel and he didn't escalate any concerns.
BROWN: Did you think, having made the observation that you had made, that it was unusual that there were three deaths on the neonatal unit, and we will come to it in a minute, but the obstetric secondary reviews didn't, as I understand it, didn't flag a problem from the maternity side; that is correct, is it?
FOGARTY: Yes, that's correct.
BROWN: So you've got three deaths which is unusual, you are not aware or no problem has been identified from
the maternity point of view and we've got the existence of the Women's & Children's Care Governance Board. Did you think it was appropriate for that to be raised and then discussed at that meeting?
FOGARTY: So that would be something that would be required, that would be tabled by the paediatricians because they are the experts in neonatology and when we attended the Serious Incident Panel in the July, Dr Brearey hadn't escalated any concerns. So, therefore, I was assured because he was the -- he was the expert in neonatology.
BROWN: We are going to come to the meeting in just a moment.
FOGARTY: Yes.
BROWN: But just dealing for a moment with the obstetric secondary reviews of [Child A], [Child C] and [Child D], I just want to be clear so that there is no misunderstanding. There is no reference in any of the obstetric reviews of any issue of infection on the maternity ward and from your perspective on the maternity ward, that played no part in the death of these three babies?
FOGARTY: No, we never had any issues with infection at all.
BROWN: And where you have, as you have explained, you came to a conclusion that at the end of the obstetric secondary review that there weren't any concerns from a maternity/obstetric perspective, in that situation as a matter of course, we will come to the 2 July meeting in a moment, but as a matter of course would you then have a meeting with your neonatal colleagues in order to understand the overview of the picture and of why in fact that baby had died?
FOGARTY: No. What we would, we always recommend that they did their own review with the same intensity that we, we did for the obstetric element.
BROWN: But there would, as matter of course, be a roundtable discussion, so to speak?
FOGARTY: So all, so they, they would be discussed at the perinatal mortality meeting that were held quarterly and -- and someone attended from Alder Hey as well, a pathologist attended from Alder Hey, and all neonatal deaths and stillbirths were discussed at that meeting and it was a joint meeting between the obstetricians and paediatricians.
BROWN: Thank you. So coming now to the meeting of 2 July and it appears that there was a Serious Incident Panel meeting on 2 July and this was to discuss the three neonatal deaths and at paragraph 55 of your statement, you quote
helpfully there, the extract from the case review of [Child D] and it's within that case review that this Serious Incident Panel is mentioned. And it says: "... the Executive Serious Incident Panel on 2 July 2015; there had been three neonatal deaths in a short period of time and the circumstances were discussed to identify if there was any commonality which linked the deaths ..." And going then at paragraph 17, you explain that that meeting was called by Alison Kelly, the Director of Nursing?
FOGARTY: Yes, that's correct.
BROWN: And was that -- did she discuss that with you in advance or --
FOGARTY: No.
BROWN: -- were you just asked to attend?
FOGARTY: No, I was just asked to attend.
BROWN: And you helpfully, in your statement, you set out at paragraph 71 confirming that you attended the meeting and setting out who else attended. Alison Kelly, the Director of Nursing, Ruth Millward, the Head of Risk and Safety, Stephen Brearey, Dr Brearey, as the clinical lead of neonatal unit, Debbie Peacock, who was the Risk and Patient Safety Lead, and then Sian
Williams, the deputy director of nursing, so the deputy of Alison Kelly?
FOGARTY: (Nods).
BROWN: And what did you understand to be the purpose of this meeting?
FOGARTY: To try and explore whether there was a concern that needed further escalation and investigation.
BROWN: And can you recall the meeting itself, how you went about that? Did you look at the medical notes, what was the process?
FOGARTY: So, no. So before I went because I knew why I was going, I reviewed the three OSR and I made a summary note in my Head of Midwifery notebook that I was able to take so that I was assured that for the three cases the mother's care had been looked at and we had no concerns, and that's how come I know who was in the meeting because I made, in my summary notes, who was present.
BROWN: Yes, I think --
FOGARTY: I made no notes from the paediatrician element. So therefore that tells me that no concerns were escalated, otherwise I would have written that in my notes.
BROWN: And we have seen a copy of your handwritten note --
FOGARTY: Yes.
BROWN: -- listing who was there. And had you -- Mrs Fogarty, had you ever been involved in a meeting to look at commonality of three neonatal deaths in this way before --
FOGARTY: Never.
BROWN: -- or was this a --
FOGARTY: No.
BROWN: So this was a unique experience?
FOGARTY: This was, yes.
BROWN: And did you have or was there discussion at the meeting of any form of checklist or agenda to assist with approaching, in a consistent way, whether there was any commonality?
FOGARTY: No.
BROWN: So at the meeting you were looking for a common feature. Had there been a common feature identified, clearly that was going to be a very serious issue, potentially a very serious issue?
FOGARTY: Yes.
BROWN: So was there any consideration, or did you raise at the meeting, or did anyone raise at the meeting, given the potential seriousness of what was being discussed, whether this meeting should be attended by the Consultants who were involved in the care of the babies and were present at the -- failed in this case -- resuscitations of [Child A], [Child C], and [Child D]?
FOGARTY: The paediatricians had elected to send Stephen Brearey to represent them so there was no discussion about other paediatricians. They didn't go in great detail about each individual case, you know, Dr Brearey, you know, provided a summary report, verbal report, and he didn't identify, as far as I recall, any issues that he felt warranted any further action at that time.
BROWN: Looking back now, given sort of the unusual nature of this meeting, looking at whether there are any common features, do you think you would have -- as a member of that meeting would you have been assisted by hearing from the Consultants who were the treating Consultants?
FOGARTY: So with hindsight, really what should have happened is there should have been a total review of all three cases by someone external from the Trust.
BROWN: And I think you may be aware Ruth Millward, her view is that at that point, there should have been a review and so I understand, Mrs Fogarty, you are agreeing with her?
FOGARTY: I agree, yes.
BROWN: And in addition to the issue of whether the
Consultants, the treating Consultants should have been considered or consulted, and attended the meeting, you were looking at commonality of deaths over a two-week period. Did anyone raise or was it considered at the time whether it was also relevant to look over that two-week period whether there had been any collapses, so near deaths? We know, of course, there was -- child B, the twin of [Child A], collapsed in that period. Did anyone say, well, we should be looking, if we are looking at commonality not just at deaths but any incidents?
FOGARTY: The death of [Child B] wasn't mentioned at all.
BROWN: [Child B] survived, fortunately, but the collapse --
FOGARTY: Yes, but the collapse wasn't mentioned at that meeting at all.
BROWN: And again, looking back, that would have been a relevant thing to take into account, wouldn't it?
FOGARTY: Definitely. Definitely.
BROWN: And as well, just so we are clear on what was discussed at this meeting, do you recall whether unusual rashes were discussed at the meeting of 2 July?
FOGARTY: There was no clinical, no detailed clinical information given.
BROWN: Because the conclusion of that meeting that you were at, you participated in, was that there was going to be no further investigation at that stage. Can you assist us with how did you come to that conclusion?
FOGARTY: That decision was made by the Director of Nursing.
BROWN: And it was -- so your evidence is, is it, that it was Alison Kelly who took the decision that no further investigation was required?
FOGARTY: Yes.
BROWN: Did anyone dissent from that at the meeting?
FOGARTY: Not at the meeting, no.
BROWN: And you say in paragraph 74 of your statement that you are unable to comment on the possibility that staffing factors might have anything to do with the deaths of [Child A], [Child C], or [Child D]. Was that something that was discussed as a possibility --
FOGARTY: No.
BROWN: -- at the meeting?
FOGARTY: No, it wasn't, it wasn't discussed at that meeting.
BROWN: And just to be clear. I've been asked to clarify, you say at paragraph 75: "The common factor of Letby as a nurse on duty was not discussed at this meeting."
Are you clear in your recollection about that?
FOGARTY: I am very clear that that, that that was not discussed.
BROWN: What action would have been taken if you had been given a name, do you think?
FOGARTY: Well, we -- you would need to -- if you've got a name then there is a concern that's attached to one person so therefore you would, you would want to escalate that and take further action.
BROWN: So you are confident in that recollection?
FOGARTY: I am confident in that recollection, yes.
BROWN: And just again to clarify as well, before we move on, you say at paragraph 36 about this meeting: "The paediatricians did not raise any concern at that meeting ..." You say "paediatricians" but it was -- Dr Brearey was the only paediatrician at that meeting?
FOGARTY: Yes.
BROWN: And you are saying that he didn't raise concerns about looking at the commonality of those deaths.
FOGARTY: That's correct, yes.
BROWN: If we can turn on now, you say in paragraph 52 of your statement, that it was also at that meeting, the meeting of 2 July that was looking at the commonality, that a full case review of [Child D] would be conducted to look at the obstetric and the neonatal notes. So the point we were discussing before about the obstetric review being done and then separately the neonatal review, for [Child D] this process was put together.
FOGARTY: Yes.
BROWN: And given that [Child A] and [Child C], from the obstetric point of view there was no explanation for those, those deaths, did you feel that in fact that should have been done not only for [Child D] but also for [Child A] and [Child C]?
FOGARTY: With hindsight definitely, that, that should have been done.
BROWN: And would you go as far as to say that as a matter of course when the obstetric review didn't reveal a cause of death, or an explanation for the death, that there should be this, this sort of joint process?
FOGARTY: Well, from the obstetric point of view we are looking at if anything contributed to the outcome. So it wasn't always relevant to, necessarily, do a -- put the two together if the standalone paediatric review is comprehensive. But it is good practice.
BROWN: And if we could go to INQ0003299, we are just going to look at the cover page of the review for
[Child D] because this really makes the point clearly that this is a review and we can see just by the investigation team that we have got present there, the obstetric secondary review team, including you and a Consultant, Dr Davis, and then we've got the neonatal review team, Dr Brearey, and Ms Powell, the neonatal unit manager, and there is -- we won't go through it but what follows is an 18-page report with appendices, an 11-page report.
FOGARTY: But these were actually two separate reviews put into one report.
BROWN: So that's my next question.
FOGARTY: Yes.
BROWN: Did you physically meet to discuss this or was this compiled out of two reviews?
FOGARTY: So it was compiled from the two reports, two separate assessments.
BROWN: And back to where we started with the two divisions, and you saying about meetings being held together. In retrospect would it have been more helpful if you had all physically sat around the same table?
FOGARTY: I mean, being in two divisions shouldn't affect work such as this because that's -- this is very specific and, and because of the nature of the work and the terminology the fact that the two meet separately to
review the care, that doesn't impact on the quality of the report and the judgments. What should really happen is the two meet separately and then when the conclusions are drawn then meet together to review the conclusions and next steps and that's what didn't happen.
BROWN: Didn't happen?
FOGARTY: Didn't happen.
BROWN: There was -- so that didn't happen in terms of the first review. There was then, we see, an addendum because after the results of the post-mortem from [Child D] were supplied, there was then a further meeting which was attended by Dr Davies, Dr Newby --
FOGARTY: Yes.
BROWN: -- you, Ms Powell and Debbie Peacock. Was that an actual meeting?
FOGARTY: That was an actual physical meeting, yes.
BROWN: So whilst paper initially, this concluded, when we look at the report, with a physical meeting --
FOGARTY: Yes.
BROWN: -- of both obstetricians and a paediatrician?
FOGARTY: Yes.
BROWN: And at the time that this review was done, the initial review of 28 August, and certainly by the time that meeting was held, which was 12 October, sadly there
had been more deaths on the neonatal unit. There had been the death of [Child E] on 4 August 2015. Were you aware of that death?
FOGARTY: No.
BROWN: Would that not have come to you by the same process of needing an obstetric secondary review?
FOGARTY: I don't even recall doing an obstetric secondary review on that case.
BROWN: Yes, but it wouldn't have come to you in your role of Head of Midwifery?
FOGARTY: It wasn't escalated to me.
BROWN: And had it been, had there been a system where you were aware of the fact that one of the children, another child had died within August, do you think that would have made you reconsider that decision on 2 July that there was no reason for further investigation at that stage because we now have a new component --
FOGARTY: Yes.
BROWN: -- we have another death within a short period?
FOGARTY: Definitely.
BROWN: And Ruth Millward, she, in her statement to the Inquiry says that was a further missed opportunity to trigger a comprehensive investigation. Are you agreeing with that?
FOGARTY: I agree, yes.
BROWN: The case review of [Child D] has a distribution list that has gone down, so we needn't turn to it. But page 11 of the report shows there is a distribution list of [Child D]'s -- we don't need to go to it, thank you -- that it would be referred to the Women's & Children's Care Governance Board as well as QSPEC and so again the same question: did you, as deputy chair, did you at that stage or it having been referred, think that this was a matter that should be tabled on the agenda having been prompted not only by 2 July but now by the review of [Child D] --
FOGARTY: Definitely, yes. It should have been, yes.
BROWN: And why did you not raise that because you had been present at the [Child D]'s review, so you were aware of the three deaths, you had now attended that review after the post-mortem. At that point, did that prompt you to think this is something we should be discussing as --
FOGARTY: I mean, I was dependent on my paediatric neonatologist specialists to be escalating concerns to -- to myself and, and they didn't.
BROWN: Moving forward then. So two weeks on from after the meeting after the post-mortem, the meeting, the physical meeting when [Child D] was discussed.
[Child I] died on 23 October. So the fifth death in approximately four months. At that stage, were you -- first, were you aware of the death of [Child I]?
FOGARTY: I don't recall being aware of the death of [Child I].
BROWN: We know from some other evidence, Mrs Fogarty, that there were or there appeared to have been rumours at this stage within the neonatal unit. Were you aware of any concerns about a commonality of staffing or concerns that something was strange about the increased mortality rates?
FOGARTY: No.
BROWN: When did you first become aware that staff on the NNU had concerns that a member of staff might be involved in harming babies?
FOGARTY: So I first became aware in the June '16 after the death of the triplet, the second triplet.
BROWN: Can I just --
FOGARTY: And it wasn't concern that the staff on the neonatal. It was concern that the paediatricians had concerns. That's when I became aware of that.
BROWN: And prior to that, just so that I can be clear, prior to that, so prior to you becoming aware of the paediatricians' concerns after the death of O and P,
were you aware of any rumours?
FOGARTY: No.
BROWN: If I could turn now to the review that was conducted of neonatal deaths and stillbirths from an obstetric point of view, Dr Brigham's review. If we could turn up INQ0003222 and this is tab 7, my Lady, in your bundle. So this was a review that was done in November, so about four months after that 2 July meeting that we have talked through in some detail, and at this stage we have gone through I. You say you weren't aware of I, but there had been five deaths on the neonatal unit from June 2015. Whose idea was it to conduct this review that was looking at the obstetric situation?
FOGARTY: So the -- so the obstetric risk leads and myself.
BROWN: Why did you decide to do that review?
FOGARTY: We had had a perceived increase in our stillbirth and neonatal death and so we wanted to be assured that we didn't have a problem with our practice.
BROWN: You say "perceived" increase, but presumably there was an increase in stillbirths, is that --
FOGARTY: We knew from our data that there was an increase.
LADY JUSTICE THIRLWALL: So I just wondered why it was called a "perceived" increase?
FOGARTY: It's the terminology that Dr Brigham put in her report in response to a perceived increase. So it was --
LADY JUSTICE THIRLWALL: But so far as you were concerned, everyone understood it was a --
FOGARTY: But we knew, we knew that that -- that there was because that's why we were meeting and we had all the records. We had the data to back it up.
LADY JUSTICE THIRLWALL: All right, thank you.
MS BROWN: And we can see there that the title is "Review of neonatal deaths and stillbirths at Countess of Chester Hospital, January 2015 to November 2015" and I think you accept in your statement, you say the title does not best describe the remit of the review. It may be very obvious but can you just explain why that's not an appropriate title?
FOGARTY: I think it should be explicit that it was purely the midwifery and obstetric care that was reviewed because that is the area of clinical practice and the expertise of the panel.
BROWN: And reading that without that knowledge, it's misleading, isn't it, that title?
FOGARTY: It, it could be for people outside of the Trust that don't know that that was the remit of the people involved or anybody who didn't receive a verbal update, where it was made clear at a verbal update.
BROWN: And you say at paragraph 88 of your statement that not only the title but on -- it's not apparent on reading the report that the review is confined to obstetric care?
FOGARTY: Yes.
BROWN: I think in fairness, if one looks at the review team, we can see there are no neonatologists or paediatricians on that review team?
FOGARTY: Yes.
BROWN: So that might be a clue. But it is certainly, on the face of the title and the content --
FOGARTY: Yes.
BROWN: -- it is not clear that this is not a complete review. And you looked at the deaths from January 2015 so that included, this has been checked, that it included the deaths of Childs A, C, D and E. Was -- that was in terms of the neonatal deaths. Was there also concern about the stillbirths in the obstetric departments? What was the concern there?
FOGARTY: Yes, we felt we had an increase so we wanted to know was it because of poor practice.
BROWN: And did you inform the Consultant paediatricians and the NNU senior nurses that you were doing this obstetric review? Did they know you were doing this?
FOGARTY: So the paediatricians were aware, yes. One of my Consultant colleagues had informed them.
BROWN: And once you had done this review, that review did not identify the causes of increased mortality because you didn't identify a cause from the --
FOGARTY: We were only looking at the obstetric and, actually, we had already -- what the report demonstrated was we had already done comprehensive reviews of all the cases anyway and it didn't, it didn't pick up anything that we hadn't already looked at. It was more of a thematic review.
BROWN: And so what did you understand was the plan to try and understand the cause or causes of the neonatal deaths? Clearly the stillbirths were completely within your remit but in terms of the neonatal deaths, you hadn't reached a conclusion. What did you understand was the plan?
FOGARTY: So we were purely looking from an obstetric point of view to see if it was anything in our practice that had contributed to a poor outcome for a baby, and we didn't find any commonality or anything that we
hadn't already addressed so we knew therefore that that same level of investigation needed to be undertaken by the paediatricians.
BROWN: Thank you, Mrs Fogarty. So as I understand it, there was a sense in the obstetric department and the midwifery department that, having done your review, it was now really for the paediatricians and the NNU to --
FOGARTY: Yes.
BROWN: -- examine their side?
FOGARTY: Yes.
BROWN: Because we have got a situation here where the maternity unit, and you have been looking at it from an obstetric point of view, you have identified clearly that we need to look at the neonatal side and it's difficult to understand why given your understanding that we needed the neonatal aspect why that wasn't raised at the Women's & Children's Care Governance Board to say, "We have done this review, we need input from our neonatal colleagues." Was that not the very purpose, the very aim of that governance board to bring the departments together?
FOGARTY: So they were already planning their review which they did in the beginning -- at the beginning of 2016.
BROWN: And that's Dr Brearey's thematic review --
FOGARTY: Yes.
BROWN: -- is how we have been referring to it. And so you -- at what point were you aware that that was planned, are you able to assist?
FOGARTY: I think it was when this report was produced.
BROWN: And in terms of this report we see it's dated November. In terms of the circulation of that report, we know that it wasn't e-mailed, in fact more widely circulated, until 9 February. Do you know what the delay was for the --
FOGARTY: So the actual report, in fact the email that circulates the report states: This is a poster presentation in the resource room. So as soon as the report was produced, it was always the practice that the resource room would have a copy of this for staff to go and be familiar with. So it would already -- it had already been actioned and all the actual incidents when they were reviewed initially that information was in the resource room. So...
BROWN: So regardless of that email, you are fairly confident that this was properly distributed certainly within your --
FOGARTY: Yes.
BROWN: -- department?
FOGARTY: And it actually states that on the email, that it's -- it's up, it's already up as a poster presentation which was our format.
LADY JUSTICE THIRLWALL: Sorry. Does that mean that it was, the report was in the resource room?
FOGARTY: Yes. Visible, visible for staff to look at.
LADY JUSTICE THIRLWALL: So every page was there?
FOGARTY: Yes, yes.
LADY JUSTICE THIRLWALL: Thank you.
FOGARTY: And staff also knew to go to the resource room every week because that's where we -- that was our training method that we used. It was very effective.
MS BROWN: So if we can just look now and go through and see what was being discussed at the Women's & Children's Care Governance Board. So if we could put up, please -- that report can go down and just maybe one more question regarding that report, Mrs Fogarty, before we take it down. That report didn't highlight within the report itself that a neonatal review was needed and my understanding is that's because you understood that that was going ahead in any event?
FOGARTY: Yes.
BROWN: So, yes, if we could pull up INQ0004235. So this is tab 14, my Lady, of the bundle.
This was 18 June, so right -- just shortly after the death of [Child A], a meeting there and if we could go to page 3 of that. It records there that JCF, so that's and you -- your initials, sorry, yes, JCF, your initials and the Consultant obstetrician reviewed a twin death and that's referring to [Child A]. If we go down: "No issues with any element of care provided. Will be subject to neonatal review." So that's as you were explaining to us --
FOGARTY: Yes.
BROWN: -- recording that there would be an obstetric secondary review. There were no issues there, but there would be a neonatal review?
FOGARTY: Yes.
BROWN: Was there a system for following up matters like that on the minutes to check that -- it says there's going to be a neonatal review --
FOGARTY: Yes.
BROWN: -- that a neonatal review was done?
FOGARTY: Yes. So at the next meeting they looked at the actions to make sure that they had been completed.
BROWN: That can come down then, please. We don't need to turn to this, but there was another meeting on 22 October and that referred, just very briefly, to
three unexpected neonatal deaths. There had in fact been four then, taking into account [Child E], but it refers to three unexpected deaths, but there is no discussion in the agenda of unexpected deaths. Was that something that on reflection should have been something that was discussed or would normally have been something that was discussed? It's the fact that they are unexpected deaths. Clearly on occasions there would be deaths, but the unexpected deaths, would that not be something that should have prompted discussion?
FOGARTY: She would have expected the paediatricians to have said, to have brought some information regarding their reviews of those cases. But that was in the October when we were aware of the increase and that's why we then did our review in the November.
BROWN: So you say that it was for the neonatologist or the paediatrician to bring that. But as the deputy chair and as observing this from a critical standpoint, knowing that the role of the committee is to flag any issues, should you not have been asking your colleagues and saying: These are unexpected deaths. We don't have a solution, is there an explanation? There seems a lack of curiosity.
FOGARTY: With -- with hindsight then, yes there should have been more probing of the paediatric staff.
BROWN: If we can go -- thank you. If we can go to the meeting of 18 December and we can call this one up. It's INQ0004371, and page 2 of that. Here we see -- so this is December. We know the Brigham report, the obstetric report we have seen was November, and we see this report came to the meeting here as one would expect?
FOGARTY: Yes.
BROWN: And we see stillbirth and early neonatal death review and action plan: "Panel set up to review each case individually. No themes identified. Overall the process showed we have a good record-keeping, good escalation. The outcomes would not have been any different." Now, we know that these minutes then went up to QSPEC?
FOGARTY: Yes.
BROWN: And reading that now, I know obviously you have the knowledge that this was an obstetric review but if one was reading that without that knowledge, that would appear to allay concerns about neonatal deaths because it's not clear from that that's just the obstetric care that's being looked at?
FOGARTY: But I presented that report at QSPEC and was very clear in my verbal presentation that it was a maternity and obstetric review of care.
BROWN: We will come to that in a moment. But from this minute, if one was reviewing the minutes, it's not clear from those minutes -- it would obviously have been clear to those at the meeting, but it wouldn't have been clear just on a paper review that there was a problem here?
FOGARTY: Yes. Yes.
BROWN: Picking up on that point, did that provoke any discussion from Dr Brearey, who was in fact present at that meeting, about the situation on the neonatal unit?
FOGARTY: Not that I recall.
BROWN: If we can just turn to some emails, this is tab 9, my Lady, in your bundle. There were some -- there was an email exchange between Alison Kelly, and this rather just demonstrates the slight confusion, I think, possibly due to the titling of Brigham's report. We see, and we could call this up, it's INQ0003220. So if one starts at the bottom the page, this is from Alison Kelly: "Hi, where are things up to re the thematic review? I am keen to get the paper to December QSPEC." So she is referring there to the Brigham review, the obstetric review because Dr Brearey's review
hasn't -- was that your understanding anyway?
FOGARTY: My understanding is she is referring to two reviews because she copied Ruth Millward in and Ruth Millward played no part in the obstetric, but would be looking for the neonatal one. And that's why I responded to say I had sent the papers in November ready for the next QSPEC meeting. It was the paed update that was missing.
BROWN: Yes, and you then make it clear your understanding --
FOGARTY: Yes.
BROWN: -- from your response is it is clear that there were two elements --
FOGARTY: Yes.
BROWN: -- the midwifery element, which we have seen and looked at?
FOGARTY: Yes.
BROWN: And then it's the paediatric --
FOGARTY: Yes.
BROWN: -- update that's missing?
FOGARTY: Yes.
BROWN: Then Ms Kelly replies: "Sorry if I hadn't been clear. I mean the thematic review of neonatal deaths recently undertaken." So you may not be able to assist but it seems to be
Alison Kelly's understanding that there was at that stage one review that combined the two. But that's not the case, is it?
FOGARTY: No, no, and Alison Kelly knew that it wasn't one report that -- she knew that from my one to one and my, my verbal. She knew we were doing the thematic review in obstetrics before it had taken place because I had escalated that to her.
BROWN: Just looking at that, your discussions with Alison Kelly then about your review. Did you discuss the obstetric review with Alison Kelly --
FOGARTY: Yes.
BROWN: -- and say we are waiting for the paediatric?
FOGARTY: Yes. Yes, I had discussed that at my one to one with her.
BROWN: And can you recall what her view was about the fact that the paediatric -- the neonatal unit, you were awaiting that report, did she --
FOGARTY: I think she said she would chase it up.
BROWN: So she was aware that there was -- that the neonatal review of the increased mortality hadn't taken place?
FOGARTY: To my knowledge, yes.
BROWN: And if we can go now. Sorry, just to be clear then. You were aware that Dr Brearey had done
a thematic review and we know that was in February 2015 and re-issued in March 2015. Did you, did you receive a copy of that, can you recall?
FOGARTY: No.
BROWN: Would that be something that you would have expected him to have raised as soon as it was issued at the women and children's governance board?
FOGARTY: I would have expected it to have come sooner than it did to the women and children's governance board, yes.
BROWN: I think we will look now at when it did come on 16 June. So if you go to INQ0003212. This is tab 18. If we could go to page 5, please. So we've had the Brigham review back in December. We are now at June, mid-June, and the neonatal aspect of the same issue, increased mortality rates, is being reported here. It is entitled "NNU Thematic Review": "There was a higher than expected mortality rate on the NNU in 2015." And it goes on: "An obstetric thematic review did not identify any common themes that might be responsible for the rise in mortality in 2015." That's a reference to the Dr Brigham report?
FOGARTY: Yes.
BROWN: And it said the aim of the neonatal meeting, that was the meeting that was held on 8 February was to: "... review the cases as a multi-disciplinary team with an external reviewer to assess." And it says there: "There was no common theme identified in all the cases."
FOGARTY: Yes.
BROWN: Do you recall any other discussion taking place at that meeting surrounding that report?
FOGARTY: I -- due to the time lapse, I don't.
MS BROWN: My Lady, I don't know if that would be a convenient moment.
LADY JUSTICE THIRLWALL: Yes, certainly. So we are going to adjourn now for lunch so if you will come back please and be ready to start again at 2 o'clock.
FOGARTY: Right.
LADY JUSTICE THIRLWALL: Please don't talk about your evidence. (1.00 pm) (The luncheon adjournment) (2.01 pm)
LADY JUSTICE THIRLWALL: Ms Brown.
MS BROWN: Ms Fogarty, we were just looking at the 8 February thematic report that had been presented to the Women's & Children's Care Governance Board on 16 June and the fact that on the entry for that it said there was no common theme identified in all the cases. So having completed that, that review going through those board meetings of the Women's & Children's Care Governance Board, at no point between June 2015 and June 2016 did the Women's & Children's Care Governance Board have any minuted discussion about the cause of serious concerns of rising unexpected and unexplained neonatal deaths; that the case, isn't it?
FOGARTY: It would be apparent from the minutes, yes.
BROWN: So it's not a case that it's not minuted, you would have recalled that discussion as well?
FOGARTY: Yes.
BROWN: And consequently, no concerns about rising unexpected and unexplained deaths rose from there to QSPEC?
FOGARTY: That's correct, yes.
BROWN: That follows as a matter of course. And at paragraph 31 of your statement you address this frankly and you say that whilst, during your time as Head of Midwifery you felt that the WCCGB, the Women's & Children's Care Governance Board, was
effective in relation to maternity services, the fact that the issues relating to the NNU mortality was not presented at this board by the NNU Team demonstrates a gap in its overall effectiveness. Just clarify what you mean by the gap in its overall effectiveness, please?
FOGARTY: Well, the whole purpose the board is to, you know, receive information and where there is risk to then forward them on and obviously that didn't happen in this case. So it was a gap that the increase in mortality wasn't flagged by the paediatric team for discussion, noting and escalating.
BROWN: And obviously you have had some time to reflect --
FOGARTY: Yes.
BROWN: -- about this. And what is your explanation for that, why a meeting that was convened for that purpose with neonatal and midwifery and obstetric representatives, concerns that did exist, why was that not being debated in that forum?
FOGARTY: I have no explanation as to why the paediatricians didn't bring that information forward or raise it for a topic of discussion.
BROWN: Do you feel that whilst, as you have made
clear, you weren't a paediatrician, you weren't from neonatal expertise, but did you think there was sufficient that you maybe should have raised it yourself as a concern?
FOGARTY: I have no neonatology experience whatsoever. I have never ever reviewed a neonatal care case because it's not my area of clinical expertise. So I am not able to interrogate the data. But certainly, you know, in hindsight then, just the fact that, you know, I was aware of the -- from our own review, our own obstetric review, there should have been some escalation at that time.
BROWN: And that's, in a sense, a question of hindsight. At the time you knew that there wasn't an obstetric cause and that's something you could have raised at the meeting.
FOGARTY: Well, I knew that there wasn't an obstetric cause but I would -- I was being guided by the paediatricians who are the experts in neonatology.
BROWN: Thank you. And just on a related issue in terms of the reporting culture within the NNU. Again, you said in your Facere Melius interview that you felt there was a good reporting culture in midwifery, and that's the case, is it?
FOGARTY: I would say yes.
BROWN: But you said that you considered that neonatal incidents were not always reported. What was the basis for that?
FOGARTY: That was just a feeling I had of the fact that not all the incidents were Datixed so therefore weren't fed through, they were put in -- my understanding was some of the incidents were put in retrospectively.
BROWN: And that was a concern that you had at the time about neonatal --
FOGARTY: Not at the time, no, because it wasn't something that I was looking for at the time because neonatal services didn't sit in my portfolio, so I therefore wasn't looking and challenging the data on a regular basis.
BROWN: So is that, that concern about neonatal reporting, was that something that occurred once you took on your new role as the Associate Director or when did that occur to you?
FOGARTY: No, it was from when -- obviously when the execs started their investigation work. That was one of the things that I had heard.
BROWN: So it wasn't something that you considered at the time, at the time of these events, 2015 to 2016, June 2015 to June 2016, that you should have raised within the context of the Women's & Children's Care
Governance Board that you felt there was a reporting issue?
FOGARTY: No, because at that time I didn't -- I wasn't aware of it.
BROWN: Just dealing briefly with QSPEC then. Before turning to the specific meetings, you say and this is paragraph 27 of your statement, that QSPEC had a role that included monitoring the implementation of recommendations from national reports such as Francis. Can I just be clear there. You are referring there, are you, to the February 2015 Freedom to Speak Up report by Sir Robert Francis?
FOGARTY: Yes.
BROWN: And in general terms -- you sat on QSPEC, can you recall what work was being done in 2015 into 2016 to implement recommendations from the Freedom to Speak Up reports?
FOGARTY: So they were getting Freedom to Speak Up Guardians within the Trust and implementing those.
BROWN: And can you recall when those came in?
FOGARTY: I couldn't be exact as to when they came in.
BROWN: And if you could turn then to a meeting -- we are going back in time now because we have looked through the Women's & Children's Care Governance string of minutes and we are going to go back in time now to
what QSPEC were doing and back to the meeting of 14 December 2015. So that's INQ0003204. This is, my Lady, tab 21 of your bundle. Sorry -- yes, 21. If we can get, yes, page 5. So this was very close in time to the meeting when you were presenting your report as well to the Women's & Children's Care Governance Board, you were reporting it also to QSPEC, and we see here at point 11, neonatal and stillbirth review: "Ms Fogarty presented a review of neonatal deaths and stillbirths at the Trust during January to November 2015. It had been recognised that there had been an increase during the period and therefore a panel was set up to independently review all the cases again on an individual basis to identify any common themes or trends and lessons to be learned." And then going down: "The review team had also included an external reviewer who had felt the Trust review process was extremely robust, open and transparent." And then going down: "The report will now be received at the Women's & Children's Care Governance Board where the action plan
will be monitored." So looking at that from the -- we will hear what you said about -- what you actually said to the meeting but from the notes of that meeting, that, from someone reading it, an outsider reading it who wasn't involved in that review, it wouldn't be apparent to them that that is purely an obstetric review?
FOGARTY: No, no.
BROWN: And if we go over the page to the end of that entry, it says: "Mrs Kelly thanked Ms Fogarty and the team for the report and the assurance it had provided to the committee." Now, just dealing with Mrs Kelly first of all, the Director of Nursing. I think your evidence was before, but correct me if I am wrong, was that Mrs Kelly was aware that this was just -- you were presenting just an obstetric report?
FOGARTY: Definitely, yes.
BROWN: And, of course, she was your line manager so she was very well aware of what your remit was?
FOGARTY: Yes.
BROWN: But having accepted that that's misleading to the uninitiated reading that, what is your recollection of what you in fact presented at that meeting?
FOGARTY: I mean, during the verbal report I was, I know I was clear that it was obstetric and maternity care that are being reviewed. The members of the meeting also knew that that was my remit.
BROWN: And did you consider raising at that meeting, or indeed subsequently, that there was a need for the neonatal care aspect to be brought back to QSPEC because they were just seeing half the picture, in effect?
FOGARTY: I mean, it was my understanding that when they had done their review that it would go to QSPEC. So I didn't raise it at that meeting because I already knew that that's -- that's what would happen.
BROWN: And I think you have explained but did you review these minutes and have a concern at the time about how it was -- (overspeaking) --
FOGARTY: Not at the time, no.
BROWN: Had you had a concern about the minutes or whether it was an accurate reporting, what was the process for approval of minutes and raising objections?
FOGARTY: So at the start of each meeting you agreed the previous set of meeting minutes were correct and that if, if -- in hindsight I would have said no, we need further clarity that it was an obstetric and midwifery review not neonatal, but at the time --
BROWN: That wasn't something you raised --
FOGARTY: But at the time I had verbalised that but I didn't appreciate the significance.
BROWN: And at paragraph 106, then, just moving on to a slightly different topic in your statement, you talk about yet a different type of meeting, this time the Cheshire and Merseyside Neonatal Network Steering Group. Just very briefly, can you explain what that group was?
FOGARTY: So I only attended one of those meetings. I don't know how I came to go to that meeting. Yet the minutes are clear that I was there. When I look at the contents, there was no other midwifery representative there and I didn't attend another meeting because the discussions at the meeting I couldn't contribute. It was all related to neonatal practice of which I had no information.
BROWN: You have answered my question. You don't recall why you were at this meeting?
FOGARTY: No.
BROWN: Could it have been that you were asked to go along to this meeting because there was a thought that the issue of neonatal deaths or deaths of babies was going to be discussed and you would contribute in relation to the obstetric aspect?
FOGARTY: No, because they wouldn't look at obstetric
care in a Neonatal Network meeting.
BROWN: And you say that the issue of neonatal deaths at the Countess of Chester, that's the increase in mortality, was not raised as far as you recall by Dr Brearey or Eirian Powell at that meeting?
FOGARTY: No, and the notes confirm that.
BROWN: And did you, whether in the context of going to this meeting or at any other time, did you ever discuss with Dr Brearey or Eirian Powell the facts -- the topic of neonatal mortality --
FOGARTY: No.
BROWN: -- and the need to flag that to this or any other committee?
FOGARTY: No.
BROWN: If we could just look at the deaths of [Child O], and [Child P], which cover 23 and 24 June 2016. When were you informed of those deaths? Do you recall how you became aware of those?
FOGARTY: I can remember being at a Consultant meeting, a Tuesday lunchtime meeting, and someone coming in and saying that, you know, another triplet had died.
BROWN: And I think that's the meeting that you look at in paragraph 115 of your statement and you say you -- that the obstetrician said "something's going on".
FOGARTY: Yes.
BROWN: Do you know who that obstetrician was?
FOGARTY: I can't remember who said it and then whoever chaired the meeting at the time came into the room and we then went -- proceeded to have the meeting. However, the person who had said about the triplets had also said that the paediatricians had gone to the executive team so I was aware that they had escalated to the executive team.
BROWN: So rather like the Consultant obstetrician, by the end of that meeting you certainly knew there was something going on?
FOGARTY: Yes.
BROWN: Any more than that? What was your understanding of the situation at that point?
FOGARTY: I, I didn't have any further explanation. All we knew was there had been an increase in deaths. But I didn't have any detail behind that.
BROWN: And was there either a suggestion that one member of staff was involved?
FOGARTY: Not at that meeting, no.
BROWN: And mention of Letby wasn't made, I think it follows.
FOGARTY: No.
BROWN: We come then to the 11 July, so just two weeks, just over two weeks after the death of [Child O] and [Child P], and you describe something that you say you have a clear recollection of and that's a recollection of you and Sian Williams undertaking an exercise to do a staffing matrix analysis. Can you, first of all, explain who asked you to do this?
FOGARTY: So it was at the executive meeting as a result of the, the increase in the mortality that had been escalated and so I can't remember which member of the executive team but it was a member of the executive team had asked, had -- a management request for myself and Sian Williams to work together to do this piece of work.
BROWN: So just going back to that meeting, what was the discussion at that meeting? What was the date of that meeting and what was the general discussion at that meeting?
FOGARTY: I can't recall the exact date of that meeting because there were several meetings that were called. But it was, it was probably the day of, if not the day before this work was undertook.
BROWN: And the discussion about that meeting was -- well, explain what was being, what was the general topic of discussion? It may seem obvious to you but can you just explain to us what was being discussed at that meeting that led to this review?
FOGARTY: Yes, yes, it was the increase in the mortality that had led to the need to undertake a series of pieces of work.
BROWN: And at that meeting and when you took this work at that point you understood that the Consultants had serious concerns about the --
FOGARTY: Yes --
BROWN: -- cause of these deaths?
FOGARTY: -- and that's why --
BROWN: And I think it is evident by the nature of the task we are going to go on to explaining but you understood there was at least concern that a member of staff may have been involved in --
FOGARTY: I didn't at that time know it was a particular member of staff but we knew that they had concerns about the increase in mortality.
BROWN: And that that was, to go back to what we were discussing, on 2 July, that was an area of commonality they were looking at?
FOGARTY: Yes.
BROWN: So having established that, you are set with Sian Williams to do this task. What exactly was the task?
FOGARTY: So we were tasked with looking through the Meditech, which is the computer records of babies that
we were given the case number for, and we simultaneously went through a record and any time there was the word "sudden collapse", we would then look at who was caring for that baby, who was on duty, and who had been on duty the shift before. So we didn't look at any clinical care because we are not trained to do that. We were simply looking at who was on duty and then we compiled a list of each of those -- for each baby a list of the carer and who was on duty before and during the actual shift of the collapse.
BROWN: So the product of your work was a number reference that would have related to a child?
FOGARTY: Yes. So we used the cc number of the child, and then it was typed in, the name, so we cross-referenced it with the off-duty from the neonatal unit of the nursing staff.
BROWN: And in what format was that off-duty? Was that a paper register?
FOGARTY: It was a paper copy.
BROWN: So you've got computer records which you are going through looking for the words "sudden collapse"?
FOGARTY: Yes.
BROWN: When you find the words "sudden collapse" you are noting down the cc reference that could be -- would
identify the baby concerned?
FOGARTY: Yes.
BROWN: And then you would be typing up which staff were on duty?
FOGARTY: Which staff was looking after the baby.
BROWN: Right.
FOGARTY: Because that would be derived from the Meditech note and then the off-duty would provide us with everybody on duty.
BROWN: And when you say who was looking after the baby, that's the designated nurse?
FOGARTY: The designated nurse, yes.
BROWN: And staff on that shift or the shift before, the shift after, just to be precise?
FOGARTY: So we did the shift before, including who was looking after the baby, and the actual shift of the collapse. Who was looking after, who was on duty.
BROWN: And when you say "the shift" we are talking about what periods there?
FOGARTY: I can't -- I am not familiar with the neonatal shift pattern but it would state on the off-duty early, late, long day, so that's what we would write.
BROWN: And I think it's because you were providing a check to each other, but correct me if I am wrong, why were there two of you doing the task?
FOGARTY: So that we didn't miss anything and to confirm that we both got the same numbers of collapses and the same staff looking after that person.
BROWN: And how long did this exercise take? Was it -- were you in the room for a day doing this or?
FOGARTY: We did it over more than one day.
BROWN: And how did you -- how did you check your work? Did you produce one report? Did you confer at the end of the day?
FOGARTY: When we -- after each baby we would confer, we wrote it down on some paper, and then we would confer. When we agreed we got identical information Sian then would type it up and send it, return it back to whoever she had been asked to return it to, because it was Sian who received the -- the case numbers for the baby, not myself.
BROWN: And did you have parity between you and Sian Williams about what you were picking up?
FOGARTY: Yes.
BROWN: And at paragraph 124 -- you might want to turn that up -- what did your analysis show?
FOGARTY: That Nurse Letby was a common denominator. So she wasn't present for all of the collapses, but a large proportion, disproportionate portion to everybody else.
BROWN: And did that lead you to suspecting that Letby
was involved or could have been causing harm to the babies?
FOGARTY: Yes, and so that's why we escalated to the execs.
BROWN: And you say in fact at paragraph 125 that "a concern we both shared".
FOGARTY: Yes.
BROWN: Is that a concern you are sharing with Sian Williams?
FOGARTY: Yes.
BROWN: Were you sharing that concern with anyone else?
FOGARTY: No, just myself and Sian, and then she escalated that to Ian Harvey on both our behalves and she confirmed that she had done that verbally to me.
BROWN: And escalated, what practically did she do? What did she do in terms of Ian Harvey? Did she go and see him?
FOGARTY: So she went to see him and she escalated the fact that during our staffing check that the name Lucy Letby had come up as being a common denominator and that both myself and her were escalating our concerns to him.
BROWN: And you were aware that there were Consultants' concerns as well at this point having been
at the meetings?
FOGARTY: We were aware of Consultants and we were also aware that there were Consultant paediatricians and children's nurses looking at the clinical aspect of care.
BROWN: And I suppose the added bit of the picture that you had was that you knew from Dr Brigham's report, certainly up to during 2015 anyway, that there were no obstetric concerns --
FOGARTY: Yes.
BROWN: -- about these babies?
FOGARTY: Yes.
BROWN: Did you make that connection?
FOGARTY: And Sian was aware of that as well because she -- Sian Williams, because she sat on QSPEC, so she was aware of the obstetric report and work as well.
BROWN: So in addition to going to -- or Sian Williams going to Mr Harvey and you said she reported back to you that that had been done, did you discuss with Sian Williams, or indeed with anyone else, the idea of going to the police. We know you didn't, but did you discuss the idea of --
FOGARTY: I personally didn't, no, because I was never fed back the outcome of the paediatric and neonatal nurse review of the care provided to the babies. That
information was never given to me.
BROWN: And at paragraph 126 you say that you accept now that you should have reported the findings to the police.
FOGARTY: Yes.
BROWN: And we know in fact that Letby wasn't reported to the police for some time after this. Looking back now, as you said, you were aware of the Consultants' concerns, you had drawn a concern that Letby may be causing harm, why do you think, doing the best you can, why do you think it was, having accepted now that's what you should have done, why did you not -- what was inhibiting you going to the police at that stage?
FOGARTY: I think I had trust in the executive team that they were, were -- not -- when I say control, I don't mean stopping people from doing things but they had the range, so they were receiving all the information, so therefore they were making decisions based on information that was being fed back from all the different workstreams.
BROWN: And just considering the other steps, your answer may be similar, but did you, did you consider first of all whether internally you needed -- other than going to Mr Harvey, did you, for example, consider that you needed to raise this on one of your committees, on the Women's & Children's Care Governance Board or on QSPEC, that you had to share what your concerns that were now heightened with either of these committees?
FOGARTY: I felt that I had shared, you know, we'd shared it with the executive team which is the, you know, they are the most senior team in the Trust and, and at the time, you know, they appeared to be liaising with, with different bodies to take best advice.
BROWN: And you are a midwife but you are also a registered nurse. Did you consider referring Letby to the NMC? Did you think about restrictions on her practice? Was that a thought process you had?
FOGARTY: Again, no, because I felt that that was -- I didn't at the time because I didn't have enough detail because I, whilst I knew she was a common denominator, I didn't have the clinical knowledge to know whether the collapses, even though they were sudden, whether they fitted within a picture of the baby's health, I didn't have that clinical insight.
BROWN: And I think we have addressed Safeguarding. That was something that didn't occur to you at the time?
FOGARTY: Not at the time, no.
BROWN: And in terms of the obstetric secondary reviews, I think you carried out the obstetric secondary
reviews on 20 July for [Child P] and [Child Q]; is that correct?
FOGARTY: Yes.
BROWN: And when we looked at [Child A], [Child C] and [Child D], they were done, those reviews, very shortly after the deaths -- in fact, I think in the case of [Child D], within 24 hours. This obviously is some time afterwards. Is there a reason for that?
FOGARTY: Possibly annual leave because of the time of year. Also, I think that the Consultant obstetrician had had a brief look at the maternal care for the mum and didn't have any initial concerns. But I think it could have just purely been annual leave that there was a slight delay.
BROWN: When you say didn't have concerns, you are talking about the maternity -- (overspeaking) --
FOGARTY: Maternity care, yes.
BROWN: Because we know there were very serious concerns --
FOGARTY: Yes. No, no, this was purely the maternity and obstetric care.
BROWN: And if we could just go to the Women's & Children's Care Governance meeting, the last one we are going to look at, at INQ0003214 [invalid], and that's at tab 19, and just looking at, first of all, who was there, there's an awful lot of apologies for this meeting but we can see that you were present and Dr Jayaram was present at this meeting along with Sara Brigham, a Consultant -- the lead for obstetrics. So we had the lead for obstetrics and the lead for the paediatricians, the clinician for children's services. If we go over to page 3, we see at the top there that [Child O] and [Child P], it was being recorded there, it was unexpected neonatal deaths. And then turning over the page again -- actually, just, we don't need to go back but just dealing with the fact that those were reported. You say, I think in relation to this meeting, that there wasn't any discussion, as far as you recall, about Letby's suspected involvement in the death of the babies. Clearly that was something that was present in your mind at this time. Are you able to give an insight as to why that wasn't discussed at this meeting?
FOGARTY: So this meeting was in May and I didn't become aware -- was it May?
BROWN: No, this is 21 July.
FOGARTY: Oh sorry, I thought it said May. So I think that the -- sorry, can you just ask me the question again?
BROWN: Yes. So we know that by 21 July concerns were in your mind --
FOGARTY: Definitely yes.
BROWN: -- because we have discussed the exercise you did with Sian Williams, and we know that Dr Jayaram had concerns and we know that the topic of the death of [Child O] and [Child P] was at least referred to at the meeting. Was there any discussion that you can recall about the issue of Letby, whether the police should be called, whether there should be restriction on her practice; any discussion about the issue that must have been at the forefront of, presumably, Dr Jayaram's and your mind at this meeting?
FOGARTY: I don't recall there being a discussion about, about that at all because at that time the Trust Executive team were still, still had a working group, I was aware of that, that were looking at all the issues.
BROWN: So you, you didn't feel the need to minute it or raise it at this meeting?
FOGARTY: No.
BROWN: And sorry, if we could go to a page where we have gone already, to page 4 of that document. Sorry, that's why I am confused. It should be 3213. Sorry. I must have said 3214. So if we could go to page 4 of 3213, page 4. Looking at page 4 of that. So maybe if we can just go back to page 3. So that's where we see the unexpected neonatal deaths that were raised -- can you see at the top of the page -- but no discussion underneath that?
FOGARTY: No, because at that time it says it's an incident. I'm not sure if that is the receipt of a report or whether it's just the incident being logged.
BROWN: But --
FOGARTY: It's not clear.
BROWN: But this is the meeting on the 21 July --
FOGARTY: Yes.
BROWN: -- and the point is that there's no minuted discussion of Letby or steps that could be taken?
FOGARTY: No. She was definitely never discussed in any Governance Board. I know that.
BROWN: Yes, that is the point --
FOGARTY: I am very clear about that.
BROWN: Thank you very much. If we could go then on to page 4, and we see there under "Risks", "New Risk for Escalation in the Month" and we see: "Potential damage to reputation of neonatal service and wider Trust due to apparent increased mortality
within the neonatal unit." So what seems surprising there is that the risk that is being identified is the potential risk to reputation. Wasn't the more important risk the risk to patients due to the increased mortality?
FOGARTY: I mean, certainly. However, this risk was a plan, an Urgent Care risk so that, that division will have had the discussion and they have decided what they were going to include on their risk register. It's -- it's come here for noting and escalation to QSPEC to follow a process.
BROWN: And did that discussion, the discussion about risk registers and the damage to reputation based on increased mortality, did that cause you to reflect as to whether the risk registers needed to be or should have been updated to reflect the risk to patients due to increased mortality? Because that doesn't appear to have been added to the risk registers at any time from June 2015 onwards.
FOGARTY: I mean, certainly the risk registers, there should have been something in it far sooner within the Urgent Care Division.
BROWN: And was it something, because obviously there was the stillbirths and the identified increased neonatal deaths from the maternity aspect. Was that
something that was raised in the risk register in terms of the planned --
FOGARTY: No, because the stillbirths, unfortunately in some cases people will present because in a lot and, you know, they have had a stillbirth. It doesn't actually mean that there is a problem with the care provided and that's why we did that review and it demonstrated that whilst we had an increase, it wasn't actually due to the care provided. So therefore it didn't need to go on the Planned Care risk register. It wasn't relevant.
BROWN: Thank you. And just before -- we are going to move now to your period as the Associate Director of Risk and Safety. But just to be clear, there was a CQC review in February 2016 and I think you didn't have any involvement in that.
FOGARTY: No.
BROWN: And you weren't involved in the RCPCH review in September 2016.
FOGARTY: Yes, that's correct, I wasn't involved in that either.
BROWN: And in relation to the grievance brought by Letby, you weren't involved or interviewed in relation to that?
FOGARTY: No.
BROWN: So moving forward to April 2017. You took over a new role now as Associate Director of Risk and Safety. Who did you -- and you took over from Ruth Millward, I think you have told us.
FOGARTY: Yes.
BROWN: Who did you report to in that role?
FOGARTY: Alison Kelly, Director of Nursing.
BROWN: So you had the same reporting structure?
FOGARTY: Yes.
BROWN: Was it a more senior role in fact?
FOGARTY: No. It's probably -- parity, just a different remit.
BROWN: And you say -- and this is paragraph 137 of your statement -- that you first met Letby in April 2017 when you moved to the new role?
FOGARTY: Yes.
BROWN: And what was Karen Rees' role in relation to Letby?
FOGARTY: So she was her manager.
BROWN: And what was your role? You had, as I understand it, you were the, what's referred to as the day-to-day manager of -- (overspeaking) --
FOGARTY: Yes.
BROWN: What's that?
FOGARTY: When I moved down to the risk and safety team, Lucy was, was working within the patient experience team but their line manager post was -- the person hadn't commenced their post. So it was being, they didn't have clear supervision from somebody senior within the Trust. So I was asked to provide some day-to-day, just support, whilst Karen Rees, who was the Head of Nursing for Urgent Care, so was responsible for neonatal unit, had kept the management of Letby insomuch of all the meetings with the executives, the unions, and any other meetings that Lucy attended, it was Karen who dealt with that. I just dealt with her when she joined my team and I provided the day-to-day support of insomuch that she was working within risk and safety.
BROWN: And we know, because you have explained to us your thought process after doing your correlation exercise with Sian Williams. What did you think about the appropriateness of Letby being employed in that role at the time and the position that you were put into as being her day-to-day manager? How did you feel about that?
FOGARTY: I mean, she was in a non-clinical role so she was not a risk to patients and at that time, we were still awaiting the next steps from the executive
management plan of their reviews of all of the care and what their next steps were going to be from external reviews, et cetera.
BROWN: And you say not a risk to patients. Were you aware of whether there were any restrictions on her movements within the hospital?
FOGARTY: So when she worked for me in risk and safety, she was office-based, she didn't need to attend, but I had her working with nothing to do with women and children's services whatsoever because I didn't feel that was appropriate.
BROWN: But in relation to her physical access to other areas of the building, was that something you ensured that she --
FOGARTY: I -- I wasn't responsible for that aspect of her, her work.
BROWN: But given your -- given the concerns --
FOGARTY: Yes.
BROWN: -- that had occurred to you after your exercise with Sian Williams and given your post of Director of Risk and Safety, was it not a matter of concern to you that you had someone who was still working in the hospital who potentially could have gone back to the neonatal unit?
FOGARTY: Well, she wouldn't be able to get in because
of swipe access. So you can't get into any areas of midwifery or neonatology without having swipe access and she didn't have access to get in.
BROWN: Was that something you checked or was it something --
FOGARTY: She's had that access taken. I knew she had had that access taken away from her.
BROWN: So you knew that access had been taken away. Do you know who made that decision to take that access away?
FOGARTY: No, I don't. But I checked when she joined my team because we had -- she needed access to join the office that one of my teams were based in where her desk was going to be, so I checked where her access was for and that's how come I know she did not have any access to --
BROWN: And related to that but on a rather wider scale, is, any restrictions on her practice by the NMC. Did you make any enquiries as to whether there were -- any restrictions had been placed on her practice, whether she would have been able to go and get a job somewhere else, for example?
FOGARTY: Well, she wasn't -- when she was working for me she wasn't working clinically, she was in a non-clinical role.
BROWN: But did you think about making those checks or did you discuss whether those checks had been made with anybody else on restrictions on her practice?
FOGARTY: Do you mean when she was in my team?
BROWN: Yes, so you became involved with her from April 2017. From that point, did you make any enquiries as to whether there were any restrictions on her practice or suggest that there should be restrictions on her?
FOGARTY: Well, at that time she was just -- she was working in an administrative role. She wasn't working in a clinical role.
BROWN: So is the answer to the question you didn't check?
FOGARTY: So I didn't check because I knew where she was working. She was office-based.
BROWN: And where was she physically working relative to you? Was it in the same room or just in the same --
FOGARTY: Not as myself, but she was working in an office with the risk and safety leads.
BROWN: And were you aware then that she was leaving on occasions to go to visit Alder Hey hospital?
FOGARTY: That was before I joined. So when that was happening I was still Head of Midwifery. That was prior to my movement to risk and safety. So I had no knowledge of that until I was in my questioning for the Inquiry.
BROWN: And once -- did you come to learn of that?
FOGARTY: Only when I received my pack --
BROWN: From the Inquiry?
FOGARTY: -- to do with the Inquiry. I didn't have any knowledge of that prior.
BROWN: What would have been your view as her day-to-day manager had she expressed the fact that she was taking leave to visit another hospital?
FOGARTY: Well, I wouldn't have -- I wouldn't have allowed -- I wouldn't have allowed that to happen. I would have had to escalate that to Alison Kelly.
BROWN: And why wouldn't you have allowed that to happen?
FOGARTY: Well, because I had done a, you know, a staffing analysis where, you know, there was an index of suspicion and so therefore you don't want someone, if they have been removed from clinical practice in our neonatal unit, I don't want them to go into another clinical area. So that's why I wouldn't have wanted that to have happened.
BROWN: And did you consider that from your perspective, while she was within your team sufficient,
consideration had been given to patient safety and safeguarding risks?
FOGARTY: I felt that had been given prior, yes.
BROWN: You were then present at Tony Chambers' briefing on 16 May, and we see -- we don't need to turn to it, but we see that you are recorded as having attended that?
FOGARTY: Yes.
BROWN: You recall that briefing, I imagine?
FOGARTY: Yes, yes.
BROWN: And you understood from that point that there was a police inquiry?
FOGARTY: Yes.
BROWN: And you understood that Letby was clearly going to be involved in that inquiry?
FOGARTY: Yes.
BROWN: Can we just look at the issues you found when you came to the role of being the Associate Director of Risk and Safety. In paragraph 152, you set these out. I am not going to go through them all, but just to highlight some of those. You say that: "Hundreds of policies were out of date." Can you just expand a little bit on that, that sounds quite a dramatic statement. What are you
referring to there?
FOGARTY: Yes. So all policies within the Trust have an end date on them because practice changes and they have to be reviewed and even if they remain the same they get reviewed and should have a new date on them. And I found that there were hundreds that were actually out of date. There were some policies that weren't even common practice, so it may be there had been a change and the policy had a new name but the old policy was still within the SharePoint document system.
BROWN: On the face of it that seems like too many policies. Was that also part of your conclusion?
FOGARTY: Well, there wasn't a good housekeeping system when old policies that were no longer valid were removed from the system.
BROWN: And just working down, then we see a bit further down: "Over 1,000 incidents in Datix that had not been reviewed."
FOGARTY: Yes.
BROWN: How did you -- how did you come up with that figure? How did you know --
FOGARTY: Because I pulled a report and it demonstrated that. So the -- because the serious incidents had been reviewed but there were a lot of low-graded incidents
that hadn't been reviewed.
BROWN: And you said before that it was only subsequently, but it wasn't that review that led you to your comment that you felt the neonatal unit weren't reporting things properly, this was a more general --
FOGARTY: These were actual incidents that had been reported so they are in the Datix system but they had never been reviewed.
BROWN: And that was -- there was no one unit that stood out in that?
FOGARTY: It was, it was -- it was across the --
BROWN: Across the board?
FOGARTY: Yes, apart from within midwifery but then we only had small -- we had small numbers. So it was much easier for us to keep on top of things whereas some areas, just by the nature of the work, had more incidents.
BROWN: And then going down a bit further, you say: "Inconsistent approach to risk across the Trust." Can you just give a little bit more -- develop that a little bit.
FOGARTY: Yes. So just in the make up of things like the governance boards, the items that went -- were received within Urgent Care and Planned Care, they weren't consistent. There were, were -- minutes were received. The way that the risk and safety leads maybe worked within the divisions wasn't consistent. Who attended what meetings. So someone from audit may attend one meeting but the -- the next division may not have somebody there.
BROWN: Underneath that, you refer to: "Out of date mandatory training package."
FOGARTY: Yes.
BROWN: Is that -- we looked at mandatory training used in the context of safeguarding before. Could that be a reference to that, is that --
FOGARTY: So this was the risk and safety, so all staff had risk and safety training as part of their annual mandatory training and the data and the statistics and some of the information that was in there was out of date.
BROWN: So that's not a reference to safeguarding?
FOGARTY: It is not safeguarding, no. It's the Trust.
BROWN: You say at the bottom: "Poor management of the risk register."
FOGARTY: Yes.
BROWN: Did that have any bearing specifically on not updating a risk register relating to neonatal deaths or is that not something you can recall?
FOGARTY: It is -- across the board in the Trust there wasn't consistency when risks registers were reviewed.
BROWN: And I think you end your list by saying: "This list is not all inclusive ..."
FOGARTY: No.
BROWN: And if we could just see -- pull up INQ0006771. My Lady, this is tab 12. This rather shows that whilst you have put it in your witness statement what was happening at -- in real-time, so to speak, because this is a message from David Semple on 16 June 2017, so about a month or so, six weeks or so after you were in post; is that correct?
FOGARTY: Yes, about that. Yes.
BROWN: It says: "Please be assured that Julie Fogarty (Interim Associate Director of Risk and Safety), Mel Kynaston (Associate Director of Nursing ...) and I are acutely aware of ongoing concerns around clinical risk within the Trust. To put it mildly, we have inherited a mess and the issues include to name but a few ..." So again, this is not an inclusive list, "previous poor leadership within the risk." Who are you referring to as previous poor leadership?
FOGARTY: Who's -- who is he referring to? He is referring to Ruth Millward.
BROWN: And it says risk and complaints team. This is obviously an email sent on behalf of you as well. Were there other people who were considered to be not performing?
FOGARTY: No. No.
BROWN: And going down to the last bullet point, it says that: "A plethora of committees and boards within the Trust with no clear reporting or escalation structure." Now we have been through minutes and reflected, do you think it would be fair to put the Women's & Children's Care Governance Board and QSPEC within that description of boards where there was no clear reporting and escalation structure?
FOGARTY: I think it could be improved upon definitely.
BROWN: Then if you just turn to paragraph 154 of your statement. You say there that you don't feel the issue with the risk processes across the Trust contributed to the failure to identify the risk Letby posed to babies. Can that -- can that really be the case given what I have highlighted some of the risk that involves not escalating, risk registers, inconsistent approach, policies being out of date, Datix not being reviewed.
Surely that, in logic, must have contributed?
FOGARTY: The reason I came to that conclusion was that it is obvious, though I didn't know it at the time, but it was obvious from the reports in the media and information within my pack, that the paediatricians had concerns for a long time and they had taken them to the Executive team to escalate their concerns and so even if you had all these processes, they had taken them to the Executive team. So that's why I felt -- possibly that's why I felt that at the time when I wrote my statement.
BROWN: But having gone through the exercise we have gone through today, would you accept that these issues with risk were a contributory factor --
FOGARTY: Oh certainly.
BROWN: -- to an environment where this was allowed to happen?
FOGARTY: Yes, certainly as time has gone on and since I have produced my statement I've been aware of more facts. Then yes.
BROWN: And yes, yes, it was part of the environment that allowed these circumstances not to be investigated earlier?
FOGARTY: Yes, yes.
BROWN: Is that a correct --
FOGARTY: I would agree, yes.
BROWN: You talked very, very briefly and we may have covered this sufficiently but about your annual safeguarding. Can I just be clear that this was training that you were having in 2015 and 2016?
FOGARTY: Yes.
BROWN: And you say, as well, when you are dealing with the safeguarding that you were trained in SUDiC, so that's Sudden Unexpected Death in Childhood. Was it your understanding that that process, referring to the SUDiC process, would be used if there was a sudden unexpected death of a baby in hospital, so a baby that's born in hospital and has never gone home?
FOGARTY: So my understanding is that the neonatal team would refer that baby to that, that person.
BROWN: So that would be your understanding that --
FOGARTY: That would be my understanding.
BROWN: -- albeit it is not a death at home so there is no suggestion --
FOGARTY: But because it was unexpected then I would still expect that that was the process they follow.
BROWN: And did you in your work ever have to refer a baby on --
FOGARTY: No, because it wouldn't be in my, my sphere of practice.
BROWN: And then, finally, if we can just go to your reflections that you helpfully set out at the end of your statement, and at paragraph 169 you say: "The ... steps I consider could have been taken to potentially identify earlier that Letby was harming babies on the NNU was a more comprehensive deep dive into the initial increase in mortality, including staffing analysis by an external team." Is there anything you want to add to that by way of detail so that we can understand exactly what, as I understand it, where you feel a wrong turn was taken?
FOGARTY: No, I think, I think I am fairly clear there. I felt that right at the very beginning the Trust should have engaged an external team to do a comprehensive review of the three cases involving in that review staffing involved, et cetera, to try and see if they could find a potential issue.
MS BROWN: Thank you very much, Mrs Fogarty, those are all my questions. Mr Jamieson will now have some questions.
LADY JUSTICE THIRLWALL: Very well.
MR JAMIESON: Is it Mrs Fogarty or would you prefer some other title?
FOGARTY: Yes, that's fine.
JAMIESON: Mrs Fogarty, my name is Alex Jamieson. I ask you questions on behalf of some of the Families.
FOGARTY: Right.
JAMIESON: All right? Can I start, please, by taking you back to something you dealt with at the start of Ms Brown's questioning. This Inquiry has received a deal of evidence about the impact of the change in the governance structure, three divisions to two, at the Countess and you gave a personal example of that in your Facere Melius interview which I think it would be useful for us to reflect on. So please could we have on the screen INQ0012993. So this is your interview on the -- in July of 2020, and can you see in the first entry ascribed to you, the top of the page, it says that what you are telling the interviewer is that at the point that the hospital had been reorganised, you had been a matron across women and children's services?
FOGARTY: Yes.
JAMIESON: And so before it was reorganised, I'm sorry I am not looking at you, I am talking this way so the microphones pick me up.
FOGARTY: Yes.
JAMIESON: You had had responsibility not just for maternity but also for neonatal services?
FOGARTY: Yes.
JAMIESON: And so you very personally felt that reorganisation because after it had happened, your responsibility for neonatal services was taken away.
FOGARTY: Well, the structure changed but my job -- my job role changed as well.
JAMIESON: Yes.
FOGARTY: Yes.
JAMIESON: And so we have understood how generally it changed across the hospital but for you, in particular, that was a change in your responsibility and your approach, and you set out in the rest of that paragraph what that meant for the management and governance structures -- I don't need to take you to that. But could we go on, please, to page 8 of this document. There just in the middle of the page you have talked about something else and the interviewer has taken you back to this theme and he says: "I'm just trying to put myself in that sort of time frame. You have been working for five years in this structure at this point." And you go on to give a description of what it was like and you say these words: "Silo working. It was true silo work." And you go on to explain that on the staff -- on the shop floor, on the clinical floor, the neonatal staff and midwifery staff were doing well but as soon as you got above that into the governance structures it was complete silo working. And I'm just wondering that phrase "silo working", what did that mean to you, why did you use that?
FOGARTY: So instead of working jointly like we would do previously in the old -- when it was a women and children's services, we were working independently and feeding up through a different structure. So maternity services were feeding up through Planned Care and a Planned Care Board and the neonatal services sat on -- so it was a change in practice. Whereas we were used to all being sat round the table and reviewing and discussing, that's not how it was in the future. It was two completely separate divisions.
JAMIESON: And by this point, that is 2020, your job in the Trust has been this Director of Risk and so it's well known in the management of risk that silos of information are dangerous; am I correct?
FOGARTY: They are not -- they are not beneficial.
JAMIESON: No.
FOGARTY: They are not necessarily dangerous. But they are not beneficial.
JAMIESON: Well, if I am going to manage a risk I need all of the relevant information, wherever it may be, and if that information is in different silos I need to be able to get hold of it; is that accurate?
FOGARTY: Yes.
JAMIESON: And so what you were reflecting here is that the arrangements that had been made in the Countess had led to the information being siloed?
FOGARTY: Yes.
JAMIESON: I think what I and The Families would be grateful for your reflections upon is how that siloed approach was relevant to the risk that was presented by Letby in 2015 and 2016. So I would just like to ask you some questions about that, if I may. That can come down, thank you, Mrs Killingback. Can we move, please, to the 2 July Serious Incident Panel.
FOGARTY: Yes.
JAMIESON: I know you have answered quite a lot of questions about that already. Just before I ask you my questions, can I just contextualise that moment in time. What has happened in the lead up to that meeting is that three children have died in two weeks in June, all of those deaths were sudden, all of those deaths were
unexpected. Those are Children A, C, and D. Another child, [Child B], the twin of [Child A], has also seriously collapsed and required resuscitation within that period. The other fact that we need to build in is that the cause of death for each of those three children was at that stage uncertain. They had all been referred for post-mortem and indeed a Datix had been raised for each death. Okay?
FOGARTY: Yes.
JAMIESON: So that's the situation --
FOGARTY: Yes.
JAMIESON: -- as you come to deal with the issue on 2 July 2015. I wonder if next, please, we could have on the screen your notes of that meeting. Those are INQ0003530. Thank you. Please may we just zoom in on that top bit of the page. Thank you. So we can see this is dated "SUI Review, 2 July '15" and to the right of that you have given the initials of the attendees. Yes?
FOGARTY: Yes.
JAMIESON: Yes, okay. So we have got the right document. Now, just before I ask my question, you have said a number of times to us in your evidence that you were
not a neonatologist, you didn't have any expertise in that area and what I am interested in, please, is your understanding of what your purpose and role was in this meeting. Because what we can see when we look at the records that you have taken is a line or a section for each child, they are identified on the left as [Child A], [Child C], and [Child D], a short description of some particulars and then on the right-hand side of the page, in relation to each one you have recorded the OSR -- is that the obstetric secondary review?
FOGARTY: Yes.
JAMIESON: Is that what that is? And that there were no M -- is that MW issues?
FOGARTY: So this note, the bottom bit with -- it didn't have [Child A], C, D.
JAMIESON: No.
FOGARTY: It will have had the date -- it will have had a Datix number.
JAMIESON: Yes.
FOGARTY: And that section underneath was written before I went to the meeting because I knew what I was going to discuss and I had to review the care from a midwifery aspect because that was my role at this meeting; was to take the midwifery aspect. I obviously added who was there when I got there.
JAMIESON: Yes.
LADY JUSTICE THIRLWALL: So when you were asked what does "MW" stand for --
FOGARTY: It's midwifery, no midwifery issues. MR JAMIESON: Really it is that answer that you have just given that I am particularly interested in. Your role at this meeting, as you understood it, was to take the midwifery information --
FOGARTY: Yes.
JAMIESON: -- and to come back with any midwifery actions?
FOGARTY: Yes.
JAMIESON: Right. So does that mean you did not understand it to be any part of your role to challenge professionally or evaluate the information that the other specialists were bringing?
FOGARTY: Obviously if I had concerns then yes, but at this time I trusted the information, as did everyone else at the meeting, that was being provided by a neonatologist.
JAMIESON: Yes. I just, if I may, I would value your reflections on this issue because it's clear from what you have written that we have read that there were no midwifery issues identified or present in relation to
the tragic deaths of these three children, right? Seen from the midwifery perspective, that is a reassuring fact, isn't it, because it means we haven't done anything wrong?
FOGARTY: It means the care provided didn't -- yes.
JAMIESON: But if I am standing back and looking at it in the round, holistically, I have three deaths that have all been sudden and unexpected, no cause of death is identified, and there is nothing in the midwifery care that can have explained why these children died. That's a concern, isn't it?
FOGARTY: It is now but obviously, you know, nine years down the line when I am looking at this, my actions would be different than they were taken at that time.
JAMIESON: To be clear, this is not -- this questioning is not directed at you personally, I am trying to understand what is going on in the meeting.
FOGARTY: Yes.
JAMIESON: All right? So that thought process that I have just set out for you, if there are no shortcomings in the midwifery care, that raises at least the possibility that there is something else that we are not seeing; was that thought process present in the meeting and, if so, who was it voiced by?
FOGARTY: I would say that thought process wasn't
present in that meeting, I would say. Though it's nine years, it's a long time ago.
JAMIESON: Okay. There is one document that may help. That can come down, thank you very much. It's the Datix report for [Child D], that is INQ0002658. Just while that's coming up, were those Datix reports available to you in the meeting? Were they considered by the attendees beforehand?
FOGARTY: So the Datix were not brought up in that meeting.
JAMIESON: No. Had you seen them beforehand?
FOGARTY: So I wouldn't have seen -- I hadn't seen the baby element but obviously the mother, yes, because we would have done the review that would have then gone into the Datix. But no, not the -- not the baby information.
JAMIESON: Okay. How does that work? So you log on to the system to see the Datix.
FOGARTY: The risk and safety lead, they, they pull the incidents. So, for us, once there is an incident we look at all of the midwifery care.
JAMIESON: And so, going back to my question about your reflections on silos, even as you prepare for this meeting, even as you look at the Datixes, you are only
looking at the bit that relates to midwifery care?
FOGARTY: Well, that's because you can't look at something you have not got the clinical expertise to interrogate data. So that isn't silo working, that is just a specialty reviewing care, that it's got the expertise to be able to interrogate and challenge.
JAMIESON: Okay. Well, let's, if we may please, look at page 2 of this document, and just zoom in on the top half of that page, please. Thank you. Now, can you see -- this is a little involved, so bear with me. Under "Incident investigation" there are a number of entries that have been made by Debbie Peacock that are and then Dean Bennett that have been timestamped. Can you see the third one of those that's timestamped 23 July '15, if you look over on to the right-hand side there are in fact a number of earlier timestamps and it's the earliest one of those that I am interested in. 24 June 2015, 10:45:05 Debbie Peacock. So it is on that line just across to the right-hand side in the body of the text. And Debbie Peacock was an attendee of the SUI meeting, wasn't she?
FOGARTY: Yes.
JAMIESON: What she's recorded is: "Just to confirm that I have met with Eirian and reviewed the case notes of [Child D] who died in the early hours of this morning. We have also discussed whether there are any other issues to address in the view of the two other recent sudden deaths on the NNU so all deaths are brought together. In regard to those three deaths, all deaths occurred in Room 1, our intensive care room but in a different cot space, all microbiology results have been negative to date, initial post-mortem result for [Child A] did not identify a definite cause of death." A point that I have made with you already. There is a bullet point about a TPN bag and why that makes a particular infection unlikely, but then the fourth bullet: "There does not seem to be any staff, medical or nursing members present at all three episodes other than one nurse, who was not the nurse responsible for [Child D] on that shift." Or putting that the other way round, there was a member of staff who was common to all of those three deaths and that entry, as I understand this record, is timestamped as having been made on 24 June '15, so a week or so before your meeting. I take it from your answer that you didn't read that before the meeting?
FOGARTY: No. No, because that is a neonatal entry so
I read the obstetric elements.
JAMIESON: But does one need to be a neonatologist to look at that and say: well, that is a common factor, we don't know if that's relevant or not. We had better think about it?
FOGARTY: Well, I would have expected this level of information to have been -- to have been presented by either Debbie Peacock who wrote it or the paediatricians who were aware of this information. That was the purpose of the meeting. I was given the remit of looking at the obstetric, I wasn't asked to review neonatal records. I was asked to take the obstetric element and that's what I did.
JAMIESON: Just with your Director of Risk hat on, if I can use that vernacular, is that the right approach?
FOGARTY: It obviously isn't now, but at the time I did the task I was given, so I was given the task of reviewing and bringing the obstetric information and that's what I took to the meeting. However, hindsight is a great thing.
JAMIESON: Yes. Okay. And the final question just to ask you to confirm this, please. We know from other evidence, I am not going to ask that it comes up on the screen, but for the record of the transcript, INQ0025743, it is the email from Dr Gibbs reflecting
Registrar concerns, that before this meeting Registrars had or a Registrar had visited a Consultant and said: we are concerned about these sudden collapses, we are concerned that there is a common and unusual rash that none of us have seen before but it's happened in three of these cases. We don't know what's happening here. Was that information brought to your meeting?
FOGARTY: This is the first time I have even heard of that.
JAMIESON: Okay, thank you. Those are the end of my questions then about that meeting. Can I just please then move briefly to talk to you about QSPEC, the Quality, Safety and Patient Experience Committee. Could we look very briefly at the 20 July 15-minute, so that's INQ0003211, and I am looking at page 2 to begin with, please. So I'm just going to note in passing, again for the transcript and for my Lady's note, that Dr Brearey has attended this meeting -- it's at the bottom of this page -- particularly to talk about the Morecambe Bay Kirkup report and about the risks to neonatology that were presented by the current divisional structure, okay? So that was a topic for discussion at that meeting.
I don't have a question for you about it. Thank you. But may we go, please, to page 5 of this document. At item 11, the agenda item is "SUI update and other incidents" and there are a discussion of a number of incident reviews that have been raised to this meeting and taken place. Now, the 2 July '15 meeting was a Serious Untoward Incident Review. That does not seem to have been discussed at this meeting, some three weeks later. Should it have been?
FOGARTY: I mean, it obviously wasn't, but I can't, you know, I don't know why that wasn't tabled at that meeting.
JAMIESON: I didn't work in this hospital. Was that the sort of reports, the sort of meeting that should have been tabled here?
FOGARTY: I mean, certainly it should, the, the concern should have been escalated further.
JAMIESON: I mean, in terms of escalation, Alison Kelly, the Director of Nursing, was in that meeting, so she would have had --
FOGARTY: She called that meeting.
JAMIESON: She called the meeting?
FOGARTY: Yes.
JAMIESON: She was aware of everything that was discussed. Could she have brought that to this meeting? She wouldn't have had to escalate it to anybody, she knew about it. Is that a fair inference?
FOGARTY: Sorry, can you --
JAMIESON: Is that a fair inference, is that a fair comment that I have just made that she was aware of those --
FOGARTY: Yes, she was aware. Yes, she called the meeting. She was fully aware.
JAMIESON: Okay. Thank you. That can come down. In relation next to the Brigham report as it's been called.
FOGARTY: Yes.
JAMIESON: You told us that there was an awareness that there had been an increase in the number of deaths from your perspective, stillbirths and neonatology deaths, and so the review had been commissioned. What I was interested in, please, is how did you capture that information that there had been an increased rate of mortality?
FOGARTY: Data.
JAMIESON: What does that mean? What did you actually do or who did it?
FOGARTY: So within data -- well, for a start the
Consultant obstetricians would be aware from being based on the labour ward, but from Datix.
JAMIESON: Okay. So who is it who is going into Datix on your side to notice those trends, to identify them and to action them with the review. Who's doing that work?
FOGARTY: So not only the risk and safety leads but all of the ladies who have stillbirth, they have a Consultant review, they go to the Pregnancy Risk Clinic, and also the neonatal deaths were having an obstetric secondary review. So because of an index of suspicion, we ran a Datix report.
JAMIESON: So but -- so you have identified I think the risk leads on the unit, they were the people who were actually doing this?
FOGARTY: There is one risk lead for women and children's service, and they were asked to pull a report for us.
JAMIESON: Okay. And who made that request?
FOGARTY: I can't remember.
JAMIESON: But it sounds like it was a matter of discussion between you and the clinicians?
FOGARTY: It was -- it was myself and the Consultants but I couldn't tell you exactly who will have said pull, pull the list, due to the time lapse.
JAMIESON: Because do you see what -- the direction of my question? The data might be there on the Datix --
FOGARTY: Yes.
JAMIESON: -- but somebody has to be prompted to go and draw it out. That hasn't happened in the NNU until later and so really I am trying to understand the process on your side, how that worked, and why it might not have worked on the other side.
FOGARTY: I can't answer for why it didn't work in neonatology because I wasn't responsible for this area of practice. But from a midwifery and obstetric point of view we were constantly looking at what was happening in our area and what our outcomes were.
JAMIESON: Okay. And there was that discussion between the senior clinicians --
FOGARTY: Yes.
JAMIESON: -- and you that crystallised that understanding?
FOGARTY: And we felt that the only way forward we could be assured that we didn't have a problem was to do a review and being open and transparent we invited an external Head of Midwifery from the Manchester network to join that review.
JAMIESON: Did you consider inviting neonatologists to
join your review?
FOGARTY: No, because it was purely a review of obstetric care, so they wouldn't be able to contribute to reviewing whether people were on the right pathway or had the right drugs, et cetera. We were also aware that they would be doing a review of their own.
JAMIESON: How did you have that awareness?
FOGARTY: One of the -- one of the Consultants had said, "Well the paeds are doing a review as well." So it was a verbal -- that we had been told verbally.
JAMIESON: But the Brigham review, as I understand it, is finished in November?
FOGARTY: Yes.
JAMIESON: It's presented --
FOGARTY: In December.
JAMIESON: -- in December.
FOGARTY: Yes.
JAMIESON: And there is nothing from the neonatology side in November, there is nothing in December.
FOGARTY: I can't account for the practices within the neonatology unit.
JAMIESON: No. You have been asked -- you have already candidly conceded, and I am grateful, that on reflection looking at that Brigham report it is potentially misleading.
FOGARTY: Definitely, definitely.
JAMIESON: Right. And may we please just look at -- it is a document we have looked at before but we are going to look at it again briefly, if we may. It is the emails with Alison Kelly.
FOGARTY: Yes.
JAMIESON: INQ0003220. So we start at the bottom. So the question is coming to you on the 2 December by which time the Brigham report has been produced but it has not been presented.
FOGARTY: Yes.
JAMIESON: "Hi, where are things up to with the thematic review? I am keen to get a paper to the December QSPEC." Now -- and you reply: "Hi, the updated midwifery element was received in November at QSPEC. It was the paed update that was missing." Now, it may be suggested that Alison Kelly was one of those who received the report and was misled by it to begin with, thought it was a comprehensive document --
FOGARTY: No, no.
JAMIESON: -- rather than just obstetrics?
FOGARTY: No, because Alison Kelly emailed myself and Ruth Millward on 2 December. So myself, for the obstetric, and Ruth Millward, for the neonatal, because Ruth Millward played no part in our decision to review or our review. And she's also copied Ian Harvey into the email. So that's why I said it was the paed element that was missing and so that's why Ruth was copied in because then she would be chasing up the neonatal element.
JAMIESON: Yes. So you have said that in terms, haven't you, on 2 December, the updated midwifery element was received in November, that document that I gave you in November was the midwifery element, it's the paed update that's missing.
FOGARTY: Yes.
JAMIESON: But her reply at the top of that: "Hi, sorry if I haven't been clear. I mean the thematic review of neonatal/deaths recently undertaken ..." I don't, in fact, think I can put any particular -- it will be for her to explain what that meant.
FOGARTY: So that, that is the neonatal review.
JAMIESON: Yes. Which you have said in the email below is midwifery element only, and just to bottom this topic out, please, can we go to the minutes.
FOGARTY: Because Alison Kelly has written at the top: "Despite terminology below this was an obs/maternity review." That's Alison Kelly's handwriting.
JAMIESON: That's her handwriting? That's really helpful. Thank you. So that's the manuscript --
FOGARTY: That's Alison Kelly's handwriting at the top, I recognise that.
JAMIESON: That's really helpful. Thank you. Because I just -- in that light, I would just like to look at the minute of the December QSPEC, please. That is INQ0003204, and can we start at page 11. It may be that I have given you the wrong --
LADY JUSTICE THIRLWALL: Do you mean page 11 or paragraph 11? MR JAMIESON: I mean page 11 but that was not the document I was expecting.
LADY JUSTICE THIRLWALL: I think you might mean paragraph 11, 0005. MR JAMIESON: So what I was hoping to see was the minutes of the QSPEC committee.
LADY JUSTICE THIRLWALL: Yes. You have given the right reference. MR JAMIESON: I have, okay, it is just not what has come up in front of me.
LADY JUSTICE THIRLWALL: I hadn't noticed that. MR JAMIESON: And my Lady is quite right. It is paragraph 11, not page 11. It is page 5, please. Right. Now, my learned friend Ms Brown took you to this paragraph and I am not going to repeat what she's done already. It is the minute of your presentation of the neonatal and stillbirth review. What I would like to do, though, is having orientated us there, just go over the page to page 6, because the final sentence says: "Mrs Kelly thanked Ms Fogarty and the team for the report and the assurance it had provided to the committee." Now, as I understand your evidence, your explanation to QSPEC had been: this is our report, it only deals with maternity, we have not found any shortcomings with it, we have an action plan to pick up the items of improvement that we have identified.
FOGARTY: That's correct, yes.
JAMIESON: That's accurate?
FOGARTY: Yes.
JAMIESON: And so nobody listening to that should have taken assurance that it answered concerns on the neonatal side.
FOGARTY: No, because they were aware of my remit. I made it clear it was obstetric and maternity only and Sian Williams in her statement makes reference to the fact that this report was an obstetric report only which confirms that that's what I verbally said at the meeting.
JAMIESON: Yes. There are no -- what you had also said in that email that we looked at a moment ago was that the neonatal review was still outstanding.
FOGARTY: Yes.
JAMIESON: But there is nothing here in terms of an action or a plan taking forward that suggests the committee were awaiting that report or expecting that report.
FOGARTY: No, it's not evident in that and I -- no, it's not evident in these minutes. But that would be something for Alison Kelly and Ruth Millward to chase outside of the meeting.
JAMIESON: That was your expectation?
FOGARTY: That would be my expectation.
JAMIESON: But didn't QSPEC have a role in monitoring these issues, making sure that actions were completed?
FOGARTY: Definitely, yes.
JAMIESON: So if, on this very serious issue an increase in neonatal deaths and stillbirths, half of the review
has been completed but the other half hasn't, shouldn't that have been formally on the agenda for future QSPECs?
FOGARTY: Well, I don't know whether, aside from the meeting, whether there were any emails being sent to the relevant people asking where the reports were. Because I wouldn't be privy to that information.
JAMIESON: But as somebody who sat on this board, if I come to the next meeting of this committee and I am asked to review the minutes, I am not going to be looking, I am not going to be prompted to look for any additional review from the NNU in relation to these deaths. I am going to read that and it says, "Assurance has been provided, no further actions."
FOGARTY: I suppose that Alison Kelly knew that there was a need for a neonatal review as did Ian Harvey, the Medical Director.
JAMIESON: Okay, thank you very much. That can come down. The final topic is different to everything that we have talked about before and it comes from one of the Families that I represent and the concern that's raised is about the use of mobile telephones on the NNU. Now, I know that you didn't work on the NNU --
FOGARTY: Yes.
JAMIESON: -- and so I am asking you really from your
position of Director of Risk, okay? So the risks that are or have been identified by Mother E/F in the evidence that she has heard, in the criminal trial and here, in staff using their mobile phones on the unit is principally a blurring of the lines between the personal and the professional because this Inquiry and indeed the criminal trial have received evidence of messages between clinicians, of friendly run-of-the-mill conversations, lighthearted social conversations, that then have interwoven an exchange of deeply personal and often tragic personal data that related to the children who died. And the question is: was that a risk that the Trust was aware of at the time that you were Director of Risk Management?
FOGARTY: So this is the first time I have heard that piece of information.
JAMIESON: Okay.
FOGARTY: It wasn't something that I was familiar with.
JAMIESON: Okay. Were there any policies or rules that governed the use of personal mobile telephones on the NNU?
FOGARTY: Not on the NNU, no. I would say that mobile personal phones were used not only in the Countess but widely throughout all of the NHS because staff are not
issued with a works telephone.
JAMIESON: But if that risk that I have identified is present, that measure that you have just mentioned, the issuing of a staff telephone, might be an effective one to reduce that risk?
FOGARTY: I mean, it's very sad to hear what you have said about the, you know, the messages. I can say I had no personal knowledge of that until you have just raised it now. MR JAMIESON: Thank you very much. Those are all my questions. Thank you, my Lady.
LADY JUSTICE THIRLWALL: Thank you very much, Mr Jamieson. I have no questions for this witness. We are finished now?
MS BROWN: Yes.
LADY JUSTICE THIRLWALL: Thank you very much indeed, Mrs Fogarty, you are free to go. Are we going to take the break now?
MS BROWN: I think that's the suggestion and then there is going to be a summary of evidence after the break.
LADY JUSTICE THIRLWALL: Very good. We will recommence at quarter to 4. (3.28 pm) (A short break) (3.46 pm)
LADY JUSTICE THIRLWALL: Yes, Ms Lyons.
MS LYONS: My Lady, this is the summary of the evidence of nurses and midwives.
LADY JUSTICE THIRLWALL: Thank you. Summary of Evidence of NURSES AND MIDWIVES
MS LYONS: My Lady, the Inquiry local team sent Rule 9 requests to 30 nurses who were involved in the clinical care or management of babies on the indictment at around the time of collapse and/or death. 20 other nurses who worked on the neonatal unit and all 14 midwives who appeared in the hospital staff list were sent questionnaires. Any individual who worked there during 2015 and 2016 and who considers they might have relevant evidence to give the Inquiry should contact the Inquiry. It remains the case that the Inquiry remains open throughout the course of these oral hearings to receive such evidence.
This is a summary of the evidence of nurses who are not being called to give oral evidence. Collectively, they have provided 22 witness statements and completed 20 questionnaires. This summary also incorporates the evidence of the midwives. The nurses and midwives have responded to specific questions in connection with the issues under investigation. We are grateful for their co-operation which is of assistance to the Inquiry's work.
This summary sets out their responses to questions about the culture and atmosphere on the NNU between 2015 and 2016, suspicions or concerns about Letby, the mortality rate, and what changes should be made to keep babies in the NNU safe from deliberate harm.
Culture and atmosphere on the NNU at the hospital from 2015 to 2016. Many of the nurses concerned described June 2015 to June 2016 as a particularly busy period on the NNU. Christopher Booth, a Band 6 nurse, who had been working on the NNU since 1993 recalled it being: "... an incredibly busy period with high acuity and it was a demanding time for all team members. As so much time has now passed my memory is somewhat sketchy but I do remember team members being asked to show greater flexibility with shifts worked and indeed even being asked to work extra shifts on a regular basis. I do remember grumblings of us needing more registered nurses to help cope with the increased workload but that did not seem to be forthcoming."
Lisa Walker, a Band 4 nursery nurse, had been providing clinical care to special care babies since 2008. She described this period as: "... very busy and stressful on the unit. We would sometimes miss breaks because it was that busy. Staff morale was low because everyone was tired. However, I always felt supported and valued."
Most of the nurses commented positively about the quality of management, supervision and/or support that they received during this period from the NNU ward manager Eirian Powell and the deputy ward manager Yvonne Griffiths. Of the Band 6 nurses concerned, Laura Eagles described the ward manager and deputy ward manager as "very present, approachable and strong in their leadership". Caroline Oakley also described Eirian Powell as "approachable, helpful and supportive", as did Ailsa Simpson who stated that Eirian Powell was "supportive and appreciated all our hard work as a team during an extremely difficult period." Other Band 6 nurses such as Caroline Bennion described Eirian Powell and Yvonne Griffiths as "very supportive, approachable and proactive with personal development. Learning opportunities, study days, and courses were often recommended and encouraged".
Both Joanne Williams and Amy Davies said they felt supported within the nursing team and were encouraged to further their qualifications and training. Nurse X noted that Eirian Powell was "open to general concerns or issues being raised". She also said: "Eirian Powell could be defensive of nurses on the unit and would generally support nurses if issues were raised by doctors, for example. That said, she had obvious favourites amongst the staff as well as a couple of staff that she clearly did not like. This meant that her response to issues, incidents varied depending on who was involved."
Belinda Williamson described Eirian Powell as "generally very supportive and fair". She also stated: "If I had a problem she was approachable and would generally work with me to solve the problem. She would often ask for the problem to be put in writing if she felt it was necessary to have a record of the issue. She encouraged the team to actively fill out Datix. Eirian supported us with trying to ensure we had adequate staffing levels and often asked us to enter a Datix if staffing levels were insufficient."
As regards the deputy ward manager Yvonne Griffiths Belinda Williamson commented that she worked well with Eirian Powell: "They balanced each other out and appeared to work well together." She expressed the view that: "At times it did feel that some staff were given opportunities based on who they were, not their abilities and/or experience. Staff were encouraged to improve their knowledge and skills through further training and education as well as secondments at tertiary centres. At times it felt staff were allocated infants above their capabilities due to the workloads occurring within the unit, relying on the nurse in charge or senior nurses to oversee their work."
Anne Murphy was the "matron of the women and children's ward", known in the Inquiry as the Lead Nurse for Children Services. Ailsa Simpson described Anne Murphy's management style as "very supportive". Nurse Y gave similar evidence. She said that Anne Murphy was: "Always contactable and supportive in the absence of management on the NNU".
Minna Lappalainen was less positive about the hospital's senior management who she felt "didn't support us or listen to staff or the NNU manager". She expressed the view that "our staffing levels remained poor at times especially during busy periods. This period was stressful and exhausting at times."
Bernadette Butterworth, Mary Griffith, Sophie Ellis, and Samantha O'Brien were Band 5 neonatal nurses in 2015/2016. They all describe the management on the NNU as supportive. As a junior Band 5 nurse working on the NNU between 2015 and 2016, Sophie Ellis found the nursing managers "supportive, approachable and knowledgeable". She felt able to talk about personal and professional matters with the nursing managers and felt "they listened to [her] with compassion". Bernadette Butterworth recalled there being a good team spirit where the nurses would all support each other. Of the Band 4 nursery nurses who had dealings with the NNU managers the majority reported feeling largely supported. Jean Peers said: "I would describe the quality of management and supervision as supportive, close and caring, as were the nurses on the NNU." However, Cherryl Cuthbertson-Taylor experience of the culture and atmosphere on the NNU differed. She said: "My line manager between 2015 and 2016 was supportive and did pass on any concerns I raised regarding staffing levels to her manager. I found the unit very stressful during this period due to increasing staff shortages and the increasing workload that was being expected of a Band 4. Even though I was an experienced Band 4 nurse I had not seen the staffing issues as bad as I had in 2015 to 2016. I was being asked to complete tasks that I was under qualified for, ie babies that required a Band 5/6 nurse. When I raised these concerns to fellow colleagues I felt very under supported."
In 2015 to 2016 Claire Bevan worked predominantly night shifts as a Band 6 bank nurse on the NNU. During these shifts she described either being in charge or second in charge of the NNU, co-ordinating staffing and care and allocating patients and staff for the shift as well as supporting staff. As to the quality of the management of the NNU between June 2015 and June 2016, she said: "Some staff found management more approachable than others. The unit generally felt neglected by senior management as we were constantly short-staffed and it appeared they weren't listening to our requests for help. If we had sickness on shifts it was always very hard to get help from other areas of the hospital. We felt like we were on our own. I think people were frightened to come and help because it was such a niche area of nursing."
Each of the nurses was asked to describe the relationship between (1) clinicians and managers, (2) nurses, midwives and managers, and (3) between medical professionals -- doctors, nurses, midwives and others -- at the hospital between June 2015 and June 2016. Several of the Band 6 nurses gave evidence that there was a good relationship between the neonatal nurses and the doctors.
Laura Eagles recalled that the nurses worked well with the doctors, particularly the Registrars and senior house officers. She describe the Consultants as approachable. Joanne Williams also commented on the close working relationship the nurses had with the Registrars who she recalled were present on the NNU most of the time when acuity was high. She described the relationships across the different professions as professional. Nurse Y described the Registrars who were allocated to the NNU as very experienced and appeared to have a good rapport with the nurses. As regards the nature of the relationships with the Consultants she said she had "worked on the unit for a long time" and that she felt she had "a good rapport with Consultants". Ailsa Simpson recalled there being stressful periods at times. She stated: "Sometimes when a baby required a review by a doctor they wouldn't always be available to attend straight away as they would be reviewing patients on the children's ward first. Overall, despite the [busyness] of the NNU, the doctors and nurses on the NNU collaborated well together as a team and the atmosphere was happy at times despite the stressful phases."
Belinda Williamson noted: "There was frustration with the medical team at times due to lack of cover for neonates, especially overnight, or if the team became busy on A&E or on the paediatric unit." Christopher Booth described the relationship between the medical professionals during this period as good. He also said: "We were a strong, mutually supportive team and all worked well together for the well-being of our babies and their families. My only slight concern though, and it is a concern that I have held for some time, is that we at the Countess of Chester Hospital really could have benefited from the expertise of a neonatologist who could offer more specific, focused and cutting-edge expertise in this very specialised field."
Abigail Lever, a Band 5 neonatal nurse stated that there has "always been a really good relationship between doctors and nurses." In 2015 to 2016, Band 5 neonatal nurse Satasha Culshaw worked ad hoc shifts on the NNU that required cover. She cared for special care and high dependency care babies. She said: "The staff I worked with all had a strong sense of teamwork ... I felt there was a good sense of teamwork between all members of staff that I worked alongside. I never got a feeling that there were any issues between colleagues."
Janet Cox, a Band 4 nursery nurse who had worked at the hospital from 1986 to 2022 stated that she did not have a clear memory of the relationships between clinicians and managers and medical professionals. She also stated that she did not wish to comment "as [her] view the Trust and various so-called medical 'professionals' is prejudiced by the horrendous way they treated Lucy, (Ms Letby)".
As to the relationship between neonatal nurses and midwives, Laura Eagles described this as: "More complex. "We as nurses would directly liaise with midwives. There was very little communication between us and the obstetricians. If we had challenging conversations to have, we would ask our Consultants to speak with them. We would sometimes face discord from some senior midwives and ourselves. This would be in relation to when we were heading to full capacity or already at it and the midwifery team not valuing our concerns. It could be quite a struggle sometimes when we were full and then wanting to deliver a baby that would need our care and us not having room. We would ask them for help and some appreciation of our situation but would not get it. I cannot say this was all the time but it was quite common to have a struggle when we were getting full and/or closed. If we as an NNU team felt the best thing for the pending admission was a transfer out, it would be very difficult to make this heard by the obstetric team." In her evidence to the Inquiry, Caroline Oakley discussed the strain in the relationship between the NNU and obstetric teams when the midwives/obstetricians did not accept that the NNU was at full capacity and could not admit any more babies. She said that neonatal nurses would report such incidents via an online reporting system, Datix.
Susan Morton was employed by the hospital as a Band 6 rotational midwife in 2015 to 2016. She worked on the central labour ward, antenatal/postnatal ward and within the maternity day unit. She described the extent to which she carried out work on or in connection with the neonatal unit between 2015 and 2016 as follows: "If I was working on the labour ward and a baby required any care or observation on the neonatal unit immediately following birth, the baby may have been transferred to the unit by the neonatal team. I would complete a situation background assessment and recommendation handover to a member of the NNU team. This is a recognised tool we use in medicine to give a clear and concise handover and would detail any relevant risk factors from the mother's pregnancy, labour and delivery. When working on the postnatal ward a nursery nurse from the NNU would be allocated to the ward's transitional care room. This was a 3-bedded bay and may include, for example, babies who were slightly premature requiring additional observation, feeding, support, temperature monitoring, or phototherapy. As midwife I would be caring for the mother and the nursery nurse would be responsible for the care of the baby. In these situations I liaised with the neonatal nursery nurse who was caring for the baby. If a baby was being cared for on the NNU, mum may be staying in a single room on the postnatal ward. If mum was unable to mobilise independently then a member of ward staff, on occasion a midwife, would transfer mum to the NNU in a wheelchair to feed and spend time with her baby. At that time any baby born on antibiotics had to be transferred from the ward to the NNU each time their medication was due as the drug and dose required checking by two of the registered nurses. On occasions that the parents or a member of the neonatal staff were unable to transfer the baby they sometimes asked a midwife or a midwifery assistant to take the baby to the unit. I cannot recall if I did this as during this time period I had completed six months' experience as a labour shift leader then went back to being a Band 6 midwife."
Susanne Boggan qualified as a registered midwife in 2014 and commenced work at the hospital between October 2014 and November 2015 as a Band 5 rotational midwife. She described the extent to which she carried out work on or in connection with the neonatal unit between 2015 and 2016 as follows: "I would primarily have contact with the neonatal team if their attendance was required at a birth where it was anticipated the baby may need assistance or monitoring outside of midwifery scope of practice, for example instrumental or operative births, premature babies, or babies who required resuscitation at birth. In such cases it was usually a neonatal doctor who would attend first and the team would include senior neonatal nurses if their assistance was required. I would also come into contact with the neonatal nurses if a baby in my care was receiving intravenous antibiotics as it was the neonatal nurses who would come to administer those. If a baby required admission to the NNU after birth, I would often accompany the parents to the NNU to see their baby once the mother was well enough. Occasionally, I would see the NNU shift leader when they would come to the labour ward to ask for updates on any anticipated birth that might require their presence. On one occasion I cared for a family in the bereavement suite after their baby had unexpectedly passed away and two neonatal nurses attended to help with bathing the baby and memory making, taking photos, hand and footprints."
Concerns or suspicions. While few of the nurses could recall receiving specific training on how to report concerns about fellow members of staff, they were all aware of how to do so. Laura Eagles: "I do not recall ever having any training on whistle-blowing formally. However, I am aware of how to raise concerns. The process would be to inform the manager, or higher, if necessary, and to complete a Datix incident form depending on the type of concerns." Caroline Bennion: "We had a good relationship with our immediate management team to feedback any concerns we may have had regarding colleagues, unsafe practices and not adhering to policies. The manager at the time Eirian Powell was very keen for staff to openly report incidents through Datix and log concerns with a no-blame culture. I was aware of the Freedom to Speak Up but at the time I would not have known who to approach or the process for doing so."
Bernadette Butterworth: "With regards to any training we had been given regarding reporting concerns involving fellow members of staff I cannot recall what training we received at the time apart from discussing concerns with the manager. We now receive Speak Up core training for all workers which is mandatory for all staff."
Amy Davies: "I cannot recall whether we had specific training on how to report concerns about members of staff at the time. However, I know I knew about whistle-blowing and I felt confident that I could report any concerns to my line manager or higher management if I had concerns and I would have done so if I had any concerns."
Nurse Y: "As a senior member of staff if I had concerns regarding another member of staff I would report this to my line manager in confidence or raise my concerns via email if they were not available at that time. As a registered nurse, it would be my responsibility to escalate any concerns about patient safety to the unit manager, or matron in her absence. This is the ethically correct course of action and follows the standard set by the NMC Code of Conduct."
Caroline Oakley: "To the best of my knowledge I was not given any training on how to report concerns about fellow members of staff. As a senior member of the nursing team and depending on nature of my concerns, I would either speak to the member of staff or escalate the issue to my manager."
Sophie Ellis: "I cannot remember whether we received any formal training about how to report concerns about another member of staff although if I did have any general concerns, I know that I could speak to my line manager and escalate as appropriate if needed."
Mary Griffith: "I would have been aware of how to report concerns about fellow members of staff. I knew that concerns should be reported to the unit manager."
Valerie Thomas: "I cannot remember ever attending formal training on reporting concerns but I knew I could go and report at any time with my ward manager."
Claire Bevan: "Annual training updates included whistle-blowing updates. I cannot remember the detail but throughout my training and career as a nurse, I was always taught that any concerns about staff, procedures, protocol not being followed, et cetera, should always be raised. There was lots of information on the intranet about how to do it. I believe that most senior staff on the neonatal unit were approachable. Even if a junior member of staff felt uncomfortable approaching management directly, the friendship groups within the neonatal unit were such that all staff, either directly or indirectly, had a route to raise concerns. I cannot think of any member of staff on the unit that if they felt for whatever reason they couldn't follow official channels didn't have someone relatively senior to discuss concerns with, that then would have been formally reported."
The majority of the midwives had no recollection of having received any training on how to report concerns about a fellow member of staff. However, they all knew how to escalate concerns to their line management or any other manager that was felt appropriate. Some midwives would have also reported any concerns regarding patient care via the Datix system. Those midwives who had received training said.
Susan Morton: "Training on how to escalate and report any concerns about fellow staff members was disseminated as part of mandatory study days via training modules, emails and campaigns, such as the 6 Cs which were the core values of the hospital at the time: care, compassion, commitment, courage, communication and competence."
Rachel Wright: "I was given training on how to report concerns about fellow members of staff during midwifery training in university and at the start of my career within the mandatory study days that I attended. Any concerns were to be reported with the member of staff, shift leader or manager."
Deborah Moore: "Yes, I have had training and am aware of processes such as Datix incident reporting and whistle-blowing. From what I can remember any concerns to be reported between 2015 onwards were to be reported, as always, through Datix incident reporting or, if this was not suitable or feasible to do so, there was the option to use the Freedom to Speak Up policy -- I'm not sure whether it was called this at the time -- and report to higher-ranking person."
Overwhelmingly none of the nurses had any concerns or suspicions about the conduct of Letby while she worked on the NNU. Ailsa Simpson had no concerns but felt that Letby involved herself more -- with more babies than she needed to be involved in: "For example, if a baby collapsed or required cardiopulmonary resuscitation but [Letby] wasn't caring for that baby she would involve herself anyway despite being told by a shift leader that she needed to look after her own babies." Ailsa Simpson also recalled: "After the death of the third or fourth baby it was generally noted that she (Lucy Letby) was involved in each case. This was the only point that the NNU staff observed. At that point, I did not consider that she was the cause of the issues and I thought that her involvement might just have been a coincidence."
Vicky Blamire said: "It wasn't until finding out about more and more fatalities that questions were asked about which members of staff were present at the time as this would have had a big impact on their mental health. Hearing Lucy's name with every occasion made me feel very uncomfortable as she didn't show any kind of emotion. I remember feeling very shocked and confused as to why she didn't seem to be upset. This was very unnerving."
Cherryl Cuthbertson-Taylor did not have any concerns or suspicions about Letby's care of the babies or as a nurse. She did, however, find Letby a little odd and said she was aware of several staff who felt the same way about her.
Nurse Y had no concerns about Letby and was not aware of any. She explained: "As a full time Band 5 neonatal practitioner who also worked regular overtime shifts with the relevant qualifications to care for intensive and high dependency care patients, Letby was regularly allocated the sicker infants on shift. Band 5 nurses do not take charge of the NNU, I remember her being taken off night shifts to work only day shifts at some point. I had presumed this was to protect her own well-being as she had been present for a number of deaths on the unit."
Janet Cox had no concerns or suspicions about Letby's conduct. In her view, Letby was "An exemplary nurse who is completely innocent of all the alleged crimes." Ms Cox could not recall the precise dates when she became aware of the suspicions or concerns of others about Letby but she does recall "gradually becoming aware that certain Consultants, in particular Brearey, appeared to be trying to make Lucy a scapegoat for the increased number of deaths/collapses".
Joanne Williams did not have any concerns or suspicions that Letby was deliberately harming babies on the NNU. However, following the collapse of [Child K] on 17 February 2016, Dr Ravi Jayaram approached Joanne Williams wanting to know what had happened to [Child K]. She said: "After this I thought he may have had concerns about Letby."
Other nurses were only aware of the concerns or suspicions of others regarding Letby's conduct after July 2016 when she was seconded to another department and the NNU was downgraded. None of the midwives had any concerns or suspicions about Letby's conduct. Most of the midwives did not know Letby or had not worked with her. They became aware of the increase in the number of deaths on the NNU as a result of the police investigation and/or from the media following Letby's arrest.
The nurses were asked whether discussions or debriefs, formal or otherwise, with or between nurses or between nurses and doctors, took place following the death of a baby. Most of the Band 4 nursery nurses said they did not participate in these types of discussions or debriefs. Vicky Blamire explained that this was not unusual because Band 4 nurses only cared for special care babies and babies who were getting ready to be discharged.
Caroline Oakley's evidence is that there was and still is no formal protocol for debriefs. Laura Eagles described then as "informal and ad hoc". There would be discussion led by a Consultant about the case and how everyone felt. Amy Davies explained that there was no formal process to discuss an unexpected event or unexpected response from a baby to treatment. Caroline Bennion stated: "There were always informal hot debriefs after a death and collapse of a baby. All staff involved including the midwifery and obstetric staff, where appropriate, would be invited too. A formal meeting would be arranged and sent out by the Consultant to all staff involved later." Christopher Booth gave similar evidence. He said: "After the death of a baby formal debriefs did occur usually a few days after the event. I did not attend any formal debriefs as either I was working on a night shift or chose not to attend. I did, however, make use of informal debriefs with colleagues where we would talk, discuss, assimilate, and try to rationalise what had happened."
Belinda Williamson said: "[Debriefs] depended on the circumstances of the death as to when or if a debrief occurred. It was voluntary for nursing staff to attend. If the ward manager or medical staff wanted us to attend it was generally arranged for a day when we were back on shift and available to attend. As a member of staff you could ask for a debrief with the medical team and raise any questions you had regarding the event even if the medical team did not necessarily know the answer. We could also ask verbally for the post-mortem results once they were completed. Nurses tended to discuss the events amongst colleagues if we felt we needed to."
Susan Needham, who worked at the hospital as a midwife, said discussions with or between midwives after the death of a baby at the hospital would depend on how much input the midwives had had with the baby and their family and whether the labour and delivery were in some way significant to the demise of the baby. She said: "Midwives are always given the opportunity to discuss the demise of a baby that dies at or soon after birth. They will be given the opportunity to go through the labour, to try and pinpoint any problem with their care, and there was usually a multi-disciplinary meeting held for midwives and doctors to attend and this had been the process prior to, during, and after 2015 to 2016."
The mortality rate. Most nurses described being aware of or worried about the increase in the number of deaths on the NNU. Laura Eagles: "I was aware of the increase in mortality rate. Obviously all deaths are concerning and it is important to ensure that all clinical care has been reviewed to make sure that it was correct. As far as I can recall, the Coroner was informed of all the deaths. As I have previously mentioned, there was an increase in activity on the unit and it felt there were more sick babies than is usual. This could then explain why perhaps that there were more deaths, in my opinion."
Christopher Booth: "I was of course worried about the increased number of deaths on the NNU. It was extremely harrowing and emotionally exhausting. As I have outlined earlier, in my mind the collapses and deaths could all be rationally explained as we were experiencing an unprecedented level of acuity with the NNU being at capacity or close to capacity for such a long time. Water pressure was low, which was not ideal for hand washing. It took time for the issue to be resolved and it is only since the events were investigated that I reflected upon it and saw it as a potential factor in perhaps cases involving sepsis."
Caroline Bennion: "I was personally alarmed or alerted to the number of child deaths when one of the triplets died on 21 st (sic) June 2016. I can remember asking my colleague, although I can't recall who, about what had happened. It was completely unexpected. They were mature babies, born at 33 weeks, good weights, and although they were receiving respiratory support they were very stable. I wondered if there was a significant infection on the unit that we were missing. This was a discussion with nursing staff although I cannot recall their names, given that infection is always a concern in relation to preterm babies. This was not a conversation I had with the medical staff or outside the unit but it was more of a speculation between the nursing staff."
Ailsa Simpson: "The increase in the number of deaths on the NNU during the period 2015 to 2016 was very concerning. It is usually very rare for a baby to die and even if they do, it's usually in cases where the babies are extremely unwell, either with sepsis or if there is a congenital abnormality."
Joanne Williams: "I was aware and concerned about the increase in the number of deaths on the NNU. I cannot recall specifically when I became aware of the increase or what I thought. At the time the acuity on the unit was always high and we were caring for vulnerable patients. It was very difficult for the team dealing with numerous deaths feeling overworked and at times under appreciated."
Mary Griffith: "All staff on the NNU were concerned about the number of deaths on the unit but regarded this as being the consequence of the gravity of the babies' conditions and the increased number of admissions."
Caroline Oakley: "I was aware that 2015 to 2016 was a very busy year and we had more vulnerable babies coming in from the labour ward. I was aware of more deaths but due to the increase in the number of vulnerable babies we were caring for I did not think it was an unnatural result that there were more deaths.
Janet Cox: "Obviously any death is a worry, but I did not think this at the time, nor do I think now, that there was anything sinister about the increase in the number of deaths/collapses. I do not see how you can set a figure on how many deaths are acceptable in one particular time frame. The very reason these babies required admission to an NNU was because they had a high chance of dying or collapsing."
Jennifer Jones-Key: "I discussed with nursing staff about how busy we had been and how sad it was with the run of babies passing away. I was not concerned by the number of deaths as we had had a very busy time and had been full most of the time."
Claire Bevan: "The increase was concerning but nobody to my knowledge expressed any concerns including doctors. As far as I am aware, although the deaths were unexpected and some apparently unexplainable, nobody voiced any concerns. In my recollection staff were discussing how odd it was but there was never any suggestion of anything untoward."
Nicola Dennison: "I was not particularly worried about the increase of the deaths on the neonatal unit because we had lots of babies who were very poorly, some of which were born to very poorly mothers, and as such our statistics naturally increased. We also had a high instance of congenital abnormalities, which included heart conditions and gastroschisis, for example. We were at maximum capacity for the majority of the time. However, I do not feel that care was ever compromised."
Susan Morton: "I remember being worried and concerned about the high number of deaths in 2016. This was when I was undertaking my developmental Band 7 labour ward shift leader role. I was the shift leader on a day shift when two of the three triplets died within a short period of time. I recall hearing that the transport transfer team were present when the second baby died and the parents had requested that the third baby be transferred to another unit. "I also recall that day that a decision was made to halt any elective inductions of labour and not commence any new inductions at that time. I don't however recall who this decision was made by. I remember feeling incredibly upset and shocked at the recent events and that morale was becoming increasingly low."
Recommendations. The nurses were asked whether Letby's crimes could have been prevented if the babies had been monitored by CCTV. The majority doubted the efficacy of CCTV in preventing Letby's crimes. Ailsa Simpson expressed the view that even if CCTV had been in place at the time Letby would have found a way: "... as she had the intention to harm the babies."
Christopher Booth stated that CCTV: "Would have little impact or effect. If a person is determined to commit any unlawful deed the CCTV camera system could be easily circumvented." Amy Davies pointed out that babies are not always in full view due to the incubators and incubator covers and the position of staff. She did not think CCTV would help.
Nurse Y, Minna Lappalainen, Joanne Williams, Mary Griffith, Lisa Walker and several other nurses expressed concern that the use of CCTV in clinical areas of the NNU was not appropriate and would interfere with the privacy rights of babies and their families. Belinda Williamson felt it would inhibit mothers from breastfeeding or expressing milk or having skin-to-skin contact, which would be detrimental to both babies and their parents. Nurse Y also considered it inappropriate to have CCTV monitoring of babies: "... during procedures or examinations when their private areas may be visible." It concerned her who might have access to these images. Nurse Y also stated: "As a practitioner, I would strongly object to CCTV monitoring and I feel it is an intrusion. It is not used in general nursing wards or in paediatric care so I feel it would be unnecessary and inappropriate." Satasha Culshaw pointed out the use of CCTV monitoring as a deterrent might be more effective in the drug dispensary where it might also be capable of capturing the commission of a crime.
Shelley Tomlins was employed as a Band 5 neonatal nurse on the NNU before moving abroad to work as a nurse. On the issue of CCTV monitoring, she said: "I am undecided whether having the babies monitored by CCTV could have prevented the crimes of Letby. On the one hand, it could have prevented any harm coming to any baby by deterring her entirely. It could also have prevented some of the later crimes as perhaps once the medical team started to suspect Letby she may have been either deterred by knowing she was being monitored or caught via the CCTV. "Some of her crimes, such as injecting insulin into TPN bags and failing to act or request help when a baby was 'crashing', would have been detectable by CCTV. However, some of the ways in which she murdered or attempted to murder the babies were by using equipment that nurses handled all the time and by doing things which were very similar to routine tasks. What I am referring to here is when she used feeding tubes to overfeed the babies or insert air and intravenous lines to inject air. "On camera these actions might be indistinguishable from routine and correct procedures. For instance, it might not be possible to tell from CCTV whether a syringe has air or clear fluid in it or whether a baby is receiving more milk than their usual feed amount. These crimes may have been detectable later on once the CCTV was scrutinised closely and people had an idea what they were looking for. By that point, it would have been too late to catch her in the act and therefore too late to prevent harm happening to the babies. "Overall though I do feel that perhaps the presence of CCTV might have been enough of a deterrent and therefore could have prevented Letby's crimes."
Other neonatal nurses and nursery nurses such as Pauline Fong, Abigail Lever, Adele McGarry, Cherryl Cuthbertson-Taylor and Faith Chidongo all considered that if the babies in the neonatal unit had been monitored by CCTV the crimes of Letby could have been prevented. Janet Cox considers that if there had been CCTV monitoring, it would have proved Letby's innocence.
Finally, as to the recommendations which the nurses think my Lady should make to keep babies in NNU safe from any criminal actions of staff, they said as follows:
Christopher Booth: "I think using the utmost vigilance in the screening of potential staff members at the time of recruitment would be a good place to start. This could involve possibly conducting personality tests as part of the recruitment process to seek to identify any personality disorders which would mean such people would probably be incompatible with working in such a stressful environment. That is not to say that I feel Letby necessarily suffered from such a disorder, but it seems to be a glaring oversight in the recruitment process. "Improving staffing numbers would always have a positive effect on neonatal nursing teams' well-being as throughout this period between 2015 to 2016 we were almost constantly short-staffed with team members being asked to change shifts at short notice or work extra shifts. This is not good for staff mental health or morale."
Paula Baden: "Parents should have more and better equipped facilities to enable a parent to stay at the bedside throughout their baby's stay. While I am unsure of the procedures around neonatal deaths and reporting, I feel that if there is more than one, regardless of reason, this should have a thorough investigation. "Medication must always be kept securely and regular medication audits should also be carried out to identify any anomalies."
Joanne Williams: "I do appreciate staffing is a main priority for all those in the NHS. Having safe staffing levels to deliver high-quality care is paramount. General District Hospitals with NNUs should ensure they understand the challenges, difficulties in working in such a specialist area and provide appropriate support. Parents and primary carers should be able to be with their babies 24 hours, if they wish to be, with NNUs designed to facilitate this."
Minna Lappalainen: "Appropriate professional staffing levels on neonatal units and open communication between all professional disciplines would improve the way concerns are addressed. Hospital executive management must respond promptly to concerns raised by nursing and medical managers."
Nurse X: "Swipe card access to drug storage areas and CCTV would track access to these areas more accurately."
Ailsa Simpson: "I believe a culture where members of staff can freely express their concerns without the fear of repercussions is necessary."
Shelley Tomlins: "I think the Inquiry should make recommendations about the ways in which members of staff can voice concerns they have about staff members. The procedure for doing this should be straightforward, dealt with much more quickly than it was for Letby, take the concerns of the whistleblower seriously and should put the safety of the babies as a priority rather than the feelings of staff members. "I am sure there are ways to deal with serious concerns that are fair and sensitive to the staff member whilst also making patient safety the top priority. There should be no red tape to get through and never any hesitation or delay in contacting the police."
Sophie Ellis: "There should be an open and honest culture with a freedom to speak up within all staff groups. Individuals who raise concerns should have guaranteed support from management and/or a dedicated team to support whistleblowers. A clear process of how to report concerns specifically about criminal actions of staff needs to be created and outlined. This should be streamlined within all Hospital Trusts. "Staff may then be more likely to raise concerns without fear of negative judgment and instead be commended for their courage. This can be very difficult to do even with a positive culture. Some of these aspects may already be in place in some Hospital Trusts. If so, there needs to be consistency amongst all hospitals."
Stephanie Terry: "As a clinical educator for student midwives, I feel that the Inquiry should investigate the practical element of when students study to become nurses. In my experience, behavioural or personal attributes can be difficult to fail a student on. This, in my opinion, needs to change. We need to ensure that students are safe to be working with vulnerable babies and people going back to basics with recruitment and education." My Lady, that concludes the summary of the evidence of the nurses and midwives. This summary is intended to assist the oral hearings insofar as it provides some indication of the themes that run through the evidence from nurses and midwives who have provided written evidence to the Inquiry and will not be called to give oral evidence. The witness statements and questionnaires summarised today will be published on the Inquiry's website in due course.
LADY JUSTICE THIRLWALL: Thank you. Thank you very much indeed, Ms Lyons.
MS LYONS: Thank you.
LADY JUSTICE THIRLWALL: I think that concludes the proceedings for today. We will start again tomorrow morning at 10 o'clock. Thank you all very much.
(4.37 pm) (The Inquiry was adjourned until 10.00 am, on Wednesday, 16 October 2024)
LADY JUSTICE THIRLWALL: Mr De La Poer.
MR DE LA POER: My Lady, the first witness today is Nurse Yvonne Farmer, please.
LADY JUSTICE THIRLWALL: Would you come to the witness box please, Ms Farmer.
MS YVONNE FARMER (affirmed)
LADY JUSTICE THIRLWALL: Do have a seat.
MR DE LA POER: Please can we begin with your full name.
FARMER: Yvonne Farmer.
DE LA POER: Ms Farmer, can you confirm, please, that you provided the Inquiry with a witness statement dated 7 June of this year?
FARMER: Yes.
DE LA POER: And are the contents of that witness statement true to the best of your knowledge and belief?
FARMER: Yes.
DE LA POER: Turn to your background. Did you obtain a degree in nursing practice in 2001? I have taken that from your --
FARMER: Oh, yes, yes.
DE LA POER: And did you complete a Neonatal Intensive Care
Course in 2000?
FARMER: Yes.
DE LA POER: And an Enhanced Neonatal Practice Course in 2002?
FARMER: Yes.
DE LA POER: And at around the same time, I think it was 2000, did you also complete the Nurse Teaching and Assessing Course?
FARMER: Yes.
DE LA POER: And having completed that course, did you shortly thereafter move to the Countess of Chester Hospital?
FARMER: I did, yes.
DE LA POER: Did you begin work on the neonatal unit?
FARMER: Yes.
DE LA POER: And so you had been on the neonatal unit for something approaching 15 years --
FARMER: Yes.
DE LA POER: -- at the time of the period that we are focused upon?
FARMER: Yes.
DE LA POER: And finally, just to complete your background, did you retire in 2019?
FARMER: I did, yes.
DE LA POER: Now, Ms Farmer, you held two roles --
FARMER: I did.
DE LA POER: -- is this right, in 2015?
FARMER: Yes.
DE LA POER: Your first role, as you tell us, was a non-clinical Band 7 with the title Neonatal Practice Development Nurse?
FARMER: Yes.
DE LA POER: Had you held that role since 2009?
FARMER: Yes.
DE LA POER: We will come back to what that involved in a moment.
FARMER: Okay.
DE LA POER: But just to introduce your second role, was that a clinical Band 6 Senior Nurse?
FARMER: Yes, it was.
DE LA POER: With responsibilities as a shift leader on occasions or otherwise caring directly for babies?
FARMER: Yes.
DE LA POER: So as to your first role, the Neonatal Practice Development Nurse, tell us what that involved you doing.
FARMER: My role was as a neonatal educator based on the unit. So I worked predominantly with students, new staff and existing staff ensuring that they were inducted into the unit, that they attended the courses
that were available. Basically I constructed a programme of development so I worked with different individuals when they started and I had overall view of the training and education and the staff on the unit.
DE LA POER: And how many hours a week were you allocated to that role?
FARMER: I think it was about 21 and a half but it did vary as clinical needs sometimes dictated.
DE LA POER: Putting that another way, does that mean sometimes you were needed on the unit clinically --
FARMER: Yes.
DE LA POER: -- and so you had to step back from educator role?
FARMER: I did, yes.
DE LA POER: I understand. And your second role was, as you have identified, a clinical Band 6 Senior Nurse. Again, just give us an idea of what that required you to do.
FARMER: Yes, I was a shift leader but sometimes I was allocated as shift leader or sometimes I was given a workload. But at that time, as shift leader, we also had a small workload as well. So I might have a patient, a couple of patients that weren't intensive care. So I had overall view of all the patients on the unit and allocated staff according to their experience and needs.
DE LA POER: So does it follow that you got to interact with your nursing colleagues both in an educational capacity, when appropriate --
FARMER: Yes.
DE LA POER: -- but also as a side-by-side colleague --
FARMER: Yes.
DE LA POER: -- or in a quasi management role/shift leader?
FARMER: Yes, yes.
DE LA POER: What was your view about what the NNU was like as a place to work?
FARMER: I really enjoyed working on the neonatal unit. It was always an area that was looking to develop, always trying to maintain safe practice. We worked well with the medical team. It was a very small unit so I felt we were a very close team and we did try and support each other when we were on shifts.
DE LA POER: And when you say a close team are you speaking there principally about your nursing colleagues?
FARMER: Yes, yes.
DE LA POER: So the nursing team was close?
FARMER: Yes, yes.
DE LA POER: Well, let's just focus upon the nursing team.
FARMER: Okay.
DE LA POER: On the unit, Eirian Powell was the most senior person --
FARMER: Yes.
DE LA POER: -- from a nursing perspective. What was she like to work for?
FARMER: I always got on very well with Eirian. I had known Eirian since I started so we did develop into our roles together. So I felt she was an approachable manager. She would always come in early so that she met with the night staff going off, so she was not only -- she saw both members of staff, day staff and night staff. So in that way she was a very visible manager.
DE LA POER: Now, the Inquiry has received some evidence from amongst your nursing colleagues about a "circle of trust" was a phrase that one nurse used. Others have used the phrase "favourites" in terms of Ms Powell.
FARMER: Right.
DE LA POER: Is that something that you recognise as applying to the neonatal unit in your experience?
FARMER: I don't think -- no, she didn't have favourites. She ensured that all staff developed. She offered opportunities. If staff approached her about a development role or different opportunities that were within the Trust she was always very willing to listen
to them. We had always advertised study days so we would allocate and she would make sure that it was divided equally so that not the same people went to study days. So ...
DE LA POER: Now, how about the relationships with the doctors? Again, in summary, what was your experience of that?
FARMER: On a personal level I didn't have any problem with the Consultants. The Registrars rotated so -- but during that time, I think we had Registrars that were on for quite some time so we did get to know them and in my role as practice development, I did work quite closely with some of the Registrars if we were introducing a new practice. On a personal level, I didn't have a problem.
DE LA POER: The way you have expressed if, I may just observe, is to say that there wasn't a problem?
FARMER: Yes.
DE LA POER: Was it a positive relationship?
FARMER: Yes, yes.
DE LA POER: Or was it --
FARMER: Yes, because of the nature of the unit, it had to be a positive experience.
DE LA POER: How busy in 2015/2016 was the neonatal unit?
FARMER: As I recall, we had some very busy moments and I feel certain we must have had some quieter moments but you always remember the busy times. So there were quite stressful shifts. But because of our unit, we weren't an intensive care Level 3 unit so it was peaks and troughs. But it felt busy.
DE LA POER: It felt busy?
FARMER: Yes.
DE LA POER: Did it feel busy out of all proportion to what had come before, or did it just feel like it was a busier phase?
FARMER: Well, in my experience I did have busy years, some years or some times seemed busier. So I just accepted the fact that we had quite a few babies that year.
DE LA POER: One of the things that you comment upon in your statement is about the restructuring of the divisions within the hospital?
FARMER: Yes.
DE LA POER: And the fact that paediatrics was placed into the Urgent Care Division.
FARMER: Yes.
DE LA POER: Do you want to just tell us what your perception was about the effect of that?
FARMER: Yes. Well, when I first started on the neonatal unit we were classed as the Women and Children's department. So we worked closely with the maternity team, with ourselves, neonatal and paediatrics, and I personally knew sort of the management tier. But when we were divided into the Planned and Unplanned, we were, the management tier was quite different and it was very adult based. So I felt they didn't really know the needs of our unit.
DE LA POER: Can you just help us with who you are speaking about when you say management tier, whether by name or by job description.
FARMER: We had a matron on the children's ward. So if the manager wasn't available I had the matron to refer to if we needed assistance. But after that, there was a management tier that were quite unknown to me, like very senior managers.
DE LA POER: The phrase you use in your witness statement is "not as visible to the senior" --
FARMER: Yes, yes, because they were physically based in a completely different building so -- and our previous managers under Women and Children's had been based within the building and I knew who I could contact there.
DE LA POER: From your experience during 2015/2016, did that change in structure make any difference, do you
think?
FARMER: It's difficult to say. I think decisions were made that we didn't know anything about. It might have changed communication problems, but I'm not quite sure.
DE LA POER: I would like to turn to the topic of policies and procedures and we will start with safeguarding. Had you received any safeguarding training as to how you should act in the event that you suspected a colleague was causing harm to patients?
FARMER: No.
DE LA POER: With all of your experience, do you think that that is properly described as a safeguarding issue?
FARMER: The fact that we didn't have training?
DE LA POER: No, no, the fact that a -- the risk from a colleague, if you perceived it, is that a safeguarding issue, do you think?
FARMER: I think it's regarded now at this time, yes. So ...
DE LA POER: Was that the way it was being thought about at the time, do you think?
FARMER: I don't think so. No.
DE LA POER: And do you have any view on why that might be the case? What's changed, in your perception? I am not inviting you to guess but if you have an opinion about it I am sure we would like to hear it.
FARMER: Not really, no.
DE LA POER: Datix.
FARMER: Yes.
DE LA POER: When did you understand that it was necessary to fill in a Datix form?
FARMER: We filled Datixes on a variety of areas, usually if there was a drug area, not following policy, an environmental issue. There was, it was all on the computer so there was, I think -- I can't remember if there was a list or there were different areas where you needed to report. So it was basically identifying a risk that needed to be reported.
DE LA POER: Now, we have received a deal of evidence that an unexpected death would be the subject of a Datix with the descriptor "expected" or "unexpected death" being the ...
FARMER: Right. I'll be honest. I don't remember.
DE LA POER: You don't remember?
FARMER: Because it's some time since I've seen the Datix reporting system and I can't remember the exact layout or reporting. Sorry.
DE LA POER: No need to apologise. We may come back to that. But the third area of policy and procedure is
debriefs?
FARMER: Yes.
DE LA POER: When did you understand that it was necessary to have a debrief? What sort of events should trigger a debrief?
FARMER: Following any neonatal death, ideally a debrief was undertaken. But having re-read all the information, I don't think that occurred on every neonatal death on the unit. But because I wasn't always involved clinically, I can't recall when and which babies were, had a debrief.
DE LA POER: And if it is the case that debriefs were not happening, what would be the explanation for that, as far as you are aware? Do you know?
FARMER: I don't know. I don't know.
DE LA POER: Would you expect a debrief to take place if a baby suddenly and unexpectedly deteriorated, was the subject of resuscitation but recovered?
FARMER: Not, not always, no.
DE LA POER: And if not always, then what would be the trigger for a debrief in that situation, do you think?
FARMER: I suppose if it was for a welfare debrief following a traumatic resuscitation. But because of the nature of our role, we may have resuscitated patients, but it might have been reviewed or discussed as part of a teaching process, but I don't really remember.
DE LA POER: And would that be formally recorded if, if it was used as a teaching --
FARMER: If it was used as teaching, I would imagine so, but it might have been from a medical perspective. So it wasn't something as nurses we did amongst ourselves.
DE LA POER: So we are going to turn now to your involvement with Letby and you tell us quite a lot about the period before 2015, starting with the fact that you completed the list of relevant requirements with her on 29 January 2012.
FARMER: Yes.
DE LA POER: And at that stage, did you have any concerns about her competence, her attitude or her approach?
FARMER: No. I had met her on the unit as a student and then she was taken on as a permanent member of staff. So that was the first -- we completed that within the first few weeks, so no.
DE LA POER: We have heard about her last placement and the fact that there were difficulties upon it. Were you aware of those?
FARMER: No, I wasn't, no.
DE LA POER: In your role of inducting Letby into the unit, would you have been expected to be told about any
problems during the student period or, from your point of view, does somebody simply arrive qualified?
FARMER: Because she was interviewed prior -- I wasn't, I didn't interview her. If she was interviewed or if another member of staff had concerns, I would imagine it would be part of her references. So I had no knowledge that that had occurred, so ...
DE LA POER: Now you speak about a requirement of the Nursing and Midwifery Council called the period of preceptorship --
FARMER: Yes.
DE LA POER: -- which is a period of approximately six months.
FARMER: Yes.
DE LA POER: And during that period, a new starter is allocated a mentor, is that right?
FARMER: Yes.
DE LA POER: And did you have some oversight role over that process?
FARMER: She had a clinical mentor.
DE LA POER: Yes.
FARMER: And I made sure that she completed, she had a file and I made sure she was completing all the relevant competencies within that six-month period.
DE LA POER: And through your involvement with that period, did you arrange for Letby to attend training at the Liverpool Women's Hospital?
FARMER: I did, yes.
DE LA POER: Following completion of that NMC requirement, were you aware that Letby attended the Neonatal North-West Induction Programme?
FARMER: Yes.
DE LA POER: Was that a standard part of --
FARMER: Yes.
DE LA POER: -- the training programme?
FARMER: Yes.
DE LA POER: Did that include a further placement at the Liverpool Women's Hospital?
FARMER: It did, yes.
DE LA POER: And at the end of all of that process, was there further training and observation leading up to a conclusion that she was safe to practise clinically?
FARMER: Yes, yes, she had a mentor in Liverpool Women's as well as a mentor on our unit during the -- the course of the training.
DE LA POER: And so far as you were aware, at the time that she emerged from that training programme, was Letby safe to practise, from your perspective?
FARMER: As far as I was aware, yes.
DE LA POER: I think that in your educational role you facilitated Letby's attendance at a number of courses.
FARMER: Yes.
DE LA POER: I'll just run you through them: the Cheshire and Merseyside Neonatal Intensive Care Course?
FARMER: Yes.
DE LA POER: The neonatal advance life-support course?
FARMER: Yes.
DE LA POER: And the mentor and assessing course?
FARMER: Yes.
DE LA POER: Now, would that be with a view, that mentor and assessing course, with a view to Letby herself mentoring students?
FARMER: Yes.
DE LA POER: And throughout all of those courses, were you available to receive feedback about any concerns?
FARMER: Yes, yes.
DE LA POER: And were you informed of any concerns?
FARMER: No.
DE LA POER: Now, in March 2012, so if we just recap, it was the end of January 2012 that you completed the list of relevant requirements and that six-month period began --
FARMER: Yes.
DE LA POER: -- so after the six-month period. The Inquiry has received evidence from Nurse ZC about an incident in March of 2012 involving a child being transferred back from Arrowe Park. Do you know the incident --
FARMER: Yes, yes.
DE LA POER: -- that Nurse ZC has spoken about?
FARMER: Yes, yes.
DE LA POER: And in summary, Nurse ZC reports that Letby was quite excited about her involvement in a cardiac arrest; that's the evidence that we have.
FARMER: Right.
DE LA POER: And Nurse ZC says that she spoke to you about that; do you have any recollection of that conversation?
FARMER: No, I don't, no.
DE LA POER: Would you have expected a Datix form to be completed in circumstances such as that or does it rather depend upon more detail than I have just given you?
FARMER: Yes, yes.
DE LA POER: Bearing in mind how you interact with your colleagues and your relationship with Nurse ZC, if she had come to speak to you about such an incident at that early stage of Letby's involvement, would you have expected to remember, or ...
FARMER: I think because of the time I don't remember
the incident. I think it would have been just a conversation, perhaps she needed some support or -- I -- I just don't remember the incident. I've been trying to remember but I just don't, sorry.
DE LA POER: But are we to understand from your position, it's that you are not saying it definitely didn't happen --
FARMER: No, but --
DE LA POER: -- you are just saying I have no recollection?
FARMER: -- I just don't remember. It has not stuck in my memory.
DE LA POER: So that's 2012. Let's move forward, please, to 22 July of 2013 and this is a morphine error?
FARMER: Yes.
DE LA POER: So you know the incident that I am speaking about?
FARMER: Yes.
DE LA POER: And we will just start, please, by bringing up the first page of the Datix for this, INQ0014469. If we can just crop in right to the centre.
FARMER: Can I expand this? Right. Thank you.
DE LA POER: Hopefully that's sufficiently legible. I think it was in your pack before coming here today?
FARMER: Yes, yes.
DE LA POER: But here we can see 27 July is the --
FARMER: Yes.
DE LA POER: -- date of the Datix of 2013 at 8.40. And we can see the description: "On carrying out fluid medication checks at the start of the morning shift it was noted that the morphine infusion was running at 1.32 millilitres per hour rather than the correct amount of 0.13 millilitres per hour. The dose was prescribed at 5 micrograms per kilogram per hour and was therefore infusing at 10 times the prescribed amount." And further figures are given. Then the action taken is shown a little below: "Immediately informed the staff nurse who had handed over the baby's care. The dose was rechecked and then changed to the correct infusion rate. The nurse in charge of the shift was also informed as well as the Registrar and the Consultant on the ward round." If we just scroll down very slightly further. We can see the categories which I think may prompt your memory a little about the sort of dropdown list?
FARMER: Yes.
DE LA POER: That the category is medicines, the subcategory, entirely unsurprisingly, administration dose error?
FARMER: Yes.
DE LA POER: So that's the Datix -- thank you very much indeed, we can take it down.
FARMER: Okay.
DE LA POER: Now, when do you think you first became aware of that incident? And it may be easiest to say by reference to how many hours or days after it had occurred.
FARMER: I don't know how many -- I don't really know the time frame. I assume it would be when I was next on a practice development day that I was told about the error. But I can't pinpoint how long after the incident I was told.
DE LA POER: Well, we will come to a record of a meeting that you were involved in --
FARMER: Okay, okay.
DE LA POER: -- which was 30 July --
FARMER: Okay.
DE LA POER: -- so it was eight days later.
FARMER: Okay, right.
DE LA POER: But plainly you knew about it before that meeting.
FARMER: Yes, yes.
DE LA POER: Just help us, please, Ms Farmer. Recognising that in the NHS at that time there was a no-blame culture.
FARMER: Yes.
DE LA POER: Nevertheless, how serious an error is this in terms of its potential consequences?
FARMER: Well, it is a very serious error, 10 times the dose is not -- it is serious, yes.
DE LA POER: And because we are dealing here with a controlled drug --
FARMER: Yes.
DE LA POER: -- there were additional safety measures built in to the handling of such controlled drugs; is that right?
FARMER: Yes, yes.
DE LA POER: Because, for example, it required two people it sign it out of the locked cabinet?
FARMER: Yes, yes.
DE LA POER: And in terms of the training given to nurses, how, how much time is devoted to warning against the risks of dosing errors? Is this something that is not well recognised or is it something part of the --
FARMER: It is well recognised and it formed part of the training, the IV training, always about correcting doses, and part of the course involves drug calculations. So it should be something that she was very familiar with. But it was checked by two nurses, so it was basically an error with two nurses.
DE LA POER: So we are here talking about the two nurses who were involved in signing out --
FARMER: Yes.
DE LA POER: -- the drug?
FARMER: Yes.
DE LA POER: Well, we will come back to that in just a moment.
FARMER: Okay.
DE LA POER: But again, it's formed part of the training you have told us?
FARMER: Yes.
DE LA POER: And that includes calculation?
FARMER: Yes.
DE LA POER: I mean, at this stage, Letby is not far into her career as a nurse?
FARMER: Yes.
DE LA POER: But she's well outside the period of formal supervision --
FARMER: Yes.
DE LA POER: -- that the NMC requires?
FARMER: Yes.
DE LA POER: And what is the expectation about her being able to operate autonomously for things like this?
FARMER: Yes, yes, it would be an expectation, as a Band 5, to work autonomously.
DE LA POER: I would just like to consider the timing of this and we know from other documents and we will come to it in a moment --
FARMER: Yes.
DE LA POER: -- that the morphine infusion was changed just before the end of the shift.
FARMER: Yes.
DE LA POER: That's something that you can recollect?
FARMER: As part of the incident, yes.
DE LA POER: Yes.
FARMER: Yes.
DE LA POER: And following this, there was a change in policy --
FARMER: Yes.
DE LA POER: -- saying that it shouldn't be changed at the end of the shift.
FARMER: Yes.
DE LA POER: Just help us to understand a little bit more about those circumstances and what would be going through a nurse's mind at the end of a shift and why they would change a morphine infusion like this?
FARMER: I think if it, if it was a very busy shift it's not really ideal to start setting up infusions, especially morphine. Perhaps they wanted to just get it set up ready for the next member of staff. It's hard to
comment because I wasn't involved in the incident, but ...
DE LA POER: So let's just move forward and we are going to go through an event that you weren't present at but which you will have known something about at the time. So let's look at the record, please. This is INQ0008961, at page 47, and my Lady, you have this at tab 6, page 3 of your bundle, I hope.
LADY JUSTICE THIRLWALL: Thank you.
MR DE LA POER: So I think it will be page 3, my Lady, of that tab, which should have 47 at the bottom right-hand corner.
LADY JUSTICE THIRLWALL: Thank you.
MR DE LA POER: So this is a meeting that takes place the following day with your colleague --
FARMER: (Nods).
DE LA POER: -- Yvonne Griffiths?
FARMER: Okay.
DE LA POER: Who was the deputy ward manager, is that right?
FARMER: Yes.
DE LA POER: Unit manager.
FARMER: Yes.
DE LA POER: And is this standard procedure in the NHS and, in particular within the Countess, that if there was a serious error made that there would be a one-to-one meeting?
FARMER: Yes, yes.
DE LA POER: And we can see here the summary of what is recorded from that meeting: "Lucy had commenced a continuous infusion of morphine at the end of her night shift (7 am) for re-intubated infant. At 8 am on handover infusion noted to be infusing at incorrect rate. Medical staff informed ..." Not sure what that last -- it appears to be some sort of shorthand involving a triangle. Do you recognise that shorthand?
FARMER: No.
DE LA POER: And we can then see recorded: "Error rectified quickly. No detrimental effect on the infant." Presumably that's because it was caught very quickly?
FARMER: Yes.
DE LA POER: You have described it as very serious. What are the risks of a 10-time dose of morphine into a newborn baby?
FARMER: Well, it's an overdose of morphine, so ...
DE LA POER: Potentially very harmful or -- can you comment
on that, you have described it as a "serious error".
FARMER: Yes. Well, morphine, because it was a controlled drug, it's a controlled drug for a reason. So that's why I am saying it's serious.
DE LA POER: So we can then -- I think that says "sustain" --
FARMER: Yes, sustain. Yes.
DE LA POER: But it may: "Sustain from checking any intravenous infusions." I think it may mean "refrain", meaning don't?
FARMER: Yes.
DE LA POER: "Any intravenous infusions requiring additives and any control drugs until incident reviewed"?
FARMER: Yes.
DE LA POER: And then finally, and this is where you are going to come in: "Complete intravenous competencies, drug calculation with Practice Development Nurse Yvonne Farmer."
FARMER: Yes, yes.
DE LA POER: And that's exactly your educational role in this situation.
FARMER: Yes, yes.
DE LA POER: The earlier entry, so the one above with my word, not the word given, "Refrain from checking any
intravenous infusions requiring additives and any controlled drugs until incident reviewed", what were you -- what would you expect the incident review to consist of? Who would do it and when and in what circumstances?
FARMER: Because the ward manager wasn't present at this time, I don't know if it's referring to a review with her or if it was to be reviewed within the risk department. So it could have been either, referred to either/or.
DE LA POER: Now, we will hear about this later from Nurse Griffiths.
FARMER: Right.
DE LA POER: But she tells us that Letby was unhappy with the instruction that she had to refrain from administering controlled drugs and that in fact Anne Murphy, the matron in overall charge of the children's, including neonatal, unit was involved.
FARMER: (Nods).
DE LA POER: In your position as an educator, would you expect if a senior nurse on the ward is saying you have made an error, you need to take a step back --
FARMER: Yes.
DE LA POER: -- would it be normal for somebody in that
situation to say, "I am not happy about that"?
FARMER: Maybe not. Yes.
DE LA POER: One of the principles that's very important in medicine and nursing is insight. I am sure you are well familiar with that.
FARMER: Yes.
DE LA POER: I am sure you teach upon the subject.
FARMER: Yes.
DE LA POER: I mean, how important is insight?
FARMER: Gosh, you mean insight from --
DE LA POER: To recognise when you have made a mistake?
FARMER: -- (overspeaking) -- recognise, right, okay. Well, I would imagine very important, yes.
DE LA POER: And can you recall any situation where you, as an educator, have made a recommendation about somebody doing or not doing something for a period of time that they have actually turned round to you and said, "I am not happy about you stopping me doing that"?
FARMER: No.
DE LA POER: So we move forward now to your involvement. The meeting was convened on 30 July, so just seven days after this meeting. Before we bring up the note, what had you been told before that meeting that you had about what was expected of Letby following the incident?
FARMER: As regard to checking drugs or?
DE LA POER: Yes, I mean, had you been told about her meeting with Yvonne Griffiths and what had been decided at that meeting?
FARMER: I think -- no, I don't think so. I -- when I came on shift I think I was told that this had been decided.
DE LA POER: When you say "this", what do you mean "this"?
FARMER: That following the incident, that Lucy wasn't able to check the drugs and that she was going to do further training with myself.
DE LA POER: So let's have a look at your meeting. INQ0008961, page 45, it is the preceding page, my Lady.
LADY JUSTICE THIRLWALL: Thank you.
MR DE LA POER: In tab 6. So is this a form that you recognise?
FARMER: Yes.
DE LA POER: And presumably that's your handwriting?
FARMER: Yes.
DE LA POER: And so we can see: "Review with Lucy and reflect critically on the clinical incident which occurred. Drug calculation was correct. However, infusion pump rate was incorrect."
FARMER: Yes.
DE LA POER: Now, would that have emerged from a discussion
you had or is that what you told her had happened?
FARMER: I didn't tell -- because that's Eirian's writing. I didn't tell Eirian that is what had happened, no.
DE LA POER: Forgive me, that's Eirian's writing?
FARMER: Yes.
DE LA POER: Was this a meeting that you were involved in?
FARMER: It was Eirian's one-to-one form that she must have had with Lucy, and I have added the amendment at the bottom.
DE LA POER: I entirely understand. So it's 6th of the 9th 2013 entry only, is it?
FARMER: Yes.
DE LA POER: That's your handwriting?
FARMER: Yes.
DE LA POER: The other party is Eirian Powell's handwriting?
FARMER: Is Eirian's writing.
DE LA POER: So this is a meeting on this date with Ms Powell.
FARMER: Yes.
DE LA POER: Again, were you aware of that meeting taking place?
FARMER: I may have been told. But I don't, I don't know.
DE LA POER: We can see and we can ask Ms Powell about what it is that she decided about whether or not Letby was allowed to continue --
FARMER: Yes, yes.
DE LA POER: -- to care for infants with infusions and whether she's -- can you help us with "is able to check CDs", is that controlled drugs?
FARMER: Yes, yes, controlled drugs. Yes.
DE LA POER: So on the face of it that is countermanding what Yvonne Griffiths had said seven days earlier?
FARMER: Yes. I don't know if there was a period of time involved in the rechecking. I don't know. You -- it's not documented but there could have been.
DE LA POER: But at all events, by this date, the 30th, she hadn't undertaken her practice calculations with you --
FARMER: No.
DE LA POER: -- because that doesn't come until 6 September?
FARMER: Yes, yes. Yes.
DE LA POER: Well, no doubt it's a question for Ms Powell but from your point of view, how important was it as an educator, that those practice calculations were performed under supervision before Letby was allowed to be involved with controlled drugs again?
FARMER: I think I gave her a work -- if I recall
I gave her a work booklet as well to go with the practice calculations. And I know I observed her inputting into the pump because that's where the error occurred. So I feel it was important that she demonstrated that she knew how to input into the pump.
DE LA POER: But is all of that in September of 2013, not in July?
FARMER: I'm not sure. I have written September, so I can't really disagree with that.
DE LA POER: That is likely to be right. So if we have got our chronology straight --
FARMER: Yes.
DE LA POER: -- just looking at this, Yvonne Griffiths appears to have said the incident need a review and she must step back and she needs to undertake the checks.
FARMER: Yes.
DE LA POER: We can then see what Ms Powell has written seven days later.
FARMER: Yes.
DE LA POER: But the calculation --
FARMER: Yes.
DE LA POER: -- practice doesn't in fact happen until six or so weeks later.
FARMER: That's when I have documented, yes.
DE LA POER: Now, the last thing, and I just need to check with the document that's being shown that it's the updated version from yesterday -- I am told it is. I am very pleased to hear that. INQ0012033. So this is on the 1st August and we don't need to worry about who's sending the message: "Hi Lucy, how are you? What happened over the drug error?" So it is talking about what had been happening over the last few days.
FARMER: Right.
DE LA POER: To which we can see that Letby replies: "Thankfully Eirian felt it had been escalated more than it needed to be. Everything is back to how it was. I just have to have more training on using the pumps and it will be on my record for six months. She was very supportive, it is a case of learning to live with it now and getting my confidence back. I am on nights this week. Still feeling a bit vulnerable and thinking about what if, but I'll get there in time. Thanks for asking. Hope you are okay." So if we can take that down. Now, from your perspective as someone who was involved in part of this incident, do you think that Yvonne Griffiths escalated it further than it needed to be with her reaction?
FARMER: Well, Yvonne Griffiths was the deputy manager and with the absence of the manager her next level would be the matron. So it was a joint decision and at the time, that was a good decision.
DE LA POER: So again, just going back to what you understand about insight. Does it appear from that that Letby is demonstrating insight into the seriousness of what she did?
FARMER: It's difficult to say, really, I would say.
DE LA POER: On the subject of errors, and we are going to move to a different error now, and we are going to jump right forward in our chronology to April 2016. My Lady, you have this at tab 6. I'm just going to bring up a reflection written by Letby. INQ0008961 at page 49. It is the final page behind tab 6, I hope. We might be able to crop into that a little bit. This is a reference to an antibiotic error.
FARMER: (Nods).
DE LA POER: And we can see that what Letby has written was: "It wasn't due and had not been prescribed." So giving a drug to somebody who wasn't in need of it?
FARMER: (Nods).
DE LA POER: Again, how would you categorise that as an error? Is it a minor error or a major error?
FARMER: It is not a minor error, so possibly a major error.
DE LA POER: So if we look down into the large paragraph towards the bottom, so the largest of the paragraphs, we can see the words "on reflection", near the very centre of that text. I am sure it will be highlighted in a moment. And what Letby has written is: "On reflection I feel this situation was unavoidable."
FARMER: (Nods).
DE LA POER: Now, again, from your perspective as an educator, if you give a patient a drug which was not due and had not been prescribed, is that an unavoidable error?
FARMER: Sorry, could you repeat that again?
DE LA POER: Of course, yes. We can see that the drug was not due and had not been prescribed.
FARMER: Yes.
DE LA POER: Is that capable of being described as an unavoidable error?
FARMER: No. But if it hadn't been prescribed I don't
understand -- well, I don't understand why it was given if it wasn't prescribed. So I don't know.
DE LA POER: Is it always going to be an avoidable error?
FARMER: Yes, yes, if it's not prescribed then ...
DE LA POER: You only have to look at what's prescribed to see that it isn't there and you avoid making that mistake.
FARMER: Yes, yes.
DE LA POER: Again, it will be my final question about your perception of Letby's insight. Does this show good insight and reflection from somebody following an error or not?
FARMER: She has written that she should have been more aware and greater effort made to ensure that all the checks were made. So she has made some statement there but ...
DE LA POER: Yes. Although she has also said it was unavoidable.
FARMER: Yes.
DE LA POER: What's your view?
FARMER: It's hard to say really without -- I don't -- I have read the incident. I don't remember the incident, so I think -- obviously it shouldn't have been given, the Gentamicin, so perhaps it is poor insight, you know, it's difficult to say really.
DE LA POER: Thank you. We can take that down. We are now going to focus, please, upon the children named on the indictment who died and in particular what you thought at the time. And we will just start with an overview which is how you begin in this part of your statement. You begin at paragraph 66 -- you don't need to turn it up unless you want to, I'll just read it to you: "I was informed by my manager that Dr Brearey and later Dr Jayaram had suspicions about the conduct of Lucy. However, I do not remember when and after which neonatal death this occurred."
FARMER: (Nods).
DE LA POER: Right. I just want to see if we can better understand that and the timings. Obviously, we know, and it's very well established, that there were three deaths in June of 2015.
FARMER: (Nods).
DE LA POER: The death of [Child E] at the beginning of August of 2015 and the death of [Child I] on 23 October of 2015.
FARMER: (Nods).
DE LA POER: So a number of deaths on the neonatal unit and, as we know from other evidence, those weren't the only deaths.
FARMER: (Nods).
DE LA POER: But focusing on the children named on the indictment. Just thinking about it now, do you think it was during 2015 that you first heard?
FARMER: Possibly. It might have been following a meeting with Eirian and the doctors. I think they were having lots of -- they reviewed quite a few notes and they were trying to find a commonality, as in a clinical one, and Eirian told me that they were also looking at staffing and there were two nurses and a doctor that seemed to be on for some or the majority of the shifts. So that's when she told me that they were looking at staff, and Lucy was one of the members of staff.
DE LA POER: Was that the occasion, whenever exactly it occurred, that she told you that Dr Brearey was suspicious?
FARMER: Yes, it must have been, yes.
DE LA POER: And so just doing the best you can, and we will have a look at some of the detail in moment, do you think that is likely to have been before Christmas 2015, so at some point in 2015?
FARMER: Possibly, possibly, yes.
DE LA POER: And when you heard that the neonatal lead Consultant was suspicious of a particular member of
staff what did that make you think?
FARMER: I was quite shocked that he thought that a member of staff was directly involved in harming babies. It wasn't something I had ever anticipated hearing or I wouldn't have expected a colleague to purposely harm babies. So I think it was quite shocking to hear that.
DE LA POER: And did you take it upon yourself to speak to Dr Brearey to better understand what it was that he was worried about?
FARMER: No.
DE LA POER: Again, just help us to understand what the relationships were at the time. Although you had some managerial responsibilities when you were shift leader --
FARMER: Yes.
DE LA POER: -- you weren't the most senior nurse on unit --
FARMER: No.
DE LA POER: -- but, nevertheless, you were extremely experienced and had been there a long time?
FARMER: Yes.
DE LA POER: Do you think that it would have been appropriate for you to go and speak to Dr Brearey yourself to say, "I just want to better understand
this"?
FARMER: No, I didn't feel in a position at that time to go to Dr Brearey directly, no. Because there were lots of reviews and I didn't know where that allegation was going. So no, I didn't take it upon myself at that time.
DE LA POER: And you had an awareness that there were lots of reviews going on.
FARMER: Mmm.
DE LA POER: Did you have the thought that perhaps the senior managers, so up to the board level, should be made aware of something as potentially serious as that? Was that a thought process that you had at the time?
FARMER: I assumed at some point that they would be.
DE LA POER: Was that something you ever discussed with anyone or were told about?
FARMER: No.
DE LA POER: So that's, best as you can, the Dr Brearey awareness?
FARMER: Yes.
DE LA POER: What you also say is "later Dr Jayaram", so now we have got the most senior --
FARMER: Yes.
DE LA POER: -- Consultant in the entire children's department?
FARMER: Mm-hm.
DE LA POER: About how far apart was learning about Dr Brearey's suspicions and then learning of Dr Jayaram's? Was it within a matter of days or weeks or was it many months that passed?
FARMER: It may -- it may have been weeks. I don't think it was days. It was just something I overheard. I wasn't told directly. I think it was just sort of hearsay -- well, not hearsay, but I had overheard it that he had mentioned, I think it was after one particular baby.
DE LA POER: Do you recall who you overheard talking about it?
FARMER: It may have been my -- Yvonne Griffiths, but I can't be sure.
DE LA POER: Having overheard that now the two most senior Consultants had this suspicion, did you speak to Yvonne Griffiths about it to say, "Look, what's all this about?"
FARMER: Not that I recall. But I may have done, but I don't recall.
DE LA POER: Dr Lambie, I don't know if you recall Dr Lambie, she was a Registrar until September 2015 so only during the first --
FARMER: Yes.
DE LA POER: -- period that we have been focused upon -- told us about seeing a huddle of nurses looking at a rota to see who was on duty and she formed the impression that it was connected to the discussion that was going on at the time about who might be the common nurse.
FARMER: (Nods).
DE LA POER: Do you recall any such huddle or did you participate in it?
FARMER: No.
DE LA POER: Well, we will just work our way through the timings of things if we may. You weren't directly involved in the deaths of [Child A] or [Child B] --
FARMER: No.
DE LA POER: -- in June 2015. You say that you remember attending a multi-disciplinary meeting reviewing the post-mortem of [Child A]?
FARMER: Yes.
DE LA POER: Bearing in mind that you weren't involved in the care --
FARMER: Yes.
DE LA POER: -- in what capacity would you have been attending a meeting about the post-mortem?
FARMER: It was, they had meetings, I think they were
monthly, and it tended to be more babies based on that had been on the maternity or it was maternity-based, but because they were reviewing one of our, our babies I thought as part of my professional development that I would attend the meeting and just to see how these incidents or babies were reviewed. So it was more of a professional development and just to see, really, what was discussed.
DE LA POER: And do you have any recollection of any discussion at that meeting about concerns that that, there may be features in common with [Child D], for example, a rash or mottling or anything like that?
FARMER: No. I don't, no, sorry.
DE LA POER: Was anybody at that meeting raising concerns about the fact that there might be something seriously wrong on the neonatal unit?
FARMER: No, no.
DE LA POER: So, again, you weren't involved in the care of [Child C] when [Child C] died. But you tell us that you -- something about a debrief in relation to [Child C]. What you say is it was not compulsory to attend the debrief and due to workload and staffing issues some staff might not be able to attend.
FARMER: (Nods).
DE LA POER: How much encouragement were staff receiving to
attend such debriefs?
FARMER: I think it tended more to be the staff that had been involved in the infant death. It was seen as a welfare and a review of the build-up perhaps to the death. So it was -- tended to be more the staff that had been looking after the baby or if anyone wanted to raise any -- well, not necessarily concerns, but wanted to talk about what had happened.
DE LA POER: Whose responsibility was it to arrange it so that it was convenient for everybody or as many people as possible to attend?
FARMER: It was usually the Consultant but obviously with the managers because they could look at the off-duty and just see when staff were available.
DE LA POER: We then come to the death of [Child D] and we have still not reached the end of June 2015.
FARMER: (Nods).
DE LA POER: I mean, at that stage, had you noticed the fact that there were three deaths in very short order? Is that something that you were aware of noticing at the time?
FARMER: No, I didn't. I know, on hindsight, when I look back I am surprised how close they were but at that time, I don't remember having that awareness that they were so close.
DE LA POER: And then a few weeks later, [Child E] at the beginning of August. Again, do you have a recollection of that being a trigger for you to think, "This isn't a usual period for the NNU"?
FARMER: No.
DE LA POER: Just looking back on it, why do you think that that that -- I mean, you can see it laid out now.
FARMER: Yes.
DE LA POER: But why at the time do you think that that sort of thought process wasn't triggered in your mind?
FARMER: I think because we were so -- we were busy, everyone was doing their own jobs, and if you weren't there at that time, or you hadn't gone to -- if there was a debrief you hadn't been involved, I think you were just so involved in your everyday working that it didn't really stand out in your mind.
DE LA POER: And then in terms of children named on the indictment deaths, towards the end of October 2015, [Child I]. Might that have been the event that -- the death that you were talking about or do you think it was later than that that the concerns of Dr Brearey or potentially Dr Jayaram started to emerge?
FARMER: Can I check on who [Child I] is, sorry?
DE LA POER: I don't know if we have a cipher --
FARMER: Oh right, okay.
DE LA POER: -- list. Oh, you do have a cipher list. No, I am corrected.
FARMER: Because --
DE LA POER: It was quite wrong of me to --
FARMER: Who --
DE LA POER: Yes, obviously, it's very important you don't mention the name but by all means, remind yourself.
FARMER: Yes. I do know that baby. I'm not sure, I'm not sure if it was Baby I [Child I]. I think it was another baby. But I think that was the time that Dr Jayaram had concerns after a different baby.
DE LA POER: So let's just try to understand that.
FARMER: Yes.
DE LA POER: So do you think that [Child I] was the trigger for you learning Dr Jayaram's concerns, so Dr Brearey's concerns must have come before [Child I]'s death or -- I'm just trying to understand what you are saying there.
FARMER: Yes, sorry.
DE LA POER: No, you don't need to apologise.
FARMER: I can't remember the infant. There was an infant that Dr Jayaram was particular -- talked about, a baby that was ventilated. I think that's after that point, that's when Dr Jayaram was more involved. But I don't remember the date, I'm afraid. But I knew about
Baby I [Child I] passing away.
DE LA POER: The baby you are speaking about for Dr Jayaram, was that a baby who died or a baby who didn't die?
FARMER: A baby that died, I think.
DE LA POER: Well, just try one more fact --
FARMER: Okay.
DE LA POER: -- that we know to be true, which is that following the death of [Child I] --
FARMER: Yes.
DE LA POER: -- Eirian Powell created a table.
FARMER: Ah, right, okay.
DE LA POER: Which -- on the same day, which highlighted Letby's name in red.
FARMER: Right, okay.
DE LA POER: Now, she sent that to Yvonne Griffiths and other people, the emails that we have don't indicate that you had received it --
FARMER: No.
DE LA POER: -- which is why it hasn't formed part of your evidence pack.
FARMER: Yes.
DE LA POER: But were you aware of any table having been created by Nurse Powell identifying each of these deaths and who was on duty and in particular that Letby was
identified?
FARMER: I may have been, but, I can't say for definite.
DE LA POER: Well, we will move forward in time, please, to the CQC visit which we know took place between 16 and 19 February 2016, and I think you have had an opportunity to refresh your memory --
FARMER: Yes, yes.
DE LA POER: -- from some notes that have been provided.
FARMER: Yes.
DE LA POER: By mid-February 2016, do you think you had an awareness that the neonatal unit had been experiencing an increase in the rate of death?
FARMER: Well, I knew there was an increase to the normal amount of infant deaths. Yes.
DE LA POER: And was that something that would have been appropriate to raise in your meeting with the CQC, do you think?
FARMER: Not the involvement that I had, no.
DE LA POER: Just explain to us why that is.
FARMER: Well, I was -- from the documents, I was shown showing the group round and it just seemed to be like an environmental audit. So you are obviously in an open, with -- on the ward, and it wasn't something that I thought about myself personally discussing with the CQC. I didn't feel it was my role to discuss that sort of thing.
DE LA POER: Do you have any recollection of whether you were thinking at the time somebody else would do it or was it simply not on your mind?
FARMER: It wasn't on my mind.
DE LA POER: And do you think it is something that should have been on your mind at that time?
FARMER: It's easy to look back on hindsight and say yes, it should be -- it should have been on my mind but at that time it wasn't on my mind, so ...
DE LA POER: We know that on 2 March of 2016, the thematic review of neonatal mortality report in its final version was circulated to a number of people.
FARMER: (Nods).
DE LA POER: Did you receive a copy of that report?
FARMER: On an email, yes.
DE LA POER: And did you read it?
FARMER: Yes.
DE LA POER: And what were your conclusions, having read it?
FARMER: That there were quite, that it was a thorough report and they had looked at all the different clinical reasons. It suggested lots of areas for improving practice, policies, I think I -- my -- I was named as
part of -- in some of the actions which I would have been obviously alerted to. And then there was an addendum, which looked at all the staffing that were involved and then there was an area -- a point that Dr Brearey and Eirian Powell were going to look at specifically, the staffing side of it. That's what I remember from it.
DE LA POER: It is a matter you comment on in your statement but I'll ask it in an open way. Do you think that report alerted you, the reader, to staffing factors and the --
FARMER: Not specifically because there was such a lot of information in the report and I think I would have been looking at all the different actions and obviously the few that I was involved in, not specifically looking at -- because Eirian and Dr Brearey were going to review, that was something that would have followed this review. So ...
DE LA POER: By this stage, the thematic review, were you aware of the concerns about Letby that the Consultants had?
FARMER: Amongst the Consultants, I must have been, yes.
DE LA POER: And being aware of those concerns, did you look at the appendix to see whether Letby's name
appeared next to the babies?
FARMER: I think I noted that she had been on but hadn't been looking after the babies specifically. So I believe I was aware that she was on the shift but hadn't necessarily looked after the baby, babies themselves.
DE LA POER: What was your own state of mind then about whether there was a problem that needed investigating?
FARMER: Because it was being looked after by senior people, I assumed that that would be looked at.
DE LA POER: We know that Letby was moved to day shifts in early April --
FARMER: (Nods).
DE LA POER: -- and we know that the thematic review had identified that six out of the nine deaths had occurred between midnight and 4 am?
FARMER: Yes.
DE LA POER: Were you aware of Letby being moved to day shifts?
FARMER: Yes. Yes, I think it was discussed with me that that was the plan; that because of all the recent incidents, deaths, that they had occurred during the night, so that's why she was being moved on to days as support for her. If, if it was a training issue or if she needed emotional support, then there were lots of
people around, the managers were around, so ...
DE LA POER: Was any part of the explanation that you were told for her move to days, to keep babies safe?
FARMER: No.
DE LA POER: Were you aware of the sudden and unexpected collapse of [Child M] just a couple of days after she was moved to day shifts, on the day shift?
FARMER: Can I refer to who [Child M] is, please?
DE LA POER: Of course.
FARMER: No, I am not familiar with that baby, so, no.
DE LA POER: Did you know that there was a meeting with the Executive Directors between Nurse Powell, Dr Brearey on 11 May?
FARMER: No.
DE LA POER: That wasn't something that was discussed with you beforehand?
FARMER: No.
DE LA POER: Were you -- did you have any discussion about it afterwards?
FARMER: No, I don't remember that at all. No.
DE LA POER: We know that following that meeting, an email was sent on 16 May -- you aren't on copy to that email, so let me assure you about that -- indicating that sudden and unexpected collapses should be drawn to the attention of Nurse Powell or Dr Brearey?
FARMER: Okay.
DE LA POER: Were you aware of any such instruction having been given?
FARMER: No.
DE LA POER: So we reach [Child O], and [Child P] in the latter part of June of 2016. Prior to the deaths of those two children, did you have any suspicions or concerns that any child may have been deliberately harmed?
FARMER: No.
DE LA POER: And what was your view at that time of the concerns that had been expressed by the Consultants?
FARMER: I think because there seemed to be lots of meetings going on, that it was being taken seriously and it was being investigated so -- but I wasn't directly involved, so I assumed that's what was happening.
DE LA POER: You describe the death of [Child O] as unexpected.
FARMER: Yes.
DE LA POER: And was that also your view of [Child P]'s death?
FARMER: Yes.
DE LA POER: I think you were involved in the resuscitation of [Child P]?
FARMER: Yes.
DE LA POER: And so were you aware that Letby was present
at the time of both of those deaths?
FARMER: Yes.
DE LA POER: Obviously the death rate has now gone up even higher.
FARMER: Yes.
DE LA POER: Was that something that struck you at the time; that before those two deaths, Letby was said by the Consultant to be of concern because of her presence and then two deaths in just two days?
FARMER: Yes.
DE LA POER: And there you are seeing for yourself Letby being present again?
FARMER: Yes.
DE LA POER: And both of these are unexpected. Did it trigger any thoughts in your mind?
FARMER: I know at the time because they were triplets I thought -- I did query whether it was some underlying infection with the babies. So it was -- I suppose it was only later on when she was taken off that I might have had a suspicion. But I don't really remember. I think it was just such a busy, shocking time and we were all devastated to lose two babies the day after. I think it just clouded your judgment. I think I was just in shock, really, that that had happened so quickly.
DE LA POER: You tell us in your witness statement that you were informed by your colleague Nurse Griffiths that Letby had been taken off-duty for the foreseeable future --
FARMER: Yes.
DE LA POER: -- as she was suspected by Dr Brearey as the cause of death in both cases rather than there being a clinical cause.
FARMER: Yes.
DE LA POER: You also say what Nurse Griffiths said to you was, "This was for Lucy's protection --
FARMER: Yes.
DE LA POER: -- and to give her time out following the two deaths."
FARMER: Yes.
DE LA POER: So what was your understanding of Nurse Griffiths' position about whether there was a genuine reason to be concerned at that time?
FARMER: Yes. I think because of confidentiality maybe, I think because if people are making serious accusations, it's not something -- it needs to be taken seriously. So I assumed they were having discussions with other people, so perhaps it was a way of explaining why she was being removed.
DE LA POER: Your report of what Nurse Griffiths said was that it was for Lucy's protection.
FARMER: Right, okay.
DE LA POER: Was there any discussion about the need to protect babies?
FARMER: Not that I remember.
DE LA POER: What you say is: "I did not have any suspicions at this time that Lucy had deliberately caused the neonatal deaths."
FARMER: Right.
DE LA POER: "There appeared to be no evidence other than that she was looking after [Child O] and [Child P]. I and my colleagues believed Lucy to be a competent and excellent neonatal nurse and it seemed to be inconceivable that she was at fault."
FARMER: Right.
DE LA POER: That's what you put in your witness statement.
FARMER: Okay.
DE LA POER: You earlier told us that perhaps the emotion of events had clouded your judgment.
FARMER: (Nods).
DE LA POER: Do you think you may have lost a degree of objectivity in that situation?
FARMER: Possibly. I don't know.
DE LA POER: Because you say "it seemed to be inconceivable" that she was at fault.
FARMER: Yes.
DE LA POER: Presumably, given you were highly experienced, you were aware of Beverley Allitt?
FARMER: Yes.
DE LA POER: And closer to home geographically, the Stepping Hill nurse who had murdered two patients?
FARMER: Mm-hm.
DE LA POER: So it wasn't beyond the realms of what was possible --
FARMER: Yes.
DE LA POER: -- that a nurse could be hurting them?
FARMER: I know but it's -- because she was a nurse that worked on the unit and she was very enthusiastic and young, it didn't cross my mind that she then would be deliberately harming babies.
DE LA POER: Now, just moving forward through a couple more events. In July of 2016, you tell us that you were asked by Karen Rees to meet Letby and complete a training update.
FARMER: (Nods).
DE LA POER: What did you understand at that time was the plan for whether Letby would be going back to clinical practice?
FARMER: I think I understood that -- I was told that
there was at some point that Lucy was going to come back to the unit. I was never given a date. It was just that's what I was, the information I was given. So I was asked to, just to, do, like, a refresher with her so that if she did come back then at least we had started to do a refresher.
DE LA POER: I think you were able to undertake some training but not the high-dependency or intensive care requirements --
FARMER: No, no.
DE LA POER: -- because the training opportunity you were offering didn't involve being on the ward?
FARMER: No, no.
DE LA POER: The RCPCH visit on 2 September, you were one of the people interviewed; is that right?
FARMER: Yes.
DE LA POER: And what you say is: "Due to the time lapse since the interview I do not remember the specific questions but I remember we were all very upset and tearful by some of the questions."
FARMER: Yes.
DE LA POER: Just help us with what it was that was making people tearful.
FARMER: I -- I just remember it being a very stressful meeting and I think at that time, when Lucy had been
removed we all felt under suspicion. If it wasn't Lucy, it could be one of us, we just didn't know, and I think we felt we hadn't been supported by the senior managers at that time. I can't remember the specific question or questions that triggered, but we all became upset at the time so ...
DE LA POER: You say: "We had felt let down by the lack of support and communication."
FARMER: Yes.
DE LA POER: Who did you perceive had let you down?
FARMER: I think because the Trust removed Lucy and then we didn't hear any communication, we weren't, we were told we couldn't speak to our colleagues about it. It all felt very -- we just felt as if we were just left. We didn't get any support following the deaths, and we were all very stressed and very emotional about it and we didn't feel we had had any well-being support at that time.
DE LA POER: Finally, turning to your reflections, you say this: "I consider a more robust policy and protocol for debriefs amongst the nursing staff and doctors following every neonatal death on the unit may have improved
communication, knowledge, information sharing and discussion at ward level." And I would just like you, please, to amplify that a little bit and why you have put that in particular in your witness statement.
FARMER: Sorry, could you repeat that again, sorry.
DE LA POER: "I consider a more robust policy and protocol for debriefs amongst the nursing staff and doctors following every neonatal death on the unit may have improved communication, knowledge, information sharing and discussion at ward level."
FARMER: Yes. I think we should have -- I think there should be debriefs after an infant death or an incident, so that it would be used as a learning process and it was a better way of communicating between all the nursing, medical staff. It's all about sharing information. We only knew one small part and you were just part of a jigsaw at that time. So I think with more knowledge, it would have helped.
LADY JUSTICE THIRLWALL: So do you mean debriefs from people other than or in addition to those who would have been involved?
FARMER: No, no, just debriefs on the unit, I meant.
LADY JUSTICE THIRLWALL: No, no, I understand that.
FARMER: Sorry.
LADY JUSTICE THIRLWALL: Just from something you said earlier, you talked about generally debriefs would only be those who had been involved in an incident.
FARMER: Yes, yes.
LADY JUSTICE THIRLWALL: I just wondered, are you suggesting that more than those who had been involved should be invited to the debrief?
FARMER: Yes, maybe more --
LADY JUSTICE THIRLWALL: I don't want to put words in your mouth. I just wondered is that what you meant?
FARMER: Yes. I think so, yes. I think so.
LADY JUSTICE THIRLWALL: Thank you.
MR DE LA POER: Finally, to draw attention to one of the recommendations that you propose. You say: "I would recommend Safeguarding training for all NHS staff to include a clear process of what to do if there are suspicions or they witness abuse of patients by a member of staff and encourage a culture to speak out."
FARMER: Yes.
DE LA POER: Is that something that you thought was lacking during 2015/16?
FARMER: Yes, yes.
MR DE LA POER: Ms Farmer, thank you very much indeed. Those are my questions. My Lady, there is a Rule 10 permission in relation to the Family Group 1, Mr Skelton I believe, and I wonder whether it would be convenient if we do that and then take our break.
LADY JUSTICE THIRLWALL: Very well. Mr Skelton.
MR SKELTON: Thank you. Ms Farmer, I ask questions on behalf of one of the family groups.
FARMER: Okay.
SKELTON: I am going to ask you first about [Child A] and [Child B], do you remember them, the twins?
FARMER: Yes, I didn't look after them but I do remember them.
SKELTON: But you were around on the unit at the time.
FARMER: Yes.
SKELTON: After they were born, Mother A and B remembers being told that they were in good condition, although [Child B], the one that survived, the girl, needed some extra help; do you remember that?
FARMER: Not specifically but ...
SKELTON: But do you remember them being in good condition?
FARMER: Yes, yes.
SKELTON: And do you remember there -- [Child A]'s collapse being unexpected and unexplained at the time?
FARMER: I must have been, yes, yes.
SKELTON: Which is generally speaking an unusual occurrence, so babies without any particular condition that's likely to cause their collapse, don't normally collapse?
FARMER: Well, we were always very vigilant with premature babies. Because of the nature of prematurity, they could be stable but very quickly deteriorate. So it's a difficult one. You don't expect a death but it's always at the back of your mind that they are very vulnerable babies, so, as such, you are always vigilant to ensure that you pick up on any clinical signs that show that they may be deteriorating, so ...
SKELTON: In the case of [Child A], he deteriorated and died very suddenly --
FARMER: Right, okay.
SKELTON: -- and without explanation; were you aware of that?
FARMER: I don't remember at the time how -- I don't know -- no, I don't remember.
SKELTON: Do you remember any discussion about any
rashes or mottling being seen on [Child A]?
FARMER: No.
SKELTON: So you can't assist on what communications there might have been with Mother A about that?
FARMER: No.
SKELTON: Can I just return to the topic of debriefs. There seemed to be, from your evidence and your statement and today, different purposes for debriefs, one of which is to support staff?
FARMER: Yes.
SKELTON: And the other of which is learning?
FARMER: Yes.
SKELTON: Is that right?
FARMER: Yes.
SKELTON: That's correct?
FARMER: I think so, yes.
SKELTON: And is the initial debrief after a child has collapsed and died to support the staff?
FARMER: Yes. It was -- we did have -- all the staff that were involved following a death, if they were on that unit at that time, following an incident you would have a discussion straight away amongst all the nurses, doctors involved and then a few days later arrange more of a debrief looking through the notes in a more controlled environment. But again, it was usually with the people that were involved in the incident.
SKELTON: So a debrief is the type of -- the second form of debrief is the type of information sharing --
FARMER: Yes, yes.
SKELTON: -- meeting by the professionals to understand what had happened?
FARMER: Yes.
SKELTON: And if there had been similar factors between collapses and deaths between two children, A and B in particular, would you expect those to be discussed in a debrief?
FARMER: If they followed the same pattern, do you mean?
SKELTON: Yes, if there had been similarities.
FARMER: Possibly.
SKELTON: Can I ask you about the treatment of Mother A and B after Baby A [Child A] died. Obviously she was in the very difficult position of having to return to the unit because her daughter was still there --
FARMER: Yes.
SKELTON: -- and was still being cared for?
FARMER: Yes.
SKELTON: Do you appreciate now that that's an extraordinarily hard position for a parent to be in --
FARMER: Oh, yes, very much so.
SKELTON: -- one child has just died but the other is still alive?
FARMER: Of course.
SKELTON: And she doesn't feel she was treated, at least by all the staff, with the necessary sympathy and consideration when she returned.
FARMER: I am very sorry to hear that.
SKELTON: Do you appreciate that she should have been treated very sensitively given that she is coming back to the scene of her other child's death?
FARMER: I would have expected her to be treated sympathetically.
SKELTON: Mr De La Poer asked you about your reflections. As I understand your evidence, throughout 2015 and 2016, you had no suspicions about Lucy Letby harming children?
FARMER: No.
SKELTON: Did you ever review any of the babies' notes?
FARMER: No.
SKELTON: So you had no personal understanding of the circumstances in which the children had died --
FARMER: No.
SKELTON: -- or collapsed?
FARMER: No, they weren't available to be reviewed,
so no.
SKELTON: Did you ever speak to Dr Brearey or Dr Jayaram about their concerns?
FARMER: No.
SKELTON: Do you accept now, looking back, that you may have closed your mind to the possibility that she was harming children without any curiosity as to what had actually happened to the children?
FARMER: Well, following the trial, there was a lot of information that I wasn't aware of. I worked with her as a colleague, we had a professional relationship and that was my understanding; that she was a professional. So I didn't have all the knowledge that we now know about it, so I -- I can't really say more than that, really.
SKELTON: Were you aware of Beverley Allitt? She was a professional nurse.
FARMER: Yes.
SKELTON: And you are aware of Victorino Chua, who was also a nurse, and both of them had killed patients.
FARMER: Yes.
SKELTON: Dr Shipman, of course, famously, killed over 100 patients.
FARMER: Yes, but it didn't cross my mind that that was happening at that time.
SKELTON: Why did you close your mind to the possibility that she was harming patients without having yourself conducted any form of investigation and without having spoken to the two very senior clinicians that did suspect her?
FARMER: I just felt it was unconceivable that a colleague would harm babies. So that was my view at that time.
SKELTON: Do you recognise that that opinion was a mistake, given what you now know?
FARMER: Well, obviously, now I know, it's very devastating. So, yes. Yes.
SKELTON: Have you got any reflections on the fact that you and other nursing staff appeared to have closed your minds to that possibility without taking any active steps to ascertain the truth yourselves?
FARMER: I think that's a very unfair question really because we are all absolutely devastated, it's had a massive effect on us all. So it's a very emotional time. So it's hard to -- of course we have all reflected on it, so -- but we only knew what we knew at the time and could only make decisions on what we knew at that time, so ...
MR SKELTON: Thank you.
LADY JUSTICE THIRLWALL: Thank you, Mr Skelton. Just to pick up on the last question. Do you think now that it's inconceivable that a nurse would harm babies?
FARMER: Well, not, not with what I have learnt from all the police investigations, no.
LADY JUSTICE THIRLWALL: I'm just thinking, sort of moving on, because I imagine there may have been those who thought like that at the time of Beverley Allitt.
FARMER: Yes, yes.
LADY JUSTICE THIRLWALL: I'm just wondering what it is you think that would make you think the unthinkable, perhaps that's an impossible question to answer but ...
FARMER: Yes, because if a member of staff had had concerns on the unit, we were a very small unit, nobody raised any concerns, like, from -- none of the nurses. I know I have heard evidence that they had a huddle but nobody actually came and spoke to me about it.
LADY JUSTICE THIRLWALL: No one spoke to you about it?
FARMER: Yes.
LADY JUSTICE THIRLWALL: Yes.
FARMER: So I think communication was quite lacking in that respect. If people had suspicions perhaps they should have voiced them. So perhaps we didn't have an
open enough relationship, I don't know.
LADY JUSTICE THIRLWALL: Thank you. Can I just ask you briefly about the incident with the morphine.
FARMER: Yes.
LADY JUSTICE THIRLWALL: I don't want to take a lot of time on it but I really just want to understand what your role was.
FARMER: Yes.
LADY JUSTICE THIRLWALL: We can see from the document which is INQ0008961, page 45, we have looked at it already --
FARMER: Yes.
LADY JUSTICE THIRLWALL: -- most of it, you told us, in Eirian Powell's writing.
FARMER: Yes.
LADY JUSTICE THIRLWALL: And it looks as though she has a one-to-one with Lucy Letby on 30 July.
FARMER: Yes.
LADY JUSTICE THIRLWALL: And at the bottom she then writes, "Review in six months, January 30th".
FARMER: Yes.
LADY JUSTICE THIRLWALL: So her contribution to the document finishes at that point and then you have written yours above that --
FARMER: Yes, yes.
LADY JUSTICE THIRLWALL: -- for 6 September. And I just wanted to understand whether, when you wrote it on 6 September, you were talking about a process with Letby or whether in fact it was a single occasion --
FARMER: Yes.
LADY JUSTICE THIRLWALL: -- when you completed practice calculations with her.
FARMER: I think it was part of a process because she had a workbook to work through and then the calculations were an addition and we had a competency for the use of the pump, and I know we went through that --
LADY JUSTICE THIRLWALL: Yes.
FARMER: -- and I asked her to input different doses. So she actually knew -- I was confident that she knew how to input the dose, whether it was a mistake, it sounds like it was a mistake in the inputting rather than the actual calculation.
LADY JUSTICE THIRLWALL: Yes, I think we have seen from the documents, it was -- she made a mistake with the pump.
FARMER: Yes, yes.
LADY JUSTICE THIRLWALL: And I presume that all of that had been tested before?
FARMER: Yes, yes. Yes.
LADY JUSTICE THIRLWALL: So was there any discussion about how come she had made a mistake? Did you have any discussion with her about that?
FARMER: No, not really. She did, she was with another member of staff who had checked it as well so we had two people at that time who had made the mistake.
LADY JUSTICE THIRLWALL: Were you involved in dealing with that nurse as well?
FARMER: No, no. No. No, she was a very senior nurse and she almost resigned over the incident, following the incident and so she had more meetings with Eirian --
LADY JUSTICE THIRLWALL: I see.
FARMER: -- rather than myself.
LADY JUSTICE THIRLWALL: Thank you, thank you very much indeed. Actually, there was one other question. You mentioned that you had gone along to the meeting which was about the post-mortem for [Child A].
FARMER: Yes.
LADY JUSTICE THIRLWALL: And the reason that you had gone, I think I have got this correctly, it was for your own professional development.
FARMER: Yes.
LADY JUSTICE THIRLWALL: Was that because you had not previously gone to such an event?
FARMER: Yes. Yes. I think in the past, we, it was always an open invite if anybody wanted to go.
LADY JUSTICE THIRLWALL: Invitation, yes.
FARMER: As part of, as I have said, my development it's important to have an overview of all the different sort of meetings, areas to go to.
LADY JUSTICE THIRLWALL: Was also a part of your decision the fact that you had been -- you knew about [Child A]?
FARMER: Yes, yes. Any, any meetings or reviews about different babies on the unit were always something of interest. You might want to go to just to see what -- it was probably a more thorough review or a review that you didn't really know about. Yes.
LADY JUSTICE THIRLWALL: Thank you very much indeed.
FARMER: Okay.
LADY JUSTICE THIRLWALL: Is there anything arising out of that, Mr De La Poer?
MR DE LA POER: No, thank you, my Lady.
LADY JUSTICE THIRLWALL: In that case, thank you for coming to give evidence. You are free to go and we will take a break now until a quarter to 12. (11.28 am) (A short break) (11.48 am)
LADY JUSTICE THIRLWALL: Mr De La Poer.
MR DE LA POER: My Lady, the person sitting in the witness box is Nurse Yvonne Griffiths, our next witness, I wonder if she may be sworn.
MS YVONNE GRIFFITHS (Sworn)
MR DE LA POER: Please could you give us your full name.
GRIFFITHS: Yvonne Griffiths.
DE LA POER: Ms Griffiths, you have provided to the Inquiry two witness statements, is that correct?
GRIFFITHS: Correct.
DE LA POER: The first one is dated 19 June of 2024. With the exception of paragraphs 70 to 77, is the content of that witness statement true to the best of your knowledge and belief?
GRIFFITHS: Yes.
DE LA POER: And I have excepted those because you provided a second witness statement, dated 15 October of this year -- that is to say yesterday?
GRIFFITHS: Correct, yes.
DE LA POER: And is the content of that second witness statement, which directly addresses paragraphs 70 to 77, true to the best of your knowledge and belief?
GRIFFITHS: Yes, it is.
DE LA POER: Did you qualify as a registered nurse in 1985?
GRIFFITHS: Correct, yes.
DE LA POER: And after a period of further training including in the United States, did you join the Countess of Chester Hospital in 2004?
GRIFFITHS: Correct.
DE LA POER: Did you complete an Advanced Neonatal Course in 2011?
GRIFFITHS: Yes.
DE LA POER: And at around that time did you become the deputy ward manager of the neonatal unit?
GRIFFITHS: Yes, I did.
DE LA POER: And for the entire period that you were deputy ward manager, was the ward manager Nurse Eirian Powell?
GRIFFITHS: Yes, correct.
DE LA POER: Upon Ms Powell's retirement in December 2017, did you become ward manager for the NNU?
GRIFFITHS: Yes, initially acting for six months, and then took over, yes.
DE LA POER: Now, as deputy ward manager, which was your role at the time, were you responsible for the nursing rota?
GRIFFITHS: I was.
DE LA POER: What other responsibilities did you have that were particular to the role of deputy ward manager?
GRIFFITHS: At the present time there was a big campaign for Babygrow Appeal so I was a big part of the fundraising activities, and I also deputised if the manager wasn't on duty.
DE LA POER: Did you have any responsibility for matters going to staff conduct or the investigation of clinical incidents?
GRIFFITHS: Not really no, I was more -- I did work clinically both managerial and clinical, so most of my time was clinical.
DE LA POER: When you say clinical that is directly caring for babies on the ward?
GRIFFITHS: Yes, I would have about three or four days a month to -- to do the off-duty and I would have additional days if Eirian was off on annual leave.
DE LA POER: Now, in your own words, please tell us what the culture and atmosphere on the neonatal unit was around the start of 2015?
GRIFFITHS: I found it to be really well. I think we worked cohesive as a team. We were very busy but we all worked really well and I thought it was a good culture.
DE LA POER: And when you say "we", are you speaking just about your nursing colleagues or are you including the doctors?
GRIFFITHS: I think -- all of us yes, I believe all.
DE LA POER: So did you think at that time there were any problems with the culture or atmosphere, whether between individuals or between groups such as nurses and doctors?
GRIFFITHS: No.
DE LA POER: You do say that you didn't think the relationship between midwives and nurses was particularly strong?
GRIFFITHS: (Nods).
DE LA POER: Why did you say that?
GRIFFITHS: Unfortunately we were in different directives so we never really mixed in any meetings together and I don't think either of us were aware of how busy each other were in our departments because we didn't have that cohesion that we do have now.
DE LA POER: In terms of the leadership at the unit level, Dr Brearey was the neonatal lead Consultant and, as you have told us, the ward manager was Nurse Powell.
GRIFFITHS: Correct.
DE LA POER: What was your perception as to how they worked?
GRIFFITHS: I thought they worked really well. They often went to network meetings together. I think they had a common goal. I know our staffing -- they always looked at doing staffing business cases. So I thought
they worked very well. They wanted to make change on the unit.
DE LA POER: And did that continue to be the case all the way up until the end of June of 2016?
GRIFFITHS: Yes, I think they worked well together.
DE LA POER: Once June 2016 was reached and we had the deaths of [Child O] and [Child P] towards the end of June was there any change in their relationship that you perceived?
GRIFFITHS: Not that I perceived, no.
DE LA POER: Now, we have heard something about Nurse Powell's conduct of herself in relation to the nursing staff, so there was a "circle of trust", is something that Nurse ZC has told us, and that some, including Nurse T, have said that Eirian Powell had favourites. Are those descriptions that you recognise, a club or a clique operating within the neonatal unit?
GRIFFITHS: No. I think Eirian was very neutral. She was old school and her famous comment was: these are your work colleagues not your friends. So she never socialised outside of work with any of, of the nurses, and she was very professional. I think she recognised people who were keen to pursue the career of neonatal nursing because it's a lot of
education, so I think she respected nurses that had the passion to develop their skill set.
DE LA POER: In terms of the, as the jargon is, the activity and acuity levels, how busy and how seriously sick were the babies, what was your perception of the busyness of the neonatal unit at that time?
GRIFFITHS: I think being responsible for the off-duty, it was very challenging. We were -- we staffed all our budgeted positions within nursing but depending on the acuity then I think the nursing staff had to do a lot of flexibility, work on annual leave, swap days, depending on activity. So it could range from one day only having seven babies on the unit, and low acuity, to particularly busy periods where we could be full and that's when we would be putting a plea out for additional staff to help.
DE LA POER: And you are describing a process where there are particularly busy periods and perhaps less busy periods. Was that true throughout the period of time that you were deputy ward manager or did that change at any point?
GRIFFITHS: I think it's reflective of every neonatal unit. You have peaks and troughs. You can have a very busy period or you can have a quieter period, depending, because it is dependent on who delivers and needing our
services.
DE LA POER: And as far as those peaks and troughs are concerned, was it a peak or a trough during the period 2015 into 2016? Or neither, it doesn't need to be --
GRIFFITHS: I think it continued, yes, yes, busy periods. We would have a quiet spell and then we would be busy, particularly around Christmas, so it just depends, if there is any occasions and we would always have busier times at certain times of the year.
DE LA POER: Were you aware of the BAPM standard for staffing?
GRIFFITHS: Yes.
DE LA POER: And was that aspirational or was it achievable?
GRIFFITHS: It was a recommendation from 2010. I think it gave neonatal units the -- the document to say: this is the standard that every neonatal should have. But obviously it was a new document that didn't really come with any additional funding. So I know we were able to use that document for our business case for additional staff.
DE LA POER: And is that the Babygrow business case you are talking about or a different business case?
GRIFFITHS: No, the Babygrow was for the new neonatal building that we are in now so that we have got a better space. The business case was for additional staff.
DE LA POER: And when approximately was that business case put forward?
GRIFFITHS: I am not aware but I have looked back and it's around about 2013/14. So that was the business case because I think the Kirkup Report came but this is just on my knowledge I have now rather than back in the day.
DE LA POER: Well, using the knowledge you have now, provided it is accurate, that's what's important. And what was the response to the business case that was put forward in around 2013?
GRIFFITHS: I know Eirian and Dr Brearey and our matron, they got together to compose the business case and I know they would go off to the meeting and would all be excited and then they would come back and it would be refused because it would be on the wrong template and so they would have to do it again. So they never really got anywhere with it. So following that we were told to Datix if we had any staffing issues, so just so we could highlight that to the Executive team.
DE LA POER: We are going to come to Datix in a moment, but is what you are saying that in the event that you felt that you were short-staffed, that should result in a Datix form noting that fact?
GRIFFITHS: And I think that was just to recognise -- to have a record of that for the Trust to say that this is why we need that business case to be approved.
DE LA POER: And so by the time we get to 2015/2016, had any change been made to the staffing level by reason of the business case?
GRIFFITHS: No.
DE LA POER: Was patient care ever compromised, in your view, by reason of the staffing level?
GRIFFITHS: No, because we all had a very flexible team. I think everybody, if there was a plea for extra staff, the colleagues always came in as they do now. So I think we were very fortunate that we had a good team. We would have benefited from that additional staff because that would have given us a supernumerary shift leader which would have been better staffing.
DE LA POER: Finally before we turn to the topic of policies and procedures, your relationship with Eirian Powell. How did you find working with her?
GRIFFITHS: I learnt a lot from Eirian Powell. I think she was a very good manager. She was very passionate about what she did and I think she never, if she had a goal, I think she always went for it, like with staffing she, you know, she persisted to try and get more staff. She encouraged staff to go and do the
courses. We were the first to ever do the R23, which is the Advanced course, because she just wanted all the nurses to be highly skilled, to provide the care.
DE LA POER: In your experience of her, did she see herself as an advocate for her staff?
GRIFFITHS: Yes.
DE LA POER: And was that an appropriate approach for her to take, do you think?
GRIFFITHS: Sorry, I don't understand the question.
DE LA POER: Well, do you think that her role as manager was to act as an advocate for her staff?
GRIFFITHS: I think she was there to represent what the unit needed and it was her voice to take it to the exec level. But I just feel because we were in Urgent Care, I don't think they appreciated the world of neonatology.
DE LA POER: Now, one of the things that you say on more than one occasion in your statement is that you were excluded from major discussions?
GRIFFITHS: (Nods).
DE LA POER: Or as you describe them, high profile meetings, and you make a reference to your banding saying it is above your banding level.
GRIFFITHS: Yes, yes.
DE LA POER: Just to try and get underneath what you are
saying by that, was it your view that you were excluded when you should have been included or was it your view that you were excluded and you didn't need to go?
GRIFFITHS: I was excluded and didn't need to go because obviously I was working on the shopfloor so we can't just all walk off and go to meetings, you know, my responsibility was to ensure that the safety of the unit was staffed appropriately, and caring for the babies, like any other Band 6.
DE LA POER: As somebody with management responsibility who needed to be in a position to step into Nurse Powell's shoes, should she not be available, how important was it that you had a clear understanding of the important workstreams that she was involved in as the unit manager?
GRIFFITHS: Eirian always cc'd me in any relevant emails so that if she happened to not be there and I had a question I could read through the thread of emails.
DE LA POER: So was it your working expectation that she would always tell you about important things she was doing as the unit manager?
GRIFFITHS: Yes, I mean, with the business case and, yes.
DE LA POER: Well, we will look at individual events --
GRIFFITHS: Okay.
DE LA POER: -- but I am talking generally here, so that's sufficient for now.
GRIFFITHS: Yes.
DE LA POER: So I said I was going to come on to policies and procedures. The first one is safeguarding. Had you received any training in how to deal with a situation in which a colleague was suspected of doing harm to patients?
GRIFFITHS: No, we would do adult safeguarding and children safeguarding and that was specifically around where I worked, it's more the scenarios around making sure that the home was safe for the baby to go home and we never had any scenarios regarding anybody in hospital causing harm because I think it's just, for me, for anyone to do any harm within a hospital setting that's a Trust -- but no, we didn't have any scenarios about staff.
DE LA POER: Do you think you should have?
GRIFFITHS: In reflection now, yes. Yes.
DE LA POER: Do you think the fact that you hadn't had any such training made any difference to how you acted when presented with the events that we are going to look at in more detail?
GRIFFITHS: No, but obviously I have read a lot about safeguarding and it is to prevent harm to, to a child, so I suppose now I realise that you could connect the
two but we never had any scenarios regarding staff.
DE LA POER: Forgive me, it will have been my question. I absolutely accept you hadn't had such training, I'm just inviting you to consider that had you had such training, would it have made a difference to how you approached the information you were being given at the time?
GRIFFITHS: No, I don't think so.
DE LA POER: And why do you say that?
GRIFFITHS: Because -- I suppose it was just the commonalities of a certain person on shift rather than witnessing any harm. If I witnessed somebody doing deliberate harm, then I would escalate that.
DE LA POER: Well, we will come back to whether it was just commonalities in due course but I'll move on from safeguarding to Datix. What was your understanding about when a Datix form was required?
GRIFFITHS: A Datix was so that we could learn from the event.
DE LA POER: Now, we know, having seen some Datix forms, and we will look at one or two over the course of your questioning, that there was a category of "Expected and unexpected death". Does that -- is that something that you recognise as an option on the Datix form?
GRIFFITHS: Not from memory, but I believe ...
DE LA POER: We will have a look at it. What was your understanding about whether or not a Datix was required if a child died?
GRIFFITHS: Looking back, I feel we did Datix any child that had died but I am not 100% back in 2015.
DE LA POER: And on what basis were you filling in those Datix forms? Why did you think that they were required? What criteria was prompting that form?
GRIFFITHS: I think on the shopfloor at the time in 2015/16, we would just complete a Datix and then we would expect a team to review that Datix. I wasn't involved in too many reviews of Datixes.
DE LA POER: But the thought process of you have just been participating as a nurse in a patient death, did you understand there was an expectation that you would fill in a form about that to record that?
GRIFFITHS: Yes, but at the time I just thought it was to -- so the Executive team would be aware that we have had a death.
DE LA POER: What about in the event of a sudden unexpected collapse that didn't lead to death? Was your understanding that a Datix was required or wasn't required in that situation?
GRIFFITHS: We didn't fill one in at that time.
DE LA POER: Has that changed since?
GRIFFITHS: No, because we don't tend to have them as often now.
DE LA POER: It may be that you don't have them as often but when they do happen, these rare events, would you expect your staff, as the current unit manager, to fill in a Datix?
GRIFFITHS: No.
DE LA POER: And why is that?
GRIFFITHS: Because working within an ITU area, I think it was quite common that that would happen and it was only if it resulted in, in the baby's demise then we would Datix the incident.
DE LA POER: Have you, and I readily accept that it wasn't in the pack that you received, have you seen anything of the concerns that were raised at the time by Ruth Millward and others about the fact that the neonatal unit was not filling in Datix forms when they should have been?
GRIFFITHS: I wasn't aware of that at the time.
DE LA POER: You weren't aware of that at the time?
GRIFFITHS: No.
DE LA POER: Are you aware of that now or not? Is that news to you, what I have just said?
GRIFFITHS: I might have read it in my pack but I can't remember.
DE LA POER: Well, it's certainly not a memory test as far as your pack is concerned.
GRIFFITHS: Yes.
DE LA POER: But I'm just seeking to understand what your current position is. Have you, as unit manager, had meetings with the risk department about what their expectation is about when Datixes are and aren't filled in?
GRIFFITHS: We normally have a Datix drop bar, so that can change depending, you know, as the, as practices change, so usually there is a drop bar that will indicate what we need to Datix.
DE LA POER: So that's the form, but I am talking about a sitdown meeting, human being to human being, you and somebody from the risk department so they can say: this is what our expectation is.
GRIFFITHS: Oh, sorry, yes. I know back in the day and also now we have NNIRG meetings, which is a neonatal review meeting, and that's with the people from the risk department and the manager and the Consultant would review any Datixes and to see any learning to come from that.
DE LA POER: Has any training been provided as to when they are and aren't expected?
GRIFFITHS: No. No.
DE LA POER: Debriefs. What was your expectation in 2015/2016 about whether there would be a debrief following a death?
GRIFFITHS: A debrief was more for pastoral care for the staff to ensure that they could all come together because obviously it is very traumatic for the staff. We try and do that as soon as the incident was, was -- had happened, but depending on other demands within the team. But I felt that it was -- it's important to just all come together to -- to talk about the incident and how people felt it went and if there was any learning or anything that anybody wanted to bring up.
DE LA POER: So if not that first debrief which you have described as occurring as soon as possible and for pastoral purposes, was there any opportunity back in 2015/16 for learning that you were invited to participate in relation to deaths?
GRIFFITHS: I might have been present in a few reviews of neonatal deaths. So that would be done by a Consultant that wasn't part of that resus and a nurse, and a manager or, if Eirian wasn't there, then I would, would present. And then I think you would look at all the maternal side and then the neonatal and then they would come together, in my understanding, to review that
case.
DE LA POER: So we have heard something about the perinatal mortality and morbidity review meetings that happened approximately every two months. We have also heard something about the neonatal mortality meetings, which were only about deaths, as the name would suggest. Is that what you are referring to?
GRIFFITHS: Yes.
DE LA POER: So I would like to turn, please, to ask you about clinical incidents before the period that we will focus on in due course, the first being the morphine infusion incident on 22 July 2013. What you tell us is that you were on a management day on that occasion, but you were made aware that it had occurred.
GRIFFITHS: Yes.
DE LA POER: And what was it about this incident that would need you, who wasn't on the ward at the time, to be told about it?
GRIFFITHS: I believe Eirian wasn't on duty. I think she was on annual leave. I was informed of the incident and because it was a very serious incident with morphine, I did seek help from my matron as well on how to handle the follow-on from the Datix.
DE LA POER: Very serious incident?
GRIFFITHS: Yes.
DE LA POER: Why do you say it was a very serious incident?
GRIFFITHS: It was a morphine error on the pump that was infusing. I can't remember the times fold of morphone.
DE LA POER: 10.
GRIFFITHS: 10-fold, so if that hadn't been picked up as soon as it was, it might have made the baby demise.
DE LA POER: It could have been fatal?
GRIFFITHS: Yes.
DE LA POER: So a very serious error, one requiring you to be contacted when you are not on the ward in the absence of Ms Powell?
GRIFFITHS: I was on the ward.
DE LA POER: Oh, you were on the ward?
GRIFFITHS: It happened -- I think it was handed over at 8 o'clock so the incident occurred at 8 when I was coming on duty.
DE LA POER: That's entirely my fault. When you said that I was on a management day --
GRIFFITHS: Yes.
DE LA POER: -- do you mean you were acting as ward manager that day?
GRIFFITHS: Correct.
DE LA POER: I'm sorry, that was my misunderstanding entirely. So you were aware of the incident, and did you speak to Letby immediately after it or had she left for -- at the conclusion of her night shift before you were able to speak to her?
GRIFFITHS: I can't remember.
DE LA POER: We know that there was a one-to-one --
GRIFFITHS: Yes.
DE LA POER: -- the next day.
GRIFFITHS: That's right.
DE LA POER: So I am not asking about that. It's just whether you have any recollection before that one-to-one of seeing Letby, what her demeanour was, what her attitude was to this error?
GRIFFITHS: No, sorry, I don't remember.
DE LA POER: I'm not going to name the member of staff, but the other member of staff who was involved, you describe as being terribly upset.
GRIFFITHS: She was extremely upset.
DE LA POER: And that she came to find you.
GRIFFITHS: Yes.
DE LA POER: Is that right?
GRIFFITHS: Yes.
DE LA POER: Are you able to say, for sure, whether Letby did or didn't come to find you on that day to talk about it?
GRIFFITHS: No, she definitely didn't. No, the only meeting I had with Lucy was on the one-to-one date of the meeting.
DE LA POER: So let's have a look at that now, please. It's INQ0008961, page 47 -- it is going to come up on the screen in front of you. Just so you know, Ms Griffiths, we did look at this with your colleague Ms Farmer earlier today. So we have read through it already but do you want to just refamiliarise yourself with the content of this document?
GRIFFITHS: Yes.
DE LA POER: I am sure you have seen it many times.
GRIFFITHS: Yes.
DE LA POER: What I would like to focus on are the three action points. So the first is happily, because somebody picked it up very shortly after the error was made, no detrimental effect on the infant.
GRIFFITHS: Correct.
DE LA POER: And had you managed to establish that conclusively by the time of this meeting?
GRIFFITHS: Yes.
DE LA POER: Now, the next word is, as I read it "sustain", I think that's your handwriting.
GRIFFITHS: Yes.
DE LA POER: Are you meaning by this that she should not check any intravenous infusions requiring additives and any controlled drugs until the incident review?
GRIFFITHS: Correct.
DE LA POER: What were you envisaging would occur by way of incident review?
GRIFFITHS: I would expect the incident to be, I expected Lucy to be spoken to and, and the pump to be checked. That's what we would normally do for -- to make sure that it wasn't an input error it was a pump error. And I would just expect someone to address it higher than me.
DE LA POER: So the incident review, were you expecting that would happen the next day or that it would require a formal meeting, put into people's calendars, what are you expecting by this incident review and when it might take place?
GRIFFITHS: Well, I think when I look at the date, 2013, I was pretty new at managing these situations, it was the first incident of a high calibre that I was dealing with, so I did have advice from my matron. And I just thought it was quite a safe practice to stop her from doing any competent, you know, IVs until it was -- somebody more senior could take that lead.
DE LA POER: Then we have "Complete intravenous
competencies, drug calculation, with Practice Development Nurse Yvonne Farmer" as your third action point.
GRIFFITHS: (Nods).
DE LA POER: Were you expecting, when you wrote this, that that competency drug calculation practice would occur before Letby was signed off to go back to administering?
GRIFFITHS: Yes. I think we normally have a process. So if a medication error is, is made, depending on the severity, then you would do a reflection and then you would have to do competencies before you are able to carry on.
DE LA POER: So you were envisaging a circumstance in which Letby met with Farmer, Nurse Farmer, before she was allowed to go back to being involved with controlled drugs in this circumstance?
GRIFFITHS: That's what I would have thought would happen.
DE LA POER: Now, what was Letby's demeanour? How was she presenting herself to you in this meeting?
GRIFFITHS: I just remember the comparison because I know the other lady was very distraught and very upset, to the point where she was going to leave nursing. Letby, I think she was upset but not to the same extent.
DE LA POER: Now, you have told us that you consulted the matron who was Anne Murphy.
GRIFFITHS: Yes.
DE LA POER: The most senior nurse on the Children's Unit, is that right?
GRIFFITHS: Correct.
DE LA POER: Including neonatology. Let's just think about the order of that. Had you spoken to her before you had this meeting with Letby?
GRIFFITHS: Yes. I would have spoken to Anne Murphy the day that the incident occurred.
DE LA POER: And so you, you already knew by the time you came into this meeting that what your plan was had been approved by the most senior nurse who worked at ward level?
GRIFFITHS: Yes.
DE LA POER: What was Letby's reaction to you telling her that she wasn't allowed to be involved in intravenous infusions requiring additives and any controlled drugs until a review had taken place and, as you have told us the third point means, that she wasn't allowed to do any of that until she had completed competencies in drug calculation with Nurse Farmer?
GRIFFITHS: She seemed to accept my decision.
DE LA POER: Did you at any point have to consult Nurse Murphy about how the situation should be handled
after you had had your meeting with Letby?
GRIFFITHS: Yes, we had a meeting after and Anne Murphy was very supportive knowing that this is the first big incident that I had had to deal with.
DE LA POER: What degree of insight do you think Letby was showing in that meeting, about the severity of the error and the need for remedial steps to be taken?
GRIFFITHS: I can't really remember but I think she accepted it and she did actually sign the form, so ...
DE LA POER: And were you involved any further with this incident?
GRIFFITHS: No.
DE LA POER: I would just like to take you, please, to paragraph 39 of your witness statement just to see if I can prompt your recollection.
GRIFFITHS: Is it in the bundle?
DE LA POER: It should be in your folder there. You should have your witness statement --
GRIFFITHS: Oh, yes.
DE LA POER: And if you could go, please, to page 8 and paragraph 39.
GRIFFITHS: Yes.
DE LA POER: I'll just read it out so you follow along: "In terms of my discussions with Anne Murphy (Matron for Paediatrics and Children's ward) I remember
showing her the 'One to One' form and discussing my plans on actions, which she agreed. The reason for my discussion with Anne Murphy was due to Letby stating that she was unhappy with my decision following our 1:1 meeting. In response, I stated I would take on board her comments and speak to Anne."
GRIFFITHS: Yes, I think perhaps she thought I was being a bit harsh.
DE LA POER: So just if we just roll it back a little bit.
GRIFFITHS: Yes, yes.
DE LA POER: The chronology you have given us to that point was that you spoke to Nurse Murphy before.
GRIFFITHS: Yes.
DE LA POER: You had an agreed plan, you saw Letby, and Letby was happy with what you decided. The account you have given in your Inquiry witness statement is that in fact your conversation with Anne Murphy happens after your one-to-one, and was only prompted by the fact that Letby was, to use your words, "unhappy" with your decision.
GRIFFITHS: Yes. I mean, she wasn't happy but after we discussed it, she, she agreed to sign the paper.
DE LA POER: So this is a difficult situation for you to manage as you hadn't, you have told us, done such a review before in such a serious incident. Was it, in
your view, appropriate for Letby to be unhappy with the decision that you had made, bearing in mind the severity of her error?
GRIFFITHS: No, and I think it's not that I want to use the word seniority but I think it's, you know, you have to -- she had -- she was only new into her role. I think she had only been on the unit for --
LADY JUSTICE THIRLWALL: I think quite a lot of people in the room didn't hear that because of the noises from outside.
GRIFFITHS: She was relatively new on the neonatal unit and I think -- and I think any constructive criticism needs to be taken on board by, by nurses.
MR DE LA POER: Well, I am sure that that's right, but it is just from what you have told us in your witness statement she wasn't, apparently, taking on board constructive criticism unless what you have told us in your witness statement is not correct?
GRIFFITHS: I just remember that she did sign the form, so I think after I spoke -- she wasn't happy that it was -- she thought it was a bit severe what I was proposing but then after I explained that this is the normal process that we would do, with any medication error, she did then sign it and then I said she could meet with Eirian the following week when she returned.
DE LA POER: Did it give you at the time any cause for concern that her reaction in the face of this error was to question your decision-making which was based on safety grounds?
GRIFFITHS: I suppose she was just protecting her reputation. I think she didn't want to think that she -- she was being judged so harshly and I think because it had been picked up so quickly she didn't think that the error had caused any harm.
DE LA POER: What does that response say about her insight?
GRIFFITHS: Sorry?
DE LA POER: What does her response say about her insight into that incident? Did she have good insight?
GRIFFITHS: I think she knew the -- how detrimental it would be if that infusion continued, if that's ...
DE LA POER: What -- was Anne Murphy supportive of your decision in terms of what you had said should happen to Letby?
GRIFFITHS: Yes, and I think the other nurse as well equally had the same, same instructions too.
DE LA POER: And did that incident lead to a change of policy, that the infusions would not be made up at the end of a night shift but would instead be made up at the start of the day shift?
GRIFFITHS: Correct.
DE LA POER: Now, if we look, please, at the same INQ that I gave a moment ago, but page 45. That's INQ0008961. Just try to understand -- this is a note predominantly written by Nurse Powell, I am sure you recognise the handwriting.
GRIFFITHS: Yes.
DE LA POER: We can see that the first action is, and there is a symbol I'm not sure that I am able to interpret it: "To continue for care for infants ..." "IC", is that including "infusions"?
GRIFFITHS: Yes.
DE LA POER: Yes.
GRIFFITHS: Yes, with, yes.
DE LA POER: "Is able to check CDs" -- is that controlled drugs?
GRIFFITHS: Yes.
DE LA POER: And then to go over with Yvonne Farmer the pump settings, calculations?
GRIFFITHS: Yes.
DE LA POER: So if we just think about what you had decided, supported by the most senior nurse. It was, as you have told us, that she couldn't do either of those first two things until a review had been carried out and that she couldn't do either of those things until she had done the practice with Yvonne Farmer. This is seven
days later.
GRIFFITHS: (Nods).
DE LA POER: Do you agree that on the face of it, it's something of a countermand to what you had decided should happen?
GRIFFITHS: Yes.
DE LA POER: And we can see that it's not in fact until 6 September that those calculations are recorded as having been done? So was this something that Nurse Powell spoke to you about at the time?
GRIFFITHS: No. It's the first time I've seen this one-to-one form.
DE LA POER: And I mean, did you have cause to be on the ward and see whether Letby was performing infusions or checking controlled drugs following the incident?
GRIFFITHS: I find it difficult to answer that question. I -- I suppose I acted in the best interests in her absence and Eirian then has gone on and done this other -- I don't know where she made these decisions or what her thought process ...
DE LA POER: You now sit in her chair on the unit. Was it appropriate that within seven days before the calculations were carried out that Letby was permitted to go back to being involved with controlled drugs and
infusions?
GRIFFITHS: We have adapted a new policy within the network, so we have clear indications now if a drug error is made. So we, we have a chart which we grade the severity and depending on the severity then actions follow. And with an infusion like this, that would be quite a high level, so we would ensure that the competencies were done before they resumed.
DE LA POER: Under the current protocol this simply wouldn't be permitted.
GRIFFITHS: No.
DE LA POER: But under the system that you were operating at the time, was it appropriate, do you think?
GRIFFITHS: We didn't really have -- not that I am aware, we didn't really have any policies, that's why I seeked help and advice from my matron. There wasn't anything I could pick up to make her -- we just tended to do reflections.
DE LA POER: I would just like to show you one more thing. INQ0012033. That's the new version of that document, page 171, the one that was shown earlier. So this, I hope, is something that you have seen before today?
GRIFFITHS: Yes.
DE LA POER: And we can see here she's being asked about the drug error, and this is on 1 August, so this is just after her meeting with Nurse Powell and just over a week after her meeting with you: "Thankfully Eirian felt it had been escalated more than it needed to be. Everything is back to how it was and I just have to have more training on using the pumps and it will be on my record for six months. She was very supportive. It is a case of learning to live with it now and getting my confidence back. I am on nights this week. Still feeling a bit vulnerable and thinking what if, but I'll get there in time. Thanks for asking." Just to give you an opportunity, Ms Griffiths, to say, just given what you were told on the ward on the 22nd, given the steps that you took, did you escalate it more than it needed to be?
GRIFFITHS: No.
DE LA POER: Thank you, we can take that down. So I am going to turn now to the children named on the indictment and we will start with [Child A]. Did you have any involvement in [Child A]'s death?
GRIFFITHS: Not that I can recall.
DE LA POER: Do you have any recollection of any discussions about [Child A]'s death and anything that may have been unusual that stood out?
GRIFFITHS: No.
DE LA POER: What you do tell us at paragraph 45 is, you sent what you described as a welfare message to Letby, is that right?
GRIFFITHS: Correct.
DE LA POER: Just help us to understand why you would have sent that message back in June of 2015.
GRIFFITHS: I think -- I like to support staff and she was a very junior staff member and to be involved in a bereavement can be very harrowing for nurses and I felt I just needed to make sure that she was okay because I know she lived on her own and maybe just giving her an opportunity to speak if she needed to.
DE LA POER: Were you aware of the collapse of [Child A]'s sibling, [Child B]?
GRIFFITHS: I think at the time -- I mean, I have had the record since but I can't remember the collapses.
DE LA POER: And were you aware of any discussion about any similarities between the death and the collapse between the two twins?
GRIFFITHS: No.
DE LA POER: In paragraph 51 you deal with a message that Letby sent to you on 11 June of 2015. This is your page 10 and very helpfully if I may say --
GRIFFITHS: Yes.
DE LA POER: -- you have recreated the message in your witness statement so we can look there. This is 11 June, so this is very shortly after the death of [Child A] and the collapse of [Child B]: "Hi Yvonne. Are you okay for staffing over the next few days? I don't have anything on if you need extra or need to change my nights?" And then you replied and said that staffing was okay until Saturday, the 13th, and Letby replied to that: "Ok. Think I need to throw myself back in on Sat X." And you replied saying you hoped things would settle down by Saturday to which she replied: "Hope so! But I think from a confidence point of view I need to take an ITU baby soon." So you have already mentioned that she was a junior nurse who you felt it appropriate to send her a welfare message about the death of -- or following the death of [Child A], just to check in on her. In your experience as someone organising the staffing rota, how common would it be that following a pair of traumatic events that a nurse would be volunteering not only to work more but to go on to ITU?
GRIFFITHS: I think sometimes young nurses that come into
the neonatal profession, they want to run before they walk, is the expression, and I think they have done all their nurse training, they have done their foundation course, and they feel they have got the skills to -- to work within the ITU unit. But I feel that, you know, you have to have that experience within the unit to -- years' experience, really, to become competent and that's why you need to work alongside more senior nurses. I appreciate a lot of nurses do want to work within the ITU and that's not unusual because they are all young and enthusiastic. But they do still need that guidance and support and I think that's down to the staff on the unit to recognise that and, you know, and that's why, you know, not to bring her in for an extra shift when they have experienced, you know, a sudden collapse and, and making sure that the allocation is fair.
DE LA POER: Accepting entirely that many junior nurses in service are keen to work on the ITU, had you ever experienced a circumstance where a nurse was expressing that eagerness immediately on the back of a death and a very serious collapse?
GRIFFITHS: I wouldn't really tend to have a lot of conversations like this over the phone. I think it was her initiating "I want to get back to ITU", but I wouldn't, I don't have that experience on the unit that people say, "Can I get back into ITU", because of X, Y, Z, you know?
DE LA POER: So, to put that another way, you tell me whether you agree or disagree, this is highly unusual?
GRIFFITHS: Yes. Yes.
DE LA POER: So [Child C]. You record within your statement at paragraph 53 a statement made by [Child C]'s father, about something said, and I'll just read it out: "I remember at one point one of the nurses, I think it could have been Letby, but I am not 100% sure, came in with a ventilated basket, she turned to us and said words similar to 'You have said your goodbyes now, do you want to put him in here?' referring to the basket. The comment shook us, Mother C said, 'he's not died yet!" Firstly, was the fact that such a remark was made drawn to your attention at the time?
GRIFFITHS: No.
DE LA POER: Would you have expected that to be brought to your attention or would it have gone to Ms Powell?
GRIFFITHS: Ms Powell.
DE LA POER: Do you recognise that if such a thing was
said, it was highly insensitive and upsetting?
GRIFFITHS: As I said in my statement, it's difficult to interpret if I wasn't there. Obviously, it's a very sensitive and challenging time for both parents and nurses in that situation and sometimes comments are misinterpreted and we do often say, you know, if you would like to pop the baby back into the basket, you know, to the Moses basket, then you can get out for cuddles. So it just depends on what context and, as I said, sometimes families find it difficult to say goodbye. So until you are actually in the room and you can't generalise because it's very individual and I think you have to be guided by the family. So I feel very difficult to comment on this because I wasn't there.
DE LA POER: You agree that you need to be highly sensitive to the parents at what is an extraordinarily difficult time and if you are acting in that way, presumably it is possible to avoid upsetting people further?
GRIFFITHS: Yes. I couldn't envisage anyone saying "put the baby back in the cot", but it all depends how -- the interpretation.
DE LA POER: I told you earlier that we would look at a Datix, INQ0000111. This is the Datix for [Child C].
I just want to see if you can help us a little bit. If we crop in towards the middle we can see there is a section entitled "Coding" and it's recorded as a clinical incident and then the category, "Neonatal unit pick list", and I think you have told us that there were a list that you could choose from.
GRIFFITHS: (Nods).
DE LA POER: And the subcategory is recorded as "Expected and unexpected death". Does that help your recollection at all as to what one of the options was on the list?
GRIFFITHS: No.
DE LA POER: No. You don't recall ever having filled in a Datix and seeing that as being the appropriate one to record?
GRIFFITHS: I don't recall.
DE LA POER: Bearing in mind that the incident is expected and unexpected death, can you help us with why the risk grading would have been result: no harm, and the potential for harm: low harm? Are you able to just help how these various fields interact?
GRIFFITHS: I wasn't involved in the Datixes back in 2015/16, but now a result of "no harm" means that they don't feel there was anything like a drug error or anything that has caused this death.
DE LA POER: So that's a reference to whether or not there is a belief at the time that a clinical error of some kind or a failure to provide good care may have contributed to the incident?
GRIFFITHS: Yes.
DE LA POER: That's what you understand it to mean. So a person reading this would think this death was either expected or it was unexpected, you can't tell which from that pick list.
GRIFFITHS: No.
DE LA POER: But that it is not suspected that a failure in clinical care contributed to it.
GRIFFITHS: Correct.
DE LA POER: That's the interpretation, is it?
GRIFFITHS: Yes.
DE LA POER: Thank you. We can take that down. In terms of Datix generally, would you expect that all clinical staff involved in the care at the time of any resuscitation or the death would be recorded within the Datix?
GRIFFITHS: Correct.
DE LA POER: So [Child D]. You tell us in your witness statement that you have vague recall of a discussion re discolouration?
GRIFFITHS: (Nods).
DE LA POER: Does that fit with your memory of [Child D]?
GRIFFITHS: Yes.
DE LA POER: It is your paragraph 58 if you want to just remind yourself: "I vaguely recall some conversation in respect of [Child D]'s skin discolouration. However, I did not get involved in any of the wider discussions. I think staff were trying to understand why we had suddenly had three episodes so close together, which was unusual. I did not see the rashes in person."
GRIFFITHS: Correct.
DE LA POER: So when you say staff, are you talking about nursing staff or doctors or both?
GRIFFITHS: Nurses.
DE LA POER: Nurses?
GRIFFITHS: (Nods).
DE LA POER: So your belief is that this was a discussion between nurses trying to understand why there had been three episodes so close together.
GRIFFITHS: I think everyone was trying to look for, for reasons why we had so many close together and I think Nurse Oakley commented about the skin discolouration. So I never saw anything but often babies do have skin blemishes when they are born. So I didn't really see any, anything further. It
was just something that she, she noted.
DE LA POER: When you say people are trying to find out, how were they trying to find out? I mean, Nurse Oakley is one example. She is saying, well, I saw a skin discolouration.
GRIFFITHS: Yes.
DE LA POER: What other methods --
GRIFFITHS: I think with anything, because I think neonatal nurses are so proud and passionate with what they do, that they always feel they are missing something, why is this happening? So I think, you know, even if you had a cannula and it tissued, you would be worried, you know. So I think it's just we, we work one-to-one, we get quite close to the families that we work with, and the babies, and we want to find out, are we missing something? Is there anything that we can do? We didn't suspect at that time any harm, but is there something that we are unaware of?
DE LA POER: So is this nurses grouped together discussing this between themselves?
GRIFFITHS: I don't remember nurses getting together. I mean, we, we only work with about five nurses on a shift so one or two if, the most, but I just remember the conversation being had rather than being involved.
DE LA POER: So Dr Lambie, who left in September 2015, told us about a huddle of nurses that she saw who appeared to be looking at the rota to see who was on, and her impression was this was connected to the deaths which had occurred. Is that the sort of situation that you are describing, with nurses in ones or twos talking to each other and trying to get to the bottom of this or is that something different?
GRIFFITHS: No, I was unaware of that being observed. The off-duty is the Bible of the unit because everybody wants to look at the off-duty because it changes that often, so it's not unusual for nurses to look at the off-duty to see who's coming on the next shift.
DE LA POER: That's obviously a routine activity. Dr Lambie was suggesting it was not looking forward but it was looking back to see who had been on duty. Were you aware of --
GRIFFITHS: No.
DE LA POER: Now, you attended on 29 July a Neonatal Mortality Meeting in relation to [Child C] and [Child D]. I'll just bring that up so that you can remind yourself, INQ0003297. So we can see [Child C] towards the top left and then [Child D], and you are recorded as the penultimate person
in the list, do you see that?
GRIFFITHS: Yes.
DE LA POER: Now, by the time of this meeting, had you heard Nurse Oakley's comment about the unusual skin discolouration?
GRIFFITHS: I can't remember.
DE LA POER: Do you know whether anybody at that meeting said anything about [Child A] and [Child B] and whether there was any common features between that death and collapse and these two deaths?
GRIFFITHS: I have no recollection, I don't think so.
DE LA POER: Do you have any recollection of whether Letby's name was mentioned at this meeting?
GRIFFITHS: No, she wasn't.
DE LA POER: Thank you very much indeed. We can take that down. You also, in relation to [Child D], attended a Level 2 root cause analysis; do you recollect that?
GRIFFITHS: Sorry?
DE LA POER: A Level 2 root cause analysis in relation to [Child D], 28 August. I'll bring it up. INQ0015152. No. In fact I think I suggested you attended, I would just like you to remind yourself of this document to see whether it's something that you recognise. You do deal with it in your witness statement at paragraph 65. You are recorded there as the penultimate member of the investigation team.
GRIFFITHS: (Nods).
DE LA POER: Do you see that?
GRIFFITHS: Yes.
DE LA POER: And if we look at page 7, it may be I'll need to help you find this, but it records that [Child D] had become extremely mottled, it is the entry about a third of the way down, 22 June 2015 at 01.40: "Extremely mottled and had tracking lesions which were dark brown/black across her trunk". Do you remember any discussion about that presentation?
GRIFFITHS: I can't recall. No, I don't remember.
DE LA POER: Do you know whether anybody at that meeting drew attention to the fact that [Child A] and [Child B] had apparently unusual or unexplained rashes?
GRIFFITHS: I really don't remember.
DE LA POER: Just to complete it, if we go to -- we can in fact take it down. You, I am sure, will, having looked at this document, be able to confirm that it concluded that no root cause was identified and a post-mortem was awaited. Does that accord with your recollection?
GRIFFITHS: Yes.
DE LA POER: Insofar as [Child E] was concerned, you tell us that you would have been notified -- you believe you would have been notified on your return to work the following day. At that stage, were you struck that you can recall the fact that there had been four deaths in a relatively short period of time, about 10 weeks?
GRIFFITHS: Yes, but it was a very busy unit and so I didn't, I wasn't -- it was very sad that they had happened but it wasn't any alarm bells.
DE LA POER: You say it was a very busy unit but four deaths in 10 weeks, we know from other data, is nothing like that unit had seen in any of the time that you had been a nurse there. So really what I am asking is whether you noticed at the time that suddenly there were a significant number of deaths taking place in a short period of time by the standard of the unit?
GRIFFITHS: Yes, I am sure I would have been at the time. Yes.
DE LA POER: I mean, you say you are sure. If I may say so, it doesn't sound as if you have a positive recollection of that.
GRIFFITHS: I don't, no.
DE LA POER: I am going to turn now to [Child I] and we just need to go through this carefully, please.
So we will start, please, with the account that you gave the police. We will bring up INQ0000531. And we will go to page 2 at the bottom, please. So the penultimate paragraph beginning "I think" says this: "I think that during 14 October 2015 Dr Brearey may have commented to me not to give Lucy child I again for a third night. I cannot remember any specific conversation or decision in relation to this. I'm just speculating regarding anything Dr Brearey said. I think he was suspicious us of her as she had been present when several babies had collapsed." This, as we see from the front of the statement, is a statement that you gave to the police in the context of a murder investigation into Letby, is that right?
GRIFFITHS: Yes.
DE LA POER: You understood all that at the time and obviously you knew that you signed a very serious and important declaration at the beginning of it?
GRIFFITHS: Yes.
DE LA POER: That account was given five years ago, just a bit more than, from today and so it was, do you agree, much closer in time to the events that you were talking about albeit it was still some years after the event?
GRIFFITHS: Yes, correct.
DE LA POER: So that's what you said first. Then if we can please bring up your Inquiry statement, INQ0102072, and we go to page 15, please, paragraph 71. So we can see that in your witness statement, in fact if we just go one page up, you rehearse that extract that I have just read to you, so it's paragraph 70, the preceding page. Do you see you quote that under [Child I] there?
GRIFFITHS: (Nods).
DE LA POER: And then you go on to give the account. So we will look at paragraph 71, please, and you say this to start with: "With respect to my discussion with Dr Brearey on 14 October 2015, I do recall having to reallocate the nurse allocation as the babies' collapses were causing a few concerns with the medical and nursing staff." So if we just pause there for a moment. As it's written, do you agree you are saying that you have a positive recollection of the event?
GRIFFITHS: Yes.
DE LA POER: And you go on to give some further context: "Despite all the cases being reviewed there wasn't anything that seemed to connect the deaths or collapses to anything specific and all the care and intervention seems untoward and obviously the medical team were very confused." So you are talking about a period of time, do you agree, when the medical team is confused?
GRIFFITHS: Yes.
DE LA POER: Then you say this: "Dr Brearey did speak to me about his concern that Letby seemed to be the common denominator to all the incidents which all seemed to happen on nights." And then: "This had not been mentioned to me before the conversation but I listened to his concerns and thought it was easier to reallocate care for Letby's protection." So again, do you agree you appear to be describing a thought process that you had at the time which was to listen to what he had to say and to think, well, the easiest solution to this problem that I am being presented with, for her protection, is to reallocate her?
GRIFFITHS: Yes.
DE LA POER: And you go on to comment: "This was a very easy solution and one which seemed to appease Dr Brearey." So, again, you appear to be describing Dr Brearey's
reaction to what you propose to do?
GRIFFITHS: Yes.
DE LA POER: Again, is that a fair description of what you have put in there?
GRIFFITHS: Yes.
DE LA POER: And at 72, your first sentence, you go on to explain your reasoning a bit more: "I did not change allocation because I had doubts in Letby's practice but more to stop fingerpointing." So, again, you are describing the circumstances that you have alluded to above namely there is confusion, Dr Brearey has pointed a finger, to use your phrase there, and that you have appeased him?
GRIFFITHS: Yes.
DE LA POER: And then at 73, following your discussion with Dr Brearey: "... I did mention my conversation and action as a result to Eirian the next time I saw her on shift which would have been the following week." And you go on to rehearse what the two of you spoke about in that conversation, which might be summarised as neither of you had any concerns.
GRIFFITHS: Yes.
DE LA POER: At 74, you consider Nurse T's WhatsApp messages and here we can just summarise what they say:
Letby is telling Nurse T that she has been, on the 14th, reallocated away from the care of [Child I].
GRIFFITHS: Yes.
DE LA POER: And you say: "I remember looking at the allocation that Nurse T had completed, and I just suggested that she reallocate so that Letby wasn't allocated to [Child I]."
GRIFFITHS: Yes.
DE LA POER: So, again, do you agree you appear to be describing a recollection you had of having a look at something and acting upon what you saw?
GRIFFITHS: Yes.
DE LA POER: And you go on to say: "This was due to it being her last night and I recall she had busy shifts in the previous nights and it was to give her a lighter load." So, again, another recollection of exactly what you were looking at and the situation you were dealing with?
GRIFFITHS: Yes.
DE LA POER: So at 77, just to complete this, you say: "In respect of [Child I]'s passing, apart from the conversation held on 14 October 2015 with Dr Brearey who raised his concerns around Letby, no other doctor or nurse spoke to me regarding any suspicions or concerns they had."
You then go on to say, as you said earlier, that you discussed the situation with Nurse Powell.
GRIFFITHS: Yes.
DE LA POER: So that's the account in these paragraphs. Then if we can bring up your new statement, please, INQ0108335, this, can you confirm, Ms Griffiths, is the statement you gave us yesterday?
GRIFFITHS: Yes.
DE LA POER: It will come up on screen in just a moment.
GRIFFITHS: Yes, that's it. Yes.
DE LA POER: And we can see that the purpose of this statement is to correct those passages that we have just looked at in some detail; is that right?
GRIFFITHS: Correct.
DE LA POER: And you have -- you tell us that you re-read your police statement and you also re-read your Inquiry statement, that's the paragraphs 2 and 3, and then at paragraph 4 you draw attention to a document the Inquiry had provided you with, namely Dr Brearey's account of what had occurred. And you also say that you consider, at paragraph 5, the neonatal mortality table produced by Eirian Powell.
GRIFFITHS: (Nods).
DE LA POER: And at 7, you say you believe you were mistaken when you said in your police statement that you'd had discussions with Dr Brearey about reallocating Letby away from [Child I] on or around 14 October. And then you go on to say, and we will need to go over the page: "I believe that this was because I was confused about the time frame of events concerning Letby as I had a number of discussions with Dr Brearey about Letby after she was seconded to the risk team." So just so we're clear about it, we're talking about therefore conversations with Dr Brearey after 1 July of 2016?
GRIFFITHS: Correct.
DE LA POER: You go on to say that you didn't fully understand the time frame and you draw attention to the fact that Eirian Powell's table, which we know is dated 23 October, you hadn't appreciated that that postdates 14 October, which was the date you had given?
GRIFFITHS: Correct.
DE LA POER: And so far as -- and you go on, I will just read it out: "In other words, the evidence of 'commonality' apparent from Eirian Powell's table was not available to me at the time of the reallocation of Letby on 14 October 2015." Then you mention the Nurse T WhatsApp messages and
you provide a reason for -- an explanation for that, you think: "I believe that it is likely that it was decided to reallocate [Child I] to one of the more experienced Band 6 nurses bearing in mind that [Child I] was in an ITU cot." And then paragraph 10 is just correcting a date error. So hopefully I have reviewed with you all of the relevant parts of each of those three statements and you must say if I have missed out or overlooked anything at all.
GRIFFITHS: No, that's very clear. Thank you.
DE LA POER: And so I just -- your position when you wrote this statement was that your two previous statements were wrong insofar as the date was concerned?
GRIFFITHS: (Nods).
DE LA POER: And does it follow that your position is that the correct date must have been some time after 1 July 2016?
GRIFFITHS: Correct.
DE LA POER: So let's just have a look at the point that you make about Nurse Powell's table. When you gave your witness statement to the police, you didn't have Nurse Powell's table, is that right?
GRIFFITHS: Correct.
DE LA POER: And so your account to the police, does it follow, cannot have been influenced by any misreading of that table because you didn't have it?
GRIFFITHS: Correct.
DE LA POER: So far as your explanation for the WhatsApp message for Nurse T, you begin the sentence that explains it with "I believe ..." Is that you doing your best to try and explain that message based on what you know would be your normal behaviour as opposed to a positive recollection or do you now have a positive recollection of that being the explanation?
GRIFFITHS: I believe I remember being on a late shift and looking at the off-duty and often I would intervene because the off-duty is what I do and I would always allocate the more sicker baby to more experienced nurses if I had them.
DE LA POER: So you say, "I would always ..." So the first bit was you remember looking. The second bit is a reference to your standard practice. Does that mean that you don't have a positive record of what you did on that occasion and your reasons?
GRIFFITHS: I do have a positive -- it was purely to change the allocation because I had more experienced nurses to look after the ITU baby.
DE LA POER: Can you just help us, given that you have that positive recollection sitting there now, how it was that that wasn't your positive recollection when you gave your statement to the police or your Inquiry statement?
GRIFFITHS: I think following Baby I [Child I]'s death then we -- a table was produced and that's where the commonality became available and I know there was lots of discussions between Eirian and Steve about who was present at each death and I got confused that that was the cause of my reallocation when actually I didn't have that information until after.
DE LA POER: Accepting that memory is a difficult thing to untangle, but really what I am just asking you to consider is you are sitting there now with a positive mental picture of what happened. What my question was just trying to understand is how you didn't have that mental picture when you gave your statement to the police and to the Inquiry. Are you able to offer any explanation for that?
GRIFFITHS: I think after Lucy was removed, I did then have a lot of conversations with Dr Brearey. So I knew that was a concern of his and I just presumed it when I had all the information that perhaps that's influenced my decision.
DE LA POER: Just about some of the details that you gave, just to see if you can help us with your recollection. I mean, the first sentence I read to you was: "I do recall having to reallocate the nurse allocation as the babies' collapses were causing a few concerns with the medical staff." I mean, is it right that sitting there right now you simply don't have that recollection?
GRIFFITHS: I -- that, that is untrue because it wasn't until after the table had been produced that I realised the severity of, of their concerns.
DE LA POER: So can you help us with how you came to write, "I do recall ..." What was in your mind when you wrote the statement?
GRIFFITHS: I think because I have given that many statements and I have had lots of conversations since with Dr Brearey about, about the events and I just remember reallocating the nurse assignment and I just brought that in because that's -- I had that information since.
DE LA POER: And again if we just look at something else that you said. You said: "This was a very easy solution and one which seemed to appease Dr Brearey." Now, do you agree post-July 2016 there was no need to appease Dr Brearey about the staffing --
GRIFFITHS: Correct, yes.
DE LA POER: -- because Letby was not on the ward?
GRIFFITHS: Yes.
DE LA POER: So again, just doing the best you can, why do you think that you wrote in your statement that you had appeased Dr Brearey in the course of this conversation that you were recalling?
GRIFFITHS: I got confused and thought that the table was pre, but actually it was post Baby I [Child I]'s death when I gave the statement.
DE LA POER: But whenever the table was, you appear to be recounting a recollection of an emotional reaction from Dr Brearey that he was appeased.
GRIFFITHS: Yes.
DE LA POER: I mean, that isn't anything to do with the table, that's just you remembering how he was.
GRIFFITHS: (Nods).
DE LA POER: But if I have understood, he wasn't appeased when, in fact, you had this conversation because Letby wasn't on the ward.
GRIFFITHS: Correct. Yes, I think he wasn't on the ward because I don't recall having a ...
DE LA POER: And just finally, and I am not looking to go over it all, but I do want to give you an opportunity to deal with some of these points.
In relation to your conversation with Nurse Powell, you say at 73: "I did mention my conversation and action, as a result, to Eirian the next time I saw her on shift which would have been the following week. Neither of us had any concerns." There you appear to be recalling a sequence of events where Dr Brearey told you something which you then relayed was the trigger for you to speak to Nurse Powell and I mean, do you agree that that is how it reads?
GRIFFITHS: It does.
DE LA POER: And do you agree that in 2016, July 2016, later, that wouldn't reflect the sequence of events that occurred?
GRIFFITHS: Correct.
DE LA POER: And so, again, just giving you the opportunity to, doing the best you can, how is it you think that that came to be in your Inquiry witness statement given what your recollection is now?
GRIFFITHS: I think I have had that many -- that much information because obviously I've been a party since, not even during the trial but after the trial and during the Inquiry, I have had a lot more information and I have had statements given to me that other people have
written, and it's clear there that Dr Brearey had never spoken to me about any concerns over Letby and I think that is more for her -- to be confidential to work colleagues. And I think it's following that with the chart produced in October 23rd by Eirian that she emailed that to me and that's when I was in the sequence of emails and that's where I saw it, so I got confused thinking that I had -- that Dr Brearey was concerned while I was doing Baby I [Child I]'s statement of allocation.
DE LA POER: So after we have undertaken that process, and I accept it's implicit in your last answer, but of the two accounts that you have given, sitting there now, which do you think is correct?
GRIFFITHS: The revised account.
MR DE LA POER: My Lady, I have transgressed into the usual lunch period but I just wanted to finish that sequence. So I hope that that was appropriate.
LADY JUSTICE THIRLWALL: Yes, thank you. So we will rise now for lunch and we will come back in at 10 past 2. (1.06 pm) (The luncheon adjournment) (2.11 pm)
LADY JUSTICE THIRLWALL: Yes.
MR DE LA POER: Ms Griffiths, we are going to move to that table that you have mentioned a number of times this morning. We will start with the email that provides it, INQ0003106. This is dated October 23, 2015, 5.25 in the evening, so this is after [Child I] has died and you are on copy to this as one the recipients, and it reads: "Just to say I have discussed the above with Anne Murphy and on reflection it was decided to leave this until Monday. Alison Kelly was not in the hospital and Sian had just left as she was not well." Would that be Sian Williams, the Deputy Director of Nursing?
GRIFFITHS: Yes.
DE LA POER: "I have devised a document to reflect the information clearly and it is unfortunate that she was on. However, each cause of death was different, some were poorly prior to their arrival on the unit and others were [question mark] NEC or gastric bleed congenital abnormalities. I have attached the document for your perusal. See you on Monday. I will discuss further with Debbie on Monday." So this is Friday, 23 October. Were you aware on that day of any plan to escalate
this to the Director or Deputy Director of Nursing before you received this email?
GRIFFITHS: No.
DE LA POER: Had you discussed the attachment with anyone before you received it?
GRIFFITHS: No.
DE LA POER: Let's have a look at it. INQ0003189. This is a table, it is -- the right-hand column is blank for medical staff but it, we have seen a version of this attached to the thematic review of neonatal mortality, but this is the first iteration, you can see, dated 23 October, bottom left-hand corner, and it comprises eight deaths, the first of which is marked "N/A" in terms of the staffing, the other seven all have Letby either allocated or on duty with her name highlighted in red. What did you think when you received this document?
GRIFFITHS: This is the first time that I had actually seen all the deaths collated in a chart and I think because you come to work and you are busy and you are working, you hear of a baby dying but you don't have that timeline. But I was reassured that the cause of death was actually entered on the chart, so -- and I know they were looking at the commonality and that's when I was aware, after a conversation with Eirian, that
there was a discussion about, you know, the commonality of, of staff on duty.
DE LA POER: At the point that you received this had you realised that there were, if you exclude the first death where there's limited information, there were seven deaths since June of 2015 and you were only October?
GRIFFITHS: I would have been aware, yes.
DE LA POER: So you had had that fact in your mind as you were going about your daily tasks?
GRIFFITHS: Yes.
DE LA POER: And did you query why it was that Letby's name was highlighted in red, why she had been picked out as opposed to other people?
GRIFFITHS: I think following discussion with Eirian, I think there was some discussion between her and the Consultants regarding the commonality.
DE LA POER: So your understanding was that Ms Powell and the Consultants, as you have just said, had discussed Letby before this document was created and this document was created highlighting her name as a result, is that --
GRIFFITHS: That's what I presume, yes.
DE LA POER: What, if anything, did you understand the Consultants were concerned about in connection with Letby?
GRIFFITHS: I recollect that they were looking at all possibilities because obviously it was a higher mortality than what we would normally see, so I think they were just trying to really pinpoint and look at everything that they could possibly do. And I know the nursing staff and the medical staff, I think both, they were looked at.
DE LA POER: When you say "all possibilities" does that include deliberate harm by a person who worked there?
GRIFFITHS: I -- at the time I didn't think it was deliberate harm I thought perhaps it was lack of knowledge or experience.
DE LA POER: Let me be more precise in my question. Did you understand not what your concern was --
GRIFFITHS: Okay.
DE LA POER: -- but what were the Consultants' concerns, whether they may include the possibility of deliberate harm by Letby as at 23 October?
GRIFFITHS: I am unsure if I knew at this point in October. But I was produced, you know, I was cc'd into this email with this chart, so obviously I can't really remember but I think it must have been a concern.
DE LA POER: It must have been a concern. So something that needs to be taken extremely seriously?
GRIFFITHS: (Nods).
DE LA POER: Would that have been your thought process at the time?
GRIFFITHS: Yes.
DE LA POER: And it would seem from the email that sent this table that it was being taken extremely seriously because there was discussion of going to the Director of Nursing herself about it, we saw that on the email.
GRIFFITHS: (Nods).
DE LA POER: Did that give you any reassurance or what opinion did you have about the fact that this table was being escalated to the very top of the organisation?
GRIFFITHS: I suppose it was just to recognise that, you know, we had recognised there was an increase in deaths and I think they wanted the execs to see if they could -- for some more guidance on how they can deal with this process.
DE LA POER: Was the contacting of director level something you discussed with Eirian Powell?
GRIFFITHS: No.
DE LA POER: So is that an inference that you drew from the information you were given in the email and the table?
GRIFFITHS: Yes.
DE LA POER: Now, what you tell us in your witness statement, we can turn it up but I am sure it will be familiar to you, is you said you didn't consider
referring it to Alison Kelly yourself.
GRIFFITHS: No, that's right.
DE LA POER: And your reasoning in your statement was you didn't believe there were any staffing factors?
GRIFFITHS: (Nods).
DE LA POER: Does that accord with your recollection of your thought process at the time?
GRIFFITHS: Yes, and I just thought, you know, I knew that this table had been escalated, so I knew that they were aware of it.
DE LA POER: So --
GRIFFITHS: -- (overspeaking) -- cc chain.
DE LA POER: So did you think that at this time Alison Kelly was contacted?
GRIFFITHS: I'm not sure. I just presumed, with Sian Williams being involved that, that it would be.
DE LA POER: So did you have a discussion at the time with anyone about whether Sian Williams had in fact been spoken to?
GRIFFITHS: No.
DE LA POER: Just in relation to your belief at the time that there weren't any staffing factors. I mean, you yourself hadn't carried out an investigation, had you?
GRIFFITHS: No.
DE LA POER: And you were being brought in to what was
clearly an ongoing conversation which involved the Consultants, is that fair, in terms of how you came to be aware of all of this?
GRIFFITHS: Yes, but I wasn't fully aware because -- not fully aware, but I wasn't involved so much in the process of this chart. During that time I was doing a degree, degree course in university, I was also doing the -- working clinically, so even though I had sight of this email I wasn't really in the major discussions about the processes of what to do with this information.
DE LA POER: Do you think at that stage you had an open mind about whether the Consultants might be right, or do you think you made a decision at this stage that they must be wrong?
GRIFFITHS: I have always stayed neutral because you never really know staff and I just felt if there was that niggling belief then it needed to be addressed.
DE LA POER: When you say "neutral" are you talking about how you presented yourself to the outside world or --
GRIFFITHS: Yes.
DE LA POER: -- what you thought internally?
GRIFFITHS: Yes.
DE LA POER: Which was it?
GRIFFITHS: How I presented myself to the outside world.
DE LA POER: So I am just here focusing not on what you were saying to people but what you were thinking?
GRIFFITHS: Yes.
DE LA POER: At this stage do you think you had an open mind about whether or not the Consultants might be right?
GRIFFITHS: I did, yes.
DE LA POER: Now, if we move forward, please, in time to the Tuesday of the following week, so this is 27 October. INQ0003107. Here we can see the recipients are Dr Brearey and you and Debbie Peacock, and it is a continuation of the previous email, and it reads: "I have spoken at length with Debbie this morning in relation to the mortality rates for this year. It was decided that it was necessary to create a table that includes all the doctors that was involved with the deceased patients on the unit. This would then ensure that all avenues have been addressed. Debbie was of the same opinion that we did not think there was a connection. However, we would be highlighting the issue once the report has been completed." And so that's what Eirian Powell is saying. I mean, did you have your own opinion about how this should be managed at this stage?
GRIFFITHS: No.
DE LA POER: Because this appears to be the day after it was planned that Alison Kelly or Sian Williams would be contacted. Did you know whether that had happened by the --
GRIFFITHS: No, I wasn't aware of these emails until after, you know, I know I've been cc'd, but as I say, often I was cc'd in these emails for -- email threads in case Eirian wasn't there, so I knew that both Steve and Eirian were dealing with this with the help of risk.
DE LA POER: So I mean, was it the case that you just weren't really engaging with this because you thought that the only reason you were being cc'd in was in case Eirian was absent in the future?
GRIFFITHS: Correct.
DE LA POER: Just looking back on it as the deputy ward manager who was provided with this information, do you think you had a responsibility to do more than you did or do you think that you acted appropriately?
GRIFFITHS: I felt as a deputy ward manager I am there to support the manager and if she asked me to be involved, I would. But when you, you know, just to clarify my hours as deputy manager was only four to five shifts, you know, seven and a half hour days a month and during that time, I was more concentrating on providing
adequate staff for the unit and constantly juggling staff to accommodate the BAPM standards. And I just feel, you know, as the role of the manager she had a better understanding and she was actually escalating these things and I was just, I just hoped that there would have been governance and policies in place that this would have been addressed, because you've got two senior people, Eirian and you've got Steve, both highlighting that there is a potential issue so I just presumed that they would both be taking that forward rather than myself as the deputy.
DE LA POER: Bearing in mind that you were responsible for the rota, did you think that exactly what Letby may be suspected of or what the concerns may be, was very much your business when it came to the sort of children that she might be caring for?
GRIFFITHS: Not at this time because there was no, no staff came and stated that they were concerned about Lucy's practice. Parents seemed to engage and liked Lucy. She was very competent. She was very highly skilled. She had done all the courses. So, you know, perhaps if somebody had come to me and seen something then definitely I would have addressed it. But actually working on the shopfloor nobody saw anything to implement --
DE LA POER: Do you think that the concern of the most senior Consultant on the unit was in itself enough for you to make more enquiries so that you could take into account his concerns when doing the staffing?
GRIFFITHS: No, that didn't occur to me.
DE LA POER: And just explain for us why do you think that is?
GRIFFITHS: I think staffing -- she would never be the most senior nurse on duty. Unless somebody said she wasn't able to work on the shopfloor I would still utilise her within the nursing numbers because she is a Band 5 that's skilled. So I would have -- really I would wait for direction as to not to allocate her any shifts, but if nobody has actually said that to me then I would be allocating shifts to cover the unit.
DE LA POER: Just to complete this and to test it. If there was a competence concern that would be a reason -- as yet unidentified competence concern --
GRIFFITHS: Yes.
DE LA POER: -- that would be a reason, for example, not to allocate her to the ITU --
GRIFFITHS: Correct.
DE LA POER: -- where the sickest -- I was just wondering whether that thought process went through your mind at
the time in terms of taking on board the neonatal leads' concerns, whatever they were, when doing your job?
GRIFFITHS: No, not at this point in time.
DE LA POER: So we will move forward in the evolution of this to INQ0003190. My Lady, this is tab 12. This is a further iteration of the table. It's dated the 19th of the 1st, and it is the same first eight cases as before but there are two more cases added to the end, so we have now got 10 cases in total. Ignoring the first one where no staffing information is provided, of the now nine cases, Letby's name is highlighted in red in either of those two staffing columns, so that's the one change. So you had seen the earlier version.
GRIFFITHS: Yes.
DE LA POER: Did you see this version, 19 January?
GRIFFITHS: No. Not, not at that time.
DE LA POER: Did Nurse Powell discuss with you the fact that she had further developed her table to include two more recent deaths?
GRIFFITHS: No. (Redacted). So I wasn't aware of this until I came back to duty.
DE LA POER: Now, what you say about these charts is: "I did not feel I needed to personally take these charts to Alison Kelly. I was aware that Eirian was in discussion with senior management."
GRIFFITHS: (Nods).
DE LA POER: And I just wanted to understand how had you become aware, who had told you, or what had you seen that led you to believe that during the period these charts were being produced that Ms Powell was in discussion with senior management?
GRIFFITHS: On my return to work I saw the email thread and I could see the email thread between Alison Kelly and Eirian (redacted).
DE LA POER: And just so that we can identify that date, you said that you were away for the month of January. Do you recall approximately what your return date was?
GRIFFITHS: I looked and I think it was the second week of February.
DE LA POER: (Redacted).
GRIFFITHS: She did.
DE LA POER: You didn't participate in the CQC visit on 16 to 19 February of 2016; that's correct, isn't it?
GRIFFITHS: Correct, I wasn't on duty.
DE LA POER: We then had the thematic review, final version, and you will know now that there were two versions of that document, the second of which, the final version had the "sudden unexpected deterioration"
part of it. If we look at INQ0003114, the lower of the two emails is one that you are on copy to, I believe.
GRIFFITHS: Yes.
DE LA POER: Yes. Left-hand side halfway down.
GRIFFITHS: Yes.
DE LA POER: Did you read the thematic review when you received it?
GRIFFITHS: Yes, I would have. Yes, if it was emailed.
DE LA POER: And the last time that you had checked in with the deaths was, you tell us, back on 23 October when you saw the table with those eight. Obviously now there were more deaths in the table. You had seen a version where Letby's name was highlighted in red but this version didn't have that. Did you look on to those additional deaths to see whether Letby's name appeared for those later deaths as well?
GRIFFITHS: I cannot recall.
DE LA POER: Just thinking about it. Having already seen a version of that report where her name was highlighted in red, do you think that would have been a natural thing to do, to see whether the updated versions maintained the trend that had been apparent before?
GRIFFITHS: As I say, I came back to work (redacted) so
I knew the unit was extremely busy and I knew I needed to come in and support my team (redacted). (Redacted). So she did protect me a lot from this. So I mainly came back to work and concentrated on making sure the unit was safely staffed and as support as opposed to Eirian but -- and worked clinically, so (redacted).
DE LA POER: (Redacted). I just wish to understand about a conversation that you report or a state of affairs that you report at around this time in your witness statement. You say: "Dr Brearey was still adamant that Letby was the common denominator but also could not pin a malpractice on to Letby. I know Eirian was protecting her nursing staff and thought it only right to include medical staff in the reports."
GRIFFITHS: (Nods).
DE LA POER: So, firstly, I just wanted to ask about what you say about "Dr Brearey was still adamant". Was that a conversation you had with him or was that his view as relayed to you by somebody else?
GRIFFITHS: I think Eirian -- obviously, it's all a little bit of a blur but I know Eirian, she really had no one to -- to vent to because I think we were within different directives. I felt that both, in hindsight
now, Eirian and Anne Murphy, they really didn't have the support of the upper exec team, and she really had no one to talk to. So I think she did discuss with both myself and Yvonne, because we shared an office occasionally with Eirian, about Dr Brearey's concerns and wondered whether we had actually seen anything or had the same thoughts or witnessed anything because Eirian didn't really work on the shopfloor like we would. And it's very difficult when I think a person is accusing somebody of something so, so huge to actually ask people "what do you think" on the shopfloor. So it's -- yes, that's all I can say.
DE LA POER: The other part I wanted to ask you about was just this phrase that you used, "I know Eirian was protecting her nursing staff". What do you mean by the word "protecting"?
GRIFFITHS: I suppose I didn't mean it in that derogative, I just meant that she was a very caring and compassionate manager and that's how you should be and you should, you know, have -- and she respected her nursing team. Had she had any clear evidence I am sure that would have been different. She wouldn't have been protecting against an act. I think she just felt more of supportive of her team rather than protecting them from something they had been accused of.
DE LA POER: When it comes to safeguarding, do you need clear evidence?
GRIFFITHS: Sorry?
DE LA POER: When it comes to safeguarding, keeping babies safe, do you need clear evidence?
GRIFFITHS: I think Eirian was -- looked at those charts, and we are a small team, there were a lot of commonalities of staff on the charts, so just to pinpoint one person is very difficult. Had we had failed competencies, failed courses, lots of Datixes regarding any, you know, abnormal, you know, any incidents, or staff complaints, then we would have had something to work on. But I think it's very difficult just to have a hearsay.
DE LA POER: Would you have any of those if the harm was being caused deliberately?
GRIFFITHS: Pardon?
DE LA POER: Would you have any of those indicators, the competencies, concerns?
GRIFFITHS: I didn't have any concerns, no.
DE LA POER: No, I understand. But you have given a list of potential pieces of evidence --
GRIFFITHS: Yes.
DE LA POER: -- but my question really is: if you are contemplating the possibility of something causing deliberate harm, you might not get any of those competency concerns because the person is competent, they are doing it on purpose, and I am just wondering whether you were perhaps thinking too narrowly at that time or -- what do you think?
GRIFFITHS: On reflection now that we have got all the information, I think you don't really know the colleagues that you work with and in work we never witnessed anything untoward and it's wonderful in hindsight when you've got all the information. But at that present time I had no concerns myself. But, as I say, I did keep an open mind, I wasn't, you know, adamant one way or the other.
DE LA POER: Now, although you didn't attend the CQC meeting when they came for their inspection in February, I think you were interviewed by a person called Helen Cain on 4 March and hopefully you have had a chance to see the notes of that?
GRIFFITHS: I have, yes.
DE LA POER: So the 4 March, we remind ourselves, is two days after that email that we just looked at circulating the thematic review. What -- did you draw to Ms Cain's attention the thematic review that had just
been circulated?
GRIFFITHS: No.
DE LA POER: And looking back on the circumstances of that meeting, was that something that you think you should have done, to tell the CQC that the hospital was in the process of investigating an increase in neonatal mortality and hadn't got to the bottom of it?
GRIFFITHS: I think when she, when CQC came and asked, I think we were given a task of things she wanted to specifically ask me about and that was more about the budget, staffing, because obviously I did staffing and I just -- so I didn't think to mention the thematic review.
DE LA POER: In terms of how the CQC was viewed at that time, were they seen as an organisation who you could turn to for support when the hospital was facing a difficult time or was there a different view?
GRIFFITHS: At that time, being just, you know, not -- just a Band 6 nurse, I didn't really think that they could take things further. I didn't -- no, I just thought they came in to inspect, to grade.
DE LA POER: INQ0003089, please. My Lady, this is tab 18 at page 2. We are going to look now at an email a little later in March. If we go to page 2, we can see the origin of
this thread which is 17 March. We have looked at this before in the Inquiry: "I was hoping that we could arrange a meeting with you to discuss how to move forward with regards to our findings." This is a reference to the thematic review, as subject line suggests. Do you know why it took two weeks from when that thematic review was circulated in its final form by Dr Brearey on 2 March for it to be drawn to the attention of Alison Kelly in this email?
GRIFFITHS: No.
DE LA POER: Just understanding how a hospital works, but also recognising that this is about an increase in the level of deaths, is that two weeks explicable in any way to your mind?
GRIFFITHS: Once again, as a deputy manager, I never got involved in timeframes or it was just, as I say, I was often cc'd in these emails just in case Eirian wasn't around and I knew the format. So I knew that things had been escalated and I was just hoping that obviously the governance and the policies would be in place for this to be acted upon.
DE LA POER: Did it strike you at the time that based upon how this email is written, it doesn't appear that this was an issue that Alison Kelly had a clear understanding of before 17 March, that's certainly one way of reading --
GRIFFITHS: I wouldn't have had a comment at that time.
DE LA POER: We know -- thank you very much indeed -- that Letby was moved to day shifts around the beginning of April. Did you participate in any way in that decision-making given that you were the person in charge of the rota?
GRIFFITHS: I was asked if I could allocate, take Lucy off the night shift and then allocate two months' worth of day shift.
DE LA POER: What did you understand to be the explanation for that, and if it helps I will remind you what you said to the interviewer at Facere Melius: "Steve Brearey said he had concerns but never found any evidence. He said he wasn't happy and we said we would take her off nights so we did that for a month." So that's the account that you gave --
GRIFFITHS: Yes.
DE LA POER: -- when interviewed. Does that capture it, that Dr Brearey is saying, "I am not happy" and to make him happy you moved her shift pattern?
GRIFFITHS: I think Eirian obviously because of the thematic review, I think it was highlighted that a lot
of the incidents occurred during the night shift and so just to look at that commonality I think the decision was to move her onto days. That's my understanding at that time.
DE LA POER: As you describe it there, that's a decision that is being driven by Dr Brearey rather than necessarily coming from you or from Ms Powell. Does that fit with your recollection?
GRIFFITHS: I'm not sure. I wasn't at the thematic review. So I think I was given the report after but I think maybe it was highlighted that a lot of the incidents were during the night shift so, following that, I think maybe, I don't know how it was discussed, the decision was to pop -- to change her to a different duty.
DE LA POER: INQ0003185, please. We will look at a new table dated 15 April 2016. As we bring it up you will know from the top of that email thread that two days after this table is dated, Ms Powell sends a chasing email to Alison Kelly. Do you know the one I mean? That's the 17 April --
GRIFFITHS: Yes.
DE LA POER: -- so this is just two days before. This is a slightly different format to what we have looked at previously. We can see that on 15 April, Ms Powell goes
back in time to February 2016 and identifies two non-indictment baby deaths and then [Child M] where we can see -- and [Child M] didn't die, so I may be wrong about the fact that those too earlier area ones are deaths, but they are certainly two occasions, but [Child M], in April of 2016 -- just a few questions about this. Had you seen this table at the time? We understand it is created by Ms Powell as is indicated at the bottom.
GRIFFITHS: I presume I would have been.
DE LA POER: Do you know why Dr Gibbs' name is highlighted in red?
GRIFFITHS: I presume maybe the commonality of a Consultant.
DE LA POER: [Child M] collapsed just a couple of days after Letby was moved on to day shifts. Was that a connection that you made at the time?
GRIFFITHS: Not at the time but when I had all the evidence I made that connection.
DE LA POER: And so when would you say you had all the evidence?
GRIFFITHS: I think it was the Thirlwall Inquiry.
DE LA POER: So it is part of this process that you have seen that connection?
GRIFFITHS: Yes.
DE LA POER: INQ0014241, please. This is an email involving Karen Rees in a meeting that took place and I am sure you know which one I am speaking about. You are, again, on copy and there are a number of attachments including that NNU mortality 2015. Did you have any discussion with Ms Powell about the purpose of this meeting or anything that took place at the meeting, anything that was said?
GRIFFITHS: No, I wasn't at this meeting. And I think it was just, as I say, for my own information of what had been discussed.
DE LA POER: Thank you. 11 May 2016, so just a few days after this, we know that there was a meeting involving Ms Powell, Nurse Murphy and Ian Harvey and Alison Kelly --
GRIFFITHS: (Nods).
DE LA POER: -- and of course Dr Brearey. In your witness statement you describe Eirian as being the voice of the nursing staff.
GRIFFITHS: (Nods).
DE LA POER: Is that how you saw her role in all of this; that she was acting as a spokesperson for nurses?
GRIFFITHS: Yes.
DE LA POER: So as an advocate, effectively?
GRIFFITHS: Yes.
DE LA POER: Do you think she also had a role to protect patients?
GRIFFITHS: Yes.
DE LA POER: And if she is acting as a spokesperson for nurses, what evidence did you see, in what she said and did, that she was also acting to protect patients as she undertook that view?
GRIFFITHS: I think Eirian openly took these charts to the Executives and was asking them for their advice and for their help. This is something you don't see ordinarily every day and I don't feel she was hiding the evidence, that these babies were actually -- and created a chart of the staff. But as I say, we had no hard evidence of seeing ill/wrong. And I feel if, you know, two senior people have taken these concerns forward then there should be that process to -- to look at these.
DE LA POER: I am going to move forward now to the deaths of [Child O], and [Child P]. And, again, just to help you I will just read out what you say in your statement. In relation to the efforts to resuscitate [Child O], you say: "I do remember Dr Brearey looking at me with concern as Letby was present but once again other than
being present, no one raised any other concerns. Dr Brearey never approached me that day to raise any verbal concerns or requests." Can you just help us just to set the scene for when you are saying that, "Dr Brearey looked at you with concern as Letby was present"?
GRIFFITHS: I think it's -- obviously some instance always are ingrained in your, in your mind, and I think I can, I can still visualise holding the father's hand whilst witnessing his child going through this. And I just -- so I just remember that vivid look, but I didn't really think anything at that time. It isn't until hindsight that I thought, gosh, that's, you know. But had he maybe voiced concerns, I might have done something. But some, some scenarios are just -- are ingrained in your brain forever.
DE LA POER: You knew by then that he did have concerns about Letby?
GRIFFITHS: Via Eirian yes.
DE LA POER: Yes. And there he is giving you this highly memorable look, as you have described it, which you in your mind have connected with the presence of Letby.
GRIFFITHS: (Nods).
DE LA POER: Do you think at that point, given that what you were all experiencing there was the terrible and
tragic death of that baby, that after that was the time to go and speak to Dr Brearey and say, "What is all of this about?"
GRIFFITHS: At that moment in time I didn't think I needed to. My main concern was supporting the family, so I remember sitting in the parents' accommodation, supporting the family who were grieving.
DE LA POER: Now, what Dr Brearey has told the Inquiry in his witness statement in relation to the period between the death of [Child O] and [Child P], and I will just read it out to you: "I had no idea at this point that Letby was returning to work the following day. I could not conceive that senior nursing staff would allocate Letby to care for the surviving triplets. I would have expected senior nursing staff to have given Letby lower acuity babies to care for after the stressful events of [Child O]'s death and I knew at least two senior nurses on the unit [and he names Eirian Powell and Laura Eagles] were aware of the Consultants' concerns." Now, you were the person in charge of the rota. Do you have any comment upon what you have just heard was Dr Brearey's view about that moment in time?
GRIFFITHS: And is he referring to the day after or the day --
DE LA POER: Yes, so he is talking about the day of [Child O]'s death, after [Child O] had died, about the following day. So in other words, he had no idea that Letby was returning to work and could not conceive that senior nursing staff would allocate Letby to care for the surviving triplets. Obviously, one reading of that, although he doesn't name you, I make that clear, that you might be included within the category of senior nursing staff, and you were responsible for the rota. I just wish to give you an opportunity to comment on what Dr Brearey has said about his state of mind at that time.
GRIFFITHS: I know I wasn't on duty on the following day when she was there and, as I say, nobody during that resus, apart from the look, nobody every came to me and said that they had witnessed anything or seen any deliberate harm. And I -- yes. That's all I can say.
DE LA POER: If Dr Brearey or Ms Powell had come to speak to you and said, "I don't think that Letby should be caring for the triplets", the two surviving triplets at that stage, "on tomorrow's shift", what would you, as the person in charge of the rota, have done?
GRIFFITHS: I think if somebody specifically had said that, then, you know, there would have been other nurses to allocate.
DE LA POER: Obviously we know now that [Child P] died the following day. You report a telephone call that you were aware of after [Child P]'s death that Dr Brearey had called, not you I hasten to add, to say that he wanted Letby removed from the neonatal unit. What was your reaction to that, bearing in mind I think you were away at a social event on that day?
GRIFFITHS: Yes, I remember (redacted) and I had a phone call when we were walking up to the races off Eirian asking what had happened and had I seen anything untoward about Lucy on shift. So I said nobody had actually said anything to me in regard to having seen anything and it was no different to any of the other, you know, cases and that's where I left the conversation.
DE LA POER: You say in your witness statement: "To believe that Letby had done anything to harm the infants was incomprehensible."
GRIFFITHS: That is following, yes.
DE LA POER: Did you at any point up to this point reflect upon the cases of Beverley Allitt or the nurse at Stepping Hill, Nurse Chua?
GRIFFITHS: No, I didn't.
DE LA POER: Do you think that that is something that it would have been appropriate for you to bring into your
thinking at that stage? That there are well-documented cases of nurses deliberately doing harm?
GRIFFITHS: Yes, I appreciate, but I feel that it was being looked -- I think, you had two senior people escalating to more senior people and you just entrust that things are, policies are in place for these things to be dealt with.
DE LA POER: In the week following the death of the two of the three triplets, and the Inquiry understands that Letby worked three day shifts, that's based upon the records.
GRIFFITHS: It is, but actually she never worked, she never came back to the unit.
DE LA POER: So was it the case that she was scheduled to work those shifts?
GRIFFITHS: She was scheduled to work those shifts and before she -- because I think I messaged her on behalf of Eirian, because I was the person that always messaged to try and get people to work extra shifts whereas Eirian would never message a nursing colleague and it was planned for her to go and meet Eirian in Sian Williams' office.
DE LA POER: And is this before the holiday that we know she had booked?
GRIFFITHS: Yes.
DE LA POER: Just a few more questions about events following. You describe a meeting on 4 July of 2016 at which senior paediatricians were present, and the way you phrase it in your witness statement was: "Consultants on a mission to remove Letby based on speculation." Just reflecting on the way that you were describing the Consultants and what they were trying to achieve, do you think that that is a fair and balanced way of describing what they were saying at that meeting, that they were on a mission to remove Letby based on speculation?
GRIFFITHS: Yes, I just -- it was a normal lunchtime meeting that we would all attend with paediatric staff, secretaries, myself -- well, Eirian or myself depending, and I just didn't think it was the format for that conversation.
DE LA POER: If we move forward in time to your interview as part of the grievance process -- we can turn it up if we need to -- but on two occasions, you describe the Consultants' approach as a witch hunt.
GRIFFITHS: (Nods).
DE LA POER: Do you remember using that phrase?
GRIFFITHS: Yes.
DE LA POER: And again, do you think that that is a fair characterisation of what they were trying to do and how they were doing it?
GRIFFITHS: I haven't seen that grievance until the Thirlwall Inquiry, and when I read the questions I just felt -- I had never been part -- I didn't even know what a grievance meeting was. I was told I had to go and do this grievance meeting and when I read back on the questions, I felt they were very loaded and I just felt that they were questioned in such a way that they wanted me to answer to -- to look that Dr Brearey was a troublemaker.
DE LA POER: So let's just be clear about the questions you are being asked. Is this the questions being asked by the Thirlwall Inquiry or the questions being asked by the grievance process?
GRIFFITHS: By the grievance process.
DE LA POER: Well, we have seen a corrected version of that as I am sure you have --
GRIFFITHS: Yes.
DE LA POER: -- with tracked changes shown on and that phrase appears twice. Is it one that you used?
GRIFFITHS: I potentially would have used that because I think there was a real strong element of "it's a nurse" rather than looking at it in a whole and I think I was just, not angry, at the time but I think it's your whole working profession and you never think a nurse would ever do anything so evil and so harmful.
DE LA POER: Do you think it's possible that you had lost objectivity by this point to be speaking about the Consultants in the terms of a witch hunt?
GRIFFITHS: Well, I think it was very close to, you know, you see one of your colleagues being told that they can never walk back onto the neonatal unit, that you are going to work in a secondment, you see her grief, you see the grief of, you know, gosh, all those deaths; was there something suspected? I think I was in a lot of turmoil and now in reflection when I have got more information, because I think as a deputy you only get part of the information, you don't get the whole picture, but I was never derogative to Consultants while I was working with them and I was trying to keep an open mind.
MR DE LA POER: Ms Griffiths, those are all the questions that I have. I think it is going to be Mr Baker, my Lady, who will be asking the first set of questions on behalf of family groups 2 and 3.
LADY JUSTICE THIRLWALL: Thank you.
MR BAKER: Thank you, my Lady. Mrs Griffiths, I ask questions on behalf of two of the family groups. I want to begin by asking you something about the drug error issue --
GRIFFITHS: Yes.
BAKER: -- which you were asked about at the very outset of your evidence. Now, the Inquiry is obviously going to hear evidence from other people about this, but one interpretation of what happened is that Lucy Letby went over your head having, you having made a clear decision about what should happen, she went to Eirian Powell and complained about that decision and you were overruled?
GRIFFITHS: (Nods).
BAKER: Now, if that is the conclusion that is reached, if that is the proper interpretation, would you with the benefit of hindsight regard that as very manipulative behaviour on the part of Letby?
GRIFFITHS: I suppose it shows a very over competent -- confident nurse, that she -- because I think part of a nursing journey is to learn from any mistakes potentially. So when I read back and got the two statements, and I think all the text messages between her and her colleagues, I didn't think that was appropriate and I agree, I think it was quite
manipulative.
BAKER: It is quite grandiose and arrogant as well, isn't it?
GRIFFITHS: It is, yes.
BAKER: I am going to ask you some questions about -- I was going to ask you some questions about Datix forms but I think they have all been covered by Mr De La Poer. So I am going to ask you some questions about suspicions about Letby and in particular your suspicions. Could we turn up, please, INQ0012986. So we can see that this is a Facere Melius interview on 30 June 2020. Do you recall that interview? Do you recall attending an interview on 30 June --
GRIFFITHS: Yes.
BAKER: -- 2020?
GRIFFITHS: Yes.
BAKER: If we could go to page 10 of that document, please. So at the bottom of page 10, can you see that you are asked a question by Kay Boyle: "Okay, I suppose really were you surprised by the arrest of Lucy by that time, bearing in mind it was a year on, after the police had gotten involved?" And over the page, you respond, if I may say so, by not answering the question but saying something else.
And there is another question from Kay Boyle about the relationship between the nursing staff and Consultants. You respond and Kay Boyle says: "So were you surprised?" And you answer: "About the police? No, not because I thought -- not because I thought she was guilty but I knew that I didn't have the answers." Did you think by this point, 2020, that Letby was guilty?
GRIFFITHS: No.
BAKER: You didn't know?
GRIFFITHS: Did I think --
BAKER: You didn't know? You hadn't reached a conclusion?
GRIFFITHS: No, I hadn't reached a conclusion.
BAKER: If we go to your position at the grievance interview, and this is INQ0003167, and if we could go, please, to page 3 of that document. At the very bottom of that page, it's the section which begins "I have" -- sorry: "It would be easy for LL to walk away but I hope that she will return to the unit. It's difficult for Letby and me as it's hard when you have lost trust. She has done wrong. However, I would hate anyone to point the finger with the evidence. She didn't know the allegations. We are looking for a new neonatal lead. Perhaps with progression it would be easier." What wrong did you think at that point that Lucy Letby had done?
GRIFFITHS: I just -- it was just more an accusation or allegations rather than wrong.
BAKER: Well, it's recorded there --
GRIFFITHS: I think it was meant to be "she's done no wrong" rather than --
BAKER: Oh, you are saying she's done no wrong?
GRIFFITHS: Yes, rather than she's done wrong.
BAKER: Then in the following paragraph -- sorry, at the end of that paragraph: "It will difficult, however, all the nursing staff are behind her and she is one of the most experienced Band 5s." And at the final part of that section: "We would be delighted to have her back. I've only seen her two or three times and told her we are behind her." So you are describing there that you had had meetings with Letby and told her you were behind her, you were fighting her corner?
GRIFFITHS: I don't think fighting her corner because we
weren't fighting for anything but just to let her know, obviously being deputy manager, we were instructed that we had to provide support for Lucy. So, occasionally, we would be asked to go and do a welfare chat/meeting and obviously when she was upset it was just reassuring to tell her that the nursing staff were still behind her, that they weren't talking behind her back negatively.
BAKER: Well, isn't that saying quite clearly that you were behind her in the sense that not that you were offering her support and well-being as a superior or line manager, but that you were fighting her corner, that you believed her, that you disagreed with the allegations that were being put against her?
GRIFFITHS: I think it wasn't until -- we were all in shock as a nursing team. I think to think that one of our colleagues was accused of, of the harm that was allegated (sic) and it wasn't until we went to court that we realised there was a lot more information that we didn't have. All we had was our nursing notes and what we had witnessed whilst working alongside her. We didn't actually see the whole picture so ...
BAKER: Isn't that rather the point?
GRIFFITHS: Yes.
BAKER: That you must have known then that there were
serious allegations being made against her, that you couldn't possibly know the answer to?
GRIFFITHS: Yes.
BAKER: And rather than standing back as somebody in a position of superiority and saying it is necessary for the safety of babies that this is properly investigated, you in fact are cheerleading for Lucy Letby, aren't you, here, saying you would be delighted to have her back?
GRIFFITHS: It sounds like that but obviously, you know, I wanted to have the clear answers as well and I never spoke to the Consultants and said she is completely innocent. But I feel that I tried to keep neutral because obviously we still had to provide a service and work together closely, nurses and doctors. So in order to do that, you know, we had to work together and at this moment in time she hadn't been arrested for anything. So for me to, I wouldn't have done justice for her if I would have gone and said, "We think you are guilty too."
BAKER: Are you really saying, though, that you would be delighted to have on the neonatal ward somebody who might be a killer of babies?
GRIFFITHS: I know it doesn't sound wonderful. I didn't mean it as in delighted and hindsight is a wonderful thing, and I'm sorry.
BAKER: Again, Mr De La Poer asked you if you perhaps lost perspective here, that you adopted a polarised position, nurses versus doctors, do you think with the benefit of hindsight that's what had happened?
GRIFFITHS: No. I don't think so. I think we still worked together and I think it was just an incomprehensible situation that you never envisage that you are going to be involved in.
BAKER: If we could go to your Inquiry statement, please, at paragraph 103. I don't know if you can see it in front of you. This is the section where you say, and it's five lines from the bottom: "I know Eirian was protecting her nursing staff."
GRIFFITHS: I can't see that, sorry.
BAKER: You can't see that. I don't know if the Inquiry statement comes up on the screen but it may be something you have in front of you.
LADY JUSTICE THIRLWALL: I think you've got it in front of you in the folder.
GRIFFITHS: Sorry, yes. Which section?
MR BAKER: I don't think we put the Inquiry statement on the screen. So it is paragraph 103 and you see five lines from the bottom of that paragraph: "I know Eirian was protecting her nursing staff and thought it only right to include medical staff in the reports". I mean, does that not give us a clear indication as to perspectives that you had, that Eirian Powell had, that it was necessary for the senior nurses to protect the nursing staff?
GRIFFITHS: I don't think "protect" is the right word. But I suppose it's everyone is innocent until proven guilty and I think it's, it is incomprehensible but nobody refused to give witness statements in support of and everybody wanted to do what was right and they would never have kept anything from any statements to protect anybody. They would tell the truth. And I think as a manager you would -- hopefully you would want somebody, if you were in a similar situation, to have their support because it could be very isolating as well.
BAKER: But innocent until proven guilty by whom? I mean, if you take that to its logical conclusion, do you have Lucy Letby working in the neonatal ward up until the point where the jury returns its verdict?
GRIFFITHS: Well, no, because she was seconded by then, wasn't she, she wasn't returned to the unit.
BAKER: That's not my point. What I am saying to you is, at what point do you think the need to safeguard
kicks in?
GRIFFITHS: I think it was around the time where she was -- I think February time of '17, I believe, that she was supposed to be coming back to work, or '18, and I know I felt uncomfortable about her return because I knew the Consultants were -- didn't really want her back and I knew that would cause problems between the dynamics of the nursing and the medical team.
BAKER: Well, in October 2016 you are describing the Consultants as engaged in a witch hunt and that you would be delighted to have Lucy Letby back on the ward. What changes between then and early 2017 that you think there's a need to safeguard?
GRIFFITHS: I suppose I have had more conversations perhaps with Dr Brearey and I wanted to keep an open mind. So I didn't have all the information. But I think just looking at the commonalities and the protection, and I think it was just the determination of Lucy wanting to come back to work which struck me as a little bit unusual. If you are accused of such acts why would you want to go back and work with these people? So just a whole combination but I tried to keep an open mind because obviously I didn't have all the pieces of the information, just what I had.
BAKER: So looking then at suspicions about Letby and those that you became aware of, now, how did you come to write a witness statement dated 15 October 2024? What was the process that led to that?
GRIFFITHS: Sorry, I have --
BAKER: How did you come to write a witness statement and sign it yesterday? What process led to that?
GRIFFITHS: I was looking at all the information from everybody's statements because I think whilst we were in court we weren't able to discuss anything with our colleagues. We weren't able to see anybody's statements and it wasn't until I received the statements from Dr Brearey and from Eirian that I was able to put pieces together and it's very difficult when you go into court trying to -- and you have only got a small piece of the puzzle and --
BAKER: So when did you receive those statements?
GRIFFITHS: It was two weeks Friday.
BAKER: And who sent them to you?
GRIFFITHS: Hill Dickinson.
BAKER: Okay. And who did you contact?
GRIFFITHS: I received them on a Thursday but I didn't read them until Friday and then on the Monday I contacted --
BAKER: Did anybody point out to you in sending those
statements particular paragraphs that you needed to read?
GRIFFITHS: Pardon?
BAKER: Did anybody point out to you particular sections of the witness statement that you needed to pay attention to?
GRIFFITHS: Yes, we had the Thirlwall's information and we had a short time to actually to get them written down. I have actually in the year preceding the -- during the court case, I hardly took any annual leave. In August, I did manage to take two weeks annual leave which I have not done in the whole 18 months, I think, this has been going on.
BAKER: Sorry, why were you --
GRIFFITHS: And I think, you know, it was difficult reading while I was -- I had a lot of statements on my phone, I am still working full time, and trying to support the team and I should have spent more time reading the statements.
BAKER: What I mean is, why were you sent Eirian Powell and Stephen Brearey's reports -- statements two weeks ago? And when you were sent them were you asked to pay any attention to any particular issues within them?
GRIFFITHS: Not that I recall, no.
BAKER: It was only two weeks ago.
GRIFFITHS: Yes, yes. No, no.
BAKER: Your original statements, and indeed your commentary to the police, are very clear in suggesting that you were -- you had a conversation with Stephen Brearey in October 2015.
GRIFFITHS: (Nods).
BAKER: Your evidence this morning, as I understand it, is that Dr Brearey didn't raise any concerns with you at all before the deaths of the triplets, is that correct, in July 2016?
GRIFFITHS: He didn't actually physically speak to me, yes.
BAKER: So to be clear Stephen Brearey, did not say anything to you at all about suspicions or concerns prior to the death of the triplets?
GRIFFITHS: Correct.
BAKER: Can we go then, please, to INQ0003167. Again, this is the note of the grievance interview, 17 October 2016, so even closer to the events than the Facere Melius interview of 2020. If you can go on, please, to page 2. We can see here under "YG" -- so "CG" is a person asking you questions and "YG", that's your response. First of all, are these the questions that you were saying are loaded
and intimidating and made you criticise the Consultants?
GRIFFITHS: I think it was obviously those questions but the actual -- I just remember, I think, Dr Brearey, I think, spent some time within the Air Force and I think they were using an analogy that sometimes they are tunnel-visioned and I remember that conversation. And, as I say, this is all new to me. I have never done a grievance before, never been involved in one, and I think there was a lot of exchange but obviously their conversation isn't written down here.
BAKER: So, I mean, you have answered questions before and the question here is: "Why were there concerns raised?" And you say: "There were some concerns around commonality." But at the bottom of that paragraph, you say: "Steve Brearey was the only one with concerns prior to the triplets."
GRIFFITHS: Yes.
BAKER: Yes, so that was your recollection in October 2016.
GRIFFITHS: Yes.
BAKER: Do you agree that's inconsistent with what you are saying now?
GRIFFITHS: No, because Eirian actually spoke to me and
said that Steve has said the commonality is Lucy on shift so that's why I was aware that Steve was concerned.
BAKER: So you are not there recounting what you understood to be the case, namely that Steve Brearey was the one with concerns prior to the triplets?
GRIFFITHS: (Nods).
BAKER: That's not your recollection that's recorded there?
GRIFFITHS: Yes, Steve was the only one with concerns and about Lucy, yes.
BAKER: So you go on to say in the next paragraph: "After the second triplet passed, Lucy was on shift the next day, then annual leave." And you talk about a meeting that you attended on 4th July where Steve Brearey voiced his concerns: "I was there because Eirian Powell couldn't attend. Steve Brearey wanted to go to the chief exec and we said you can't just do that on a gut feeling. He got Ravi and Dr V on board. It's not like Steve Brearey to cause trouble." I mean, what you are describing here is that Steve Brearey had had concerns prior to the deaths of the triplets, that you were aware of, and that he then brought Ravi Jayaram and Dr V on board?
GRIFFITHS: (Nods).
BAKER: Now, that's in and of itself inaccurate, isn't it, because you knew that Ravi Jayaram had concerns for a lot longer than that?
GRIFFITHS: I was just more -- more aware that Steve had, and I think it was in this meeting when they were all there that that's when they all voiced their concerns. But as I say, I was never in attendance to -- no Consultant ever came to me personally and made their concerns.
BAKER: Well, let's be clear about the use of the word "concerns" and what that means. If you can go to INQ0000531. This is your interview with the police and if we could look on page 2, please. At the bottom, you have been taken to this section before and it's: "During the 14 October 2015 Dr Brearey may have commented to me not to give Lucy [Child A] (sic) again for the third night."
LADY JUSTICE THIRLWALL: [Child I].
MR BAKER: [Child I], sorry. "I cannot remember any specific conversation or decision in relation to this. I am just speculating regarding anything Dr Brearey said. I think he was suspicious of her as she had been present when several babies had collapsed." It wasn't concerns, it was suspicions, wasn't it, it was suggesting that she had harmed babies?
GRIFFITHS: As I say, this is an error. And I wasn't aware of Dr Brearey's concerns or suspicions until after the table had been created and I think, as you can see, it was more "I think I had a conversation" because since I have had lots of conversations with Dr Brearey and I think it's, there's lots of information. I have given lots of statements. And I think that was an error.
BAKER: Well, you say you weren't aware of his suspicions until after the table was created. The first table was created in October 2015.
GRIFFITHS: Yes.
BAKER: Again, what you just said now is inconsistent with what you said this morning, isn't it?
GRIFFITHS: Well, no, because I was not aware -- because that grievance was in 2016.
BAKER: You said you weren't aware of his suspicions until after the table had been created.
GRIFFITHS: I meant from him, I was aware of the commonality and Steve had raised to Eirian about his concerns that she was on, so to me that was a suspicion.
BAKER: So when did you become aware that Stephen Brearey had raised with Eirian his concerns
and/or suspicions?
GRIFFITHS: After the table was created I was cc'd in that email and Eirian had spoke to me and said that, you know, Steve has got concerns because Letby is on shift at each incident. But it wasn't until after when Baby O [Child O] and P, when I was in that meeting that I heard actually Dr Brearey voice that he had concerns.
BAKER: So you were aware of Stephen Brearey's concerns in or around the end of 2015 when Eirian Powell told you about them?
GRIFFITHS: Yes.
BAKER: So the section of your grievance interview which you suggested I may have misinterpreted, where you said that Stephen Brearey is the only one who had raised suspicions before the deaths of the triplets, in fact that was based upon your firsthand knowledge that he had raised suspicions, dating back from the end of the previous year?
GRIFFITHS: Yes.
BAKER: In fact you also knew, didn't you, that Ravi Jayaram had been copied into emails to Eirian Powell about raising suspicions?
GRIFFITHS: As I say, it was just more a conversation with Eirian. Email threads are cc'd to lots of people. But
I knew she voiced that only Dr Brearey, because he was our neonatal lead, spoke to her about the concerns.
BAKER: Can I very finally deal with the issue that you raised in relation to [Child C]. Can I be frank and upfront about what I am about to say to you. The -- paragraph 53 of your witness statement in which you describe reference to a ventilated basket, you know that a ventilated basket is a cold cot, don't you?
GRIFFITHS: Yes.
BAKER: At paragraph 54, and indeed this morning, you were the only witness who has not expressed horror at the words that were used to [Child C]'s parents. A cold cot is not something you put a living baby in, is it?
GRIFFITHS: No, and I think I just read and I realised that the mother had said, "but she hasn't died", that "the baby hasn't died yet".
BAKER: Yes.
GRIFFITHS: Yes.
BAKER: So Letby came in with a cold cot, which is designed to keep a dead baby cool so that parents can spend longer with them?
GRIFFITHS: Yes.
BAKER: And said, "You have said your goodbyes now, do
you want me to put him in here?" or "Do you want to put him in here?" and mum said, "He's not died yet."
GRIFFITHS: Yes.
BAKER: That is horrifying, isn't it?
GRIFFITHS: It is horrifying.
BAKER: You would, therefore, correct what you say at paragraph 54 and sharing the horror that is expressed by the other witnesses in relation to that point?
GRIFFITHS: Yes.
BAKER: But can I say as well that you raise here that: "I do not recall anyone coming to me and complaining about a nurse saying the phrase", which is capitalised above. I can take you to your police interview, if necessary. In fact, it is INQ0007707, page 20 of that document. This is a transcript of a recording of an interview that you gave to the police. So page 20 at the bottom. You previously described how you were working on the 12th of --
LADY JUSTICE THIRLWALL: We haven't got the page yet.
MR BAKER: We are not quite there. Yes, thank you, my Lady. Towards the bottom there is a reference there to: "Okay, so that was Friday the 12th." And you have previously described, a few lines up, how mum had enjoyed holding the baby but obviously she was very anxious. Earlier, you say that when you stopped your shift on the 12th, Baby C [Child C] was in a stable condition and appeared to be doing, doing well?
GRIFFITHS: (Nods).
BAKER: And that is your recollection, isn't it?
GRIFFITHS: Yes.
BAKER: That is the evidence you gave in the criminal trial. So that was Friday the 12th. He passed away on Sunday but you weren't back in work until the Monday and you say that's right.
GRIFFITHS: Yes.
BAKER: So Baby C [Child C] died at a little before 6 am on Sunday the 14th of June. You weren't in until the Monday so you weren't there for anybody to complain to you about what had been said?
GRIFFITHS: Correct.
BAKER: So there is nothing unusual at all about the fact that nobody complained to you?
GRIFFITHS: No.
MR BAKER: Thank you. Thank you, my Lady, I have no more questions.
LADY JUSTICE THIRLWALL: Thank you very much indeed, Mr Baker. Mr Skelton.
MR SKELTON: Ms Griffiths, a few questions first about Mother A and -- Mother A and B. First of all, information provided to her by the nursing staff. Are you aware that she was told that her children were doing well, albeit they were premature, and that particularly [Child A] was doing really well?
GRIFFITHS: Yes.
SKELTON: And therefore the collapse and death of [Child A] was a complete shock both to her and to everyone else that was caring for her?
GRIFFITHS: (Nods).
SKELTON: What was your explanation for the death of [Child A]?
GRIFFITHS: I didn't recall until I see because -- I wasn't personally involved, I don't think, in the care of [Child A].
SKELTON: The reality was, wasn't it, that there was no probable cause for his death found by the clinical staff and indeed that continued to be the case right up to and including the Inquest that took place a year later.
Were you aware of that?
GRIFFITHS: No.
SKELTON: Were you aware of the rashes or the mottling that had been found on [Child A] when he collapsed?
GRIFFITHS: No.
SKELTON: Or [Child B]?
GRIFFITHS: No.
SKELTON: So you are not aware of any communications about that either between the staff or between the staff and --
GRIFFITHS: Not that I recall, no.
SKELTON: Mother A's evidence is that she arrived, effectively, to a scene where her child had collapsed and was being resuscitated with a lot of staff around him and that during that period a nurse came up to her and asked if she wanted to say a prayer. This was before she had been told what was going on and whether her child would die. Do you recognise that that is inappropriate to say to a mother who doesn't know if her child is going to die, in fact doesn't know what's going on, if she wants to say a prayer?
GRIFFITHS: Yes.
SKELTON: Another point raised by Father M in his evidence to the Inquiry is that he had the impression when he was on the unit that he felt that his child
wasn't his own and he felt that the nurses or the staff were the ones in charge and wanted to care for him rather than the parents. Do you see that as being problematic?
GRIFFITHS: I think when a baby is first admitted often, especially fathers, it's very stressful and distressing and I think initially if the babies do need that care then it can appear that the nurses are doing all that care. I know now that we have Family Integrated Care, so that has changed dramatically and, you know, the family are really involved in the care. I can't really say anything regarding that situation but I know the nurses, you know, try and encourage parents to be a part of that but I think if it's busy, the babies are needing attention, then the nurses are more concentrating on, on that. And I don't like to hear that they didn't feel that they were welcomed because that's not what we, you know, want families to feel.
SKELTON: And also that they have contact with the child, you recognise that's important? He --
GRIFFITHS: Especially important, and I think, you know, especially fathers, they never -- they feel too scared to hold their babies, but it's so important, so we do -- that loving close relationship, we, we, you know, we do realise that is most important.
SKELTON: So the fact that he didn't feel encouraged to handle his child until he went to Alder Hey, that's something perhaps that shouldn't have occurred?
GRIFFITHS: That shouldn't have occurred.
SKELTON: Can I ask you about your reflections about what has gone on at your hospital. You said to counsel to the Inquiry that by early 2016, you had no concerns yourself and you kept an open mind.
GRIFFITHS: (Nods).
SKELTON: But the reality is, from your statement both to this Inquiry and during the grievance process, is that you talk repeatedly about speculation on the part of the Consultants; in other words, they didn't have any particular concrete reason to be concerned about Letby, to be suspicious of her, they were speculating?
GRIFFITHS: Yes.
SKELTON: Do you recognise that that is effectively dismissing their concerns?
GRIFFITHS: I think if I would have said that the concerns were true then I would have -- and I just don't like sides. You know, there isn't this side or that side. We all want to get to the common goal of finding out
what is the problem. And I just -- for my own sanity I had to keep that neutral. The nurses were very upset wondering why this nurse was taken away and it was like, it's okay, we are supporting Lucy, the execs were coming in and saying, "Don't worry, Lucy is okay, she's being supported", but then I didn't dismiss, especially the latter part, going to court, the beliefs of the Consultants either. And I think it's -- hindsight is a wonderful thing and if I would have had all the information that I received following the arrest, then that would have been a bit more clearer and I just feel often you are always in that difficult situation where not being able to disclose information, and I think that's been throughout the whole process for the nurses and for, especially the nurses because it's very difficult to share those concerns that we have about a certain member because obviously you've got to protect their, their confidentiality as well and I don't even know where I am going with this.
SKELTON: Can I just take it in stages. Dr Brearey was a highly experienced senior doctor. He had been treating sick babies for many, many years?
GRIFFITHS: (Nods).
SKELTON: And there -- nobody in this Inquiry has
suggested that he was anything other than a caring, competent professional, correct?
GRIFFITHS: Correct.
SKELTON: He and other Consultants of similar similarity and experience began to suspect that a member of staff was harming children. That in itself, his seniority, his experience, his concern, is significant, isn't it?
GRIFFITHS: Yes.
SKELTON: And ordinarily, if a child comes into hospital and any healthcare professional has a concern that that child is being harmed you have to take active steps to prevent that child from being harmed any further, don't you?
GRIFFITHS: Yes.
SKELTON: And it doesn't -- you don't need proof of the harm, you don't need to have had a photograph of the parent injuring the child or the school teacher abusing the child. If you are suspicious you have to act, correct?
GRIFFITHS: Correct.
SKELTON: And indeed, that accords with one of the nurse's primary duties as a nurse, as a healthcare professional. Your first duty is to your patients; that's right, isn't it?
GRIFFITHS: Correct.
SKELTON: Not to your colleagues or your friends or anyone else but to the patients, the service users in the hospital?
GRIFFITHS: Yes.
SKELTON: So when a Consultant comes to you and says, "I am concerned that there is a member of staff harming children", the first duty you have is not to the person who may be harming the children but to the person who may be harmed; do you understand that?
GRIFFITHS: Yes.
SKELTON: And it's correct, isn't it?
GRIFFITHS: Yes.
SKELTON: It's basic.
GRIFFITHS: (Nods).
SKELTON: In this case, what it appears from your statement and from the contemporaneous records is that you thought that Dr Brearey was running a witch hunt against Lucy Letby, you used that word, unprompted, repeatedly, in an interview and you didn't correct it when you had the chance. In other words, there was something malicious about the way she was being treated by this senior experienced doctor. Is that right?
GRIFFITHS: If that's been written down.
SKELTON: Well, you said it.
GRIFFITHS: I did but, as I say, at the time I wasn't suspected of anything -- I wasn't suspecting a nurse to do such evil things and I think all the deaths were reviewed by a lot of senior clinicians and everything was gone through and there was a cause of death for the babies. So I wasn't suspicious that a nurse had actually done deliberate harm.
SKELTON: But there wasn't a cause of death, was there, for all the babies? [Child A], who I have just asked you about at the start of my questions, there wasn't a cause of death, right up until the point of the Inquest, no one knew what he died from, and that was the primary problem, wasn't it, these babies had unexpectedly collapsed without explanation? The Consultants had spent a very long time and a great deal of energy looking to see if they could find what the explanations were and they haven't found them so they were driven to the possibility that it may have been deliberate harm. And presumably they were as unwilling as everyone else to contemplate that possibility because it is horrifying but they needed tod, they had a duty to, didn't they?
GRIFFITHS: Mmm.
SKELTON: Now, you had that duty, too. In other words,
you needed to confront that possibility, not to think of protecting Lucy Letby from a witch hunt but to think that actually it might be possible and if it is, what do I need to do? Do you recognise that?
GRIFFITHS: Yes.
SKELTON: And you weren't in a position to be 100% certain at any stage that the Consultants were wrong, were you?
GRIFFITHS: No.
SKELTON: Dr Holt gave evidence a few weeks ago and she said that the touchstone that she would use is that if she had to speak to her friends or her family about coming into the unit, what would she want to say to them and she would be concerned to allow anyone to come into a unit where someone was suspected of murdering the patients, and that is an obvious point, isn't it?
GRIFFITHS: Yes.
SKELTON: In what way did you protect these babies from being murdered in that situation?
GRIFFITHS: I suppose my role, as I say, as the deputy manager, not the manager, taking things forward I just had to ensure that the unit was staffed appropriately, that the staff were confident. If there was a negative culture on the unit that
didn't embrace change, guidelines, we were a very highly skilled workforce and not one of us saw anything that we would have been suspicious of and I appreciate that the doctors did have -- think of that but all they had was the commonality and I think on that chart there was a lot of commonalities, not just one nurse.
SKELTON: Would you want to send a friend or a family member to a unit in a hospital where the senior Consultants almost unanimously thought that a nurse was killing patients?
GRIFFITHS: Personally I wouldn't but, as I say, I didn't think that at that time.
SKELTON: But as I say, your duty was to the patients and you weren't 100% certain they were wrong. So I am putting to you that you should have taken action personally to ensure the safety of the patients on your unit. What is your response?
GRIFFITHS: I accept your conversation, your critique.
MR SKELTON: Thank you.
LADY JUSTICE THIRLWALL: We haven't finished yet, I just want to ask you something about the morphine --
GRIFFITHS: Yes.
LADY JUSTICE THIRLWALL: -- pump error. So the morphine was being pumped at 10 times the rate that it should have been, understood. That it was
observed about an hour after that had been done?
GRIFFITHS: (Nods).
LADY JUSTICE THIRLWALL: I just would like to know, what are the parents told in that situation?
GRIFFITHS: The parents would have been informed of the error at that time.
LADY JUSTICE THIRLWALL: What would they have been told about the reason for the error?
GRIFFITHS: They would have just been told that it's been programmed in wrong and it's been administrated at that dose, at that rate, and it was caught within one hour and that that person has been spoken to, the two people, and that things have been put into place.
LADY JUSTICE THIRLWALL: So there would have been a full explanation to the parents?
GRIFFITHS: Yes.
LADY JUSTICE THIRLWALL: Thank you very much. I have no other questions. Did you have anything else, Mr De La Poer?
MR DE LA POER: No, thank you, my Lady.
LADY JUSTICE THIRLWALL: Well, thank you very much indeed for coming to give evidence today. I realise you have been in the witness box for quite some time (redacted). Thank you for coming to help. Now, is there a break for --
MR DE LA POER: My Lady, I am informed we need a full 15 minutes to re-arrange but my expectation is that that will not prevent a 4.30 finish.
LADY JUSTICE THIRLWALL: Very well. If we need 15 minutes, we better take that. So 4 o'clock. (3.44 pm) (A short break) (4.02 pm)
LADY JUSTICE THIRLWALL: Yes.
MR DE LA POER: My Lady, the final witness for today is Nurse Anne McGlade, please.
LADY JUSTICE THIRLWALL: Ms McGlade, will you come forward.
MS ANNE ELIZABETH McGLADE (affirmed)
LADY JUSTICE THIRLWALL: Do sit down.
McGLADE: Thank you.
MR DE LA POER: Two matters of formality before we start. The first is, can you give us please your full name.
McGLADE: It's Anne Elizabeth McGlade.
DE LA POER: Can you confirm that you provided to the Inquiry a statement dated 3 June of this year?
McGLADE: That's correct.
DE LA POER: And there are just four matters, which I will just read out to you, that you wish to correct in that statement, I will just run through them, that at paragraph 21 the word "student" should read "staff"; that at paragraph 27, "2017" should be "2016"; that at paragraph 37, in relation to the typed version of the notes that you took for your July 2016 exercise, they were prepared by someone else and the passage in red does not correspond?
McGLADE: Yes.
DE LA POER: And finally, that at paragraph 39, "2017" should be "2016"; is that right?
McGLADE: I think the "2016" should be "2017" for both of them, actually.
DE LA POER: Thank you. Other than those corrections that you have just agreed to, are the contents of that statement true to the best of your knowledge and belief?
McGLADE: It is, yes.
DE LA POER: So we will start, please, as I understand you want to make a statement.
McGLADE: Yes, I would like to. Before I start I would just like to give my sincere condolences to all The Families that have been affected leading us to be here today. And I am in awe at their
bravery, at the way they are dealing with what has happened to their babies. Thank you.
DE LA POER: Thank you. If we begin with your background, please. Did you qualify as a nurse in 1996?
McGLADE: I did, yes.
DE LA POER: And did you start that same year at the Countess of Chester Hospital?
McGLADE: Yes.
DE LA POER: And did you become the children's ward manager in 2012?
McGLADE: That's right, yes.
DE LA POER: And within the management structure, was your immediate and direct line manager Anne Murphy?
McGLADE: That's right, yes.
DE LA POER: And effectively, although I daresay your unit was larger than the neonatal unit, you sat in an equivalent position to Nurse Eirian Powell --
McGLADE: That's correct.
DE LA POER: -- is that right?
McGLADE: Yes.
DE LA POER: You were both head of your respective parts with Anne Murphy sitting above both of you?
McGLADE: That's right, yes.
DE LA POER: In terms of which of the two of you, as unit
heads, would act up? Was it the position that you would act up in the event that Anne Murphy was not available?
McGLADE: That's right, yes.
DE LA POER: And were there a number of occasions over the course of 2014, '15 and '16 when it was necessary for you to act up?
McGLADE: Yes, that's right.
DE LA POER: And I think we are going to see an example of one of those occasions when it comes to the report that you participated in?
McGLADE: Yes.
DE LA POER: So having introduced you, tell us please in your own words what your perception was of the sister unit to yours, the neonatal unit; what was your view of the culture and atmosphere?
McGLADE: It was a professional relationship with the staff. They were very, they were a busy Level 2 unit and it was -- the culture was like it was on paediatrics, we are very close as a medical and nursing team and we would work together very well.
DE LA POER: In early 2015, so before the period that we are going to focus upon, did you perceive any difficulties between any of the relationships between nurses and each other and between nurses and doctors?
McGLADE: In early 2015?
DE LA POER: Exactly.
McGLADE: No, I didn't, no.
DE LA POER: No. Did there come a time when you perceived some tensions within the relationships?
McGLADE: Yes. I would say that was mid-2016 when there were -- when I initially found out there was some suspicions that a member of staff could be hurting babies on the neonatal unit and I know that my nursing colleagues, Eirian and Anne, did not feel the same way as the medical staff so I think that was potentially causing some issues.
DE LA POER: Well, we will come to that in the chronology --
McGLADE: Okay.
DE LA POER: -- but I would just like to focus on those relationships and how people were before the tensions arose.
McGLADE: Yes.
DE LA POER: What sort of manager was Eirian Powell?
McGLADE: I mean, bearing in mind I work on the Children's Unit, so Eirian, it was a very separate entity, the neonatal unit to paediatrics, but to me Eirian was a good manager. She was fair with the staff. She had a good relationship with the staff. They had high standards on
that unit that I could see. We would both attend the meeting of managers and we would give regular updates regarding our services and yes, that was the general feel that I had.
DE LA POER: We have heard it suggested that she may have had favourites; was that something, a suggestion that you were aware as being made at the time?
McGLADE: No, I wasn't aware of that.
DE LA POER: Now, did you have a safeguarding role as part of your duties?
McGLADE: As ward manager for the children's unit yes, I would have. Part of my role would be to ensure that we adhered to our safeguarding policies and guidelines.
DE LA POER: And did that responsibility require you to attend any meetings in that capacity?
McGLADE: Yes, I would attend safeguarding meetings both as a manager and as acting up as Anne Murphy for lead nurse, so we would have regular safeguarding meetings that we would attend.
DE LA POER: And did Nurse Powell also attend those meetings or was that particular to your role as head of the Children's Unit and when acting up?
McGLADE: I can't recall actually. I think because I was acting up for Anne on some of those meetings, Eirian would not have been at those because that would
have been Anne Murphy that would have gone to that and me in turn. So I can't, I don't recall Eirian being at safeguarding meetings that I attended.
DE LA POER: At any of the safeguarding meetings that you attended over the period 2015, '16 and '17, was a concern that a member of staff on the neonatal unit might be harming babies ever raised?
McGLADE: No, not that I can recall.
DE LA POER: In your view, would it be appropriate even if not naming the member of staff for such a concern to be raised at those meetings?
McGLADE: I don't think it would have been appropriate to have raised them at those meetings. But I do think it would have been appropriate to have raised them out of those meetings with the safeguarding team.
DE LA POER: Had any of the safeguarding training that you had received helped you to understand what you should do in the event that you suspected that a colleague was deliberately causing harm to a patient?
McGLADE: Are we referring to 2015 or now?
DE LA POER: 2015.
McGLADE: 2015, no.
DE LA POER: One thing you do say, and we will need to be clear about when in time you are talking about, you say:
"The training instructs you to report any concerns even if others may not agree or have the same concerns." So that is quite a general statement about the approach you should take.
McGLADE: Yes.
DE LA POER: Are you there referring to training which existed in 2015 and '16?
McGLADE: So what I am referring to there is if, for example, there was a child on the ward who, for example, a nurse had safeguarding concerns for and maybe the medical staff didn't agree, as a nurse we would still have that responsibility to do that referral to safeguarding regardless of what our medical teams, you know, if they weren't in agreement.
DE LA POER: And was that the position in 2015?
McGLADE: Yes.
DE LA POER: So whilst there was no specific training on particular circumstances involving a colleague --
McGLADE: Yes.
DE LA POER: -- there was general training that it didn't matter what your colleagues were saying, if you had that concern you should act upon it?
McGLADE: Yes. Yes.
DE LA POER: Unusually, but I think it will be a helpful way of doing this, I would like to just bring up a part of your statement on to the screen so everybody can see what you have said about safeguarding.
McGLADE: Okay.
DE LA POER: So it is INQ0101322, and we are going to go to paragraph 46, please, which is at the bottom of page 10. This is in your reflections section so we can crop straight into that, please. I would just like you to just remind yourself of what you said here in your statement and as you just refresh your memory from it once, you are ready I will just draw your attention to one or two elements and ask you to amplify them.
McGLADE: Okay. (Pause) Okay, thank you.
DE LA POER: We will need to tip over the page but I think we can start on this page. One of the things you say in the fourth line is: "I do not understand why Lucy Letby was allowed to continue working in a clinical environment when medical colleagues' concerns had apparently been escalated. Anyone who had allegations like these shouldn't have been working clinically." Can you just tell us, please, why you say that?
McGLADE: Because, first and foremost, we are there to
protect patients that we are looking after. And we also have a duty of care to our staff so all allegations need to be investigated and that member of staff, in my opinion, should be removed while those investigations take place.
DE LA POER: Can I just explore with you what the threshold for that is. In the event that a doctor or a nurse thinks, "Having thought about it carefully and investigated what I can, I think there is a chance that a colleague of mine is harming babies", is that enough for action?
McGLADE: For me as a manager, yes, it would be.
DE LA POER: Now, you say two-thirds of the way down the paragraph: "At the very least Lucy Letby should have been stood down from clinical practice earlier to safeguard the babies." And then you say this: "As a senior nurse in my role today I know that any nurse that works with children and faces allegations pertaining to causing harm to a baby or child would be stood down immediately until a thorough investigation had been carried out and any nurse that is accused of harming a baby or [and over the page] child would be referred to the Local Authority Designated Officer".
And you then go on to set out the procedure which is a strategy meeting.
McGLADE: Yes.
DE LA POER: And then you add this: "As a Trust we would be expected to say how we would be investigating these issues. This process has been in place since 2013." So, again, can I just ask you to amplify a little what you have said there?
McGLADE: So, actually, when I was putting this statement together, I Googled -- I don't have the policy that was in place at the Trust in 2015/16, but I Googled the process called LADO, so I just Googled to see how long that had been around, and 2013 was the date. So that's how I came to the date.
DE LA POER: And did you come across a document which is commonly referred to as Working Together?
McGLADE: Yes.
DE LA POER: So is it that that you discovered the 2013 version which we know there was one that set out that procedure?
McGLADE: I would have to look at the document to absolutely confirm it. But, yes.
DE LA POER: In terms of your awareness at the time of the procedure, I appreciate you are sitting here in 2024
Googling --
McGLADE: Yes.
DE LA POER: -- to just try and reconstruct things, but do you think you knew about that process in 2015/16?
McGLADE: No, I didn't. No.
DE LA POER: And who, bearing in mind that you had a role that went to safeguarding meetings --
McGLADE: Yes.
DE LA POER: -- whose responsibility would it have been in the hospital to ensure that you did know about that in 2015?
McGLADE: Well, I would have to take some responsibility of that as a manager. But I also cannot remember exactly what was laid out in our safeguarding training at that time. So I would imagine the Trust have a responsibility in terms of the training that was rolled out to ensure that we have the correct information. Yes.
DE LA POER: Thank you. We can take that down. So I would like to move off the topic of safeguarding and just touch briefly upon the period of Letby's training. So this is her training as a student and then her very earliest period. Did anybody at any stage make you aware of any concerns about the period of Letby's training?
McGLADE: The only concerns I was aware of was when she was on my ward doing her third-year last placement and she was doing her management OSCE with us, and at that point there were concerns that she potentially wasn't ready and wouldn't pass the OSCE.
DE LA POER: And did you have any direct involvement in the management of that or was that something that was taken forward with the deanery?
McGLADE: It was the deputy ward manager that was actually mentoring Lucy Letby at that time and I can't remember exactly the conversation that we would have had, but as my deputy she would have informed me there were concerns. It is very unusual for a third-year nurse to get to that stage where they are failing at that point. So it would have been a topic of conversation for us.
DE LA POER: So that is all I want to ask you about Letby's training. I want to turn next to the topic of when you first became aware of a number of facts that we now know very well. So the first fact is: when did you first become aware that there was an increase in the mortality rate on the neonatal unit?
McGLADE: I think that would have been when I attended
a Women & Children's Governance meeting. I think that was in November or December of 2015.
DE LA POER: We are going to have a look at that document in a moment.
McGLADE: Yes.
DE LA POER: So you think that is moment in time that you first became aware of it?
McGLADE: Yes.
DE LA POER: So I won't ask you any more questions about that for now. We will come back to it. When did you first become aware that a Consultant, or more than one Consultant, was concerned about a particular member of staff?
McGLADE: I think, and I cannot recollect exactly, but I suspect that was around June/July of 2015.
DE LA POER: If we date stamp a moment in time, you were asked in early July together with Dr Gibbs --
McGLADE: Yes.
DE LA POER: -- to undertake a review. Do you think it was before or after that request?
McGLADE: It was before.
DE LA POER: And do you think it was immediately before, as part of your briefing for that, or do you think you had known for some time?
McGLADE: No, I don't think I had known for some time.
I think it was around that time.
DE LA POER: And when you first learned that a Consultant or Consultants were concerned about a particular member of staff, did you also learn at the same time that their concern was about the possibility of deliberate harm or was it not so clearly defined as that?
McGLADE: It's hard to remember due to the passage of time but I think it was around -- the suspicions were that it was related to a member of staff.
DE LA POER: And deliberately or incompetently or was it not specified?
McGLADE: I think the inference was it was deliberate. Yes.
DE LA POER: And doing the best you can, who do you think you learned this from?
McGLADE: This would have either been at one of our Monday lunchtime senior clinicians meeting, with the Consultants, or it would have been a conversation with Anne Murphy and Eirian Powell.
DE LA POER: Now, we know that on 27 June there was a senior paediatrician meeting --
McGLADE: (Nods).
DE LA POER: -- the Monday meeting, at which the evidence suggests that the Consultants were speaking openly about their concern that deliberate harm may have been caused.
Does that sound like the meeting that you are recollecting, where there is an open conversation or was it more guarded?
McGLADE: I don't think I was at that meeting so I think it was afterwards I found out those concerns.
DE LA POER: So we have also heard about a meeting on 4th July, we just heard about that from your colleague Nurse Griffiths. Might that have been the occasion --
McGLADE: Possibly.
DE LA POER: -- if not the 27th?
McGLADE: Yes.
DE LA POER: You worked in the same department but on a different unit.
McGLADE: Yes.
DE LA POER: Do you think you should have been told sooner than that of those concerns?
McGLADE: We were, at that time, which is very different to how we work now, we were very, very separate units. So whether I should have been told or not, I wasn't.
DE LA POER: Now, we will just look briefly at a couple of documents. The first is the one that you have referred to, the Women's & Children's Care Governance Board of December 2015. This is INQ0004371. We can see that Dr Brearey attended in lieu of Dr Jayaram, do you see that about halfway down?
McGLADE: Sorry.
DE LA POER: It is the entry immediately above your name.
McGLADE: Oh, yes. I can see Dr Jayaram -- yes, sorry, Dr Brearey attended.
DE LA POER: Dr Brearey has attended in his stead?
McGLADE: Yes.
DE LA POER: And you are identified in the row below?
McGLADE: That's right, yes.
DE LA POER: So we don't need to go through these minutes but just doing the best you can, what's your recollection of what was said at this meeting about the increase in the mortality rate?
McGLADE: I'm afraid I have no recollection of the report that would have been presented at that meeting.
DE LA POER: But you can see that you were there.
McGLADE: I was, yes.
DE LA POER: And you have no reason to doubt the minutes.
McGLADE: No, no, not at all no.
DE LA POER: If it had been the case that Dr Brearey or other Consultants were by that stage concerned about Letby, in particular, was that an appropriate forum for that to be raised?
McGLADE: I -- I couldn't -- yes, I would say it would be an appropriate forum for that to have been raised.
DE LA POER: Because you have said it wouldn't be
appropriate to raise it in one of your safeguarding meetings but I am just really trying to look at, within the governance structure, how does something like that get reported up?
McGLADE: Yes, yes.
DE LA POER: And, to your mind, having been at such meetings --
McGLADE: Yes.
DE LA POER: -- even if the member of staff is not named, is it your view that nevertheless something should be said there?
McGLADE: Yes.
DE LA POER: Thank you. We can take that down. In February of 2016, did you meet with the CQC?
McGLADE: Yes, I did, yes.
DE LA POER: And was that effectively to show them round your ward?
McGLADE: That's right, yes. Yes, it was a full inspection that was carried out over several days.
DE LA POER: And by that stage, we can see from the meeting that you knew something about the increase in the neonatal mortality?
McGLADE: (Nods).
DE LA POER: In your view was that an appropriate forum for you, showing the CQC around the Children's Unit, to be
mentioning what you were aware of in the wider department or was that for the neonatal unit to say?
McGLADE: It's not that it wouldn't be appropriate for me to say it. I think the assumption that I would have had, and had, was that as they were doing a review of the neonatal unit, that the increase in mortality would have been discussed at that point.
DE LA POER: So you would have expected your colleagues on the neonatal unit to say something about that to the CQC?
McGLADE: Yes, and I would have expected the CQC to have asked about that. Yes.
DE LA POER: Now, there came a moment in time where you were told about something you have described as gossip.
McGLADE: Yes.
DE LA POER: Do you think that was before or after you were informed in early July about the Consultants' concerns?
McGLADE: It was after.
DE LA POER: And did you take steps to make clear that such gossip, as you viewed it, was not appropriate?
McGLADE: Yes. Because at that point I was aware that allegation, serious allegations had been made by the Consultants and that reviews were taking place. And obviously this was so sensitive that, yes, you know, we had to -- the message very clearly coming to us as
managers was that we had to make sure that this wasn't being gossiped about because that would be very unfair for the investigation process.
DE LA POER: Dealing with your reaction to learning about the Consultants' concerns and obviously subsequent gossip, you describe yourself as shocked and horrified that someone could do this.
McGLADE: Yes.
DE LA POER: And did you become aware of what your nursing colleagues, Nurse Powell's and Nurse Murphy's, views were?
McGLADE: Yes.
DE LA POER: And how soon after you learned of the Consultants' concerns do you think that was?
McGLADE: I think it was all around the same time.
DE LA POER: Did you speak to them directly and in private or is it simply conversations in public spaces or when others were present that you learned of their position?
McGLADE: I am assuming you are talking about Anne and Eirian.
DE LA POER: Yes.
McGLADE: We would have had a private conversation and I did ask how they could be so sure as to know that it could possibly not be the case. I wasn't privy to, at that point, the information that they had been given from our medical colleagues, but I could only assume that maybe they didn't have the full picture because of their views that they had.
DE LA POER: So let's just examine that just for a moment.
McGLADE: Yes.
DE LA POER: The starting point is: did they tell you what they thought about the Consultants' views?
McGLADE: They told me what the Consultants' suspicions were.
DE LA POER: And did they tell you about their own opinion about those suspicions?
McGLADE: They said that -- I think they wanted a more generic approach to what was being investigated, to not rule anything out.
DE LA POER: You use the phrase in your witness statement that "they didn't agree".
McGLADE: Yes. Yes.
DE LA POER: And when you are saying they didn't agree, are you saying they didn't agree that there were grounds to be suspicious? Is that what they weren't agreeing with?
McGLADE: They -- they didn't agree and hence wanted a more generic look at what potentially could be going on.
DE LA POER: That, of course, prompted you to say. How can you be so sure --
McGLADE: Yes.
DE LA POER: -- that there are no grounds to be suspicious presumably?
McGLADE: Yes.
DE LA POER: That is what you were challenging them on.
McGLADE: Yes, yes.
DE LA POER: And what did they say in response to that challenge?
McGLADE: I think the initial comments were that other people were present at the times of potentially, you know, collapses, et cetera. But, again, I wasn't privy to a lot of the information that perhaps they were or they weren't privy to.
DE LA POER: And was that all that was said between you or was there any other discussion that emanated from their response?
McGLADE: No, no.
DE LA POER: A final matter to ask you about, Ms McGlade, is your review with Dr Gibbs.
McGLADE: Yes.
DE LA POER: You were asked to undertake that review with him, is that right?
McGLADE: That's right. Yes.
DE LA POER: Do you think you were appropriately qualified to do the role that you undertook with him?
McGLADE: The remit of the -- what I was asked to do was to look at nursing notes of a list of babies that we were given and to look for something that looked, you know, sorry. The remit that we had was for babies that had been transferred out after collapse. And we were given a list of the babies to look at, I looked at the nursing notes, Dr Gibbs looked at the medical notes. So from a point of view of areas that could be suspicious or unusual, that was led by Dr Gibbs because yes, you are quite right, I am not a neonatal nurse and for me, you know, that isn't my area of speciality.
DE LA POER: So you say that I am quite right. Does it come to that perhaps you weren't quite the right person to be undertaking that role of looking at the nursing notes to look for what was suspicious in a specialty that wasn't yours?
McGLADE: I think -- undertaking the remit that we had, I think I was able to do that. But what I wouldn't have been able to do, and didn't do, was say that, you know, I thought this was wrong or this, you know, Dr Gibbs very much led that.
DE LA POER: But Dr Gibbs was only looking at the medical notes, he wasn't looking at the nursing notes, so he wouldn't be able to do that from a nursing perspective; is that right?
McGLADE: What was happening, he would read out the medical notes, I would read out the nursing notes, so he would know what I was looking at. Yes.
DE LA POER: But he wouldn't have a particular nursing perspective on what --
McGLADE: No, and obviously as a children's nurse, I can, you know, pick out some situations that looked unusual. But that would always be confirmed by Dr Gibbs.
DE LA POER: And in summary, is this right, that of the 30 or 40 cases that you looked at, six stood out as unexpected deteriorations or collapses?
McGLADE: That's right, yes.
DE LA POER: So even assuming 40 cases, someone will check my maths, but I think that's 15% of the cases that you were looking at?
McGLADE: (Nods).
DE LA POER: Did you regard that as a very small number and not a cause for concern or did you think, gosh, that's quite a lot of cases where we don't have an explanation?
McGLADE: I think, personally, that's quite a lot, yes.
DE LA POER: Did you ever convey that opinion about the number that you had uncovered to anybody outside of your conversation with Dr Gibbs?
McGLADE: No, because I wasn't asked.
DE LA POER: Did you ever receive any feedback on the work that you had done and how it fitted into the larger picture?
McGLADE: No.
DE LA POER: And were you expecting either you or Dr Gibbs to receive some feedback?
McGLADE: Yes.
DE LA POER: And so what did you think happened to the work that you and Dr Gibbs did?
McGLADE: My understanding was that it was going to be part of a larger review, that it was going to be looked at from a staffing point of view because part of the remit of what we were doing, we weren't looking at doctors or nurses that were taking care of the babies, we were purely looking at the medical and nursing information. So my understanding was that our report was then going to be looked at, analysed and the staffing grid would be, would be looked at.
DE LA POER: Now, you have described it as a report. In fact, in terms of what you handed over, was it some handwritten notes that you had made along the way?
McGLADE: Absolutely, yes. So it wasn't -- we hadn't tidied it up, there was no conclusion written there, was no introduction, it was literally just some handwritten
notes.
DE LA POER: Was there any discussion about how you and Dr Gibbs could formalise what you had found so as to help the next stage of the process?
McGLADE: I was never asked to do that. I don't know whether Dr Gibbs was.
DE LA POER: Do you think, looking back on how that process was conducted, that that was in fact a necessary step that was missed out; that you and Dr Gibbs drew your conclusions together and made them absolutely clear what it was that you were saying?
McGLADE: Yes. Yes.
DE LA POER: Those are all the factual matters I want to ask you about. I just want to return to safeguarding and a recommendation that you gave. You propose that the chair considers this: "Any suspicions about someone working in healthcare needs to be taken escalated, taken seriously, and that member(s) of staff needs to be stepped down from clinical work immediately whilst investigated and for allegations as serious as this, police need to be informed immediately."
McGLADE: Yes.
DE LA POER: And is that your reflection on how things
might have turned out differently?
McGLADE: Yes.
MR DE LA POER: Yes, Nurse McGlade, thank you very much indeed for answering my questions. My Lady, those are all the questions that I have. There are no Rule 10 questions.
LADY JUSTICE THIRLWALL: Thank you, Mr De La Poer.
MR DE LA POER: I beg your pardon, my Lady, I am just having Mr Kennedy drawing my attention and I think as this is a witness who comes under his umbrella, I should just speak to him if I may.
LADY JUSTICE THIRLWALL: Yes, of course. (Pause)
MR DE LA POER: Mr Kennedy, and I have an understanding. There is no need for any further questions.
LADY JUSTICE THIRLWALL: Very well, thank you very much. Thank you very much indeed, Nurse McGlade, for coming, for providing a statement and helping us this afternoon, you are free to go now.
McGLADE: Thank you.
LADY JUSTICE THIRLWALL: So we will start again at 10 o'clock tomorrow morning.
MR DE LA POER: My Lady.
LADY JUSTICE THIRLWALL: Thank you, all, very much indeed.
(4.37 pm) (The Inquiry adjourned until 10.00 am, on Thursday, 17 October 2024)
LADY JUSTICE THIRLWALL: Ms Langdale.
MS LANGDALE: My Lady, may I call Ms Powell.
LADY JUSTICE THIRLWALL: Would you come to the witness box, please, Ms Powell.
MS EIRIAN POWELL (affirmed)
LADY JUSTICE THIRLWALL: Do sit down.
POWELL: Thank you.
MS LANGDALE: Ms Powell, you have provided the Inquiry with a statement dated 9 September 2024. Can you confirm whether the contents are true and accurate as far as you are concerned?
POWELL: So far as I am aware, yes, thank you.
LANGDALE: And do you have that in front of you? We are going to take you through the statement, Ms Powell, and also some documents that will come on the screen in front of you there when we refer to them. If there's anything you can't see or hear just say so.
POWELL: Thank you.
LANGDALE: You begin your statement at paragraph 2 by saying you would like to express sincere condolences to all the parents and their families for the loss of their children and harm suffered. Would you like to expand upon that at this point or not?
POWELL: I don't think anything I can say will alleviate the pain that they continue to endure throughout this process and beyond, but I can't ...
LANGDALE: And before we go into the detail of the documents and the evidence, are there any reflections you have, looking back now, about your role in events, your trust in Letby, and how you described her at the time; what do you think about that looking back now?
POWELL: Sorry, could you repeat that, I can't quite --
LANGDALE: Yes. What do you think now, have you got any reflections, looking back, about the trust you placed in Letby throughout the period of time she was working at the Countess, and the support you offered her? Do you have any reflections about that now?
POWELL: I think at, at the time, with the information that we had at the time, all staff had that level of support. I can't at that time -- on reflection today, you mean, or at the time?
LANGDALE: Yes -- no, on reflections now, looking back, is there anything you would have done differently or think about differently now?
POWELL: I can't, I can't see at that time or now anything different, based on the evidence that we were
given at the time.
LANGDALE: Your nursing career and employment, you set out from paragraph 4 onwards. And you say, tell us that you were working at the neonatal unit between 1993 and 2017, is that right, so a long time?
POWELL: Yes.
LANGDALE: And you became the neonatal unit manager, what time roughly?
POWELL: July 2011.
LANGDALE: And what were your roles and duties as the neonatal unit manager. If it helps you, you set them out at paragraph 8.
POWELL: I will just take a minute. It was responsibility for the day-to-day running of the unit, which incorporated, it sounds oversimplified in that one sentence, but that sort of ensured that the skill set for the acuity on the unit at the time required, recruitment. It was buying, trialling equipment, buying equipment from capital resources, attendance management, performances.
LANGDALE: You said you dealt with any performance attendance or conduct issues involving members of staff; were you ever involved in disciplinary matters, you don't have to tell me who of the nurses, but for any of the nurses?
POWELL: I did, yes.
LANGDALE: So you were part of the process, were you?
POWELL: Yes.
LANGDALE: Investigating conduct issues if they needed to be investigated?
POWELL: Any performance issues were dealt with.
LANGDALE: Performance issues?
POWELL: Yes.
LANGDALE: Did you have HR support for that?
POWELL: It was unnecessary at the time because when we actually dealt with it, by, by encouraging extra support by providing more training, where there was a deficit, an obvious deficit for a new member of staff, they -- but they left, actually, within a very short period of time because they were not happy being -- what's the word? -- being directed in that manner. You know, being shown that they needed to improve their performance.
LANGDALE: So you had had experience when you were a manager, so from 2012 --
POWELL: Yes, yes.
LANGDALE: -- onwards of trying to raise the performance levels of somebody and them not being happy about that and leaving?
POWELL: And they have left, yes.
LANGDALE: Left nursing or just left your unit?
POWELL: Left our unit.
LANGDALE: To work somewhere else?
POWELL: Yes.
LANGDALE: And what kind of documentation would you keep in that situation about somebody, did you record --
POWELL: Yes, that would be on their profile.
LANGDALE: You tell us you were responsible for ensuring that all data recorded via the BadgerNet system was up to date. When did the BadgerNet system come in? Can you remember?
POWELL: We had different versions of it throughout. We had it before I became manager. I can't, I couldn't remember.
LANGDALE: Is that an electronic system for record-keeping?
POWELL: It is, it is.
LANGDALE: Do you still have handwritten notes for patients, but this is an electronic system for the work that you were doing, or was everything moved electronically?
POWELL: Sorry, I don't understand what you --
LANGDALE: Was everything electronically -- done electronically from the moment the BadgerNet system was introduced?
POWELL: No, not everything, no.
LANGDALE: Right. So what stayed manual?
POWELL: The patients' notes stayed manual. And the staff profiles were manual and I think, at that point, so was -- until electronic prescribing came in and again I can't remember exactly when that came in.
LANGDALE: You tell us you also dealt with parent and visitor complaints either directly or via the Patient Advice and Liaison Service, PALS?
POWELL: Yes.
LANGDALE: Roughly in your time as manager, how many patients complained directly to you about service or patient safety, their babies?
POWELL: Yes, there was quite a few. I can't recall their names obviously.
LANGDALE: No, I don't need names.
POWELL: No. But yes, they would come to the office and complain or they would complain to a member of staff and they would ask to come and speak to me.
LANGDALE: And did you document that kind of complaint or was that treated informally that they would come to see you directly at the time and you could deal with it in that way?
POWELL: Gosh, I can't remember what we were doing at that point. It would be, if it was at all, it would be in the patients' notes.
LANGDALE: So if it was going to be anywhere, you would go back to that patient's notes and put it in there?
POWELL: Yes.
LANGDALE: Would you speak to parents about them? If it was the parent making the complaint presumably you would, would you tell them what you thought about the complaint or what had happened?
POWELL: Yes. Oh, yes, yes. Yes.
LANGDALE: How did you find PALS worked, was that effective --
POWELL: It was.
LANGDALE: -- for bringing complaints?
POWELL: That was quite good because it was, it was -- it came via electronic system via email and then you would get the information, the actual complaint, and then we would then research it or involve the people that were either being complained about or had more information about it.
LANGDALE: We have one complaint made via PALS by one of the parents named on the indictment, parents of Baby H [Child H]. Can I ask you to have a look, please, on the screen. INQ0030106, page 2. That's page 1. If we could have page 2. Have a look at this, Ms Powell. This is an email from you to Dr Gibbs and Yvonne Griffiths and a Belinda Simcock and you are referring, if you have a look there: "Brenda from PALS came to speak to me this lunch time to say that the family of Baby [Child H] have put in a complaint. The complaint was the fact that there was no communication from the medical or nursing staff that her baby had been put on the ventilator." And you set out that Dr Harkness spoke to the parents at approximately 11.30 to update them. "At no time did they voice any concerns." Presumably you mean to Dr Harkness and you continue further down and say: "Midwives are preparing to discharge Mum today. However, Nurse W is going to speak to them to allow her to stay longer. Brenda has conveyed this information to Dad they are considering the offer." And you say this: "My question as an addendum is why has it taken Mum so long to come to the unit when she was aware how poorly her baby is? Just a thought. Especially as she is an inpatient or even ask the midwife to ring/use her mobile for an update." Had you spoken yourself to Mother H? It appears that you hadn't, reading that?
POWELL: I can't remember.
LANGDALE: You can't remember?
POWELL: No, I cannot.
LANGDALE: She gave evidence to the Inquiry that she was indeed in the unit having treatment herself and she was having difficulty getting the midwives to take her down to the unit and she wasn't getting mobile phone calls either from the unit. You didn't find that out or know that?
POWELL: No, I didn't know.
LANGDALE: Do you think you should have tried to find that out before making a comment on the complaint, finding out what she had to say about it?
POWELL: Well, yes.
LANGDALE: And instead it seems as though you are saying there, "It's just a thought, why hasn't she got there?" What were you meaning by that?
POWELL: I honestly, I can't, I can't remember. But -- I wasn't -- when was discharge? I just, I can't remember it at all. I'm sorry.
LANGDALE: But it appears reading it, doesn't it, as though you are critical or potentially critical of her for not asking a midwife or using her mobile phone to get an update herself? You have turned it on to the person who's making the complaint: why weren't they doing a bit more?
Is that what you are trying to say there?
POWELL: Well, no, I am just trying to ascertain the information that I was getting from the complaint itself.
LANGDALE: If we look at page 1. Dr Gibbs begins: "I'm sorry that [Child H] parents were not informed reasonably promptly when she was ventilated." "I'm sorry". That's what that needed, didn't it?
POWELL: Yes.
LANGDALE: "I'm sorry." You come down, your child is ventilated. It is very scary to see that, isn't it?
POWELL: It is.
LANGDALE: It is a newborn, you haven't seen it before. We are not all trained nurses to see this?
POWELL: Yes.
LANGDALE: Then "I'm sorry" would have been a nice response?
POWELL: Yes.
LANGDALE: It doesn't necessarily cover the issues but it is a start, isn't it?
POWELL: No, no, and to be fair, she should have been updated by -- predominantly because it's a mechanical ventilation, she should have been updated by the doctors. However, if they were detained through stabilising the infant then hopefully the, the nurse
should be able to go and speak to the parents and update them or ring them if they are at home.
LANGDALE: It's a combined effort, isn't it?
POWELL: It is.
LANGDALE: Nurses and doctors on the unit?
POWELL: Yes.
LANGDALE: The impression -- that can go down now, thank you. The impression we got from parents giving evidence was that on the neonatal unit they could feel they were in the way, either asking about how their children were or what was going on.
POWELL: That's sad to hear. Because that's not what we try to achieve.
LANGDALE: And that they were encouraged to rest, go and rest, which can be important, but now the thinking is much more mothers or parents and carers should stay with their children on the neonatal unit.
POWELL: Yes, as much as possible.
LANGDALE: Yes. And that wasn't happening. It is clear from what the parents have told us that wasn't happening?
POWELL: No, they should have been, they should have been.
LANGDALE: Should it have been even then happening?
POWELL: Well, as you are aware the facilities there were not very, very good, especially in the intensive care because of the room. We only had two parents accommodation on the unit. And we had Christopher Wing which was over on children's ward. But even so, they needed additional help from the midwives, so they needed to be an in-patient if they were upstairs.
LANGDALE: I think later on in your statement you say there could be problems communicating with midwives, couldn't there?
POWELL: Well, yes. Yes.
LANGDALE: What were they? Why were there difficulties there?
POWELL: If, if for instance we would go to the labour ward, which is mandated now that we have the safety briefs, but at the time we would go there for an update every morning to see what was potentially an admission for the unit, and then we would we were able to plan for the next 24 hours with staffing and equipment preparation. But we would have to wait to be spoken to. So we are taking a nurse out of the unit to speak to somebody, predominantly now it is a shift leader, but then it would be anybody to give us an update as to what was potentially coming through, and sometimes they would completely ignore us.
LANGDALE: You mean you would literally be standing there and someone would ignore you?
POWELL: Oh, yes, you could be standing in the office and we would be ignored. And it depended on how experienced the person was going through and say, "Excuse me, we need to know this." But if somebody came into the unit we would straight away ask, you know, what did they want to know, what was the problem? But it was never, well, not that it was never reciprocated, that's incorrect. It wasn't always, some midwives are great, so you had this sort of -- you didn't know when you went in there whether you would get an update so --
LANGDALE: Did you send different nurses in for the update from your unit?
POWELL: Well, usually it is the shift leader.
LANGDALE: Right. So they are experienced nurses?
POWELL: Well, some of them are; others have just gone into the role so it takes a little bit of development to --
LANGDALE: They are Band 6s?
POWELL: Yes, yes.
LANGDALE: So your various Band 6s would go over, and did
they come back and say to you, "We are not getting the information, I have just been standing there"?
POWELL: Well, they would have to wait until they got the information.
LANGDALE: Right, okay. Did you ever go over to get the information?
POWELL: Yes.
LANGDALE: And what was the response to you?
POWELL: It was very dependent on who was there at the time?
LANGDALE: And was it senior midwives --
POWELL: Yes, yes.
LANGDALE: -- that were -- did you ever raise that with the Executives or more widely that that was an issue?
POWELL: Not that I can recall at the time. But I did as, as time went on, did mention it because we had more meetings sort of with maternity and that seemed to help discussing the, the issues.
LANGDALE: Because if your nurses were experiencing it, it's not surprising the parents were feeling, those who were staying and needing the assistance of midwives, that it was difficult or they were getting in the way to ask for assistance, is it?
POWELL: Yes.
LANGDALE: Did you think: if we are having this
experience, what must the patients or the parents be experiencing?
POWELL: Well, I was hoping -- because obviously I wasn't privy to the parents' care that they were getting, it was only on the unit from our perspective.
LANGDALE: The other issue relating to communication is one parent told us that in another hospital the parents could be involved in the huddles or the conversations about the babies' treatment, even if they didn't follow it, they could be there, ask questions. That didn't happen on the neonatal unit in 2015 to 2016, did it?
POWELL: No.
LANGDALE: If there was a ward round or huddles discussions, parents were not invited?
POWELL: No.
LANGDALE: Why not?
POWELL: Well, we weren't aware of this but because Bliss was actually doing -- had a toolkit, we incorporated that with parents to help us develop more of the parent-led care because we needed -- because the new unit was being developed and what we needed in the unit, this was part and parcel of what we needed to improve our services of having the mother besides the cot side for as long as she wanted.
LANGDALE: Mmm.
POWELL: Because there we would have that square footage around the incubator that would allow that. So it was a safe, safer space and that happened in the new unit and we were able to do that.
LANGDALE: So what year was the new unit again?
POWELL: When I left.
LANGDALE: Okay.
POWELL: Yes, that was built in 2018, I think.
LANGDALE: So that permitted parents and babies to be next to each other?
POWELL: Yes. Yes.
LANGDALE: Even without the physical space, was there a reason, even if it's a bit more cramped, that they couldn't be standing together with the nurses or doctors when their babies were being discussed?
POWELL: Well, ideally, we would have the parents there when the ward round was there, we would encourage that, that they would be there, and we did -- we were very good at doing skin to skin with the mums and with the dads, and they had that time and we had the -- were able to make the environment more feasible to do that. But we had champions on the unit that were actually facilitating that, as part of the champions for parental support.
LANGDALE: I haven't heard about those champions so far, so tell us what you mean by -- what's their role, who are they?
POWELL: They would actually look at -- because it went hand in hand with -- I have got to try and remember -- the breastfeeding initiatives and not all parents, not all mums want to breastfeed but some would need to express, some didn't want to at all. But they still had the opportunity for the skin to skin for as long as they wanted, or as long as the baby's stability warranted. But to be fair, babies did stabilise far better with the parents than they did in the incubators.
LANGDALE: And for those mothers who do choose to breastfeed it's really important, isn't it, expressing best milk --
POWELL: Yes.
LANGDALE: -- it is a hugely significant thing to be able to do for your infant? We have heard from a number of parents that when they left breast milk in the fridge, named, it wasn't there when they went back again. Were you having an issue at that time with where breast milk was ending up when it was in the fridge?
POWELL: Well, yes. We, we tried, we weren't in isolation here. This was network-wide. So we were getting information from other units in addition to
postnatal ward were having the same problem. So we had to put things in place in order to make sure this did not happen and it became difficult. In the end, we had to have the breast milk put in a locked fridge in the milk room so that the nurses would actually give it to the mum, they would check it together, and then they would actually, as long as they were happy with that, they would then use it.
LANGDALE: And one parent told us that they knew of someone who was worried because they had had medication that their milk wasn't there, not just that it wasn't there for their baby, but if somebody else's child would have that breast milk without awareness of that, that's very worrying, isn't it?
POWELL: It is. But these things were put in place and it has to be treated like a blood product, and treated with the same care that requires the -- to take the numbers out, to check it, two nurses check the numbers and then they would actually give it to the mums and they would have to check it. But that's how it became -- in the end, that was the only way to manage it.
LANGDALE: Again, can you roughly remember when you got that system in place to manage these issues?
POWELL: I cannot -- my timelines are not accurate, I'm
sorry.
LADY JUSTICE THIRLWALL: You said it was "in the end".
POWELL: Sorry?
LADY JUSTICE THIRLWALL: You said it was "in the end".
POWELL: Well, I was head until 2017, so -- because we had incidents, clinical incidents that actually highlighted this as being a problem. And there were different varieties of it, you know, we said, well, we will get the mums to take the milk out because that's what they were doing on postnatal but then there became an incident from that. So in the end we had to have two nurses to check the milk out and then to check it with the, with the mum before actually administering.
MS LANGDALE: You refer in your statements in paragraph 16 onwards to the culture and atmosphere on the NNU in 2015 and 2016. You say that, in your view, the quality of the management, supervision and support of the nurses was excellent at that time.
POWELL: (Nods).
LANGDALE: In what way do you say it was excellent?
POWELL: Because there was three of us in the office
and three different, completely different personalities.
LANGDALE: So this is Yvonne Griffiths, Yvonne Farmer --
POWELL: Yvonne Griffiths, Yvonne Farmer, and myself. Yvonne Farmer dealt predominantly with developmental, performance issues and appraisals and revalidation, and Yvonne Griffiths did predominantly welfare of staff with regards to the off-duty and facilitating the requests. And then they were very good at coming forward saying, well, do we think about this? Well, I am not happy. Well, we would investigate further as to why somebody wasn't happy, that we have a consensus. So that was an ideal opportunity. And also we had an open-door policy and staff did come in as and when there was a problem. Or wasn't a problem, maybe it was a welfare issue or it was an issue that they wanted expanded further or developed further in their careers.
LANGDALE: You tell us that Occupational Health were available to provide additional support to staff where needed?
POWELL: Yes.
LANGDALE: And we know -- indeed, we have heard evidence from Kathryn de Berger who provided support for Letby.
POWELL: Yes.
LANGDALE: Were there any other -- you wouldn't have to give me names, but nurses that benefited from support from Occupational Health --
POWELL: Yes.
LANGDALE: -- coming down to the unit?
POWELL: Well, the -- they would not necessarily come down to the unit at that time but -- well, they did sort of, obviously, when we were going through -- during a period of time. But prior to that, staff would go to Occu Health for additional support.
LANGDALE: And you have referred they could also speak with a vicar about any concerns. There is a number of references to baptisms and contacting the vicar and -- was that something that was a very present theme on the unit, the --
POWELL: Well, he came to the unit anyway on a weekly basis and he's a very approachable guy. He wasn't necessarily -- he was just there just generally chatting to staff or to parents or anybody that would stop and chat, really. It wasn't a -- he would just come and if there was nobody to talk to then he would go again but he would always pop in and say, you know, how is everybody, how are things? But it wasn't an organised, it wasn't an organised visit as such.
LANGDALE: You say about relationships between doctors
and nurses, at paragraph 19: "In my view, the Consultants felt that all staff members worked cohesively but that was because the staff did exactly what they were told to do by the Consultants and did not challenge them. I felt that the Consultants' communication with managers, nurses and midwives was sometimes poor and that they did not listen to the views of others." The nurses that have given evidence so far to the Inquiry have said they did feel supported by the Consultants and could speak to them.
POWELL: Yes.
LANGDALE: Do you think that wasn't the case for some reason?
POWELL: It is not all the Consultants. There were a few Consultants that were difficult to work with.
LANGDALE: And when you say they didn't listen to the views of others, what do you mean by that? Give an example of that.
POWELL: An example. Gosh. Well, I can't give a specific example. I can give a difficult scenario where you go in ... There was an incident where there was a vent setting not documented. Normally, when you change ventilation settings you put it down on the chart that
these vent settings were changed, date and time, in response to the blood taken. The vent settings itself apparently were changed and it wasn't documented and immediately it was the nurse in charge, the nurse looking after the baby was accused of changing the ventilator. We didn't change the settings of the ventilator. Sometimes we would ring the Consultants and say: this is the blood gas results and they would say, "Just up the rate" or "Change the pressure." That was fine. And then we would document and say: as per Consultant. But this particular incident was immediately -- it would point at the nurse and accuse the nurse. Fortunately, this nurse was particularly experienced and therefore she challenged it and, as it happened, it was the Registrar that had changed the vent settings but just hadn't documented it.
LANGDALE: But the Registrar accepted that presumably when --
POWELL: Well, not initially, no.
LANGDALE: Okay. So there had to be an investigation, see how it had happened?
POWELL: Well, yes, I mean, as it happened, but it was resolved. But instead of sort of looking at the avenues it was straight away, well, you have done it, so you
must have done it, but the person said, well, no actually, I didn't.
LANGDALE: But it's not unreasonable to say to anyone in the room: you might have done it, you might have done it, let's find out, is it?
POWELL: True. It does sort of come down straight away when that's not what our role was about. It was about documentation, the Consultants or the doctors didn't always document what they had actually done.
LANGDALE: Yes. You said that, the quality of case notes was raised on a number of audits, that you didn't feel the documents were full enough and that is, of course, important to do.
POWELL: Yes.
LANGDALE: If doctors and nurses have got time, they should be doing it, shouldn't they?
POWELL: Yes.
LANGDALE: But it is a question of does somebody have to feel accused in that situation if it's a challenge to say: have you done that? Have you done that?
POWELL: It is, but it's just the accusation. Had it been discussed with another doctor the accusation would have been different. It's just, just the slight nuances that are there that makes it difficult and if somebody is less experienced that would be very traumatic.
LANGDALE: Very traumatic.
POWELL: Yes.
LANGDALE: Why is it very traumatic if you are accused of doing something?
POWELL: Because of the insinuation of how -- that your, your practice is questioned and then you have to justify your practice which is fine. But it's instead of sort of having a chance to think, oh well, let me see, you know, give an opportunity to sort of see where we are at, because we are already still looking after the infant and then you are having to answer the questions.
LANGDALE: Staffing issues at paragraph 28. You tell us you were doing a lot of workaround staffing issues and indeed I think one of the nurses we have heard from was in the office with you at some time and realised how much time you spent on this kind of stuff, putting together data and material around staffing; was that a big thing for you?
POWELL: Yes, yes. Because it was -- it was a -- staffing issues were for different people at different times.
LANGDALE: Yes. You say: "I do not feel the staffing issues were ever fully addressed and I am aware that neonatal nursing staffing
shortages was a national issue." How were you aware it was a national issue from these meetings that you went to?
POWELL: When, when we actually go to the Neonatal Network meetings this was discussed quite often, and it was realised that a lot of us were not measuring the same things. I think the incidents were saying we are not measuring apples with apples and pears with pears, we are measuring bodies on the unit, feet on the ground, as opposed to who they are and the calibre of staff. So we did quite a bit of work with the Network with regards to that because a lot of BadgerNet doesn't actually show that, what your staffing is. Our staffing at the time I think was 60:40 ratio, of 60 qualified against 40 unqualified, but they were untrained as in trained nurses. They were qualified because they were nursery nurses but they were not registered nurses.
LANGDALE: You say: "I can, however, say that the NNU was always covered by the appropriate skill mix of staff but this was often not to the British Association for Perinatal Medicine standard."
POWELL: Well, in its entirety.
LANGDALE: Right.
POWELL: It wasn't actually -- through people, through
staff changing their shifts to accommodate the acuity and working overtime, this is how this was met to the BAPM standards at that time. But it's, it's inevitable that burnout will happen because you can't keep doing that all the time.
LANGDALE: You look as though you and Dr Brearey did a nurse staffing, a business case for paediatrics neonatal unit nurse staffing. If we can go, please, to INQ0003829, page 1. So this is a draft in December 2015. If we scroll through it, just to remind you of the document. We go to a conclusion on page 22: "The recommendation by the Urgent Care Division is for the exec board to fund. Query [is that Whole Time Equivalent] Band 5, 10 [Whole Time Equivalent] Band 5s will be need to be recruited and the reshuffle of the Band 4s to accommodate some of the changes required to meet the staffing standards."
POWELL: Yes.
LANGDALE: So this is -- I think this is December 2015 this one. And you have to look at the data of the years previously, don't you?
POWELL: Yes.
LANGDALE: It is difficult to understand what the staffing level actually was in 2015/2016 because your
analysis always relies on that 2014 to 2015 --
POWELL: Yes.
LANGDALE: -- I am going to call it the tax year, we know what the months are.
POWELL: Yes, and also the potential within -- because this takes time by the time the business case goes in, by the time actually it's -- we put adverts out. Also what was potentially leaving through retirement --
LANGDALE: Yes.
POWELL: -- as well. And that was quite high. So to reshuffle, to accommodate that was -- there was quite -- and there is a time lag as well between one and the other from 2014 to 2015.
LANGDALE: Exactly. We see that with your -- again, we can put it on the screen just to see the work that you were doing on it. But if we look at INQ0042844_0001, we see that's a synopsis in preparation for the business case, March 2016. Sorry, if we can go further down to the graph. And the data you are relying on is that 2013/2014 data, by the time you are in 2016.
POWELL: (Nods).
LANGDALE: So in terms of how that data was put together, about staffing across the network, was, how long did it take to become available? Looking at that, you were looking at it a couple of years before to do an analysis for March 2016 --
POWELL: Yes.
LANGDALE: -- but what do you remember now about that? How old was the data you were looking at when you were putting these things together?
POWELL: I don't know. Well, it would probably be 18 months, I would imagine.
LANGDALE: And did you understand why it takes that long to come through the system? Was that ever discussed at the network meetings or not?
POWELL: Well, I -- from when I took over, it takes, that also took a bit of transition. But when you actually look at what is required and what it is potentially going to look like in a two-year forecast, five-year forecast, and to also get what you want for already the 2014, it then becomes apparent you probably need an awful lot more to accommodate. But it's, it's, I suppose everybody has the same issues or similar issues. But we were already low anyway at that point.
LANGDALE: That can go down now, thank you. You say in your statement -- we have seen that the recommendation was at that time to get more Band 5s in, but you say at paragraph 30:
"There was a push to phase out the nursery nurses but I felt they were in fact very experienced as we had provided them with extra training in order to make up for the shortfall in qualified nursing staff. I believed that by phasing out nursery nurses it would impact the integrity of the NNU." What did you mean by the "integrity"?
POWELL: It, it was almost like a knee-jerk reaction: oh, right let us do this, let's -- we will do, we will get -- this is what she wants, more Band 5s, we will get rid of or redeploy the Band 4s. But by then, we had sent them on massage courses, we had sent them -- they were doing parent craft, they were doing a lot of work. So to take them out and put a newly-qualified Band 5 to replace them was not of equal measure at that point because they were so well qualified. There were also BFI, breastfeeding initiative counsellors we were putting in place. So it was difficult to quantify that because I had already said we need more staff, well, yes, we did, but we needed more staff in addition to what we currently had and looking at the forecast for the next 18 months, they were actually -- we were losing some of them anyway to retirement.
LANGDALE: Some doctors and indeed nurses have raised the
suggestion that having Advanced Neonatal Practitioners can really help a neonatal unit. Continuity --
POWELL: Yes.
LANGDALE: -- better links between the doctors and nurses. Would you agree with that?
POWELL: I would.
LANGDALE: Did you have experience of that?
POWELL: Yes. Well, we, we lost two of our advanced neonatal nurse practitioners early on because they, that was in, I think, pre 2011 and the opportunity for development was, was great because we tried to get the, I have forgotten the name of the course -- Examination of the Newborn, we sent four senior members of staff on that course so that would assist with the delay with the babies going home or the delays in seeing what was available, what -- any medical problems that may arise, they could be seen sooner because they had to be seen within, I think it was 72 hours. Well, that was difficult to do if you haven't got the medical staff, if they were busy through paediatrics and neonates. So that was a great opportunity. So that helped. But it was still a shortfall to help with additional needs and that's why we put forward for the Advanced Neonatal Practitioners course, to send two members of staff for that.
LANGDALE: You say, as I have said earlier, in your view the NNU because always covered by the appropriate skill mix of staff. Does that remain your view that it was?
POWELL: For that time. And that's only through -- I mean, normally when you have a week of staffing your off-duty, most hospitals, you know what you are working from Monday to Sunday. Unfortunately, that wasn't the case on the unit but that was kind of the way it worked. When you had the busy moments things were changing and things changed anyway from people being off sick. But for the acuity, to match the acuity with the staffing, we would have to change staffing in order to accommodate that.
LANGDALE: Were you generally satisfied with the standard of care that your nurses were providing --
POWELL: Yes.
LANGDALE: -- leaving aside what we are going to come to, but when you observed them, some were doing extra shifts but when you observed, you were content with the way it was being run?
POWELL: I was.
LANGDALE: Did you think it was safe the way it was being run?
POWELL: It wasn't -- I can't think of the word, it's not enduring, you can't keep doing that. It's not feasible to continue to request staff to come in to do extra, for staff to change their shifts from nights to days, days to nights. It's not in their best interests or well-being.
LANGDALE: Did you have a time when no one would come in and you were stuck or generally did you manage to get people in?
POWELL: They were so accommodating. They were amazing.
LANGDALE: Well, from what some of them have said it felt like a family to some of them.
POWELL: Yes.
LANGDALE: Was it quite a tight ship --
POWELL: It was.
LANGDALE: -- in terms of them getting on and being prepared to come to work?
POWELL: I mean, everybody has likes and dislikes but we were all very professional and we got on with the job.
LANGDALE: You say very professional. In an article in a newspaper a nurse anonymously speaking to the newspaper said that how: during night shifts nurses on the ward would pull a name out of a hat and whoever got picked would be able to leave early, despite being in charge of a baby, and they would leave a handwritten
note by the infant leaving the baby without oversight for hours at a time.
POWELL: No. I don't know where that's coming from. But if the, if the unit was quiet, as in that you had six staff and you sent -- say, four had gone home, there was two left or three left, the one allocated would never go home.
LANGDALE: That is what Ashleigh Hudson told us.
POWELL: Sorry?
LANGDALE: That is exactly what Nurse Ashleigh Hudson told us --
POWELL: Yes, I'd never send an allocated -- an allocated nurse is somebody that stays with that child throughout.
LANGDALE: But it might be that someone could go, if they had done a lot of shifts or overtime, if it was quiet someone could leave a bit earlier?
POWELL: They could leave a bit earlier at the end of the shift but that time would be minused from their total running time owing.
LANGDALE: What was the culture like between the nurses? Was it mocking? Was it unpleasant? Or was it supportive?
POWELL: Sorry, I ...
LANGDALE: Was it mocking, in any way, or unpleasant or
was it supportive?
POWELL: Very supportive. Very good.
LANGDALE: The use of mobile phones on the unit, you address that at paragraph 41 in your statement, and you say: "The use of mobile phones evolved significantly over a relatively short period of time."
POWELL: Yes.
LANGDALE: What was your understanding in 2015 to 2016, about the rules about using a mobile phone at work or about work?
POWELL: Well, on the unit they were not meant to use their mobile phones on the unit. However, we were having difficulties with LanguageLine and there were quite a few issues on the unit with regards to language barriers from international parents. So midwives were using the translators app on their phone and this was something that we actually thought -- we discussed, you know, is this the way forward? We are a bit antiquated, and we are not e-tech savvy, that we should be perhaps looking at this in a different way.
LANGDALE: Yes, how it can help us?
POWELL: Yes, as in a helpful format. But I mean, as it happened, we got another two LanguageLine facilities, so that kind of eased that
issue. But I guess we have moved on such an awful lot these days. I don't know what they do today. But at the time it was not to be used for personal use, that's for sure.
LANGDALE: And you weren't on, we have seen WhatsApp groups with Letby and some managers, you were not on those groups; it is not -- it wasn't your thing --
POWELL: No.
LANGDALE: -- messaging?
POWELL: No.
LANGDALE: Did you discover at the criminal trial how much messaging had taken place or did you not really follow the criminal trial and the details of that?
POWELL: There were a few messages that I did actually see and that was -- that was one of my concerns, was the use of mobile phones within, within the unit as to -- we set -- well, Yvonne set up a WhatsApp group for the off-duty and it works really well, but sometimes it would come back with perhaps a statement, you know. And I said: can we keep this to just staffing? Just, can you do it or can you not do it? It's simple, like just to do it that way.
LANGDALE: Were you on the staffing one?
POWELL: Yes, I was on the staffing one --
LANGDALE: Yes.
POWELL: -- whether you could work this or the other. So I kind of knew when there was a problem. But that was, that was always my concern. So I was -- I felt justified in that, that that's what I worried about when they did social groups of WhatsApp. I mean, they did it when they were going to go for a Christmas venue or whatever, of where does that -- to be very mindful of keeping it professional always, even for an event that was held outside the unit.
LANGDALE: So did you have that conversation widely with the nurses or some nurses or how did you set the tone?
POWELL: We would just -- we would -- Yvonne would actually say on the WhatsApp to keep it professional. And that was -- that's enough to tell them to say, oh, hang on a minute, we shouldn't be discussing that, that should be done independently.
LANGDALE: Paragraph 42, you say: "Staff were permitted to have their phones with them in their lockers but were not allowed to use them on the NNU as this was both unprofessional and unsafe. If a nurse on duty was seen using their mobile phone it would be reported to the ward manager or deputy ward manager. The member of staff would then be interviewed and the interview would be documented. It would also be documented during NNU meetings and via email ...
an email to all staff would be sent out warning them about the use of mobile phones on the unit." Again, I don't need names but can you remember dealing with anybody yourself about that issue or having a conversation with a staff member?
POWELL: There was one, yes. Yes.
LANGDALE: And I assume it wasn't Letby; it was a different one?
POWELL: No.
LANGDALE: So you spoke to one member of staff, and did that stop? Is that somebody that you had seen with a phone on the unit?
POWELL: Sorry?
LANGDALE: Was it someone that you had seen with a phone on the unit?
POWELL: Yes. Yes.
LANGDALE: So you had seen that for yourself?
POWELL: Yes.
LANGDALE: And you had the conversation with them?
POWELL: Yes.
LANGDALE: And did you see that again, them --
POWELL: No, no.
LANGDALE: So you were very clear and that was the tone of the unit; that messages about work, patients, things that are matters within the unit, shouldn't be being
communicated?
POWELL: Yes.
LANGDALE: Did you expect ever handover nurses to share some information about what they were coming into or leaving or not, on a phone?
POWELL: Well, no. No, I didn't expect any of them to be discussing over the mobile phone. No.
LANGDALE: Can we move now to the risk register. You tell us at paragraph 44 you were responsible for the risk register on the NNU which was stored on a shared drive. And if we can put up INQ0004657, page 1. It will come up in a moment. We see here various risks entered onto the register and who's entered them. There is a couple that have been entered by you. You have at the bottom: "Nurse staffing levels for all Urgent Care wards." That is not been entered by you, it's been entered by Mrs Rees. So was it just not the NNU that was experiencing staffing level issues? Can you remember?
POWELL: I presume so. I mean, staffing's a problem for everyone --
LANGDALE: Yes.
POWELL: -- at some point.
LANGDALE: Yes. If we go further up, you see pseudomonas in taps, you enter that on the -- in May 2015. What was that about, the pseudomonas in taps?
POWELL: Oh, the pseudomonas?
LANGDALE: Yes.
POWELL: Yes. That was around -- when was it? We had two incidences of pseudomonas. And that was tested. The estates came to test and they would, they would test all the taps and I think, I can't remember because there were two episodes, I can't remember exactly with which one, but then the filters then had to be applied to the taps and then they were retested and then they would have to come and do some work on the pipes.
LANGDALE: And so what were the -- what kind of filters were there on the taps?
POWELL: The water filters.
LANGDALE: Yes.
POWELL: They are like miniature water filters that are actually inputted at the base of the tap.
LANGDALE: And this is where nurses are washing their hands and the like?
POWELL: Yes.
LANGDALE: If we go further up. You say: "Doctor shortage and impact on medical cover on NNU." That is March 2016. Can you remember that?
POWELL: Yes, I think it was --
LANGDALE: The same issue?
POWELL: Yes, there, there was a problem.
LANGDALE: "Potential damage to reputation" has been entered by Karen Townsend at the top, July 2016. Do you see that?
POWELL: Yes.
LANGDALE: What did you understand that one to mean?
POWELL: That was with the downgrading, I believe, of the unit from -- transferring out after anything less than 27 weeks to, I think it was 32 weeks.
LANGDALE: So how would that damage the reputation of the service?
POWELL: Well, because of the implications that that comes from, of the reasons being. So why -- that Karen thought that by the potential -- by downgrading that there was a knock-on effect that will have on the unit and the Trust.
LANGDALE: It looks as though she's actually talking about apparent increase in mortality, so the number of babies dying. I know that led to the downgrading of the unit in some ways, but if you look at that, was she more express or clear about increase in deaths and how that links to reputation?
POWELL: I don't understand the question, sorry.
LANGDALE: Okay. So she doesn't expressly refer in this to the downgrade in unit or transfers, does she?
POWELL: But I think it comes at the same time. So I am assuming that's why she's -- I haven't put that on, Karen has.
LANGDALE: Okay. If we look at INQ0004625. These are the same risks that you have identified but we just see there you see the "not compliant with staffing", the last one, that's first been added, hasn't it, in June 2010?
POWELL: Yes.
LANGDALE: Next review date, so that is just an ongoing feature, non-compliance, just all the time you are there really --
POWELL: Yes.
LANGDALE: -- from when you have certainly been a manager in 2011 and the year before --
POWELL: (Nods).
LANGDALE: -- not being compliant with staffing and those issues are ongoing; they are chronic?
POWELL: Yes.
LANGDALE: You see at the top it says risk graded 16 to 20. How are they graded, risks?
POWELL: They are graded, there is a matrix that you
have to score, it is a matrix score, that's how it comes to 16 to 20 is the severity of the situation.
LANGDALE: What are they all added up together or something?
POWELL: Yes, you add, you add it up as you actually do the risk assessment and then it comes up as what you -- well, what somebody feels it is a 16 to 20, so if you think it warrants to be in the red.
LANGDALE: Do you know who -- when you say somebody feels, was that you as the ward manager for the neonatology unit, who was the one who came up with the figures for this?
POWELL: Sorry?
LANGDALE: Who was the one that came up with that number for these concerns, then?
POWELL: It comes from the scoring matrix.
LANGDALE: Right. Do you score those?
POWELL: Yes.
LANGDALE: Presumably a person does the scoring?
POWELL: Yes, a person scores that.
LANGDALE: So you applied the scoring matrix?
POWELL: Yes.
LANGDALE: Is that all of those in combination represent 16 to 20, or what does it mean?
POWELL: Well, yes. Yes.
LANGDALE: Right. Can we have a look -- that can go down, please. And can we have a look at INQ0004511. This is a clinical risk assessment document, 18 February 2015. Is this something that you have produced?
POWELL: Yes, I think so.
LANGDALE: Do you recognise it?
POWELL: Yes, it looks familiar.
LANGDALE: Yes? So if you look at the next page, you see your grading between 5, 8 risk scores, the last page, page 3. 12. And you say there: "A business proposal was completed and a business case is being prepared, staff shortages", et cetera, in February 2016. And that's graded -- is that amber? The colours matter, don't they, that's not a red then, that is an amber, is it?
POWELL: Yes.
LADY JUSTICE THIRLWALL: I think the date is 18 February '15'?
MS LANGDALE: Sorry, that is right, my Lady, it's the review date that's February 2016. Yes, so February 2015, the risk is always 12, yes?
POWELL: Yes.
LANGDALE: Who are these -- who did you produce this for, do you know?
POWELL: Oh, well, they would be discussed with my line manager which would be -- yes, my line manager.
LANGDALE: Who was your line manager?
POWELL: Anne Murphy.
LANGDALE: Anne Murphy?
POWELL: Yes.
LANGDALE: And who was her manager? So where do you fit in the hierarchy, Ms Powell? If I am using that phrase correctly?
POWELL: Nurses, then myself, and then Anne Murphy, and then -- I think it's -- it kind of it goes a little bit -- I think it was Jackie who was, although it was changed to the business manager and then, gosh, I can't remember. Then Karen Townsend, although I think it might have been Lorraine at one point.
LANGDALE: Lorraine Burnett?
POWELL: Yes.
LANGDALE: That is in the risk department. What about nursing, other nurses. Who did you turn to for support or if something you were worried about?
POWELL: Anne Murphy.
LANGDALE: Anne Murphy?
POWELL: Anne Murphy, yes.
LANGDALE: What was your interaction with Alison Kelly?
We will see it later on, but what ordinarily was your interaction with her as Director of Nursing?
POWELL: With ward -- yes, the ward managers meeting, she would be there, in the meetings there.
LANGDALE: Which meetings, sorry?
POWELL: The ward managers throughout the hospital, Trust ward managers.
LANGDALE: So you, that is Nicola Lightfoot from Children's Unit, is it? Would she be there?
POWELL: Well, most of the ward managers for the hospital.
LANGDALE: How many of you would that be at those meetings?
POWELL: There would be a lot, there would be a lot.
LANGDALE: Roughly?
POWELL: I wouldn't necessarily go to all of them because there would be competing meetings in between that I would have to attend.
LANGDALE: But how many wards are you talking about, roughly?
POWELL: Within the hospital?
LANGDALE: Yes. How many managers is it? 10, 20?
POWELL: Must be about 40.
LANGDALE: 40?
POWELL: Yes.
LANGDALE: So about 40 of you invited to the same meeting and who took those meetings, who chaired them?
POWELL: There would be Karen Rees, it was -- and it would be Alison Kelly. Yes.
LANGDALE: So they would chair the meetings with all the managers?
POWELL: Yes.
LANGDALE: And what kind of matters were discussed at those meetings?
POWELL: It was just an overall meeting of the managers. So anything of interest, any points, any discussion with infections control issues and suchlike.
LANGDALE: So you would discuss generic issues --
POWELL: They were very generic, yes. It was for information, really, to cascade down to staff.
LANGDALE: And is there anything striking in this period, 2015 to 2016, in those meetings, at the ward managers meetings that you were discussing or not?
POWELL: No.
LANGDALE: Nothing?
POWELL: No.
LANGDALE: So nothing that was affecting the hospital at large or something that you were all worried about?
POWELL: Not that I was aware of, no.
LANGDALE: That can go down, thank you.
While we are on the subject of meetings, at paragraph 54 you talk about Cheshire and Merseyside Neonatal Network meetings. I want to understand a bit more about those if I can. Can I ask you, first of all, before going to the meeting that discussed Babies O [Child O] and P [Child P], to look at the Datix that were reported in relation to O and P. So the first reference is INQ0008615. We see there on the first page it says "Subcategory: Expected and unexpected death". Is that a dropdown box?
POWELL: Yes.
LANGDALE: So do you have to tick whether it's expected or unexpected or does it just -- there we see both, so what does it look like?
POWELL: Yes. It's, it is a dropdown, you click on the arrow that drops down and then it gives you the categories within that category.
LANGDALE: And is that one category "expected and unexpected death", they are not separated?
POWELL: No. No.
LANGDALE: So you can't just say "unexpected death", because if you read that it's not clear on the face of the front of it that it was an unexpected death, is it?
POWELL: But the important thing is that it is a death. That's what it's highlighting there.
LANGDALE: What's even more significant in terms of processes? If it's an unexpected death --
POWELL: Unexpected --
LANGDALE: -- do you see there's a difference in terms of the processes that would be triggered with an unexpected death?
POWELL: True. But I -- I couldn't -- it's very difficult at that time with, with hindsight, sometimes you say, oh well, yes, we can understand now why that child collapsed at that time, that is quite obvious. But if by categorising them together, I guess, it's you are looking at both aspects. Because if you were expecting it you wouldn't therefore look for anything unexpected, whereas if it's completely unexpected it's taking the death per se as an issue as opposed to whether it's expected or not, so that somebody from risk would have to look at that closely.
LANGDALE: There is no question that Baby O [Child O]'s death was unexpected, is there? No question about that at the time with what everybody was saying. Nobody expected Baby O [Child O] to die, did they?
POWELL: Just wait a minute. No.
LANGDALE: No. If we look and you do refer under
"Description" -- "Sudden collapse of Triplet 2"?
POWELL: Sorry, I -- when you put your head down, I'm sorry, I lose the thread.
LANGDALE: Have a look at the document in front of you and it's being highlighted in yellow and that will help you.
POWELL: Yes.
LANGDALE: So "Sudden collapse of Triplet 2", so you have written that or entered that, yes? And you said the baby has died "cause as yet unknown" at the bottom -- can you see there in the last box? And then if we go to the next page, page 2, we see you are the person who's reported it, Eirian Powell, clinical nurse manager as reporter. Employee involved, Lucy Letby. Neonatal nurse. "Directly involved in the incident." In terms of Baby P [Child P], if we go to INQ0008624, page 1, again, we see you have entered that Triplet 1 collapses and dies. You put at the bottom: "Parents present and updated fully throughout." Pausing there, what do you think they were updated about at that time?
POWELL: Updated about the condition of their child.
LANGDALE: So that means told about the death --
POWELL: Yes.
LANGDALE: -- or aware the death. And if we go over the page again at page 2, we see you are the Datix reporter and confirm that Lucy Letby was the employee directly involved. At that time, why did you report she was the person directly involved?
POWELL: Because she was the allocated nurse.
LANGDALE: Yes. So as the shift leader you put her down?
POWELL: Yes.
LANGDALE: So do you think the shift -- sorry, allocated nurse, not shift leader, the allocated nurse should always be the person put down even if they weren't the person with the baby when they died? What did you think?
POWELL: Yes, because -- the reason being is that was the person you went to to actually obtain more information, whereas if there was anything that I couldn't ascertain as a manager, or the shift leader couldn't, then at least you knew who the allocated nurse was.
LANGDALE: Their deaths are discussed at a Cheshire and Merseyside Neonatal Network meeting. If you could go, please, to INQ0005564, page 1. We see, if you look at page 1, at the front, clinical leads from other hospitals, transport
consultants, a wide range of expertise across a number of units, is that right, at these meetings?
POWELL: Yes.
LANGDALE: And if we go to page 3, we see Countess of Chester discussion about [Child O] and P [Child P] and lessons learnt. It says: "Awaiting PM report but no clear cause of death identified from review in relation to P." And we can see there what it says in relation to O. You were at that meeting. We see Dr Brearey wasn't. Who was presenting and reporting to that meeting about the deaths of O and P?
POWELL: Well, I think Dr Brearey must have sent the resume, the -- of the findings and lessons learnt via email to the Network and then they just asked me for some input, which I don't -- that's not something we normally do. It's the lead that does it.
LANGDALE: But given the lead wasn't there, that is Dr Brearey --
POWELL: Yes.
LANGDALE: -- they asked you. What was your input? What did you say?
POWELL: I can't remember what I said.
LANGDALE: We know that those deaths devastated the unit and people were very upset, weren't they --
POWELL: Yes.
LANGDALE: -- at the time?
POWELL: Yes.
LANGDALE: Dr V has told us that she also let you know that Letby made the remark to her that P wasn't going to get out alive. Do you remember her telling you that?
POWELL: I remember her saying that she did an inappropriate comment. She never said what it was. And I asked her, "Like what?" And she said, "Well, I can't think now. I can't remember what it was." But, but I asked her what, what was it, because I had come back. I was away at Glan Clwyd at the time and I came back on the Monday and we had a senior clinicians meeting and she told me after the meeting.
LANGDALE: She was upset that it happened and she said she wanted to tell you that remark, and are you saying she forgot in the final moment having gone to see you about it, that she didn't say it?
POWELL: No. She said that she couldn't remember exactly what because I said, "Like what?" Well, it was, like, "Like what?" "Well, I don't know, I can't remember." But she couldn't give me a definitive response.
LANGDALE: Did you go back and ask her what was it the next day? She was obviously upset, you have said, or
couldn't remember, or --
POWELL: No, I didn't. No.
LANGDALE: What do you think about the remark, "He's not going" -- "I don't think he's going to get out here alive."
POWELL: Well, take -- yes, it's, it's totally unacceptable.
MS LANGDALE: My Lady, I note the time and I am moving to a different topic.
LADY JUSTICE THIRLWALL: Very well. We are going to take a break now and we will come back in just after half past 11.
(11.16 am) (A short break) (11.31 am)
LADY JUSTICE THIRLWALL: Ms Langdale.
MS LANGDALE: Ms Powell, I am going to take you to "Letby and Clinical Incidents", paragraph 68 of your statement, and can we have on the screen, please, INQ0014469, page 1. This is a Datix. Can you read that, Ms Powell?
POWELL: Yes. Yes.
LANGDALE: This is the Datix that reports a baby was receiving 10 times the rate of morphine than the baby should have been administered.
And we know from yesterday's evidence, if we go, please, to INQ0008961, page 47, that Yvonne Griffiths speaks to Letby about this. While we are finding the document can you help me with this, the Alaris pump, when you set a rate of infusion in an Alaris pump, what do you need to tap into the device to do that?
POWELL: Well, you need to tap up -- the up or down keys to actually get the, the amount that's displayed.
LANGDALE: And does it ask you to confirm instructions?
POWELL: Yes, it does.
LANGDALE: So it has safety checks, doesn't it, the Alaris pump?
POWELL: Yes.
LANGDALE: It is not just a turn up, it reminds you -- you have to put in patient data and you --
POWELL: It is only confirming what you have actually put in.
LANGDALE: Yes, but it asks you to confirm, it gives you that check to think "What have I just done"?
POWELL: Yes.
LANGDALE: Yes. Does it require you to put the patient details at every stage? In other words, when you are putting the infusion up and the rate, or do you -- do you do it just once? How often do you have to put the
patient details in?
POWELL: No, you just put in what you want it running at and then you press "confirm".
LANGDALE: So how long does that take?
POWELL: It doesn't take long, that in itself, no.
LANGDALE: But you have to think about it and you have a chance to check it yourself as you are doing it --
POWELL: Yes.
LANGDALE: -- before you confirm it?
POWELL: Interestingly enough, though, they have actually put guardrails on these Alaris pumps now, where it doesn't allow -- you have to put in the details that's on the syringe pump. That actually you have to input 10 micrograms per kilogram or -- in the guardrails and if, therefore, the calculation is incorrect, it will not let you proceed.
LANGDALE: And that guardrail was introduced when, do you know?
POWELL: Well, it's it -- I am sure it was, it was ongoing at that time in other units, and Level 3 units were using them. But obviously there's a cost implication in -- in putting them on but we were actually on, in the process of trying to get these guardrails to go on the Alaris pumps.
LANGDALE: That actually prevents the dose being administered?
POWELL: Yes.
LANGDALE: But there was still, even with the ones you had, an opportunity to check the rates after you have inserted the rate --
POWELL: Yes.
LANGDALE: -- and set the rate?
POWELL: Yes.
LANGDALE: We see on this Datix -- sorry, not Datix, the one-to-one form with Yvonne Griffiths?
POWELL: Oh, yes, right. Yes.
LANGDALE: This is the one before you are involved: "Lucy had commenced a continuous infusion of morphine at the end of her night shift (7 am) for a re-intubated infant. At 8 am on handover infusion noted to be infusing at incorrect rate." So it's very clear there that with Yvonne Griffiths, Lucy was accepting she had commenced that continuous infusion at the wrong rate?
POWELL: Yes.
LANGDALE: So she had set the wrong rate?
POWELL: Yes.
LANGDALE: No doubt about that looking at this document. She was the one --
POWELL: But there's two members of staff doing that
together.
LANGDALE: Well, let me come on to that in a moment.
POWELL: Yes.
LANGDALE: One person sets the rate --
POWELL: Yes.
LANGDALE: -- and at some point someone checks the rate, yes?
POWELL: Yes.
LANGDALE: It doesn't have to be at the same time, it can be subsequently; they just have to check the rate. Is that right?
POWELL: Correct.
LANGDALE: They don't have to stand there while someone is checking it, they can come back moments later, as long as they check it; is that the position?
POWELL: Yes.
LANGDALE: So we know someone at some point has checked the rate or seen the rate, but the person who's inputted it is Lucy Letby; there is no denial about that?
POWELL: Mm-hm.
LANGDALE: She is the one who has commenced that rate, yes?
POWELL: (Nods).
LANGDALE: Yvonne Griffiths told us she was pretty new at managing these situations. She took advice from
a matron -- you weren't there, you were on leave, I think, weren't you, at that point?
POWELL: I know I wasn't there but ...
LANGDALE: You weren't there. She thought it was safe practice to prevent Letby at this time from checking any intravenous infusions or requiring additives and any controlled drugs until the incident had been reviewed. So she put a pause on her practice in those respects, didn't she --
POWELL: Yes.
LANGDALE: -- at that time? Do you think that was a sensible thing for her to do --
POWELL: Yes.
LANGDALE: -- Yvonne Griffiths? Why?
POWELL: Well, because she obviously needed to discuss it with me once I was -- I had returned and that we could actually come up with a -- an action plan.
LANGDALE: So you do return and we see INQ0008961, page 45. Is that your writing at the top?
POWELL: It is.
LANGDALE: "Review with Lucy and reflect critically on the clinical incident which occurred. Drug calculation was correct, however the infusion pump rate was
incorrect." So what did you or how did you discuss this with her? What did you say to her?
POWELL: Gosh, I can't, I can't remember exactly what I was talking to her about. This is 2013. I would have, you know, ascertained first how she felt about it and gone through the process with her and stated that -- what the action plan moving forward was.
LANGDALE: And what did you understand the action plan to be?
POWELL: Was that she wasn't to check CDs and that she wasn't to care for infants with infusions with controlled drugs.
LANGDALE: How long for? What did you think the position was?
POWELL: Until we had had a discussion, a review of the situation.
LANGDALE: Until you had had the review with her or someone else had had the review?
POWELL: No, since we had had the review with her, that she does her competencies with Yvonne, goes through it to check through it, but we also had a discussion with, what's her name, the pharmacist, Gemma, she was the allocated neonatal pharmacist and she actually devised a failsafe system on -- where you could actually check CDs -- not CDs, infusions. So they would come in in syringes of 10 mics, 20 mics, 40 mics in the infusion. So she would actually do an average so that you -- it was like a final check. So if you were coming up with -- it should be 1.17 an hour and she -- for a similar gestation and birth weight, she would actually look at that and she would give what at 10 mics per kilogram would that be running at, should that be running at. So if it was 10 times the amount you would have to go back to the drawing board, you would have to think, well, hang on a minute, something's not right. But that was in the transition period for us waiting for guardrails on the Alaris pumps.
LANGDALE: How --
LADY JUSTICE THIRLWALL: I'm sorry, Ms Langdale. So when was that?
POWELL: Well, that would be after this incident.
LADY JUSTICE THIRLWALL: Thank you.
MS LANGDALE: How serious was this incident in your view?
POWELL: It could have been catastrophic. It could have been.
LANGDALE: What do you mean by that?
POWELL: Well, it would cause a death.
LANGDALE: What was your understanding in terms of how and when she went back to checking drugs and doing infusions?
POWELL: She was only checking drugs with another member of staff of the controlled drugs in the CD cupboard. So she was doing that with a member of staff. But the -- the infusions itself was -- preparing infusions was to be given to other members of staff until her competencies was met.
LANGDALE: If we look at this document on screen --
POWELL: Yes.
LANGDALE: -- your writing says: "Is able to check CDs."
POWELL: "Is able" -- yes, because it's CDs in the cupboard, it is not CDs, controlled drugs are those that are in the cupboard.
LANGDALE: But she is able to check them, so check them being given?
POWELL: No. Check that there was 10 in a pack, nine in a pack, that it equates to what's in the book.
LANGDALE: If you look at the one above: "To continue to care for infants with infusions." Yes?
POWELL: Yes.
LANGDALE: So she can do that. She can carry on caring for infants with infusions and she can check the drugs?
POWELL: Yes. But not giving that to patients. That's just checking it in the cupboard.
LANGDALE: So what was your understanding about whether she would give any drugs or any infusions to patients at this time?
POWELL: Sorry?
LANGDALE: What was your understanding about whether she could give anything to patients at this time? Just go and be around patients. Could she stand and check Alaris pumps and have patients under her care when they are having drugs?
POWELL: Yes.
LANGDALE: Yes. So she could do that?
POWELL: Yes. But not CDs. She was checking those only in the cupboard. But she could actually care for the infants with -- a lot of infants have only infusions that you don't need to add to; they're just infusions, IVs, whereas in fusions that you actually bring from the, the fridge, that actually you add to the infusions is different.
LANGDALE: Nothing here that you write prohibits, expresses anything she is prohibited from doing. Do you see what I am saying? It is not clear from this --
POWELL: No.
LANGDALE: -- or your evidence what you are saying she cannot do at this point?
POWELL: Yes.
LANGDALE: Is that because, in fact, she could do what she had been doing before and treat patients and be with patients --
POWELL: But not to do the infusions. The actual -- I am not making myself clear -- the -- the syringes that goes into, to add on additional infusions, whereas the infusions that come up from pharmacy already made, you don't need to add to them.
LANGDALE: So she could put infusions up that you say didn't have any additives?
POWELL: The IVs themselves, intravenous infusions that come up from pharmacy, they actually go into the baby. These -- the morphine one was an additional one that because baby had been re-intubated, that actually had been put on to help with pain relief.
LANGDALE: You don't write here what she cannot do or that this could have been fatal for the baby and that this was serious. That's not the impression we get reading this, is it?
POWELL: But she had already had the review with Yvonne. Not the review, the actual one-to-one. This was actually speaking to her subsequently, after speaking to Yvonne Griffiths -- Farmer.
LADY JUSTICE THIRLWALL: I think it was Yvonne Griffiths.
MS LANGDALE: It was Yvonne Griffiths she had spoken to on the previous one-to-one and Yvonne had put it on hold.
POWELL: No, Lucy had yes, but this is with Yvonne Farmer, I needed to make sure that she was able to go over the Alaris pumps with Lucy.
LANGDALE: Yes, we see that Yvonne Farmer, 6 September, records: "Practice calculations completed with Lucy. I observed doses required being inputted into the Alaris pump by Lucy. We discussed the pump settings and safety features and I am happy she is competent to use this equipment." She says: "Review in six months." And we see January 30, 2014 as a date. What did you think in those six months Letby was able to do?
POWELL: In the following --
LANGDALE: Yes, the six months.
POWELL: Well, that she was able, after her tuition
with Yvonne, that she could actually go back to doing what she was doing subsequently, before.
LANGDALE: So is it your evidence you thought there was a restriction for six months until she had done that, until January 2014? I want to know --
POWELL: No, no, the review was in case there was a recurrence of the same issue.
LANGDALE: Right. So if there wasn't a recurrence you wouldn't be worried about it?
POWELL: No.
LANGDALE: And how long do you think she stayed not doing the CDs? How long do you think there was any restriction on what she did on the wards?
POWELL: Once she was complete with the Alaris pump she was fine.
LANGDALE: So is that, in your view, September, by 6 September?
POWELL: Yes.
LANGDALE: So she was unable between July and September --
POWELL: Yes.
LANGDALE: -- for three months. Was that common to have nurses on the unit that were prevented from doing anything for a period of months?
POWELL: This, on -- on the unit if you did clinical incidents on all the drug errors that happened, and not that they were happening all the time, but they were happening and to say that you didn't have a drug error or that you didn't do a drug error would be more worrying than those that actually come forward and actually say, "I have made a mistake here" or, "This has happened" or whatever.
LANGDALE: She didn't come forward. She was caught, wasn't she, by the next morning -- (overspeaking) --
POWELL: I know, but there was two of them. There was a very senior Band 6 with her and she should have seen that the infusion pump was actually incorrect.
LANGDALE: So let's focus on the person you were dealing with first of all. We know the other Band 6, we don't need to know her name, she wanted to resign and was really distressed by the episode, wasn't she?
POWELL: Yes.
LANGDALE: Really distressed. Meanwhile, we see the text, the message, if we can have it, please, INQ0012033, page 171. We see the last text. She is responding to someone asking her what happened over the drug error: "Thankfully Eirian felt it had been escalated more than it needed to be. Everything is back to how it was.
I just have to have more training on using the pumps and it will be on my record for six months. She was very supportive, a case of learning to live with it now and getting my confidence back. I am on nights this week, still feeling a bit vulnerable and thinking what if, but I will get there. Thanks for asking." So this is a text that's been sent on 1 August saying, "Everything's back as it was." So it doesn't look like she understood there were any restrictions about how she was practising at that point around the pumps or the drug error, was there?
POWELL: Well, she was told. We went through it and she was obviously very, very upset about it as, as was the other practitioner, was the same. And, you know, they appreciated, both of them did, what could have been. It is -- it makes them a better nurse from reviewing what it is that was a near miss.
LANGDALE: Did you tell the parents at the time or do you know if someone else did about the near miss?
POWELL: I can't remember.
LANGDALE: What would be the policy on that?
POWELL: Well --
LANGDALE: That can go down now.
POWELL: The Consultant, I would imagine, or the Registrar would have actually informed the parents or the -- I am sure Yvonne would have spoken to the parents.
LANGDALE: There is another reflection on a drug error in April 2016 on the -- from Letby. INQ0008961, page 49. This is a reflection on a drug Gentamicin --
POWELL: Yes.
LANGDALE: -- a drug that wasn't due and wasn't prescribed for the baby.
POWELL: Yes.
LANGDALE: So not due, not prescribed, but was given.
POWELL: Yes.
LANGDALE: What do you make of the last paragraph of that? "I do not feel that anything can be added/changed in order to prevent this happening again ... I do need to develop my own professional role to ensure I adhere to protocol and adjust my workload, escalate inadequate staffing, skill mix, to ensure that a mistake like this does not occur."
POWELL: I don't think -- I mean, it says "I do not feel that anything can be added", well, yes, it wasn't prescribed. Period. She was incorrect. However, Gentamicin, unfortunately, you've got antibiotics, two antibiotics that go together, one is penicillin, one is Gentamicin. Penicillin is very easy,
it is twice a day, morning and evening. Gentamicin, however, changes. It changes throughout the doses. It's given to a particular gestation, it will change dose because -- the intervals will change, they have a pre and post level done. So the, the intervals can, can actually change according to the pre and post level that's taken from the blood. So in this period, I think 2016, it would have to be 2016/2017, e-prescribing came into force and at one point we were using prescription drugs, prescription charts and electronic, which confuses and compounds things in addition to -- NICE guidance came in that we were giving antibiotics a lot more than we were. So we were having to do a lot of antibiotics upstairs on the postnatal ward in addition to downstairs. There is a lot of chaos going around. Still not prescribed. So she's wrong. It's, it is a prescribed drug. I don't know how she gets this, but yet again, there is a very senior practitioner that's actually drawing this up with her. And it can't be drawn up without a prescription.
LANGDALE: So does that look like that's even been explored that it can't be drawn up without a prescription?
POWELL: I wasn't aware of this until the Inquiry.
LANGDALE: "I don't feel anything can be added changed in order to prevent this happening again."
POWELL: It --
LANGDALE: What about, "Sorry, my mistake".
POWELL: Yes.
LANGDALE: "I don't know why I did this."
POWELL: Exactly.
LANGDALE: This is a very defensive response, isn't it? It is supposed to be a reflection but this is a very defensive response referring to workload, inadequate staffing and skill mix for what is a basic error?
POWELL: Yes, it is.
LANGDALE: A basic error?
POWELL: But -- and also she's actually realised -- the mistake was realised by herself and she has reported on it.
LANGDALE: She reported it herself?
POWELL: Yes: "This mistake was realised by myself and a colleague immediately after the dose had been given." But I don't understand how they actually drew it up without a prescription.
LANGDALE: How could you do that?
POWELL: I don't know.
LANGDALE: So there is more questions than that
answers --
POWELL: Yes.
LANGDALE: -- from your point of view? How did that even happen in the first place?
POWELL: Exactly.
LANGDALE: And if you can get that drug without a prescription can you get other drugs without a prescription? It doesn't make sense, does it?
POWELL: Yes.
LANGDALE: Thank you, that can go down. When you were first interviewed by the police, you said that when Lucy had qualified you had no qualms about employing her: "Even during her interview, although I can't remember much about it, I wanted her on the unit, I really did. When students come through the system you are almost able to hand pick the creme de la creme and she was one of those." We have had evidence now that she failed and had to have a retrieval placement in her final year at university. She had the clinical incidents that we have just gone through, and there was a period of three months where you understood she wasn't doing what other nurses who were qualified would be doing. How was it you came to describe her as "creme de la creme" with that history at that point?
POWELL: Well, when the students come through on the unit, you get to know them because their, their placement is quite a lengthy placement. And you -- those that don't want to be there are obvious. They have just got no interest whatsoever, but there are others that actually stand out and I think we employed three from that same cohort.
LANGDALE: And she really wanted to be on intensive care units, didn't she? You discussed that with other nurses at some point.
POWELL: She wanted to be?
LANGDALE: Yes. Letby, when you were there managing, I think it was --
POWELL: Oh, yes, yes.
LANGDALE: -- Kathryn Percival-Calderbank --
POWELL: Yes.
LANGDALE: -- who spoke to you after the death of the triplets about her desire to always be in intensive care, and she was worried about that and you were worried about that, weren't you?
POWELL: Yes.
LANGDALE: Why were you worried about that?
POWELL: Only because I realised from my own, this is from my own experience, that being in an intensive care
environment isn't always healthy for your own mental well-being because it's a very stressful situation to be in constantly and it does need time out, take a break.
LANGDALE: So you were worried about her, not the babies, about her --
POWELL: Well, it goes hand in hand because the last thing that parents need is somebody who will actually burst into tears for no reason, but that is something that can happen.
LANGDALE: I am going to move on now to the meetings in July 2015, relating to [Child A], C, and D between you and Dr Brearey and it's page 86 -- sorry, paragraph 86 onwards of your statement. If I can ask, please, to go on the screen INQ0003110, page 1, which is an email from Dr Brearey to Ravi Jayaram. Before that is put up, can I ask you this: Baby A [Child A], Baby C [Child C], Baby D [Child D], they die really closely, don't they, on your unit?
POWELL: (Nods).
LANGDALE: Did you have any conversations with nurses or doctors, at the time, about their deaths, dealing with [Child A] first of all. We know, we have heard from Melanie Taylor, Caroline Bennion, Nurse T, Dr Harkness, Dr Ogden, Dr Teresa MacCarrick, Dr Thomas, did you speak
directly with any of those nurses or doctors about Baby A [Child A]'s death at any time?
POWELL: Not that I can recall, no.
LANGDALE: Why not?
POWELL: I don't recall it. I just can't remember anything sort of stand out in my mind. I remember -- hang on. Just -- I will just refer to this.
LANGDALE: I think you are referring to a list of dates you have, is that right, as a document? Death of Baby A [Child A].
POWELL: Because the staff would have spoken to me about, about them.
LANGDALE: They would have done?
POWELL: They would have done.
LANGDALE: And they probably told you what they told the police and the Inquiry; that they were shocked and surprised, that Baby A [Child A] was stable --
POWELL: Yes.
LANGDALE: -- stronger than his twin sister, expected him to live. Did they tell you these things?
POWELL: I honestly -- I can't remember.
LANGDALE: All of them, with one voice, have spoken about the unexpected nature of it --
POWELL: Yes.
LANGDALE: -- and the concern about a rash. Any
discussion with you about that?
POWELL: I don't remember anything about a rash, no.
LANGDALE: When say you don't remember, these are -- this was a significant three weeks for anyone, wasn't it?
POWELL: Yes.
LANGDALE: A, C and D had died, B had collapsed. You can't have had that in your career at any other time.
POWELL: No.
LANGDALE: That many babies die so closely together in unexpected circumstances?
POWELL: Yes.
LANGDALE: So can you try and remember then, please, who told you what about whether it was unexpected.
POWELL: I don't know because we did a review, a deep dive review on --
LANGDALE: I am not talking about a deep dive. A conversation.
POWELL: Yes.
LANGDALE: You walk into work, you run into Dr Harkness, you see Melanie Taylor. You say, "How was that for you?" You support your staff, don't you?
POWELL: Yes.
LANGDALE: "How was that for you? What went on? How do you feel about it?"
POWELL: Yes.
LANGDALE: Did you ask that?
POWELL: I can't -- honestly, I cannot remember. I -- I remember them coming and telling me and how upsetting they were -- it was. But I, I cannot recall exactly.
LANGDALE: Did you have any interest to understand, if it was unexpected, how it could have happened?
POWELL: Well, we were just going through the process and making sure that all the Datix was completed and the staff themselves, how they felt, and -- because we didn't -- did a lot of work on the bereavement process of how we are reporting.
LANGDALE: So you did know the staff were struggling with it and they were upset by it and it was unexpected?
POWELL: Well, yes, but not -- I don't actually remember the actual conversation.
LANGDALE: What was the impact of the conversation? Sometimes we don't necessarily remember the words but --
POWELL: -- (overspeaking) --
LANGDALE: -- a feeling, we remember a moment?
POWELL: Yes, it was unexpected.
LANGDALE: Right. So it was clear, unexpected.
POWELL: Yes.
LANGDALE: They were upset and it was unexpected. [Child C], you had already been approached, hadn't you, by Nurse W about [Child C] and "Letby not looking
after the baby she was allocated to but keep winding her way back to [Child C] when she shouldn't have been". That was something Nurse W spoke to you about --
POWELL: Yes.
LANGDALE: -- didn't she? And you say in your statement it was really important that people stayed with their allocated babies.
POWELL: Yes.
LANGDALE: You thought that was important?
POWELL: For an ITU and a high-dependency baby, you have to -- you don't move from that space. Nobody touches your baby without you knowing.
LANGDALE: So you were told by Nurse W that Letby did go and be with [Child C] when she shouldn't have been and she should have been looking after another baby that in fact Nurse W, a shift leader, was worried about. She told you that, didn't she?
POWELL: Yes.
LANGDALE: You must have realised at the time that was a serious breach of your ward protocol. You are nodding but yes, you had said people should stay with --
POWELL: Yes, it is.
LANGDALE: So what did you say to Letby about that when Nurse W told you that with Baby C [Child C] that is --
(overspeaking) --
POWELL: That is why I asked Nurse W to do a Datix and have it documented.
LANGDALE: But the Datix was about the other baby, presumably, the one she was worried about.
POWELL: Yes, because I didn't know about the other one.
LANGDALE: Yes.
POWELL: Yes.
LANGDALE: So that didn't deal with Letby, did it? The Datix doesn't deal with the complaint she was bringing to you. She was saying she felt angry at the time, she had been selfish, she wasn't obeying instructions, she was a law unto herself, effectively; that is what she was saying, wasn't she?
POWELL: Yes.
LANGDALE: So did that worry you when she told you that?
POWELL: Well, yes, it did. Because, again, it goes back on past experiences of when you are actually -- she was, Nurse W was a Band 5 that was promoted not -- around that time to a Band 6 and therefore it's very -- it takes a period of adjustment to actually get somebody to respect -- that respect is very difficult to --
LANGDALE: So rather than questioning Nurse W's authority, can we question what Letby did, please?
POWELL: Yes.
LANGDALE: And what you did with what she did?
POWELL: Yes. So it would be that she had to have -- she wanted to go to work more with ITU babies but this was a special care baby, I think it was, that she was to take time out from.
LANGDALE: So she told you she wanted to be in the ITU not the special care baby unit?
POWELL: No, that's what the understanding, this was prior to this, this is why I think she was allocated to take time out because she had been busy the night before with an ITU baby.
LANGDALE: Right. So what did you say to Letby about the complaint Nurse W made to you? Did you sit down and speak to her? You have said you told her to do a Datix.
POWELL: Yes.
LANGDALE: Did you actually speak to Letby about the serious matter that Nurse W had reported to you?
POWELL: I have no recollection of it.
LANGDALE: We don't see any reflections from her in it so do we take from that you didn't speak to her about it?
POWELL: I am saying that this is 22 -- what date was it, sorry? The Datix?
LANGDALE: The Datix for the other baby we haven't looked at, we are not looking at that baby. I am looking at Baby C [Child C]. So Nurse W tells you about Baby C [Child C], if you look at your document you've got the date of the death, it is actually the 14th but --
POWELL: Of?
LANGDALE: -- it was overnight -- June.
POWELL: Okay.
LANGDALE: So Nurse W tells you promptly that she's not happy --
POWELL: Yes.
LANGDALE: -- about that shift and the way Letby has behaved on that shift.
POWELL: I can't recall.
LANGDALE: Does that mean you didn't?
POWELL: I can't recall. I'm sorry, I can't. I just cannot -- there are some things that I have no recollection.
LANGDALE: Is that selective, Ms Powell?
POWELL: Unless somebody is screaming at me, which I can remember, I cannot. When you say "selective", I cannot.
LANGDALE: Dr V's comment, she did say that to you, didn't she --
POWELL: Nurse W I remember because I said to do a Datix.
LANGDALE: No, I'm not talking about that. I'm going
back it Dr V who said this baby -- she was worried about that baby. She said that to you.
POWELL: Yes, but she was screaming to me at the time. That's why I remember that.
LANGDALE: So you remember her screaming?
POWELL: Yes.
LANGDALE: But you don't remember what she said?
POWELL: Well, no, she was saying that it was out of -- she couldn't remember, and I said to her "Then I can't help if I don't know what she said."
LANGDALE: Why would she come to you to say "I can't remember anything"?
POWELL: This was at a meeting, a senior clinicians meeting at the end of it.
LANGDALE: Did you speak in relation to [Child C], to Nurse Ellis, Dr Beech, Dr Davis or Dr Gibbs about their level of surprise at the death of [Child C]? Did you have a conversation with them?
POWELL: I did not.
LANGDALE: Did you speak to any doctors or nurses about the death of Baby D [Child D] at the time about their surprise?
POWELL: I don't, I don't remember.
LANGDALE: So there's not a single person now that you remember describing any of those baby deaths to you in any way that strikes a chord today as you sit here?
POWELL: Because I -- Steve -- Dr Brearey and I were doing the reviews and I was arranging the debriefs but ...
LANGDALE: Let's go through those then. So on the screen, we have an email from Dr Brearey to Ravi Jayaram and this follows a conversation that you and Dr Brearey have had and you have been reviewing the case notes of [Child D]. And it says here: "In regard to the three deaths all deaths occurred in room 1, our intensive care room, but in different cot spaces. All microbiology results have been negative to date. Initial post-mortem results for [Child A] did not identify any definite cause of death." Then if we move to the bottom: "[Child D] was not on TPN and died at less than two days of age. There does not seem to be any staff, medical or nursing members present at all three episodes either than one nurse who was not the nurse responsible for [Child D] on that shift." So in your first conversation together it looks as though you were both discussing whether one person might have been there for these unexpected deaths; is that fair?
POWELL: Yes. Yes.
LANGDALE: Do you know who raised that first, you or Dr Brearey?
POWELL: I think it was Dr Brearey.
LANGDALE: So he's got three unexpected deaths on his hands and he says: let's look at who's around and who has been caring for the babies?
POWELL: Yes. Because the allocated nurse is quite a key issue. If -- when the allocated nurse actually stands by the incubator and looks after the babies, I don't know how to stress this unless, unless you are there. Nobody else is allowed in that space.
LANGDALE: Well, that's not what happened to Baby C [Child C], was it, because Nurse W told us about that?
POWELL: Well, this is the role of the allocated nurse. This is what they are meant to do, they are an advocate for the baby. They do not allow anybody else, even the doctors will say, "Is it all right for me to do my examination on the baby?"
LANGDALE: You and Dr Brearey, and it is you I am questioning more because in practice you knew the position, say one of the babies, for [Child D], that nurse was not responsible on that shift. He appears to have misdirected himself that because Letby wasn't responsible on that shift she wouldn't have had any dealings with Baby D [Child D]. You knew in practice that wasn't always the case, was it? Nurses obviously were, and she was with Baby C [Child C] and Baby D [Child D], looking after or being with other babies?
POWELL: Mmm.
LANGDALE: You knew that?
POWELL: Sorry, I'm misunderstanding what you are saying.
LANGDALE: Just because you were allocated a particular baby did not prevent anybody going to look after that baby. We know that, don't we?
POWELL: That's only in the special care room but in the ITU and high dependency that is different.
LANGDALE: You both have the discussion about finding a person. Presumably because you are suspicious about three deaths happening so rapidly and when they are unexpected. Yes?
POWELL: Yes.
LANGDALE: That is uncontroversial.
POWELL: Yes.
LANGDALE: You are looking at it, it is such a short period of time and you don't know about any of the deaths and they are babies that seemed well and stable; yes?
POWELL: Yes.
LANGDALE: You have an action plan, if we go over the
page of that document, please. Agreed an action plan, set out there. If we go to INQ0003110, page 4, we see: "Morning all, three babies nursed in different incubators. The monitors have been checked and they are all in good working order. The antibiotics that were prescribed were given as per Emar." So you go and do what you are required to do on the action plan, don't you?
POWELL: Yes, and that suggests that the electronic prescribing was in 2015.
LANGDALE: Dr Lambie told the Inquiry that by September time, in 2015, she observed a group of nurses looking at information to try and correlate who may have been present, she didn't know exactly what they were doing but looking for data to see if someone had been present or around at the time of, she took it to be the deaths or events, even in 2015 trying to do that. Do you know which of your nurses were looking and interested to see who could have been on duty all the times these were happening?
POWELL: No.
LANGDALE: You don't know about that?
POWELL: I don't know.
LANGDALE: She also told the Inquiry that at that time
there was real anxiety on the unit as further babies became unexpectedly seriously ill or collapsing such that they were feeling nervous at the start of shifts. Did any of your nurses or did you know any of the Registrars felt that way?
POWELL: No, they didn't speak to me about that.
LANGDALE: They didn't what, sorry?
POWELL: They didn't speak to me about that.
LANGDALE: Didn't you pick that up?
POWELL: No, I didn't.
LANGDALE: You didn't pick up that tension or anxiety?
POWELL: Well, the anxiety, yes, I -- I picked up that there's anxiety there about the unexplained deaths, yes.
LANGDALE: In what way did you pick it up, the anxiety? What did you sense or see?
POWELL: Well, just that you just feel it, just feel the aura.
LANGDALE: Tell us about that, the aura?
POWELL: You just -- when you come on the unit sometimes it's -- you can feel it's quite -- it's quite, quite jovial, you know, you can feel sort of the pressure in the, in the air. But when -- sometimes you go there and you think, oh, what's up, you know, what's happened? So you go and find out. But, yes.
LANGDALE: Were you feeling like that, were you
thinking --
POWELL: Yes.
LANGDALE: -- what's going to happen next?
POWELL: I was.
LANGDALE: So at what point were you feeling like that, you know, Baby A [Child A]'s death? Baby C [Child C]'s death? Baby D [Child D]'s death?
POWELL: No, by Baby C [Child C] it was -- that's three, but I've been in a situation where we have had spikes in the mid-90s. But the situation was a bit different then.
LANGDALE: Spikes of unexpected/unexplained deaths that caused surprise?
POWELL: Yes, yes.
LANGDALE: And how were they investigated? What did you learn from those?
POWELL: Well, we were having babies, all gestations, we weren't transferring out at that point.
LANGDALE: Do you mean in the 90s?
POWELL: Yes.
LANGDALE: So what were these gestation babies?
POWELL: Well, they were 23 weekers.
LANGDALE: So under 24 weeks?
POWELL: Yes, yes.
LANGDALE: You will be aware that didn't apply at all to any of these babies, did it?
POWELL: No, it did not.
LANGDALE: When did you take the time to look at their gestation periods? It's 31 weeks for Baby A [Child A], 30 weeks for C, and 37 weeks for, 37 for D [Child D]?
POWELL: Yes, I know.
LANGDALE: You know. So when did you look at that?
POWELL: It would have been in that time frame.
LANGDALE: So you knew very distinctly from your earlier experience of a spike --
POWELL: Yes.
LANGDALE: -- with a 23 week baby, many decades ago, I think you would agree with me time has moved on in terms of how those babies can be cared for now, hasn't it?
POWELL: Mm-hm.
LANGDALE: Medicine has increased and it is better for them. But these babies were in a different category, they were nothing like that gestation, were they?
POWELL: No.
LANGDALE: They were expected to survive, all of them?
POWELL: A different -- different set of circumstances.
LANGDALE: Different set. So they are expected to survive and it is not acceptable --
POWELL: Yes.
LANGDALE: -- to say, is it, premature babies die and
therefore we weren't worried about these? That's not acceptable, is it, because they were not babies where you were worried on their delivery --
POWELL: Yes.
LANGDALE: -- about their ability to survive, were you? There was no concerns about that?
POWELL: No, but we, we have been caught out before, sort of, by the premise of the neonatal unit, it has -- the babies are there for a reason, not just the gestation. They are there sometimes because there are things that have occurred during their obstetric --
LANGDALE: And they need to feed and grow and they need to be looked after, but that is not sick, is it? None of these babies were sick?
POWELL: Some of them are not well. They have gone dusky on the postnatal ward or they have become unwell since.
LANGDALE: I am talking about A, C, and D, are you saying any of those babies were underlying --
POWELL: No, no.
LANGDALE: They were not, were they?
POWELL: No.
LANGDALE: Let's just focus on these three. So you are saying by Baby C [Child C] you felt something and there was an aura. Did you, with your experience, think
this isn't right, these two?
POWELL: Yes.
LANGDALE: This isn't right? You are nodding. Is that what you thought at the time?
POWELL: I agree yes.
LANGDALE: So you felt these two are not right, something's gone wrong. And then when you got Baby D [Child D], did that compound that, make it worse?
POWELL: Yes. But there didn't seem to be anything coming out of the debrief of the -- the deep dive review.
LANGDALE: Let's go into the documents to see what was reviewed at the time. So if we go INQ0026017, page 1. This is a document about Baby A [Child A]. On the front it's you, Yvonne Griffiths, and Debbie Peacock. If we go to the last page, page 3: "Awaiting full report. Note also collapse of twin with successful resuscitation?? Related to." Do you remember now having any meaningful discussion about Baby B [Child B] and the link to Baby A [Child A] either in terms of how the baby appeared, whether it was rashes or the collapse or anything like that?
POWELL: There was nothing on the review, was there?
No.
LANGDALE: So you don't remember that?
POWELL: No. Well, I don't remember anything coming out of this --
LANGDALE: No.
POWELL: -- other than any actions that were to be made.
LANGDALE: This suggests that both you and Dr Brearey had at least, discussing Baby E [Child E], even if it's one line, have added something about Baby B [Child B], and the collapse. But in terms of you reviewing the deaths, you are looking at A [Child A], C [Child C] and D [Child D] and Baby B [Child B] falls out of the picture.
POWELL: Yes.
LANGDALE: Do you think it would have been beneficial to be looking at Baby B [Child B] as well then where you may have made links about rashes or other signs?
POWELL: Yes, could be, yes. We tended to do them, well, one by one because normally we wouldn't have a collection.
LANGDALE: So you were organising a lot of debriefs at this time, weren't you, or trying to?
POWELL: Yes.
LANGDALE: Let's go to one of the first ones, INQ0000108, page 27. So this is a debrief that you are present for, Melanie Taylor, Sophie Ellis, Nurse, and Lucy Letby and Dr Gibbs. We can see here what's set out in the first paragraph: "Didn't seem unwell, was active." We know what's set out below. Did you say at this debrief or raise the point that had been raised with you by Nurse W about Letby invading and becoming involved in the grief of the parents of C and also in looking after the baby? Was that discussed? Did you raise it in the debrief?
POWELL: Not on the debrief, no. No.
LANGDALE: Did she raise or anyone else raise those final moments of the parents with C or not?
POWELL: No.
LANGDALE: Because a debrief is to support everybody and to discuss what's happened, would that not have been discussed?
POWELL: Well, this particular debrief is obviously looking at the resuscitation aspect. So it was looking at lessons learnt, it is seeing whether they were doing things that they should have, you know what I mean, the collective doing the right things at the right time.
LANGDALE: Can you learn lessons until you know how a baby has died or what you might have missed? I mean,
don't you need vigorous investigation to see what's happened?
POWELL: You sometimes do need to know what has happened especially on a post-mortem to see what had happened because sometimes it's not always obvious.
LANGDALE: What is the purpose of debriefs as far as you are concerned?
POWELL: It's for the staff that were involved to be able to have a safe area where they can actually discuss how things, how they think they went, how things they thought could have gone better, whether they felt there was any issues regarding the resuscitation.
LANGDALE: If we go to INQ0005585, page 1., we see in the last message you are trying to set up debriefs. As you say, normally it would be one at a time but you are trying to set up a number at this point, aren't you?
POWELL: Yes.
LANGDALE: The Inquiry doesn't have a record of [Child D]'s debrief. Do you think that went ahead? You probably can't remember after this passage of time. Do you see at the bottom you say: "[Child D]'s debrief will be held on Monday the 6th."
POWELL: It should have -- I thought it would have -- it would have done but I can't remember.
LANGDALE: Were attendance at debriefs compulsory?
POWELL: No, they were not. Not these particular ones. The one they -- how it worked is that they did a debrief as soon as possible after and then with the view of doing a repeat 7 to 10 days later.
LANGDALE: So it was your understanding there would be a discussion on the NNU, which would be a debrief, and then there would be something more formal later on, or what?
POWELL: Not necessarily no, it would be very much -- unless of course there was -- if they were involved with other hospitals. So, for instance, if they had gone to Alder Hey or -- and then come back or they had input, surgical input, they then had an opportunity to be invited at the 7 to 10 day slots.
LANGDALE: Who did you tell at the time, Executives or risk department or anyone else, that you felt uneasy about the deaths of A and C and were suspicious? Looking for a name or links, you were looking actively at who was on shift?
POWELL: Yes.
LANGDALE: Do you agree with me that that's someone with suspicion: it is unexpected, I need to look at what's there. Yes?
POWELL: Yes.
LANGDALE: Who did you share that with?
POWELL: It was with Anne Murphy.
LANGDALE: Anyone else?
POWELL: Debbie Peacock.
LANGDALE: So Debbie Peacock knew that. Debbie Peacock you definitely told that -- by Baby C [Child C]?
POWELL: Well, yes, because she's involved here.
LANGDALE: What was -- did anyone give you any advice or thoughts about that?
POWELL: I just said that obviously we have this, this spike in, in deaths, unexplained deaths. So obviously the risk team were aware.
LANGDALE: Was Ruth Millward aware?
POWELL: Well, by the fact we do a Datix for a death, whether it's unexplained or not, it goes to the risk team anyway. And then Debbie Peacock's already in with the meetings.
LANGDALE: Did any of them ask you more questions about what you thought in your opinion about the rareness of this?
POWELL: I'm not sure if it was at this point. It could be. Because I can't remember if it it's July, August, when I actually did the -- the table showing Lucy.
LANGDALE: Dr Brearey sends to Debbie Peacock, copying in you and Dr Jayaram, doesn't he, his report on the three babies. If we can go, please, to INQ0003191, page 2. "Learning from these cases". It sets out learning, there's lots of discussion about delayed cord clamping, isn't there, between the two of you? And if we go to page 3, within this report, he puts neonatal mortality deaths in and the figures. Do you know if those figures represent unexpected and unexplained deaths or if they are deaths of both types?
POWELL: I would imagine they are deaths.
LANGDALE: Deaths, full stop.
POWELL: Yes.
LANGDALE: So not exactly a direct comparison with the situation you were all in, was it? You were in a very different situation with three unexpected and unexplained deaths; do you agree?
POWELL: I do. Yes. Yes.
LANGDALE: Be that as it may, he sends the figures that would suggest you have more deaths, and certainly unexplained deaths, and he also sets out the survival percentage for gestation rates, we see there. So presumably he is setting those out so we can do, you both do what we did earlier, and appreciated that at
31 weeks, 30 weeks and 37 weeks, these babies were in a strong position?
POWELL: Yes.
LANGDALE: When you received that report, what did you make of it? When he put those death rates in and the gestation stats in, what did you think of it?
POWELL: I thought it was comparative, comparable to some of the others, spikes that they had.
LANGDALE: Comparable to which spikes?
POWELL: We, we tended to have, it looks like it tends to be two or three a year.
LANGDALE: Yes, and you had had that in three weeks?
POWELL: And then we had had that three.
LANGDALE: But in a way did it alter your view about the circumstances because what mattered was what had happened to these babies, wasn't it?
POWELL: Yes.
LANGDALE: Not the figures generally, they didn't help with A, C and D; it mattered investigating the circumstances of their deaths, didn't it?
POWELL: Mmm but -- yes.
LANGDALE: What do you think now, looking back, could or should have been done to rigorously investigate their deaths at that time?
POWELL: Well, I think perhaps we need, needed the
Consultant that was there at the time.
LANGDALE: Yes.
POWELL: I don't, at the time there was nobody, there was no evidence of any wrongdoing.
LANGDALE: I am not asking about that question. I am asking how do you find out the cause of death in a baby? What expert reports or analysis is done? Do you think that is a matter for the doctors to deal with? Who does further reports or investigations?
POWELL: Dr Brearey does, yes.
LANGDALE: So you would have listened to the doctors, would you, about whether a paediatric pathologist should be instructed or how you should examine the deaths?
POWELL: Yes, yes. And also I think -- well, I don't know what is actually discussed with, with the Coroner when they actually do the post-mortem because it is the remit of the medical team, but whether they actually defined the unexplained deaths at the time. I don't know if they do that or they do actually say -- so, perhaps, are they -- do they automatically look for anything suspicious.
LANGDALE: We know that because a serious untoward incident report was made in relation to Baby D [Child D] there was a STEIS referral, a root cause analysis investigation report; do you remember seeing that report?
POWELL: I think I do.
LANGDALE: And there was an addendum when the post-mortem was added in relation to Baby D [Child D]. So much more detailed documentation for him; do you remember that?
POWELL: Not offhand. I would have to refer to the --
LANGDALE: If we go to it, it is INQ0033765, if we go to page 10. This is a report with -- the one with the post-mortem added and what the pathologist found. Pneumonia with acute lung injury. Of course, what we know is Mother D didn't accept that, none of it made sense, the explanations she was getting, and the investigations continued. There was a referral to the Coroner and we know where we are now with all of the reports that have been obtained in relation to Baby D [Child D]. But at the time -- that can go down, thank you -- at the time did you think there should be more medical reports being obtained? I know what you were doing looking for members of staff, but just medical analysis as well?
POWELL: At the time, probably not.
LANGDALE: Because you thought the doctors would deal with that?
POWELL: Yes.
LANGDALE: In terms -- I am not going to take you to it, you know it and the Inquiry has seen it. The charts that you were producing with Letby's name in red, you were the one who was going through the shift patterns first --
POWELL: Yes.
LANGDALE: -- and linking her, weren't you?
POWELL: Yes.
LANGDALE: And you had her name clearly in red around the indictment babies?
POWELL: (Nods).
LANGDALE: And you had other names and then later on you added the doctors, didn't you? You wanted a doctors column as well?
POWELL: Yes.
LANGDALE: Why did you want the doctors column?
POWELL: Well, only for, if, if we had -- if we had everybody there that they could actually see who was actually there at the time rather than homing in on my own investigation. I didn't want -- I'm not one that can actually investigate, but I could actually see from my staff but I needed to make sure that everybody was covered in the columns.
LANGDALE: Did you feel that you were being pulled into an investigation-style role by the time you were digging
out rotas and seeing who was there on that shift or the previous shift?
POWELL: Well, yes.
LANGDALE: It is a different territory, isn't it, for a manager, ward manager to be doing?
POWELL: But then it's also sort of asking, am I doing, you know, am I looking at the right thing? Am I doing right thing here? And it's ...
LANGDALE: Was there a time you were doing that when you thought, actually, the police should be doing this, not me? I don't have the tools, I don't have the information, I don't have the powers to know what people are saying in their messages or anything else? Did you ever think that?
POWELL: In hindsight yes, I do.
LANGDALE: So in hindsight, when did that first occur to you that, actually, you had been getting involved -- an unwilling investigator, because you supported her as one of your staff, wasn't it?
POWELL: Well, nothing changed as far as evidence was concerned, nobody saw anything, nobody heard anything, nothing changed in any of the information at the time. However, you know, as time goes on, you sort of think how things changed to reflect on that and it is out of our remit in that respect because you need some
objective person to come in that's able to look at the information from an objective point of view.
LANGDALE: You were adding to the information, weren't you? So your table, you were adding Baby E [Child E], Baby I [Child I]?
POWELL: Yes.
LANGDALE: You were continuing with it and you kept coming up with her name?
POWELL: Yes, yes.
LANGDALE: As you continued to add and then do that --
POWELL: I know but she did work.
LANGDALE: -- report --
POWELL: When we got busy she did the overtime, so she was there more often. There was a lot of staff that did part time so they were a lot less so, but she did -- she was there more often by working full time and overtime.
LANGDALE: It wasn't just about whether someone was there more often, was it? It was about whether someone was there when something unexpected happened?
POWELL: Mm-hm.
LANGDALE: And she was the one that you found was there when the unexpected was happening?
POWELL: Yes.
LANGDALE: You, we know, added, as I have said, doctors to the table. But when you had finished it, doing it and adding to it and keep finding her name, when did you
start to really worry about that -- if you did start to worry about that?
POWELL: The question that was always asked of me and it was the same, nothing changed, from Dr Brearey saying he has some concerns but he wouldn't define them, and nothing actually changed from each time. But had anyone seen anything or -- there was no evidence there. So when I was questioned: well, evidence have you? I hadn't got any evidence.
LANGDALE: Your evidence was dead children.
POWELL: It was the commonality.
LANGDALE: Well, dead children --
POWELL: Yes.
LANGDALE: -- unexpectedly dying and collapsed children, that was the evidence of the problem, wasn't it?
POWELL: Yes.
LANGDALE: This was unexpected.
POWELL: Yes.
LANGDALE: So looking around, who was in the pool? Who might have had an influence on that?
POWELL: Yes.
LANGDALE: At that point, shouldn't the police have been called to investigate it?
POWELL: Yes.
LANGDALE: And you seem to have thought they needed solid evidence or direct observation of her doing something wrong before she could be removed from the unit, the hospital or referred to the police. Is that what you thought, you needed to see something?
POWELL: Well, that was the information that I was given.
LANGDALE: Who from?
POWELL: Well, it was Karen Rees had said that there was, you know, if there is no evidence and she took it further to discuss further with her respective colleagues. So -- I can't remember his name. Stephen Cross.
LANGDALE: Yes.
POWELL: And discussing with them and them saying based on what? On commonality.
LANGDALE: What was your relationship with Dr Brearey like up until this issue?
POWELL: Fine.
LANGDALE: And Dr Gibbs?
POWELL: Yes.
LANGDALE: They seem -- certainly Dr Gibbs, a mild-mannered pleasant man?
POWELL: Yes.
LANGDALE: He said that he was very influenced by you saying that Letby couldn't have done anything wrong, was
an excellent nurse, et cetera, and described if he was dithering, that was influencing him about reporting the matter? Can you understand that? Your position that she couldn't have done anything may have impacted on the doctors --
POWELL: Well --
LANGDALE: -- who were dealing with it?
POWELL: I find it difficult -- that difficult to take that on board. Because I find that I don't normally influence the Consultants.
LANGDALE: And when you say Karen Rees said there were no concerns, the paediatricians had concerns that they couldn't give a medical cause for these deaths, that was their concern, it became suspicious --
POWELL: Sorry, I am missing the thread.
LANGDALE: The paediatricians' concerns were that they had no medical explanation for these deaths.
POWELL: Yes.
LANGDALE: That is what was worrying them?
POWELL: Yes.
LANGDALE: That is a concern, isn't it?
POWELL: Yes.
LANGDALE: If the doctors can't tell you --
POWELL: Yes.
LANGDALE: -- what they think has happened? Wasn't that
a concern enough -- when you say you didn't have concerns, wasn't that enough for you, that the doctors were telling you that?
POWELL: Well, it, it is. But the question was given to me each and every time was: what is the evidence?
LANGDALE: And that is from Karen Rees?
POWELL: I haven't got any -- yes.
LANGDALE: Who else?
POWELL: I haven't got evidence other than --
LANGDALE: Just --
POWELL: Nobody's seen anything. She works overtime, full time, she's a common element on a rising mortality.
LANGDALE: What about Alison Kelly? Did you have a conversation further down the line with her?
POWELL: Well, I did. I think that was, from what I understand, the timeline was a bit further on. It was in 2016.
LANGDALE: And what --
POWELL: After a thematic review I believe.
LANGDALE: And what was her view about that, the concerns of the paediatricians, what did she say to you about them?
POWELL: She -- well, she was of the same -- on the same opinion as Karen.
LANGDALE: That you needed evidence?
POWELL: Mm-hm.
LANGDALE: Can you remember how she expressed that to you?
POWELL: Not directly. But I can -- just she would ask you know what, I -- you know, had I seen anything. Well, if I'd have seen anything, we wouldn't have been having that conversation. We would have moved much further along. But I hadn't seen anything. Nobody else had reported seeing anything.
LANGDALE: Were you aware of the case of Beverley Allitt?
POWELL: Yes.
LANGDALE: And her crimes?
POWELL: Yes.
LANGDALE: So she -- catching somebody in the moment is quite difficult, isn't it, because nurses have access to patients, don't they?
POWELL: (Nods).
LANGDALE: They have access and having somebody, a nurse over an incubator or a patient wouldn't of itself raised suspicion, would it?
POWELL: No, but in the neonatal unit it was -- it's more intensive. So like I was explaining before with the allocated nursing intensive care it was -- it's harder to be interfering with a baby that is not your patient.
LANGDALE: But you know that it can happen. People don't always play by the rules if they are committing crimes, do they?
POWELL: No, they don't.
LANGDALE: So is it a mistake to think everybody plays by the rules all the time when you are a manager?
POWELL: Yes, I think so. Yes.
LANGDALE: What have you learned in terms of management that might be of help to others managing wards today from this experience?
POWELL: I think we need an external reviewer or an external source to come in and review any unexplained deaths that is not affiliated to the NHS perhaps.
LANGDALE: Do you think having a confidential helpline to report concerns about another member of staff, if you think they are causing harm or you are worried about their association with events, would be useful or helpful?
POWELL: Yes.
LANGDALE: A safeguarding unit of sorts where --
POWELL: Well, I think safeguarding would have been difficult given the circumstances of -- we have been before to safeguarding with other things. But to actually say, "Well, what have you seen? What have you heard?" "Our mortality is going up."
Yes, but who -- all I can give them is the commonality. I don't know how they would address that.
LANGDALE: Do you think of safeguarding as something that's relevant to parents or families when you have got concerns about them rather than members of staff in a hospital, if you have got concerns about a member of staff, would you think about going to safeguarding then or not?
POWELL: If they were doing harm, yes. But if it was a performance issue we would deal with it then. But all you are doing, I guess, is removing them from one unit only for them to go somewhere else.
LANGDALE: You deal with the safeguarding issue with the CQC I think and picking up from paragraph 152 in your statement, if we can go please to INQ0017339, page 206. While that's coming on the screen, Ms Powell, you say at paragraph 152 that: "In the six weeks leading up to the CQC visit, I attended weekly meetings with an external CQC team to ensure that the NNU was prepared for the visit." Do you mean an external team or do you mean internal?
POWELL: No, they're internal. Sorry.
LANGDALE: Yes. So who was the internal team --
POWELL: Oh, I can't remember her name. It was part of
a team that was put together that was actually making sure that the -- everything was in place that should be in place.
LANGDALE: Can you help us with that? What do you mean in place, that should be in place?
POWELL: For instance, if, if any -- we had issues with some of the locked doors, the internal lock door needed fixing or whether there was -- if there was anything that I was putting out that needed doing and it still hadn't been done that they would actually have authority to push it forward to be done.
LANGDALE: Were any of the Executives part of this internal team?
POWELL: No, no. No.
LANGDALE: No. So ward managers or what --
POWELL: Oh, Sally, Sally Good. Sally Good I think it was.
LANGDALE: Was there any discussion at those kinds of meetings about what you would and would not say to the CQC?
POWELL: No.
LANGDALE: Nothing like that?
POWELL: No.
LANGDALE: So practical things that needed addressing?
POWELL: Yes. Everything was practical and to make
sure that everything was as it should be.
LANGDALE: Which you should be doing anyway without --
POWELL: Yes.
LANGDALE: -- a CQC visit, shouldn't you?
POWELL: But they were just making sure that everything was, was right; that standards hadn't slipped at all.
LANGDALE: Was that usual in preparation for CQC visit, to have a run-up to it to check things were being done properly?
POWELL: Yes.
LANGDALE: Did you ever think we should be doing these things anyway not just when there's a visit --
POWELL: Well, true. But it was a way also, it was a tool to actually get things done as well. So it gave strength to sort of say, "We need this doing because CQC is coming." So it gets done. So it's...
LANGDALE: So the same end result?
POWELL: Yes.
LANGDALE: If we look at the document in front of us we see in the last box, this is where you are interviewed by Inspector Helen Cain and two others. Sorry, Ben Doeka I think is the inspector. And you have in that bottom box "Safeguarding Child Death Review", and also a reference to morbidity and mortality meetings. I think you tell us fairly in your statement you didn't raise with the CQC the raised mortality rate.
POWELL: Yes.
LANGDALE: Did you raise unexpected deaths at all?
POWELL: No. I did not.
LANGDALE: No. Where it says safeguarding Child Death Reviews, is this just discussing processes then, not cases?
POWELL: Sorry?
LANGDALE: Can you see in the bottom box "Safeguarding" -- it looks like "Child Death Reviews", is it?
POWELL: I don't --
LANGDALE: What were you telling them?
POWELL: Child ... I don't know.
LANGDALE: Also on the topic of safeguarding, the same INQ reference, page 213, 0213. Do you see that last paragraph? Safeguarding again. "Phone if concerned". Can you see that?
POWELL: Yes, I can see it.
LANGDALE: So what are you telling them there about safeguarding?
POWELL: Just the process of safeguarding.
LANGDALE: And you were Level 3 trained, you say?
POWELL: Yes.
LANGDALE: So what was the process as far as you were concerned?
POWELL: To any concerns that were highlighted to the team because our team was just on the corridor.
LANGDALE: They shared offices, I think, with one of the -- that is the doctors. Where was the team as far as you were concerned?
POWELL: Just down the consider door from, from the unit. Between paediatrics and ourselves.
LANGDALE: So who was in it? Who were the safeguarding team at that time?
POWELL: Paula and Karen Milne.
LANGDALE: So you could pop in and out as much as you wanted to --
POWELL: Yes.
LANGDALE: -- with them, get advice, talk about babies, families?
POWELL: Yes.
LANGDALE: Did you ever talk about any member of staff or concerns of patient safety with them --
POWELL: No.
LANGDALE: -- from a member of staff? Never?
POWELL: No.
LANGDALE: Would that not have been the route that you would have thought to do that even if you had them?
POWELL: No, I didn't.
LANGDALE: Where would you have gone with those sorts of worries if it was about a member of staff harming children?
POWELL: It would have to be through the hierarchy, to Anne Murphy, Karen Reece or --
LANGDALE: Executives?
POWELL: Yes.
LANGDALE: You tell us you didn't mention -- that can go down now, thank you -- the raised mortality or increased mortality rate or unexpected deaths. As we know, by this time you had identified in that table with Letby in red that she was a commonality. You had updated it 19 January, 8 February, and that thematic review report had been completed by Dr Brearey and shared with you. Given all of that, and indeed you have added to it the aura and the sense you had, do you think you should have told the CQC?
POWELL: Yes.
LANGDALE: What do you think now, looking back, you should have said to them or might have said to them at that time?
POWELL: Well, I don't know. Maybe to my superiors I
-- it would be better that we went and got some -- although we -- we kind of did try and get an external review, which wasn't really external because it was part of the Network, but it was trying to sort of use peer --
LANGDALE: Is that Dr Subhedar's review you are thinking of there?
POWELL: The thematic review.
LANGDALE: Okay, yes.
POWELL: Yes. Trying to get them to give an opinion on what to do.
LANGDALE: They are still local, but you are right, external to Countess of Chester. But as far as the CQC's concerned, somebody completely independent of the hospital, what about sharing where you had got to with the information then?
POWELL: Sorry?
LANGDALE: What about sharing that information, the reviews that you had done then, you know, they are asking about --
POWELL: Well, I thought -- I did think maybe the Consultants would have done that, maybe Dr Brearey would have done that. Because they went to the feedback meeting, which I came after the fact.
LANGDALE: Your meetings were quite long, weren't they?
POWELL: Sorry?
LANGDALE: Your meetings were quite long with the CQC. There is a lot of the notes in the ones you had. How long was it, roughly?
POWELL: With, with --
LANGDALE: The inspector, yes.
POWELL: Well, I think it was an hour with, with the CQC for looking at storage and drugs and suchlike and then I think there was another hour with looking at the risk register and I think it was the donor milk and discussing about staffing and --
LANGDALE: What was the thing with the donor milk?
POWELL: We had the donor milk bank on the unit, the satellite -- well, initially, it was the major -- I don't -- I think they moved in 2016 but we still had the satellite milk bank on the unit. So we were running that as well.
LANGDALE: One of the texts that Letby sent Dr U on 23 June 2016 was this: "I lost my handover sheet. Found it in the donor milk freezer".
POWELL: Say again, sorry.
LANGDALE: It says: "I lost my handover sheet. Found it in the donor milk freezer. Clearly I should still be Ibiza." So a sort of jokey "I found my handover sheet in
the donor milk freezer"; does that make any sense to you?
POWELL: Well, I don't know. Other than went to check the donor milk out for a satellite hospital to pick up and gone to check the numbers and obviously must have put her sheet down, I am presuming. I'm only guessing.
LANGDALE: When did you learn that she had taken 241 handover sheets home?
POWELL: I -- I didn't know until after the fact.
LANGDALE: And 21 relating to the babies on the indictment. So you had no idea --
POWELL: No.
LANGDALE: -- that those sheets... They should not have been leaving the ward, should they, the unit?
POWELL: No. I was, yes, surprised.
MS LANGDALE: My Lady, I think that's a convenient moment.
LADY JUSTICE THIRLWALL: Very well. So we will rise now for lunch and we will start again at 2 o'clock. (12.54 pm) (The luncheon adjournment) (1.58 pm)
LADY JUSTICE THIRLWALL: Thank you, Ms Powell. Ms Langdale.
MS LANGDALE: Ms Powell, a few more emails, if I may, on the screen, they will come up. The first one is one that you sent to Alison Kelly. It's INQ0003558, page 2. We see your email there: "I was hoping we could arrange a meeting with you to discuss how to move forwards." You say: "With regard to your findings from the thematic review, high mortality, 8 as opposed to our normal 2 to 3 per year, commonality that particular nurse was on duty either leading up to or during." And you point out this particular nurse commenced working in January 2012 without incident. "A doctor also identified as common theme but not as many as the nurse. Despite reviewing these cases nothing obvious we are able to identify. Your input would be valued." Pausing there. You don't mention that they are unexpected deaths in there, do you?
POWELL: No.
LANGDALE: No?
POWELL: No, but it was high for us.
LANGDALE: It was high anyway?
POWELL: Yes.
LANGDALE: And you are asking for input, aren't you, you are asking for assistance?
POWELL: Yes.
LANGDALE: What were you hoping, when you emailed that, to get?
POWELL: Well, some way of moving forward and to have some closure.
LANGDALE: If the response had come back, "I think we need to go to the police now", would you have accepted that?
POWELL: Yes.
LANGDALE: So you wanted a decision about what would happen?
POWELL: Yes.
LANGDALE: It appears that you and Dr Brearey had been, in your case, looking for commonalities doing those tables. But you wanted someone to make a decision about where you went?
POWELL: Yes.
LANGDALE: We see at page 1, same INQ reference, 0003558, page 1: "Thank you." You have sent the information so "thank you" from Alison Kelly. "Thanks for the update, Eirian ..." The bottom email: "... could you please send Ian and I the report. Once we have reviewed, I think it would be good for me, you, Ian, Steve and Ravi to meet and discuss." Then if we go to INQ0003089, at page 1, you have sent that email I have just read on 21 March, and on 14 April you are asking your follow up. "What were your thoughts after going through it? I noticed it didn't include the medical team, I have attached the document that includes it." We know Dr Brearey had sent it on without the doctors, you have added that, but you are continuing the discussion, aren't you, with Alison Kelly?
POWELL: Yes.
LADY JUSTICE THIRLWALL: Just pause, Ms Langdale. It's very hard for the witness and for counsel and it is very hard for people in the room because there is a sprung floor and so that when people move on the floor it makes much more noise than you realise and the same with the chairs. And I know everyone is trying very hard but sometimes we just have to pause so the witness can hear properly and so counsel can concentrate. Yes, Ms Langdale.
MS LANGDALE: So April, you are following that up. Did you feel at the time you were getting as swift a
response as you wanted from the Senior Executives or not? Were you fine with that?
POWELL: Probably not at the time. It just needed some sort of resolution.
LANGDALE: Because we do see with that toing and froing with the thematic review, when there is an action plan you complete them, don't you, you do your bit?
POWELL: Yes.
LANGDALE: We have seen the bit about the incubators, we see other things where you are adding nursing notes to a thematic -- you do get on and do the bits you are requested to do?
POWELL: Yes.
LANGDALE: Did you feel that was always the same pace for others around you on this topic?
POWELL: Did I feel like --
LANGDALE: That they worked on the same pace with the topic? The importance of it, you know, responding quickly?
POWELL: Well, probably not. But that -- yes, probably not. Not in my view.
LANGDALE: That can go down, thank you. If we have instead INQ0003138, page 2. This is an email from Dr Brearey to Alison Kelly, again cc'ing you, saying:
"There is a nurse on the unit [this is 4 May now] who has been present for quite a few of the deaths and other arrests. Eirian has sensibly put her on day shifts only at the moment but can't do this indefinitely. It would be very helpful to meet before she is due to go back on night shifts. There is some pressure regarding staffing numbers with this at the moment." That can go down. And can you tell us about moving her on to day shifts. If it helps you, you deal with it at paragraph 180 in your statement. But we know that you moved Letby to day shifts in April 2016. Can you tell us why?
POWELL: Again, I -- I guess it goes back to discussions with the two Yvonnes, that maybe this was an opportune moment to put Lucy on to days as a well-being approach because she had been involved in so many of the recent deaths that that must have a profound effect on her well-being. And, therefore, we felt that there would be more support on the days, on the day shifts, and also able to see how she was in herself because we would be there to -- to monitor.
LANGDALE: I think the expression you used in your
statements to the police "eyes watching her as well" --
POWELL: Yes, to see whether she was missing out on any other competency levels or whether she needed any additional assistance with the new, the new machines that were in place. It gives an opportunity to check out her appraisal, to make sure that if there was anything lacking that we could deal with straight away or if we could see any wrongdoing, that that was also an opportune moment as well, because there were more people about.
LANGDALE: And the night shifts had fewer people. More opportunities to be on your own with a baby?
POWELL: They did -- well, not on your own because we actually made sure that the nursing calibre was there on nights. But you haven't got the same level, you haven't got as many doctors on shift, you have only got those that are covering the night shift, managers are obviously not in, practice development is not in. So on days you have got all those people around.
LANGDALE: And you said the decision to move to day shifts was made collectively with Yvonne Griffiths, Yvonne Farmer, and Karen Rees was also aware of it?
POWELL: Aware of the night shift -- yes.
LANGDALE: The move to day shifts?
POWELL: Yes.
LANGDALE: So did you have a discussion together about the rationale or the reasons for that or not?
POWELL: With, with the two Yvonnes, yes. And with Anne Murphy, I think. Was it with Anne Murphy, I don't know whether Ann was there or not. But certainly it was the two Yvonnes.
LANGDALE: And you didn't tell Alison Kelly, it was Dr Brearey's email that I have just read out that informed her of that, that she had been moved to day shifts?
POWELL: I believe so, yes.
LANGDALE: Was there a reason not to discuss that with Alison Kelly at the time?
POWELL: Putting her on to days or nights -- from nights to days was, I guess, a staffing issue and we wouldn't necessarily have discussed that with, with Alison herself. But Karen was aware.
LANGDALE: And what did you say to Letby about the reasons for it?
POWELL: The same reason. As in that we felt that she had been involved in a lot of cases and therefore felt that for her well-being that it would be prudent to do so.
LANGDALE: Did you tell her at this point or any other point that you had been doing those --
POWELL: Yes, I did.
LANGDALE: -- charts --
POWELL: Yes.
LANGDALE: -- finding her presence? And what did you say to her about that?
POWELL: I said that, actually, before we had the thematic review. Because Nim had actually asked me that question in the review and I'd said that I had said that she seemed to be a commonality within, within the deaths that were actually on the unit and she, she took it on board. But I said, you know, and obviously we need to investigate further as to why that is the case.
LANGDALE: Did you ever give her the impression you were investigating her?
POWELL: Well, I said she was the commonality. But there were a couple of others also at the time. But we would be investigating further.
LANGDALE: So you broadened it --
POWELL: Yes.
LANGDALE: -- so she wouldn't have felt you were targeting or investigating her?
POWELL: Well, I did say that she seemed to be the common, the commonality.
LANGDALE: And when you moved her to day shifts did you
tell her it wasn't simply for her welfare, but that more eyes would be watching her --
POWELL: No.
LANGDALE: -- which could mean a number of things, couldn't it? You didn't tell her that?
POWELL: No.
LANGDALE: You gave the welfare reason?
POWELL: Well, I said it was actually to ensure that she had a respite from all the events that were happening as appeared to be happening at night.
LANGDALE: Can we go next, please, to INQ0003115, page 1. This is the meeting on 5 May, Ms Powell, which you set out at paragraph 187 in your statement. You tell us you attended a meeting on 5 May with Karen Rees, Stephen Brearey and Anne Murphy to discuss the increase in mortality and you can't remember specifically what was discussed but you have done a note which we can see. If we go to the note that you produce after it, INQ0003243, page 1. If we look there at page 1, "Various remarks". If we go to page 2 -- I will come back to page 1 in a minute. "Advice sought; Risk facilitators; External Neonatologist; Network; Higher management".
Would you like to expand, if you can, on what advice was being sought at that point?
POWELL: The risk facilitators were for obvious reasons because we were going through the neonatal clinical incident meetings, so we were getting feedback. But nothing how to move forward. The external neonatologist was the thematic review.
LANGDALE: Dr Subhedar with Dr Brearey?
POWELL: Yes. The network was relating back on the mortality, and the higher management were the natural progression, you know, the Anne Murphy, Karen Rees, Alison Kelly, Ian Harvey, and suchlike.
LANGDALE: We don't see in writing, at least, in the network or more widely a lot of discussion around the higher mortality. Was it your impression that that was being discussed at the time within networks or not?
POWELL: Well, yes, because we had to write the numbers of the mortality in each month.
LANGDALE: Right.
POWELL: That had to be highlighted and then Dr Brearey would actually send the deep dive notes or yes, the notes that were found on the deep dive.
LANGDALE: If we go back to page 1 of this document, we see what you say at paragraph 1 about Letby working full time and having the qualification and specialty: "She is therefore more likely to be looking after the sickest infant on the unit." Just pausing there, I think you agreed with me earlier that for A, C, and D and onwards, these were not sick babies, were they?
POWELL: They weren't, sorry?
LANGDALE: Not sick babies. They weren't sick babies when they collapsed, they were stable infants, weren't they?
POWELL: Yes, yes.
LANGDALE: You say there: "There are no performance/management issues and no members of staff that have complained to me or others regarding her performance." Nurse W had complained to you about her performance, hadn't she?
POWELL: Yes.
LANGDALE: Did you forget that when you wrote bullet point 2?
POWELL: Well, that was one incident.
LANGDALE: One incident relevant to one of the children who had died?
POWELL: Well, she wasn't actually looking after that one, she was looking after the other one --
LANGDALE: She was, but the point was she was gravitating
towards the baby who died --
POWELL: Yes.
LANGDALE: -- and intruding on the grief --
POWELL: Okay.
LANGDALE: -- of Baby C [Child C]'s parents. So when you say "no performance/management issues", you had not thought that one was relevant or didn't want to say --
POWELL: I don't know, an oversight.
LANGDALE: Likewise, although I recognise it was earlier --
POWELL: Sorry.
LANGDALE: Although I recognise it was earlier, likewise the morphine incident, you didn't --
POWELL: Yes.
LANGDALE: -- refer to that and she had actually had to have a review with you about that, hadn't she?
POWELL: Yes.
LANGDALE: Was that an oversight?
POWELL: Was that, sorry?
LANGDALE: An oversight not to mention that?
POWELL: Well, we all have, I mean, if you, if you looked at everybody's drug incidents on the unit, somebody somewhere -- I mean, I have been involved in a drug incident myself and like I say, the majority of
them have in one way or another.
LANGDALE: I appreciate that, Ms Powell. It's really that you were asserting there were no issues. It's a very positive statement: I have never had an issue to deal with with this nurse, and that wasn't the position, was it?
POWELL: Yes. Okay.
LANGDALE: You say at point 6: "The 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." What was your evidence base for that? Again, not relating to the babies on the indictment but what was making you say that?
POWELL: Well, it was causing additional anxiety and stress on the unit that when we actually needed transport at that time, to come and collect, they were not available. So it was an additional anxiety for the staff on the unit and, and for the parents that were currently on the unit.
LANGDALE: But at this point and in this meeting, having focused on particular babies, it seems, once again, there were generalisations being made, rather than looking at each baby to see what, if any, of these could
apply to that baby; do you see what I mean?
POWELL: True. But I was trying to sort of show what, what else was going on in the unit at the time. Trying to share the information that I had and then it's like okay, that's, that's all the thinking that I have.
LANGDALE: So giving your input, it was really, you would say, would you, for someone else to say, "Well, we have got that general picture but now we are looking at this, these are the specifics we need to focus on"?
POWELL: Yes.
LANGDALE: That can go down, thank you, and document INQ0003181, page 1. A meeting on 11 May which you deal with at paragraph 198 of your statement. This is a meeting you attended with Anne Murphy, Dr Brearey, Alison Kelly and Ian Harvey and the notes here are made by Alison Kelly, you think, and you have had a chance, I hope, to have a look at these again. This is a meeting where we see recorded halfway down on the first page: "Absolute no issues with nurse. Circumstantial". Again, we have seen your document from the 5 May but you are the source for saying there are no issues with the nurse presumably, that's what you said before and that is what you continue to say --
POWELL: Because there was nothing, nothing had changed.
LANGDALE: -- that she is excellent. And "circumstantial"; do you know what that was referring to?
POWELL: Probably commonality, I am assuming.
LANGDALE: And if we go over the page, to page 2, we see at the top: "Actions. Review all babies who deteriorate. Stay on days for three months, two further months to go." So it looks here as though there is a decision to look more closely at deteriorations, is that right?
POWELL: Yes.
LANGDALE: Whose idea was that, can you remember, of the group?
POWELL: I don't know. I think, I would I not -- I would be guessing, sorry.
LANGDALE: And then when it says "three months, two further months to go", is that about Letby being on days?
POWELL: Yes.
LANGDALE: So what was the discussion about any risks she might represent or otherwise staying on day shifts as opposed to being offer the unit at this point?
POWELL: That wasn't discussed, no.
LANGDALE: So no, no challenge to the notion that she
should stay on days for three months with two months to go?
POWELL: No.
LANGDALE: Given everything that had been put together at this point?
POWELL: (Nods).
LANGDALE: That can go down, please. Just on that meeting, I think it's that meeting where Alison Kelly says you were very vociferous about Letby. You were vociferous, vocal in your support of her, that there were no issues?
POWELL: I was, I was asked a question so I answered it.
LANGDALE: Very clearly that you felt --
POWELL: Yes.
LANGDALE: -- she was excellent, you were telling the police the following year you thought she was creme de la creme, so you were expressing your view.
POWELL: Yes.
LANGDALE: Do you look back on that now and consider that you might have been more reflective in that view, given what you knew around the unexpected deaths of the babies and the concern that you must have had looking and finding the same name?
POWELL: Yes. I think it would have helped. Yes.
LANGDALE: You say in your statement: "I wasn't being defensive, I was just being honest, I didn't think she was harming babies." But the question for you may have been, well, is this suspicious? Does someone else need to look at this, not that I definitely know one of my team is doing this?
POWELL: Yes.
LANGDALE: Did you ever stand back and think, well, there is a lot to look at here now?
POWELL: I did. I mean, we discussed this: is there anything that we are getting wrong here? Is there something that we are missing? To the point I think I actually even went in Case to review any Datixes where -- outstanding that we didn't know about. Also the fact that we considered if there was anything that we could have done differently or -- really, all the time, because we were told at the time -- I mean, Karen said that we were to discuss obviously amongst ourselves, as in the two Yvonnes and myself, and -- and above but not anywhere else. So it was difficult.
LANGDALE: On the subject of Datix, we know they are completed for deaths. For the collapses and serious
incidents it is much patchier, isn't it --
POWELL: Yes.
LANGDALE: -- when a baby recovers? Were you aware of that at the time that they were not being completed as they might be for collapses and you were losing intelligence through that?
POWELL: Well, they were doing anybody -- it was the definition of the collapses that I think was proving the difficulty instead of the -- anybody that had full resus that required -- was Datixed, but obviously I'm not sure -- I mean, I was doing a table on the sudden and unexpected collapses.
LANGDALE: We see at INQ0005721, page 1, Dr Brearey sends an email to the Consultants cc'ing you: "If you do come across a baby who deteriorates suddenly or unexpectedly please could you let me and Eirian know." Did you send a similar email to the nurses on the unit?
POWELL: I don't think so, I don't know. I don't --
LANGDALE: I haven't seen it.
POWELL: I haven't seen it.
LANGDALE: Do you think it would have been useful to because he is clearly -- in that meeting you have realised there's not as much information around those as you need.
POWELL: But any, I guess any -- yes, it would have been helpful, I think, if I had or hadn't, I can't remember, but bearing in mind that if it was requiring full resus the doctors would be there anyway and would complete a Datix.
LANGDALE: And so when you did your table, we know you did it for deaths and collapses, you started it on 15 April 2016 and you send it -- to 5 May 2016. When were you -- what data were you looking at to find those collapses when you were adding them?
POWELL: I think I start -- although I did the table on a certain date, I think the first collapse was before then when I was looking at the table.
LANGDALE: So you couldn't rely on Datix. Or could you, how did you --
POWELL: I would have to go through -- anybody that let me know when I came in that -- the Datix would either be completed or somebody had said that this one needed resuscing.
LANGDALE: We spoke earlier about O [Child O] and P [Child P] and you deal with June events from paragraph 215 in your statement. Can you go, please, to this meeting, which is INQ0004884, page 1. And we see this is a mortality review when it comes on the screen, Ms Powell, in
relation to Baby P [Child P]. And if we go to the third page, "Lessons learnt" and "Actions". We see Dr ZA, Hayley Cooper, Yvonne Griffiths, Sian Williams, yourself and Dr Brearey. "Dr ZA said that both herself and Dr Brearey stressed the fact that we could not medically explain these deaths. There was the continued escalation of sudden and unexpected deaths and collapses and that the association with Lucy was beyond coincidence and her working pattern. We thought she must be involved in some way." Can you remember this meeting and that being communicated that both doctors could not explain these deaths and felt she must be involved in some way?
POWELL: (Pause) Sorry, what were you saying?
LANGDALE: Can you remember that at the meeting?
POWELL: I do, yes.
LANGDALE: That is what the Consultants were saying. Do you remember hearing that message that they --
POWELL: No, I do not.
LANGDALE: We know you filled the Datix in for O [Child O] and P [Child P] , we have seen that, and you identified Letby on the Datix, you go to that meeting and they say they were both clear that there couldn't be a different
explanation, a medical explanation, they didn't have one. Do you remember them just not having one --
POWELL: Yes.
LANGDALE: -- these two babies collapsing one day after the other, no one knew why, did they?
POWELL: Yes, they did say something similar.
LANGDALE: Yes, they did say -- you were aware in that meeting they didn't know why they had died?
POWELL: Yes, they didn't know.
LANGDALE: And you were aware yourself, having done the Datix, that Letby was there for both of those deaths?
POWELL: Yes.
LANGDALE: On day shifts when you had moved her to day shifts, two occurring, when the others had happened in the night. Putting that all together, what did you think, leaving that meeting, about referring it to the police?
POWELL: Well, I was, as Steve Brearey had the concerns, I guess as, as the neonatal lead he should have forwarded it to the police being of his, he's -- he is the neonatal Consultant.
LANGDALE: Did you think you had any safeguarding obligation to the babies on the unit. Here you are in charge of the unit, these two have died, no explanation, the coincidence of Letby being on day shifts, coming
back in, back from her holiday, again, marrying the table that you had produced?
POWELL: Again, I -- I would find unless -- all I could go with is commonality and the high mortality.
LANGDALE: Commonality and mortality?
POWELL: Yes.
LANGDALE: But --
POWELL: I am not -- I mean, yeah, I'm not sure what they would have done with that but I guess the police is, is a good way to have gone because they would do their own investigation.
LANGDALE: And they had more powers, more resources?
POWELL: Yes, yes.
LANGDALE: They could investigate the person. If you look at paragraph 216 in your statement you say you attended several meetings on 27 June and you and Anne Murphy were called to Alison Kelly's office for an update meeting regarding the mortality review meetings and the outcomes. The purpose of this meeting, you say, was to ascertain how we felt with regard to the accusations made against Letby, made regarding Letby. "We were advised that the Consultants had stated that as a collective all felt the same about Letby. In other words, that we agreed with the concerns raised by the Consultants that Letby could be directly responsible." What are you saying here? I am just trying to understand that paragraph. Have a read of it.
POWELL: Well, they wrote a letter, the Consultants wrote a letter to say that we collectively all think that Letby was responsible when in actual fact we weren't consulted about that, that letter.
LANGDALE: You weren't consulted?
POWELL: No.
LANGDALE: Did you know about that letter?
POWELL: No. Only until they said "sign this" but we hadn't -- we said we can't sign something we haven't read or seen. So we didn't sign it.
LANGDALE: So you didn't want to sign it that you were concerned?
POWELL: We were concerned but we were not -- what they were saying was it was -- that Lucy was responsible.
LANGDALE: And you would not have been happy to say that clearly?
POWELL: But it was an -- it wasn't, I didn't feel it was our place, if they had the concerns they put it forward.
LANGDALE: But you had had some concerns from Nurse W and others being raised with you?
POWELL: Yes.
LANGDALE: Did you put yours forward? You may say they didn't seem significant to you but others might have thought they were, mightn't they?
POWELL: Mightn't -- yes.
LANGDALE: In terms of what Letby was being told at the moment, there's a confidential email, INQ0014306, page 1. This is after the deaths of O [Child O] and P [Child P] . You had: "... spoken to Letby this afternoon to ascertain her welfare in relation to recent events." You say you've referred her to Occupational Health for additional support. "I asked her that she needs to ensure she attempts to step back from the ITU area for her own well-being. Informed her she will be on days for a period of time and until she has attended the Occupational Health sessions." So what was your expectation at the moment here?
POWELL: What was my what, sorry?
LANGDALE: Expectation that she was going to do, what did you want her to do the next few days?
POWELL: I wanted somebody to take the decision.
LANGDALE: What decision?
POWELL: Well, it wasn't going to go away, this. So we were going round in circles, really.
LANGDALE: And you wanted her to take the decision because the unit -- you hadn't taken it and said you can't come back at all now, that is not what you had said?
POWELL: That I was what, sorry?
LANGDALE: You hadn't said, "You can't come back now, I don't want you back on the unit."
POWELL: No, I didn't say that, no.
LANGDALE: And if we look at another email, page 2, I think it is the same INQ number, page 2. You are cc'd into this from Dr Brearey: "Just to confirm then Ian and Alison are happy for LL to work on the NNU in the same capacity as last week despite the paediatric consultant body expressing our concerns that this may not be safe and that we would prefer her not to have further patient contact." What did you think when you saw that email?
POWELL: Well, that Steve didn't want Lucy back on the unit.
LANGDALE: Was he right to think that?
POWELL: On reflection, yes, I guess he was.
LANGDALE: What did you think at the time?
POWELL: Well, I felt at the time that something had to change, something -- a decision had to be made.
LANGDALE: Either for her to come back and ignore the
suspicions, carry on as normal?
POWELL: Which was untenable.
LANGDALE: Was it?
POWELL: Yes.
LANGDALE: For you that was untenable?
POWELL: Well, they couldn't cope -- the working environment was untenable with the Consultants and the staff then because obviously the staff felt that she was not responsible.
LANGDALE: Which staff felt that?
POWELL: The majority of the staff.
LANGDALE: The nursing staff?
POWELL: Yes.
LANGDALE: The nursing managers?
POWELL: Yes -- no, the nursing staff.
LANGDALE: Nursing staff. People who worked with her?
POWELL: Sorry?
LANGDALE: The people who worked with her?
POWELL: Yes.
LANGDALE: Who were close-knit, you would say?
POWELL: Yes.
LANGDALE: And did you think that?
POWELL: At the time, yes. But after this incident, it ...
LANGDALE: After the deaths of O [Child O] and P [Child P] ?
POWELL: Yes.
LANGDALE: The murders, we now know?
POWELL: Yes, the unexpected ...
LANGDALE: So after the unexpected deaths, you wanted?
POWELL: Yes, I wanted some resolution because it wasn't, it wasn't helpful for anybody.
LANGDALE: We then see some emails that all the nurses had been shown that you sent to the unit, the first one INQ0002879_91, page 91. Actually, the email looks as though it's from you at the top but it's your -- sorry, Yvonne Griffiths, but it is your name at the bottom "Kindest regards, Eirian", I don't know why that's happened. Have a look at the email.
POWELL: I was to prepare an email.
LANGDALE: Right.
POWELL: But it had to wait until Karen had actually, or Sian had actually seen it to say that it was okay to go.
LANGDALE: Have a look at the email. So this is when the RCPCH review is happening, is it? Is that what -- the review that you are referring to or something else?
POWELL: Yes.
LANGDALE: So and you say: "In preparation it has been decided that all
members of staff need to undertake a period of clinical supervision." That wasn't the case, was it? Or was it? That all members of staff were going to have a period of clinical supervision. That wasn't going to happen, was it?
POWELL: Well, it was going to initially because this was thinking that perhaps -- it's not clinical supervision as such. It was an opportunity for all staff to have their competencies checked and ensure that they were able to ensure their appraisal and revalidation was, was up to the mark.
LANGDALE: So this was suggesting everyone on the unit would be supervised by another person for a period of time to check they were all working as they should be.
POWELL: Yes.
LANGDALE: And Lucy was going to be the first one, on the 18 July. In fact, there was difficulty finding supervisors or being able to do that, was that the case? Or why did that not happen?
POWELL: There was what, sorry?
LANGDALE: Why did that not happen?
POWELL: I think she was taken off anyway before that.
LANGDALE: Did you think that was a constructive way forward?
POWELL: I just felt, again, it was just another action
to -- to complete.
LANGDALE: If we go to INQ0002879, page 75. This time, you are emailing about opportunities to apply for secondments throughout the Trust and Lucy being seconded to the Risk and Patient Safety Office. Why was she seconded to the Risk and Patient Safety Office?
POWELL: That was a decision that Karen had made with, I think it was with Sian.
LANGDALE: And what was the basis for that decision?
POWELL: That was actually to take her off pending an investigation.
LANGDALE: Pending the RCPCH investigation?
POWELL: No, I think it was the Trust investigation.
LANGDALE: Do you mean the grievance procedure?
POWELL: No, that came subsequently.
LANGDALE: So which investigation?
POWELL: So this was an investigation within the Trust.
LANGDALE: Conducted by whom?
POWELL: I don't know.
LANGDALE: You don't know?
POWELL: I don't know.
LANGDALE: So it was an internal investigation?
POWELL: Yes.
LANGDALE: So she was taken there for that reason. Did
you have other staff asking for secondments as a consequence of this?
POWELL: Sorry.
LANGDALE: Did you have other staff asking for secondments as a consequence of this?
POWELL: Yes. Yes, because we were downgraded, there were therefore opportunities then for staffing to -- it was like an opportunity to, if anybody wanted to sort of look elsewhere.
LANGDALE: At this point, we know that nurses and doctors were talking about what had happened and the deaths of O [Child O] and P [Child P]?
POWELL: Yes.
LANGDALE: You yourself say as far back as A and C there was an aura, something you were worried about. By the time Letby was seconded to the Risk and Patient Safety Office, it must have been known that there was some kind of investigation going on into her, mustn't it?
POWELL: Yes.
LANGDALE: So did that seem slightly odd sending that kind of letter to all of the staff when everybody knew, in effect, that she had been moved while there was this investigation going on and the deaths had occurred?
POWELL: I don't think they were aware.
LANGDALE: Don't you?
POWELL: But I'm not sure. It's not something that I could have asked them.
LANGDALE: No? Nicola Lightfoot gave evidence to the Inquiry that she was involved in advising staff and in meetings not to discuss the neonatal mortality rate or Letby. Were you doing the same, that people were advised not to discuss her?
POWELL: Not to discuss, no.
LANGDALE: Not to discuss. So what were you saying to people about what they couldn't discuss?
POWELL: What was I?
LANGDALE: Saying to people that they could not discuss?
POWELL: I didn't say anything that they couldn't discuss. It was me that wasn't allowed -- I wasn't able to discuss with anybody on the shop floor, as it were.
LANGDALE: Right. Who told you that?
POWELL: That was Karen.
LANGDALE: Karen Rees said to you, "You cannot discuss this with your nurses"?
POWELL: We are okay to do it in the office with -- because we were already aware because we had been discussing that, and Anne Murphy. But we couldn't discuss anything, that it was confidential, that we
couldn't do that.
LANGDALE: So Karen Rees, you and Anne Murphy could discuss it, but you couldn't discuss it with --
POWELL: With anybody on the unit.
LANGDALE: Could you discuss it with Yvonne Griffiths?
POWELL: Yes, yes, she was in the office, Yvonne and Yvonne Farmer.
LANGDALE: But everybody else working on the unit, you couldn't?
POWELL: No.
LANGDALE: What did you think the reason for that was?
POWELL: Well, to keep, we were told to keep it confidential.
LANGDALE: And why was there a need to keep it confidential?
POWELL: Because that's what I was told to do.
LANGDALE: Did you question that?
POWELL: Well, no, because I thought it was for her well-being. I -- confidentiality was a big thing, that you can't -- you know, for parents, for the infants, for staff. It's not something that you take lightly anyway, so if somebody said this is a confidential matter, then.
LANGDALE: At this point --
POWELL: Yes.
LANGDALE: -- did you know whether or not the parents
were informed -- of the babies named on the indictment -- that there was an RCPCH investigation, or other investigations?
POWELL: I am not aware that they were.
LANGDALE: Do you think they should have been?
POWELL: That's a very difficult question. Should they have been? It would have caused possible harm if everything was proved to be, that it wasn't the case. But open and honest, if it was the case. And I guess the -- it would -- it would be up to the Consultants to do that.
LANGDALE: You had more information about their children than they did at this point, didn't you, the association of one person, the pattern of unexpected deaths. Do you think it's right that as a professional healthcare professional you should have more information than they have about their babies at any point?
POWELL: Yes, I guess -- it's very difficult to know what is the right way.
LANGDALE: Moving on to a different topic, INQ0058624, page 1. We know that Letby invoked a grievance procedure and we will come to that in a minute but at the end of that, this letter is sent or email is sent to you and others. Did you know this email was coming before you
got it?
POWELL: No, I didn't.
LANGDALE: She says: "As you can imagine this whole episode has been extremely distressing for me and my family. I will begin my return to the unit in the coming weeks. I will need colleagues to be sensitive and supportive at this time." We know that there was as least one tea party planned on the unit for her return over a weekend. Are you aware what steps were taken to welcome her back to the unit?
POWELL: A tea party, it sounds more than it is. A cup of tea and a cake.
LANGDALE: It sounds like a tea party, a nice thing, nice thing to do normally.
POWELL: But we did it if it was somebody's birthday, we did it if, if -- it wasn't --
LANGDALE: A celebration? Something positive?
POWELL: Sorry?
LANGDALE: A celebration? Something positive, a nice thing to do?
POWELL: Yes.
LANGDALE: So when one was held to support Letby and when she was invited in, were you there at it?
POWELL: I don't remember it, no. But I remember being shocked by this, the way it was written. But then ...
LANGDALE: The way it was written by the nurse who told the Inquiry about it?
POWELL: By Lucy, yes.
LANGDALE: Oh, by Lucy. Sorry, I thought you were talking about ...
POWELL: It was a bit full on, I felt at the time.
LANGDALE: What did you think when you read it?
POWELL: Well, I am thinking, well, it's -- she's been fully exonerated but then by whom?
LANGDALE: If we can go, please, to INQ0060238, page 1. You see: "Off-duty is requested for new medical staff. Cover from March 2017. Looking forward to seeing you soon." So when did you think she was coming back, March 2017 or --
POWELL: When did I think?
LANGDALE: Yes, looking at this email. When you wrote that email, what did you think the position was?
POWELL: Would it be March or was it April?
LANGDALE: If we look below she's asked you and Yvonne Griffiths for a copy of the latest off-duty and the March doctor rota in order to plan visits.
POWELL: I am not -- I don't think it ever happened anyway.
LANGDALE: Well, what visits was she trying to plan and what information was she asking to see before she came to make the visits?
POWELL: I don't know. I can't remember what Karen said. Because she went through Karen because Karen was liaising a lot with, with us at the time.
LANGDALE: She's certainly cc'd Karen but it looks like she's asking to know what doctors are on, isn't she?
POWELL: Off-duty, the latest off-duty and March doctors rota. I think -- I don't think she wanted to visit when there were certain members of the medical team there, which is what makes it untenable for her coming back.
LANGDALE: So she was setting her terms to come back?
POWELL: Mmm.
LANGDALE: None of the doctors -- what did you make of that?
POWELL: Well, only that she was going to feel extra nervous if certain doctors were there, because I think wasn't the -- the grievance had finished by then so obviously that came out in the grievance, that she felt she were got at.
LANGDALE: Dr Rackham, who the Inquiry will hear evidence
from, is a doctor from a neighbouring hospital?
POWELL: Yes.
LANGDALE: And he says he was contacted by you by email to ask you to put some positive comments together --
POWELL: Yes.
LANGDALE: -- comments he had made about a resuscitation for [Child P], and he said it was a slightly unusual request: "The manner of this request at a later date was slightly unusual." Why had you gone to Dr Rackham for any statements?
POWELL: Well, on the review, on the deep dive, a doctor -- and I think I can't say him.
LADY JUSTICE THIRLWALL: Just check the list.
POWELL: Okay. Dr U had said in the deep dive that Dr Rackham had actually said how excellent she was and that it was noted. So this was -- revalidation was now in place with the NMC. So this is something that would come out of that; that you get some sort of verification of good practice and that was the only way -- that was an email that was sent to Dr Rackham for, for that.
MS LANGDALE: Was that going above and beyond for Letby at that point?
POWELL: Well, no, because we had revalidations anyway going on, that was a new thing that came out, and that
was something that was added to your portfolio and anybody, really, that had a good word or praised you in a particular way or even if it was the NLS course that you were doing and you had a good response from that, that also would, would go ahead for the revalidation process.
LANGDALE: You were interviewed in the RCPCH review, weren't you, and also spoke about Letby? If we go to INQ0014603 [not found], page 1. We see in the second section: "EP care issue taken line on LL that it's felt to be unfounded, meticulous, high standards, good communication skills. Other skills: key person to go to when need someone to help. Felt not been honest with LL and others. Very upset by the situation." Further down: "LL is clever, exceptional, very professional. Incident reports herself and her best friend too ... "Impose the removal on her by doctors." And over the page, page 2. You refer to when babies die you organise a debrief within a week: "Always have hot debriefs. If any member of staff has had more than one incident in short space of time they try to allow them to step back a little bit. Not always possible." That's something that you thought was a good idea but it never happened, did it? She would ask consciously to go back into the nurseries, intensive care nurseries?
POWELL: Sorry, I --
LANGDALE: Letby would ask to go back to intensive care nurseries?
POWELL: Yes.
LANGDALE: So although you thought the best practice was to step back a little bit, you knew she was not doing that and choosing not to do that. She wasn't stepping back from the intensive care nursery, was she? What did you make of that when you knew she wasn't doing what you thought was a good thing after you had experienced --
POWELL: Well, it was -- well, it was for her well-being. But then I felt that wasn't in place when, when it was happening to me and I felt it would have been a good thing to happen currently.
LANGDALE: In terms of the earlier page, "Clever, exceptional, very professional", did you feel able to say that in September 2016 without any of the things that you had been told coming into your head?
POWELL: Hindsight's a wonderful thing. Probably not.
LANGDALE: Were you comfortable at the time saying it?
POWELL: But I thought nothing had changed as far as --
nobody had seen anything.
LANGDALE: But you knew those words, you weren't comfortable, you say, probably not, you weren't comfortable. Did they feel hollow when you said them?
POWELL: Was what, sorry?
LANGDALE: Did they feel hollow? Just ...
POWELL: Well, no, because she had done what, you know, reported herself on incidents, she had actually done -- reported on her friends as well.
LANGDALE: Is that Nurse T or someone else? I don't know when you say friend, not Nurse T, sorry. It doesn't matter. She had reported on somebody else?
POWELL: Yes, she is on here, I've seen, Nurse Z.
LANGDALE: Did -- what did she report about herself?
POWELL: About the Gent.
LANGDALE: Gentamicin?
POWELL: Yes.
LANGDALE: So that one point enabled you to say she incident reports herself, the Gentamicin?
POWELL: Yes. I mean, I can't remember if there were any more but I mean, that's -- we have many, many incidents reported per day.
LANGDALE: I thought you weren't aware of that incident until we sent it to you, but ...
POWELL: No, but that's one incident that -- of Gent
she's reported herself it said on the top, which I highlighted.
LANGDALE: Oh, the one about the morphine?
POWELL: No, the Gent.
LANGDALE: Yes, the Gent. I thought that was one that you hadn't seen before?
POWELL: I didn't know, no, but when I was reading it today.
LANGDALE: Yes.
POWELL: Yes.
LANGDALE: But this is an interview you gave in 2016?
POWELL: Right.
LANGDALE: So you said then that she reports herself --
POWELL: Yes.
LANGDALE: -- incident reports herself. So I am asking what in 2016 did you know she had reported herself about, just to be sure that we are not missing anything?
POWELL: No. But she did. She would -- she did a few clinical incidents.
LANGDALE: Tell us what they were.
POWELL: God. I can't -- I can't recall.
LANGDALE: Well, roughly. You have said it to them, you have said clinically reports herself, so what kind of errors, clinical incidents was she reporting?
POWELL: I can't remember. I can't remember them.
I can't -- I can't recall them.
LANGDALE: Does that mean they can't have been particularly significant or of importance?
POWELL: Well, they weren't significant, they were just reporting Datixes.
LANGDALE: Datixes reporting in relation to a child rather than her own errors?
POWELL: To her own errors? Yes.
LANGDALE: Yes. And you say here, clearly, in 2016, you imposed the removal on her by the doctors -- you imposed the removal on her because of the doctors imposing it?
POWELL: Yes.
LANGDALE: Okay. That can go down, thank you. The grievance procedure now. We know you were interviewed by Dr Chris Green and that, if we can go to it, INQ0002879, page 37. 0037. You say "LL switches" -- in the box at the bottom: "... switches from days/nights to suit the unit. She's so amenable and flexible. One of my best nurses. Was also a student in the department. Quiet but diligent. Her practice is second to none."
POWELL: (Nods).
LANGDALE: "Compared to part-timers, full-time staff working overtime are going to be higher commonality. "I met with Letby. She asked if anything had come from the review. I told her she was a commonality. She didn't seem concerned as she was full time plus overtime. If you are allocated a baby, no other staff should touch the baby without your permission." That is exactly what Nurse W told you Letby had done in relation to Baby C [Child C], wasn't it?
POWELL: Mmm.
LANGDALE: Why didn't you tell them that?
POWELL: Why did I, sorry?
LANGDALE: Why didn't you tell them that on the grievance? But now I mention it, you bothered to mention that you shouldn't touch another baby without permission, but you didn't say "But I know that she did that" on the grievance you didn't mention that extra --
POWELL: But I didn't know that she had done that. I had done, what -- that I hadn't -- was that she was caring for the baby that she should have been caring for in Nursery 3, but I was unaware of the one where she was looking or interfering, as you said, for Baby C [Child C].
LANGDALE: Where was she going to be if she wasn't looking after the baby she was looking after?
POWELL: But I gathered if it's Nursery 3, it is not an ITU or high-dependency baby.
LANGDALE: The question is the same. Where would she be if she wasn't looking after the baby she was supposed to
be looking after?
POWELL: Where wouldn't she be?
LANGDALE: Where would she be? She would have to be looking after a different baby, wouldn't she? If she wasn't looking after the one she was allocated to, she would have to be looking after someone else's?
POWELL: Yes.
LANGDALE: So the very thing you point out that it's important not to do, you knew at the time you were having the interview she had done that. So why not point that out as well?
POWELL: I don't know. I mean, in, in the greater scheme of things that was hopefully an isolated incident.
LANGDALE: So you assumed it was a one-off and not worthy of mentioning?
POWELL: It's not that it wasn't worth. It's just that it's trying to see if there's a pattern in that respect and if there was then it would be documented on her profile.
LANGDALE: Moving down. At an urgent meeting -- the dates, I don't think it's 16 May, but at that meeting that a number of witnesses are giving evidence about, regarding the downgrading of the unit you say: "Stephen Brearey alluded to Letby being
responsible. I told him not to as it wasn't his place. Jim McCormack stood up, pointed to EP, and said 'You are harbouring a murderer'." First of all, is that what you say happened?
POWELL: Sorry?
LANGDALE: What do you say happened at that meeting? Did Jim McCormack say that?
POWELL: I heard him -- well, that is my interpretation of the meeting.
LANGDALE: Tell us -- were you at the meeting?
POWELL: Well, yes.
LANGDALE: So what did you hear him say and where were you when he said it?
POWELL: That's what I heard him say to me.
LANGDALE: How far away was he from you?
POWELL: It wasn't a very big desk, it was perhaps from there.
LANGDALE: And you say -- tell then that he pointed to you and said, "You are harbouring a murderer"?
POWELL: Yes, but he doesn't remember that.
LANGDALE: No. He says that in response to Dr Brearey who was raising concerns about a nurse on the unit, that he said, "Are you saying that a nurse on the unit is murdering babies?" That's what he said.
POWELL: That is what he said, yes.
LANGDALE: Could he be right about that?
POWELL: I heard him say what he said. Like I said, I -- I remember when it's traumatic, I remember when somebody is shouting at me and I remember when somebody is also screaming at me.
LANGDALE: Screaming?
POWELL: He wasn't no, but from a previous example.
LANGDALE: Dr V screaming?
POWELL: Yes.
LANGDALE: Upset?
POWELL: Yes. Well, yes. Steve.
LANGDALE: "Stephen Cross is ex police and he said they'd have no evidence. If they put it together it would be looked at." What did you understand if Stephen Cross said that, he meant by "if they put it together"?
POWELL: What, what did I think he means?
LANGDALE: Yes, did he say "put it together"? He said, "If they put it together it would be looked at."
POWELL: There would be no evidence, said Stephen Cross.
LANGDALE: So you understood Stephen Cross to be saying even if you put it together there would be no evidence?
POWELL: Yes.
LANGDALE: Are you sure about that?
POWELL: No. That's the interpretation but that he had been actually discussed with Stephen Cross and they said that there was no evidence.
LANGDALE: Did you ever have a discussion with Stephen Cross?
POWELL: No.
LANGDALE: Right. So that is what you had heard, was it?
POWELL: Yes.
LANGDALE: So this is hearsay?
POWELL: Yes.
LANGDALE: Whereas Dr McCormack, you say you were present and that's what was said. You say also: "Ravi Jayaram was heard by a nurse in outpatients, when asked if anything had come from the review, to say somebody is causing these deaths on this unit." That nurse has said that what she heard was Ravi Jayaram saying: "Just because they haven't found anything doesn't mean there isn't something to find", or words to that effect. That's that nurse's evidence. Not that he said somebody is causing these deaths on this unit. Did you hear this or is it, again, hearsay,
something that you had been told?
POWELL: I believe that nurse actually spoke either to myself or Yvonne.
LANGDALE: So did she speak to you about that?
POWELL: I can't remember if it was me but I -- I recall that particular nurse telling, telling me or Yvonne that. I can't remember which one. But either way, it came back to the fact that she had overheard them discussing it in the clinic.
LANGDALE: Who had overheard?
POWELL: Nurse T.
LANGDALE: Well, that's not the evidence she's given here.
POWELL: Oh.
LANGDALE: And to be fair to you, Ms Powell, the nurses giving evidence generally describe you as a supportive manager. Nurse T describes feeling bullied and intimidated by you.
POWELL: Yes.
LANGDALE: And I think there's also a suggestion that you had favourites. I don't know if that is from Nurse T or another nurse. But, what do you say about that? Did you ever bully or intimidate people on the unit?
POWELL: No, I didn't. I didn't bully anybody.
I supported everybody equally. I was one of those people that -- I didn't go out on many staff dos because I needed to keep objective about the staff because things would get, get said outside, and you can't run the unit when you are running too close.
LANGDALE: I think Dr Holt gave evidence she went to a retirement party of yours or a Christmas party. She thought it was 2016, but realised it may have been 2017; that's when you retired?
POWELL: Yes.
LANGDALE: There was a Christmas party then when Letby came and some of the doctors; yes?
POWELL: Yes.
LANGDALE: Was that a strange situation in 2017?
POWELL: I couldn't have done it.
LANGDALE: If you were who?
POWELL: If I were her.
LANGDALE: If you were Letby?
POWELL: Yes, I couldn't have done that.
LANGDALE: So she came. And was it your retirement or a combined party?
POWELL: Well, the -- it was a Christmas do, but I didn't want a retirement. So we agreed that it will be fine if I went just for the retirement bit.
LANGDALE: Do you know who invited her there? When you
say you couldn't have done it, were you in charge of the invites?
POWELL: I didn't -- no, no. The Christmas party was already --
LANGDALE: Right.
POWELL: But Lucy had actually asked would it be all right if she came and I said, "That's entirely up to you."
LANGDALE: You also say going back to this grievance interview: "Because you are good at your job you get in the position of looking after the sickest babies. LL will question Registrars or Consultants and will call and say if she wants them to look at the baby now if she has any concerns. She will Datix herself and even close colleagues." Again, as far as you knew in relation to the specific babies, the babies who had died, they were not sick babies, were they? So --
POWELL: Well, the potential is there.
LANGDALE: But that's not the question. The potential may be there.
POWELL: Yes, otherwise they wouldn't be on the unit.
LANGDALE: Well, they can be there because they are born early, need feed support and some help along the way.
POWELL: Yes. But also they can have underlying conditions that you are not aware of.
LANGDALE: But do you see the point that, once again, you are generalising as part of this grievance process and saying: she looks after the sickest babies, these are premature babies, it's all coincidence, there's nothing in it. It's not that you are just not saying there is no evidence. You are actively saying why she cannot have done this. Do you see the difference?
POWELL: Yes.
LANGDALE: What do you think about that now?
POWELL: Well, looking back at it, it looks obvious. But -- with hindsight, it looks obvious.
LANGDALE: You say, finally from me, in reflections, paragraph 261: "I remained open minded about potential factors which could have contributed to rise in deaths. I participated in the various reviews undertaken and there was no information arising from the review work to indicate that there was an issue with Letby. As the unit manager, I was used to managing staff and challenging them when issues arose and had there been anything more than a gut feeling ... I would have immediately addressed this."
Do you think you were able to challenge, when there were concerns raised about Letby or comments she had made, that you were able to challenge her and address the things --
POWELL: Well, I have done it on numerous -- well, not numerous -- on a few occasions; not with Lucy. I did it with others and as I mentioned before, you know, they didn't like it and, and left.
LANGDALE: When you say "gut feeling", what do you mean by that?
POWELL: Well, this is what Dr Brearey said; that he had a gut feeling.
LANGDALE: And you said earlier there was an aura. It had an aura. We know --
POWELL: Well, yes, you always have that aura, you know, if things had gone well or not and it's like: Oh, it's very quiet, the staff are quiet. But that would be through and through. That's not just for that area, that time frame. It could be like today I would go and it would be different and then the next day you would go and you think: Oh, there's that sort of subdued quietness about the place.
LANGDALE: A gut feeling can amount to a suspicion, can't it? A suspicion, I don't know why but something doesn't
feel right. It's suspicious?
POWELL: Mmm.
LANGDALE: So you knew they had a gut feeling, or I am going to say suspicion, of something was going wrong and she was --
POWELL: Yes.
LANGDALE: -- associated with it. Is that fair?
POWELL: Yes.
LANGDALE: And don't say it if it's not. Is that fair?
POWELL: It is.
LANGDALE: You understood "gut feeling" meant suspicion?
POWELL: Yes. That was Dr Brearey's gut feeling.
MS LANGDALE: Thank you, I have no further questions, Ms Powell. My Lady, I think this is probably the best time to take a break so that others asking questions afterwards can go in sequence.
LADY JUSTICE THIRLWALL: Very well. So we will take a break and start again at 25 past 3. (3.08 pm) (A short break) (3.25 pm)
LADY JUSTICE THIRLWALL: Mr Skelton.
MR SKELTON: Thank you, my Lady.
Ms Powell, I ask questions on behalf of one of the families groups?
POWELL: Sorry?
SKELTON: I ask questions on behalf of one of the groups of families?
POWELL: Okay, thank you.
SKELTON: Can I just ask you briefly about [Child A] and [Child B], first of all, please.
POWELL: Yes.
SKELTON: You told Ms Langdale earlier that you were not aware of the rashes and mottling that were found on those children as they collapsed and one of them died, is that correct?
POWELL: Yes.
SKELTON: So would it be right that you weren't aware that Mother A was asked by one of the doctors to photograph [Child B] and her rash? You weren't aware of that either?
POWELL: No.
SKELTON: Were you aware of any communication with the parents of A [Child A] and B [Child B] about the rashes?
POWELL: I don't recall any, any rashes at the time. Mottling, I do, more so, but rashes no. And certainly not rashes and mottling.
SKELTON: What were you aware of in relation to mottling?
POWELL: Well, only that mottling can be a precursor to sepsis or hypoglycaemia or a cold -- a cold injury, but not in the context of the children.
SKELTON: So nothing in relation to A and B?
POWELL: No.
SKELTON: So far as [Child A] is concerned, the first death, were you aware that his death was unascertained throughout 2015 and 2016 and indeed right up to and including the Inquest into his death?
POWELL: Was, sorry?
SKELTON: Unascertained?
POWELL: Oh, unexplained. Yes.
SKELTON: Mother A and B didn't get the chance to hold her son in her arms before he died and that is a source of enormous regret and upset to her. Do you recognise how unfortunate that is?
POWELL: That's awful.
SKELTON: And every effort should be made to allow a parent to hold their baby, even for the briefest of times before they die?
POWELL: Which is as practice should be. That's how it should be.
SKELTON: Can you explain why that might not have happened in her case?
POWELL: No, I don't. There's no excuse for that.
SKELTON: Some of the parents, Father N for example, if you want to refresh your memory about [Child N], some of them such as Father N has expressed the view that he didn't feel like he was treated as the parent of his own child in the sense of being able to hold the child and involve himself with him. That, again, is quite unfortunate if that is a parent's view of what occurred?
POWELL: Yes.
SKELTON: It should be that the parents are allowed to hold their children are encouraged to do so?
POWELL: Exactly.
SKELTON: There is also a sense on part of some parents that there was a lack of communication about the collapses of their children. So the mother of [Child N] wasn't aware initially that her child had collapsed and suffered a serious collapse -- as it turned out it was an attempted murder, but she wasn't told about it at the time?
POWELL: No.
SKELTON: Again, do you think parents should be told if their children --
POWELL: Well, they are supposed to. The -- it's understandable that if -- while the doctors are actually
stabilising an infant or putting them on a ventilator or that there has been a collapse in place, once that child is stable, normally, normal practice is that the doctors go to update. Failing that, the nurse should actually undertake it. So there's -- there should be no excuse why they didn't. They should have been.
SKELTON: So the only excuse might be a practical one in that the staff are fully engaged in resuscitation?
POWELL: Exactly.
SKELTON: But beyond that period?
POWELL: No excuse at all. Updating is part of one of the BadgerNet's data set, it is updating parents, and it's, it's held in high practice that that is the way that you are supposed to do it.
SKELTON: Another theme of some of the parents' evidence, particularly the children that died, is that they were offered the possibility of speaking to a priest or saying a prayer or some other form of religious --
POWELL: Yes.
SKELTON: -- action before they even knew that the child was going to die. In other words, before a healthcare professional had told them the child was in a perilous condition, somebody spoke to them about that and by
definition that would have made them incredibly fearful and distressed; do you recognise, again, that that shouldn't happen?
POWELL: It is part of admission process that if a child is deemed to be unstable, or expected -- I mean, as, as the case may be that isn't the issue here, but on the admission page asking for permission for baptisms so that we have an idea of what is important to them. But it's got to be timed appropriately and obviously not in this case, if it was the case.
SKELTON: And in this case it's not just baptism, it is, "Do you want to speak to a priest?"
POWELL: Yes.
SKELTON: "Do you want to say a prayer?" But before the parent even knows that their child might die?
POWELL: That they're that unwell.
SKELTON: That shouldn't happen, should it?
POWELL: No.
SKELTON: After Mother A was discharged from hospital, obviously she left hospital having lost one of her twin children, her son, but with another child still in the unit, they were both being cared for obviously, as you know. She felt afterwards -- obviously going back to the unit was particularly distressing for her because for most parents they will leave the unit after their child has died and probably never want to go back but for her she had to go back again and again. She didn't feel that the staff recognised or empathised with her for that. It's admittedly an unusual situation but one which was acutely difficult for her. Again, that was most unfortunate, wasn't it?
POWELL: They should -- I mean, it doesn't -- you don't have to be particularly experienced to know that and it's part of a bereavement package anyway, that, you know, a lot of parents have lost one of their children and have to come back. I mean, it constitutes PTSD, it's so traumatic. It's -- I can't believe that the staff didn't know that.
SKELTON: So you agree then, she should have been treated with the utmost sensitivity particularly if she wanted to spend time with her other child?
POWELL: Exactly, yes.
SKELTON: A final specific issue is about private messaging. Ms Langdale asked you a bit about private messaging. In respect of the parents of [Child N] again, they are particularly concerned that Lucy Letby and Dr U engaged in private messaging on a personal form of messaging, so not the professional WhatsApp that you have discussed, but a private form of messaging about their child. And they think that just simply should not
have happened.
POWELL: No. It shouldn't.
SKELTON: How do you think it was -- it came about that one of your nurses was engaged in that kind of discussion with a doctor?
POWELL: Well, I wasn't -- I mean, it was only subsequently was I aware that that was ever going on. But I was always fearful of -- of mobile phones, WhatsApp group. Unless you have got an invigilator or somebody that actually is overseeing it, it's open to abuse especially in the NHS. Anywhere else might be considered okay. But certainly not in the NHS.
SKELTON: And there are obvious issues, aren't there, with privacy --
POWELL: Yes, exactly.
SKELTON: -- and the private nature of that information? Can I turn, then, to some general matters, please. I think you have accepted with Ms Langdale that it's doctors who have the primary responsibility for diagnosing patients and deciding what medical treatment they require --
POWELL: Yes.
SKELTON: -- in a hospital setting and elsewhere. Of course, nurses routinely assist with diagnosis and will triage patients and so on who come into the hospital,
but they ultimately defer to doctors when it comes to diagnosis and treatment?
POWELL: Yes.
SKELTON: It's also right, I think, that nurses can confirm or verify deaths but they can't certify them or determine them?
POWELL: (Nods).
SKELTON: In other words, it is not for a nurse to say this caused the death; that is ultimately for a doctor to determine or, in some cases, a Coroner.
POWELL: Yes.
SKELTON: Correct?
POWELL: (Nods).
SKELTON: Dr Brearey, who you worked with very closely, was a highly respected senior doctor --
POWELL: Yes.
SKELTON: -- with many years of caring for extremely sick children. There isn't any suggestion that he was in any way incompetent, is there?
POWELL: No.
SKELTON: Or that he had a history of raising unfounded concerns or allegations about colleagues?
POWELL: No.
SKELTON: There's also no evidence, certainly that this Inquiry has heard, that he was generally thought of as
being vindictive towards members of staff, whether nurses or other doctors?
POWELL: No.
SKELTON: And there is no suggestion that he had a personal dislike of any particular members of staff for any reason?
POWELL: Oh, maybe. But that was somebody -- yes, it's a clash of personalities.
SKELTON: Well, is it something that caused any concern to you?
POWELL: No.
SKELTON: He's repeatedly been spoken of as someone who is respectful of nurses as were all the Consultants?
POWELL: Yes.
SKELTON: And indeed respectful of his junior doctors, correct?
POWELL: Yes.
SKELTON: And as far as the Inquiry has heard, there is no evidence that either he or any of the other doctors had a personal dislike of Lucy Letby.
POWELL: Sorry?
SKELTON: There is no evidence that he or any of the other doctors had a personal dislike of Lucy Letby prior to the concerns --
POWELL: No.
SKELTON: -- about her harming children. Neonates generally, you are obviously extremely experienced at caring for neonates and have done so for -- how much of your career?
POWELL: Since 1982.
SKELTON: Many, many years?
POWELL: Yes.
SKELTON: Decades. They are highly vulnerable --
POWELL: Yes.
SKELTON: -- patients for obvious reasons. They are extremely small. Many of them will be premature. Many of them will have quite serious conditions that you are dealing with, and they can be suddenly caught up in sudden events because of their vulnerability.
POWELL: Yes.
SKELTON: So that you do see neonates deteriorate suddenly. Ms Langdale asked you about the difference between expected and unexpected events. Most of the time when neonates deteriorate, there is a reason for it --
POWELL: Yes.
SKELTON: -- that is medically identifiable by you a nurse, or by a doctor. In fact, overwhelmingly that is the case?
POWELL: (Nods).
SKELTON: You need to say "yes" for the transcript.
POWELL: Yes.
SKELTON: What is different in this case is that there isn't a medical explanation immediately for the deteriorations, they are unexpected. In other words, the doctors and the nursing staff weren't expecting stable neonates to suddenly collapse and require resuscitation and certainly not to die and that is a common factor between these deaths, isn't it?
POWELL: Yes.
SKELTON: And I don't know whether you have followed the earlier evidence of some of the doctors who have given evidence. Did you follow the evidence of Dr McGuigan, for example?
POWELL: No.
SKELTON: You know who Dr McGuigan is?
POWELL: Yes.
SKELTON: He came in relatively late.
POWELL: He did.
SKELTON: He is a new Consultant to the unit and he made it clear that it was extremely concerning, in his words, that children would unexpectedly die without explanation.
POWELL: (Nods).
SKELTON: It is extremely concerning, isn't it?
POWELL: Yes.
SKELTON: Just pausing on the unexpected nature of things. If a child unexpectedly collapses would you expect a Datix to be completed for them?
POWELL: Well, yes, but if it needs resuscitation it would do.
SKELTON: So any child that collapses requiring resuscitation --
POWELL: Yes, I mean, a lot of children, especially if they are on a ventilator, sometimes the tube needs changing and would require resuscitation, but if they normally recover with bagging and masking, using the bag and mask, and actually oxygenate, usually that is all that is required. But these went on to full, full resuscitation and then failed resuscitation.
SKELTON: So in those cases where the children didn't die but they require resuscitation the Datix should have been completed?
POWELL: Yes. Yes.
SKELTON: As a senior nurse you are obviously well placed to recognise or identify deficiencies in nursing care so, for example, the wrong drugs being administered?
POWELL: Yes.
SKELTON: Inadequate observations, failure to respond to
a deteriorating child, failure to escalate, all of those things are squarely within your expertise, is that right?
POWELL: Yes.
SKELTON: What isn't in your expertise, as I think you have agreed, is diagnosis and identifying causes of death?
POWELL: Yes.
SKELTON: So you needed to defer to your doctors, your Consultants about that?
POWELL: Yes, and the Coroner, yes.
SKELTON: Sorry?
POWELL: And the Coroner.
SKELTON: And the Coroner?
POWELL: Yes.
SKELTON: We have seen on the screen a number of times now a table of the children which you compiled in which you list their deteriorations and deaths and, of course, we know that Lucy Letby is on that column on the far right. I am not going to ask about her at present but just the causes of death. In many cases, in fact in each case, there were possibilities being discussed. So in some cases sepsis, NEC, in [Child A]'s case there was a possibility that the mother's condition might have affected the child, all of those are possibilities but there wasn't a direct and probable cause of the deaths, was there?
POWELL: No.
SKELTON: So in each case what was worrying about them was that you didn't know why they had died?
POWELL: No.
SKELTON: As I understand it, you yourself never investigated the deaths and causes of deaths and indeed that wasn't your job?
POWELL: No.
SKELTON: Had you investigated the deaths, it might have been possible that you could have seen the commonality between some of them. So you are very familiar with the rashes that many of the children had, which we now know is associated with air embolism, and you will also be familiar that two of the children, [Child F] and [Child L], had unusual insulin C-peptide results, which were in the notes but hadn't been spotted. Had you seen that would you as a nurse have known that was unusual, that children appeared to have been given high doses of exogenous insulin, non-internal insulin, which they shouldn't have been given?
POWELL: I -- well, I personally wouldn't have been in that position to investigate it. I guess even the -- it was -- it would be a supposition if, if I -- I wouldn't
be in that position anyway to do that.
SKELTON: That would be for the doctors?
POWELL: Yes. And even on the deep dive that would be something that, that would be evaluated and assessed.
SKELTON: Were you aware, though, that the -- taking the deaths across apiece, and there were many of them throughout 2015, as you know, and then into 2016, that there hadn't been a full investigation of all of them to determine all the causes of death and any common factors between them, were you aware of that?
POWELL: Other than the commonality? I thought they had -- Dr Brearey had done a deep dive.
SKELTON: Well, he had done a deep dive but in fact he didn't identify all the causes of death, as I think you have accepted. So [Child A], for example, never had a cause of death ascertained. It was always possibilities.
POWELL: Right.
SKELTON: Were you aware of that?
POWELL: That there was a possibility of?
SKELTON: That across the piece --
POWELL: Yes.
SKELTON: -- a full review of all the deaths to identify why the children had died and whether there were common causes in respect of them had not been done?
POWELL: No.
SKELTON: And, indeed, it might have required something extra than a clinician looking at them?
POWELL: Yes.
SKELTON: It might have needed pathology evidence, for example?
POWELL: I think, yes, I think Dr Brearey contacted the Coroner regarding pathology.
SKELTON: He did and [Child A], for example, had a post-mortem or a pathology examination and again the pathologist couldn't find a cause of death either. But none of them, I think, had a forensic pathology check, did they?
POWELL: I think a few -- a couple did but ...
SKELTON: I may be corrected on that, but overall --
POWELL: Okay.
SKELTON: -- for most of them, those extra investigative steps weren't taken?
POWELL: Yes.
SKELTON: You then, just taking that, putting it all together, you weren't clear about the causes of death for these children, the doctors were concerned about that there was a pattern of deaths which was highly unusual in terms of each death was unusual --
POWELL: Yes.
SKELTON: -- and a high number of them was unusual, and you weren't in a position to rule out unnatural causes, personally?
POWELL: Mmm.
SKELTON: You couldn't, could you?
POWELL: No.
SKELTON: You said earlier, and I think you say in your statement that you were aware of Beverley Allitt?
POWELL: Yes.
SKELTON: Everyone was aware of Beverley Allitt?
POWELL: Yes.
SKELTON: She was national news. Were you also aware of Victorino Chua?
POWELL: Of who, sorry?
SKELTON: Mr Chua, a nurse --
POWELL: In a local hospital?
SKELTON: Yes, not far away, Stepping Hill.
POWELL: Yes, yes.
SKELTON: Were you aware of the recommendation that came out of the investigation or Inquiry into Beverley Allitt's murders by, it was called the Clothier Report or the Allitt Report. One of the recommendations, I will just read it to you.
POWELL: Yes.
SKELTON: Was that her actions should serve to heighten awareness in all those caring for children of the possibility of malevolent intervention as a cause of unexplained clinical events. You have been in practice a very long time, I think you probably were in practice around Beverley Allitt being in post?
POWELL: Yes.
SKELTON: You were certainly there when Victorino Chua was there, and of course Harold Shipman. Had it got into your consciousness, as a senior nurse, that this could happen?
POWELL: Well, yes, we discussed it.
SKELTON: Who?
POWELL: Myself and my colleagues, Yvonne Griffiths and Yvonne Farmer and Anne Murphy.
SKELTON: When did you first discuss it?
POWELL: Oh gosh, we discussed it because it was -- Dr Brearey was suggesting it was a gut feeling and we were trying to sort of establish, well, are we looking everywhere and just I mean across the board, what are we missing?
SKELTON: Can you try and pinpoint when that discussion took place?
POWELL: It was, it was all the time.
SKELTON: From June '15?
POWELL: Maybe not, maybe just after then. But I would be guessing.
SKELTON: I think [Child E] is August 2015 and [Child I] is October 2015; would it be around that time?
POWELL: It is more likely to be when we realised this wasn't just a peak.
SKELTON: Were you aware that some of the children that Beverley Allitt harmed, at least, she'd used insulin, it would appear?
POWELL: Yes, yes.
SKELTON: And obviously Nurse Chua had used insulin as well?
POWELL: Yes.
SKELTON: Did you think to try and exclude that possibility with the children on your unit?
POWELL: Well, we had had ours in a locked, in a locked fridge.
SKELTON: But a locked fridge to which nurses had access?
POWELL: They did but they had to have the keys from the shift leader.
SKELTON: Did you check who had had access to the fridges?
POWELL: Not without them signing their names for it, no.
SKELTON: Did you ask the doctors to think about whether insulin might be a possibility and look at the notes because you weren't qualified to --
POWELL: No.
SKELTON: No?
POWELL: No.
SKELTON: So you thought about it but didn't actually investigate it?
POWELL: No.
SKELTON: You conducted what's called a neonatal or you call it a neonatal review in May 2016 and we have seen that document. I won't call it up on screen unless you want to see it. Why did you produce that document?
POWELL: Which one was that one, sorry?
SKELTON: We will put it on screen. INQ0003243. Do you remember it?
POWELL: Yes.
SKELTON: Why did you produce it?
POWELL: It was trying to internalise all the information, trying to put out there everything that I knew to try and, I suppose it's just trying to put out there that -- the thought process really, well, it's trying to put it in sections to try and see if anything would come out.
SKELTON: But you must recognise and you have recognised in answers just now that you hadn't investigated the deaths?
POWELL: No.
SKELTON: And in many cases the causes of actual death were not known?
POWELL: No.
SKELTON: And you have also recognised that the possibility that someone was harming children was a real one?
POWELL: I did, yes. But I didn't feel that there was anyone that fit that bill at that time.
SKELTON: Were you expecting a particular presentation or --
POWELL: I don't know.
SKELTON: -- demeanour from a potential murderer?
POWELL: I just don't expect people to behave that way.
SKELTON: Of course not. Hardly anyone does. But that's the whole point of the Allitt recommendation, is to think that somebody might do and to identify that person --
POWELL: Yes.
SKELTON: -- in circumstances where the other possible factors have been excluded. The key, Ms Powell, was that you had senior doctors coming to you with concerns and they couldn't find medical causes for these children's deaths but they had found a common factor. That should have been enough to make you suspicious that these babies were being harmed, shouldn't it?
POWELL: On reflection, yes.
SKELTON: What is odd about the communications at this time is that no one says the word "murder" or "killing". Was there a sort of reticence about even confronting the possibility that this could be happening to you and your colleagues?
POWELL: Well, yes we did. We considered it.
SKELTON: Well, you considered it, what it looks like is you dismissed it?
POWELL: We considered it yes, and we said it can't possibly be, it must be a commonality.
SKELTON: But how could you rule that out without investigating the deaths?
POWELL: It was only that we were saying -- we put in that this is what, you know, she was there often, she was full time, she worked overtime. There were no problems with her in respect to being at Liverpool Women's or for her induction or her -- what's it called? -- induction and the QIS course. So there was no -- nothing to suspect. The colleagues hadn't said
that there was anything to suspect.
SKELTON: But why would there be the kind of signs of obvious murder that you were expecting to see?
POWELL: I don't know.
SKELTON: Why wouldn't the murderer, whether it is Lucy Letby or anyone else, have tried to operate secretly and covered their tracks?
POWELL: It's very difficult in a neonatal unit to do anything secretly.
SKELTON: Well, it isn't, is it?
POWELL: Obviously not.
SKELTON: I mean, it actually isn't. These babies were murdered and no one noticed. You were not in a position, were you, to rule out the possibility --
POWELL: No.
SKELTON: -- that the children had been murdered, and you were certainly not in a position to rule out Lucy Letby's involvement in that murder, were you?
POWELL: No.
SKELTON: And the fact is that you didn't actually, as a manager, need to take a position, did you? You could have simply said, "This is an extremely serious allegation. My babies, who I am responsible for as a manager and a nurse, may have been harmed. I need to ensure that they are -- they and their families get the
answers they need and as importantly I need to ensure that all babies coming onto this unit are safe."
POWELL: Yes.
SKELTON: That was your responsibility and if you could not exclude the possibility that they were murdered then you failed in that responsibility, didn't you?
POWELL: Yes.
SKELTON: You were asked about the police earlier in your evidence. I appreciate that you are not alone in this, Ms Powell, and that matters were escalated above you to your Nursing Director and further up into the Medical Director and the Chief Executive, and that steps were not taken immediately to intervene. But you recognise now that if professionals, when the professionals raise suspicions that couldn't be excluded and that were not obviously malicious, that the police needed to be called?
POWELL: Yes.
SKELTON: And that should have happened as soon as those suspicions were articulated; is that right?
POWELL: Yes.
MR SKELTON: Thank you.
MR BAKER: My Lady.
LADY JUSTICE THIRLWALL: Just a moment.
MR BAKER: Yes.
LADY JUSTICE THIRLWALL: Are you all right to continue? Do you want to have five minutes?
POWELL: Okay.
LADY JUSTICE THIRLWALL: See how we go and if you want a break we will take one. Mr Baker.
MR BAKER: Thank you, my Lady. My name is Richard Baker. I ask questions on behalf of two of the groups of families. The question you were asked by Mr Skelton, just now, was that the moment suspicions began to be raised, about the possibility that there was a murderer on the ward, the only appropriate thing to do was to call the police?
POWELL: Yes.
BAKER: Your answer to that was "yes"?
POWELL: Yes.
BAKER: Can I ask a few questions directed towards why that didn't happen, from your point of view?
POWELL: Yes.
BAKER: You were asked some questions about a complaint by Nurse W following the death of [Child C] and those questions were directed towards why you didn't act or whether you did act, but what Nurse W said to you in terms was that Letby had behaved in a very, very unusual way following [Child C]'s death, that she had spent all her time in and out of the family room focusing in on the family who were caring for their dying child --
POWELL: Yes.
BAKER: -- which was a job which was to be done by a different nurse, was being done by a different nurse, and in doing that she put the life of another baby at risk. That is what was said, wasn't it?
POWELL: Yes.
BAKER: And that that baby, the other baby's condition deteriorated during the course the night and the care needed to be escalated the following morning and that Nurse W had told Letby to pay particular attention to this child because she was worried about it; yes?
POWELL: Yes.
BAKER: And that Letby had ignored the instructions of Nurse W, a senior nurse, over and over again about this and made Nurse W very angry?
POWELL: (Nods).
BAKER: The thing is you did nothing at all about that, did you?
POWELL: I don't recall. I would have documented something surely in her, in her.
BAKER: HR file?
POWELL: Yes. And it's not -- I don't think it's there anyway.
BAKER: No.
POWELL: So I just don't recall it. I recall Nurse W speaking to me about it and I discussed it.
BAKER: You remember speaking to her about it.
POWELL: Yes.
BAKER: Now, this is quite a serious thing to happen, isn't it?
POWELL: Yes.
BAKER: It is not a trivial thing and it warranted action on the level that was taken in response to the morphine incident, didn't it?
POWELL: It's different.
BAKER: Well, is it really that different? I mean, leaving unsupervised a patient who your senior nurse has told you to keep a particular eye upon --
POWELL: Yes.
BAKER: -- in order to do something that is being covered by other people and has no real patient safety issue?
POWELL: Business being with her, no.
BAKER: Can I suggest the reason you didn't do anything about it and if you had done something about
it, it would be documented. The reason you didn't do anything about is that Letby was a particular favourite of yours?
POWELL: Not at all, I don't have favourites, at all. I don't, I didn't. There was nobody on the unit that I favoured. That wasn't part of who I am. I don't have favourites.
BAKER: You see, doesn't this exact same thing happen in 2013 when we have the morphine --
POWELL: Yes.
BAKER: -- and the pump incident, that a different nurse tries to take appropriate steps in order to make sure that Letby is safe and that they are countermanded by you and Letby is allowed to go on back to normal practice?
POWELL: But it was with adjustments.
BAKER: You see, I suggest it wasn't with adjustments.
POWELL: Yes.
BAKER: That Letby's text message, which you were taken to, is quite clear that she was allowed to go back to things being normal.
POWELL: Well, that's -- that was her interpretation as it was her interpretation with the other reflection that she did. It's not quite as it was.
BAKER: So you are saying her text message was a lie?
POWELL: I am saying it is her perception of what it is.
BAKER: There is no documentation, is there, to suggest that Letby was kept on reduced duties with regards to medication?
POWELL: No, but what she was meant -- I mean, maybe I should have been clearer on the one-to-one; that she was to continue as she was with not additional fluids, fluids that come up from pharmacy that are just actually put, attached, they are changed -- the bags are changed, to the fluids that go into the line. But the IVs, they come up from pharmacy and you attach them to the three-way tap or the other line, that is different. Then she would have to have somebody else to do that, but the IVs are different. They are just saline IVs with --
BAKER: But your note, with the one-to-one inquiry, is quite clear that there is no reference to restrictions with controlled drugs or using morphine in a syringe driver?
POWELL: No, but the controlled drugs were checking the drugs in the pharmacy room, where the drugs are kept, checking them with the nurse.
BAKER: There is no reference to her having restrictions on her practice within that note. You were taken to it by Ms Langdale.
POWELL: I don't know -- sorry, I don't understand.
BAKER: The one-to-one supervision you provided?
POWELL: Yes.
BAKER: The note that you wrote of that one-to-one supervision makes no reference to restrictions on Letby's practice. Now, you are saying there were restrictions but the note makes no reference and Letby's own text --
POWELL: Yes.
BAKER: -- suggests she was allowed to go back to things being as they were. You seem to have a very specific memory of this --
POWELL: Yes, well maybe --
BAKER: -- but a very defective memory of --
POWELL: Yes, you could be right.
BAKER: Can I take you to an email that you sent in June 2020. It is INQ0003527. If you could scroll to the next page, please, just so you can see the email that prompted this. You are receiving an email here from the Countess of Chester Hospital regarding an investigation that is being carried out by an organisation called Facere Melius, into neonatal death from 2014 onwards. I can take you to the letter that's attached to it
if you like --
POWELL: Yes.
BAKER: -- but that is what it says. And you are being invited for an interview as a number of members of staff were regarding incidents at this time, so between 2015/16 onwards. Your response to that email, if we can scroll up to the previous page, is: "It has been six years since the beginning of the relevant time frame. I regret to say that my recollection would and is problematic at the best of times I would not feel confident in any relevant recall for your review."
POWELL: Yes.
BAKER: Now, again, is that you -- is that a response that's given in good faith given that a year later you give a very detailed interview for the police?
POWELL: (Redacted).
BAKER: You don't need to give details about that.
POWELL: Okay, but they will actually -- I had to be -- (redacted).
BAKER: Do you think it's fair though to say that you had a particular bias towards Letby?
POWELL: No.
BAKER: Your evidence to the counsel to the Inquiry is
that you didn't go out on staff do's in general --
POWELL: No.
BAKER: -- because you wanted to remain impartial?
POWELL: Yes.
BAKER: Could we go please to INQ0007482 and to page 68, please. Thank you. So this is an extract of a police interview that was given by you as part of Operation Hummingbird. Can you see about two-thirds of the way down, it says: "We went to London on an outing and Lucy was there."
POWELL: Yes.
BAKER: "What was that for?" "I think we went to see The Bodyguard."
POWELL: We did.
BAKER: So if we go down to the next page, we are attempting to pinpoint the date, you say, "Before 2015?", you were asked. And you say, "Yeah." And then you say, "I think it could be in 2013." So in 2013 you went on a trip with other neonatal nurses and Lucy Letby?
POWELL: Yes, there were a few of us there.
BAKER: To London to see The Bodyguard?
POWELL: Yes.
BAKER: Again, did you invite all neonatal nursing staff to accompany you on trips to London?
POWELL: To accompany me?
BAKER: Or just a select few?
POWELL: Sorry?
BAKER: Did you go on outings with all neonatal staff to London or just a few?
POWELL: Well, no, they were all -- it was, it was for everybody.
BAKER: It was for the entire department?
POWELL: Yes.
BAKER: You all went to see The Bodyguard?
POWELL: Yes, but we didn't all go, obviously, somebody has to stay behind to do the shifts.
BAKER: Then you talk about Lucy Letby at the bottom of the page: "I remembered them asking me what I thought of Lucy, you know, as a person and I said, 'Well, she's quirky'." If we go on to the next page. And you were asked: "I think it was in a meeting that Ravi asked me, he said, 'What do you think of her personality?' 'Well, she's quirky, but then, like, so am I quirky. So, well, actually if you went through the off-duty, through the list, we are all quirky and that is why it works'." Again, did you see a particular connection to Letby?
POWELL: Did I?
BAKER: See a particular connection to Letby?
POWELL: No. We are all different but we are all -- I think it takes a certain personality to work on the unit and yes, that's been quite evident. You know, over the years that I've been there, it's -- it is the quirky ones that actually survive the unit.
BAKER: This fits with the suggestion, though, doesn't it, you saw her as like yourself, that you were --
POWELL: No.
BAKER: -- she was a favourite of yours?
POWELL: Quirky is different from the norm as in perhaps sees things a little bit differently.
BAKER: You see, the fact of the matter is that when it came to Lucy Letby you favourited her, you gave her favourable treatment?
POWELL: No, not at all. Not in the slightest.
BAKER: If we look at how you behaved towards people you took a dislike to, if we look at page 92, please. So about halfway down, you say: "We had one member of staff that she was not safe and we had her gone within weeks. We had supervised" --
"Who was that?" "Oh, that was years ago, that was 2011."
POWELL: Yes.
BAKER: "Right? She had a first in a degree".
POWELL: Yes.
BAKER: "She was -- nobody failed her, nothing, everything was grand, yes. She came in and she wasn't doing something that was right and I said, Right, if she can't see that we will have to pull her right back and start again. Oh, she didn't like that. So she left. Great haha."
POWELL: Yes.
BAKER: What do you mean by "Great haha"?
POWELL: Well, she -- it was a parent that came to complain, came to the office and said that she hadn't given the child oxygen when they desaturated and that the parent had to take over from her. So when we went there to discuss with her, I got Yvonne Griffiths -- Yvonne Farmer to actually have a word with her about her dealing with desaturation and performance and that's what Yvonne did.
BAKER: Is that less serious or more serious than almost giving a baby a 10 times morphine overdose?
POWELL: Yes, but in the context of things of a whole unit, you can, there are so many drugs that are given
over a period of time, I mean, there is a picture on the website that shows how many lines that a baby can actually have and how much medication that child requires, and they have the minuscule amount over a tiny -- they will have micrograms given over a period of maybe 20 minutes, half an hour, over an hour, and it actually is -- it is extremely difficult to actually get it right all the time.
BAKER: No, it isn't, it is a very basic exercise in making sure you put the right figures in the syringe driver and if you get it wrong the baby dies.
POWELL: Well, yes, but what I am trying to say is in the context of doing medications, if you looked at other units and see what their medication, that's why they do guardrails, that is why they make a lot of money out of you using guardrails on the Alaris pumps, is because it actually helps those errors not happening. It only takes a lapse of concentration and when you have got things going on all the time and you are busy, it is very difficult.
BAKER: You see, you will make every excuse for Letby but this nurse was straight out the moment she made a mistake, wasn't it?
POWELL: But she didn't like being told that what she did was wrong.
BAKER: Yes, so there was a clash of personalities with you and she was gone?
POWELL: I didn't, I didn't speak to her. It was Yvonne Farmer that spoke to her.
BAKER: Was it -- did you find it particularly funny that she had to leave?
POWELL: No, I didn't.
BAKER: Why are you laughing --
POWELL: I just thought it was a relief that it was, just -- you can't have somebody who can't take the criticism.
BAKER: So why does it say, "Great haha" at the end of your quote at the top?
POWELL: It's taken ...
BAKER: I'm sorry, I couldn't hear that?
POWELL: It's taken it out of context. It's -- it's not "Great haha". It's great that it's not -- it's a relief that it's not a problem.
BAKER: You see, I suggest that when people make the observation that you had favourites and if you weren't a favourite, life could be made difficult for you, that's borne out there, isn't it?
POWELL: I don't think so. I think that is very unfair.
BAKER: How did you view the doctors, the relationship between doctors and nurses?
POWELL: It was very good. On the whole.
BAKER: Could we look at document INQ0003166. So this is a document you have already been taken to. It is an interview, a grievance interview that was conducted. If we could go to page 2 of that document, please. So the second paragraph at the bottom there, you are recorded as stating that you believe that Letby is 100% innocent. Now, you knew at the time of making that statement or your evidence today is at the time of making that statement you were aware that there had been an incomplete investigation and that there wasn't all the evidence available to you and that you felt slightly concerned about the quality of the investigation and, indeed, Lucy Letby's email saying she was coming back. Now, how does your evidence today fit with this statement, that you believed she was 100% innocent?
POWELL: Well, I couldn't believe that she had done it?
BAKER: That is a different -- an answer to a different question. Here you have expressed the view that Letby is 100% innocent.
POWELL: Yes.
BAKER: Yes. Further down in this document, forgive me a moment, so this is on page 4 of the document and it's the final box. So: "How would the Consultants respond to Letby coming back? "Not good. Equality doesn't run both ways. Brainwashed other Consultants." Who are you suggesting has brainwashed the other Consultants?
POWELL: Well, once somebody sort of suggests something, then it runs a bit like wild fire.
BAKER: Well, you are suggesting that Stephen Brearey and Ravi Jayaram have brainwashed the other Consultants; it is very emotive language, isn't it?
POWELL: No, I know, but at the time we didn't think that this was going to -- that I had to watch what I was saying and how I was saying it.
BAKER: Well, doesn't this tell us this much: that there are very clear battle lines drawn here between the doctors and the nurses and that you are very much in the camp of the nurses criticising the doctors?
POWELL: Well, no, not really. It was just there was double standards. The doctors were treated differently to nurses. We were told we couldn't do certain things,
doctors did them, and they actually carried on doing it.
BAKER: Well, do you think that, again, reveals a 'them and us' attitude towards staff who weren't nurses? You had that attitude and possibly still do?
POWELL: Well, no, because we had a good relationship, not all Consultants, I mean, we were lucky with our Consultants in certain respects but they did have their moments where they were allowed to scream and shout at the staff and it was accepted as, well, that's fine, he's a Consultant.
BAKER: Well, screaming and shouting about their concerns that one of your staff is a murderer --
POWELL: No, that wasn't just concerns, that wasn't it, he was a surgeon. This, this is different. The behaviour on the unit, on, with staff.
BAKER: Your evidence before the Inquiry is that you were a mediator, that you were somebody who was being objective, who was standing back, and this is the complete opposite, isn't it, you are very much shouting the odds on behalf of the nurses here, aren't you?
POWELL: No, I was answering a question. When they asked me what did I think, and I would say, well, there is the commonality, she does supernumerary, she works full time. I was being honest each time. Why would I lie? If I would have lied it would have made, made it
a lot easier.
BAKER: You see, Letby was protected because she occupied an intersection between two things: she was a nurse who was being criticised by the doctors and she was a nurse who you liked and that's why she was protected, isn't it?
POWELL: I think you are mistaking liking with actually supporting your staff.
BAKER: Can I go to suspicions and whether they were raised. You have been asked a little bit about this and I just want to clarify one point about an email. So it is INQ0025743. So this is an email you have seen already. It begins on the next page, or the email chain begins on the next page. It's an email from John Gibbs: "Rachel Lambie came to see me this morning, I think because I was the only person in the office and she says Registrars are very concerned about recent neonatal deaths from collapses ([Child B]) where all the infants showed strange purpuric looking rash." Now, this is a reference to concerns regarding A, B, C and D, isn't it, and if we go up to the next page, we can say -- I will reorientate myself on the screen -- we can see that there is an email from Stephen Brearey at 10.55 on 23 June, towards the bottom of the page: "Hi John and Liz I have reviewed [Child D]'s care with Eirian yesterday and looked to see if there are any common threads in the deaths." Were you made aware that the Registrars and, indeed, doctors were concerned about the deaths of A, C, and D but also the collapse of B?
POWELL: No.
BAKER: Are you sure about that?
POWELL: Well, not -- not that I can recall, no.
BAKER: Is a collapse in this sense not something that should also have been looked at in the context of the neonatal review that was carried out or begun and that you took part in, in October --
POWELL: Well, we subsequently did do that afterwards. But what -- yes, later than this.
BAKER: Yes, but when you were looking at events and you began your chart in October 2015, should that chart not have also included collapses?
POWELL: Well, on reflection, yes.
BAKER: Because a collapse is only really differentiated from a death --
POWELL: Yes.
BAKER: -- by the fact that you resuscitate the baby?
POWELL: Yes.
BAKER: And I think you have described in a police
statement a collapse as being, effectively, a respiratory arrest from which a baby is resuscitated?
POWELL: Yes.
BAKER: Now, if you'd looked at collapses as well, you would have looked at A [Child A] and B [Child B] but you would also have looked at E [Child E] and F [Child F], wouldn't you?
POWELL: Yes.
BAKER: Because E and F were twins and A and B were twins -- if you want to check the references.
POWELL: Yes.
BAKER: Yes. So in looking at A and B as twins, you would also have looked at E and F as twins and, of course, if you had investigated F then there would have been a review of F's medical records and it would have revealed that F had received an insulin, exogenous insulin overdose, wouldn't it?
POWELL: Yes.
BAKER: If you had been aware that one of the babies had been given insulin, which wasn't prescribed to them, that would have started alarm bells ringing, wouldn't it?
POWELL: Yes, yes.
BAKER: Do you think, on reflection, alongside all the other points that have been put to you today, that not including the collapses alongside the deaths was
a missed opportunity to find the answer to what was happening?
POWELL: Yes.
MR BAKER: Thank you, my Lady, I have no more questions.
LADY JUSTICE THIRLWALL: Thank you very much, Mr Baker.
LADY JUSTICE THIRLWALL: I gather there are no further questions from anyone else? No. Thank you. I just have two short questions about something that you mentioned very early on, the first of which you mentioned very early on. You were asked about Advanced Nurse Practitioners, do you remember that, quite early in the evidence this morning?
POWELL: Yes.
LADY JUSTICE THIRLWALL: And you said that you thought they were a good idea and you have told us about how they are currently being brought on within the unit.
POWELL: Yes.
LADY JUSTICE THIRLWALL: And we have heard some evidence about that, but you told us that earlier that -- you said, "We lost two of our Advanced Nurse Practitioners." Can you help me as to when that was, approximately?
POWELL: It was quite a while back.
LADY JUSTICE THIRLWALL: Was it at about the time of the restructuring which was 2015, I think?
POWELL: No, no, we lost them --
LADY JUSTICE THIRLWALL: Was it before that?
POWELL: -- way before then.
LADY JUSTICE THIRLWALL: 2009?
POWELL: It's more in keeping with -- possibly even earlier than that.
LADY JUSTICE THIRLWALL: And what was the reason why they were lost, as you put it?
POWELL: Financial more than anything.
LADY JUSTICE THIRLWALL: So they were made redundant?
POWELL: Yes.
LADY JUSTICE THIRLWALL: I see.
POWELL: One was brought back on. She actually went elsewhere and the other one was made redundant.
LADY JUSTICE THIRLWALL: So it was for financial reasons for the Trust?
POWELL: Yes.
LADY JUSTICE THIRLWALL: And were they replaced by more junior nurses?
POWELL: No. Well, it would be a Band 6. They would be replaced, but I can't recall whether they were.
LADY JUSTICE THIRLWALL: No. All right. Thank you. The second question I have is about phones and obviously in 1982 when you started there weren't any mobile phones.
POWELL: No.
LADY JUSTICE THIRLWALL: It seems unbelievable now but there weren't. I understand the point you make about people not gossiping on their phones or messaging on their phones while they are at work. Before mobile phones were everywhere, did nurses, did you as a young nurse, talk to each other about patients?
POWELL: No. Not on the phone, no.
LADY JUSTICE THIRLWALL: Not on the phone. You wouldn't ring somebody up to do that?
POWELL: But sometimes we'd ring the ward, say, if we would have been on the night shift or the day shift and we would have gone home and we thought, well, I wonder --
LADY JUSTICE THIRLWALL: You wanted to know how they were getting on.
POWELL: Were they okay, we would ring up and just ring the unit and, and ask. They wouldn't give much information other than "Yes, he's doing fine."
LADY JUSTICE THIRLWALL: Yes, I understand. And so when you were on the ward, presumably you would talk to each other about the babies when there was time to do that, if you wanted to, or did you not?
POWELL: Well, only if it was relevant and pertinent to that child or the patients.
LADY JUSTICE THIRLWALL: What do you mean?
POWELL: You mean, when we were on the unit?
LADY JUSTICE THIRLWALL: Yes.
POWELL: We would talk about other babies, you mean?
LADY JUSTICE THIRLWALL: Yes, whether you would talk to each other about the babies you were caring for? I haven't got a view one way or other I am just trying to work out --
POWELL: No, I'm just trying -- no, not necessarily unless we had a problem or we wanted some help or -- no, not necessarily, no.
LADY JUSTICE THIRLWALL: I'm just trying to see what it is that people use their mobile phones for that people didn't talk about before --
POWELL: Yes.
LADY JUSTICE THIRLWALL: -- when they didn't have mobile phones.
POWELL: And the handover was quite clear. The handover sheet and the handover that you had at the
board was, well, you know, when you went to have your handover you got an inkling of what was --
LADY JUSTICE THIRLWALL: What was going on.
POWELL: What was going on, yes.
LADY JUSTICE THIRLWALL: Thank you. And so far as chitchat and gossip, I am not going to ask you whether there was any of that on the ward, I assume there would have been. But that's the thing you really are very clear about that that's -- people shouldn't be using their mobile phones to gossip --
POWELL: No, they shouldn't be using their mobile phones for personal use. The only exception that came later on was the translation because we had a lot of Polish ladies.
LADY JUSTICE THIRLWALL: Yes, you told us about that. That was quite useful, I imagine.
POWELL: Yes.
LADY JUSTICE THIRLWALL: Yes. Thank you. Does anyone have any questions arising out of those points? Thank you very much indeed, Ms Powell, you are free to go now.
POWELL: Okay, thank you. Do I take these with me?
LADY JUSTICE THIRLWALL: If you would like to or you can leave them and someone will pick them up. You are free to go. Now, Ms Langdale, next week I think we are sitting.
MS LANGDALE: Monday and Tuesday.
LADY JUSTICE THIRLWALL: Monday and Tuesday only. And then we will rise and have the following week as a break week, a break from evidence rather than a break from the Inquiry. All right, thank you all very much indeed. We will reconvene Monday morning at 10 o'clock.
(4.27 pm) (The Inquiry adjourned until 10.00 am on Monday, 21 October 2024)
LADY JUSTICE THIRLWALL: Yes, Mr De La Poer.
MR DE LA POER: My Lady, the first witness for today is Anne Murphy, please.
LADY JUSTICE THIRLWALL: Very good. Ms Murphy, would you come to the table, please.
MS ANNE MURPHY (sworn)
LADY JUSTICE THIRLWALL: Thank you, Ms Murphy, do sit down.
MURPHY: Thank you.
MR DE LA POER: Please could you give us your full name?
MURPHY: Sorry, could you just repeat that?
DE LA POER: Of course. Please could you give us your full name?
MURPHY: Mrs Anne Murphy.
DE LA POER: Mrs Murphy, is it right that you gave a witness statement to the Inquiry dated 7 June 2024?
MURPHY: Yes, that's right.
DE LA POER: Are the contents of that witness statement true to the best of your knowledge and belief?
MURPHY: Yes, it is.
DE LA POER: I am going to begin by introducing your background. Did you qualify as a nurse in 1977?
MURPHY: Yes.
DE LA POER: Did you move to the Countess of Chester Hospital in 1985?
MURPHY: Yes.
DE LA POER: Since moving there, did you work in various children's based departments?
MURPHY: Yes.
DE LA POER: As part of the Agenda for Change banding in 2004, were you banded as a Nurse Consultant?
MURPHY: Yes.
DE LA POER: And having held various leadership roles with different names in 2011, was your job title Lead Nurse for Children's Services?
MURPHY: Yes, it was.
DE LA POER: At some point prior to 2015, did the neonatal unit come under your remit?
MURPHY: Yes. It did, it came under the child health children's services. But my main responsibility was for the ward, the manager of the children's -- of the neonatal unit.
DE LA POER: You say your main responsibility, just so that we understand the position correctly, did you have a supervisory role over the neonatal unit?
MURPHY: Yes.
DE LA POER: Did Nurse Eirian Powell report directly to you as her line manager?
MURPHY: Yes, she did.
DE LA POER: You describe yourself in your statement as having overarching responsibility for all children's services; is that correct?
MURPHY: Yes, yes.
DE LA POER: Just so that we are clear about what that means, you had management responsibility not just for the children's unit and neonatal unit, but also various community-based children's services; is that right?
MURPHY: Yes.
DE LA POER: Finally by way of introduction, did you retire from nursing in 2018?
MURPHY: Yes.
DE LA POER: So we are going to turn now to 2015 and we are going to just look at an organogram that you mention in your witness statement and identify some of the personnel on it, please. The reference is INQ0002594. That will come up on the screen in front of you. We don't need to look at every aspect of this but this is a document that you are familiar with; is that right? Mrs Murphy, I think you produced this in your
witness statement?
MURPHY: Yes.
DE LA POER: So we just have a look at the top. It's dated 15 January 2015 and you are going to make a comment I think about one of the personnel involved, namely Jane Evans but before we get to Ms Evans, we can see that Karen Townsend sits at the top of the division; is that right?
MURPHY: Yes, but to my recollection in January 2015 it was actually Jane Evans.
DE LA POER: Well, I think that Jane Evans held the equivalent role to Karen Rees?
MURPHY: Yes, she did.
DE LA POER: So not Karen Townsend who is --
MURPHY: Sorry, Karen Townsend, yes, it was, it was --
DE LA POER: It is just being highlighted.
MURPHY: Divisional.
DE LA POER: Head of the division?
MURPHY: Yes.
DE LA POER: Then if we come down to the next layer of management and follow the nursing line, we can see Karen Rees who is identified there as head of nursing. Now, you are quite right looking at the evidence that we have from Karen Rees and from Jane Evans, the position appears to be that until August or September of 2015, Jane Evans was the head of nursing?
MURPHY: Yes.
DE LA POER: And Karen Rees took over from her, I will just let you know what they say in their statement because this is going to be important to a piece of your evidence in a moment. Karen Rees says in her witness statement -- she is of course giving evidence this afternoon -- that she took over that role in August 2015, Jane Evans says that she gave notice in August but didn't in fact leave the role until 30 September 2015. But she also says she was on annual leave for much of that period and that there was a period of handover. So it appears that by 30 September everybody agrees Karen Rees was in position. So I hope that helps your recollection because we are going to have a look at the timeline as to who you were speaking to at different times.
MURPHY: Yes.
DE LA POER: So if we consider that now and focus on Jane Evans who held that role until 30 September, you say in your witness statement that you have a -- and I am quoting you here -- vague recollection of speaking to Jane Evans with Eirian Powell about the increase in mortality on the neonatal unit.
So if we just have a think about that for a moment and I will just try and help you with it. We know that there were three deaths in June of 2015. There was then another death, that's [Child E], at the beginning of August. Do you think it was following those four deaths that you would have had a conversation with Jane Evans?
MURPHY: Yes, I would, I would have assumed that it would have been something that we would have highlighted to Jane Evans; that there had been a series of infant deaths.
DE LA POER: Obviously there is a difference between having a positive recollection of something and assuming that you would have done something because that's how you would normally act. Can we just be clear here. Do you have a recollection of having spoken to Jane Evans?
MURPHY: I have a recollection that we did speak to Jane Evans but I couldn't be absolutely certain about that.
DE LA POER: And are you able to say anything beyond what you have just said about what it was that you said to Jane Evans?
MURPHY: I think that we would have said that you know there had been a -- a number of, of baby deaths which
was slightly unusual for the neonatal unit to have a spate of deaths all at once.
DE LA POER: So does that fit with your thinking following the death of [Child E] in August of 2015 that you regarded the neonatal unit as experiencing something unusual?
MURPHY: Well, it was certainly not something that was or had been in the past that there were several more than -- than normal, certainly.
DE LA POER: Were you meeting Jane Evans regularly or did you go to see her specifically about this issue, do you know?
MURPHY: No. We had a monthly one-to-one with Jane Evans so it wasn't specific, I don't think, to -- to the occurrences on the neonatal unit.
DE LA POER: And you say "we". Was Eirian Powell also attending that one-to-one that you went to?
MURPHY: It -- it was all of the, the staff who were in a management position. So it was Eirian, myself, Anne Martyn, who's manager of the Children's Unit, and Sarah Jackson who was manager of the community children's packages.
DE LA POER: So it was in the context of one of those one-on-one meetings with your immediate line manager that you think you drew attention to the fact that the neonatal unit was experiencing something unusual?
MURPHY: Yes.
DE LA POER: So that's all that I want to ask you about Jane Evans, unless you have any other recollection of that discussion or anything that arose from it?
MURPHY: Not as far as I am aware.
DE LA POER: Well, we will come back to the timeline in due course. Thank you very much. We can take this down.
LADY JUSTICE THIRLWALL: Mr De La Poer, just before you move on, I just wonder if I can clarify something in my own mind?
MR DE LA POER: My Lady, of course.
LADY JUSTICE THIRLWALL: Mrs Murphy, I just want to understand how many people were at the meeting because it's mentioned as a one-to-one which I assumed was one person and one manager. But you refer to "we".
MURPHY: There could have been one or there could have been four of us there, it would depend, and occasionally if there was something untoward we might have or I might have asked to stay behind or, you know. So it may have been that that we informed Jane after the meeting but stayed behind and let the other two managers go. So -- but not all of us could attend every month, you know, so it could have been two or four of us that were there.
LADY JUSTICE THIRLWALL: Thank you. Thank you, Mr De La Poer.
MR DE LA POER: So we are just going to talk generally now about your impression of the neonatal unit and in particular in early 2015, so before those unusual deaths as you have described them, the first four, occurred. What was your view about how well that department was functioning at early 2015?
MURPHY: Are you asking me prior to the infant deaths?
DE LA POER: Yes.
MURPHY: (Redacted). But prior to that, the neonatal unit was a well run unit. They didn't appear to have a lot of problems. They often had staffing issues relating to the acuity of the patients. So they -- they may well have needed additional staff at times for, to look after the babies. But generally, it was well run, the staff were always very friendly and, you know, they seemed to get along very well. They -- they managed to get the, you know, mandatory training and things all done so that from a management perspective that was fairly well completed. And -- and, you know, from the perspective of the people that actually went to the unit to visit or who were working there from a medical and a nursing perspective, everyone appeared to get on very well.
DE LA POER: Presumably you had regular meetings with Eirian Powell who you managed directly?
MURPHY: Yes.
DE LA POER: Did she ever report to you any problems with relationships as between nurses or as doctors and nurses or as between doctors?
MURPHY: No, not at all.
DE LA POER: Did you have experience of working with the doctors yourself or seeing them work with the staff on the children unit?
MURPHY: On the children's unit, yes.
DE LA POER: What was your impression of the Consultant body?
MURPHY: The Consultant body were, you know, very, very good. We didn't have any real issues with any of the Consultants. Everyone did get along. I think, you know, from a paediatric and neonatal perspective, we were sort of in our own little bubble I suppose a lot of the time, segregated from the rest the Trust, and because -- I think because we worked with children and families we are quite different to looking after adult patients.
DE LA POER: Your medical equivalent was Dr Ravi Jayaram so he was the equivalent to your role but in a medical perspective. Would you agree with that, he was the
lead --
MURPHY: Yes, yes.
DE LA POER: For the children's, you were lead for nursing?
MURPHY: At that time, yes, he was the Lead Clinician.
DE LA POER: What was your relationship with him?
MURPHY: I -- I believe it was very good, you know, there were -- we didn't have an issue at all.
DE LA POER: Dr Stephen Brearey who was the lead for the neonatal unit, did you have experience of working with him and seeing how he worked with others?
MURPHY: From a paediatric perspective, I worked with -- with Steve Brearey. I didn't have a lot of contact with Steve from a neonatal perspective, so I didn't -- I didn't work within neonates as, as a professional nurse. So I didn't have the experience of making a comment about Steve within the neonatal unit working area. But I know from my work with him in the paediatric area, you know, that he was a very good clinician.
DE LA POER: It wasn't being reported to you that he was any different in the neonatal unit?
MURPHY: No, no.
DE LA POER: So you have mentioned the phrase "little bubble".
MURPHY: Yes.
DE LA POER: There I understood you to be referring to the fact that the Children's Unit and the neonatal unit were to some degree separate from other parts of the hospital. Am I right to understand you to mean that?
MURPHY: Yes. The -- the staffing were, were different and they didn't, the neonatal unit didn't share the same coffee area as the paediatric nurses because they were -- once they got to work they were maintained within that area and, you know, for infection control reasons, really.
DE LA POER: I understand. So the two units were not -- they were separate from each other to some degree?
MURPHY: Yes.
DE LA POER: But of course they had the same Consultants serving both?
MURPHY: Yes, yes.
DE LA POER: So was that separation more from a nursing perspective rather than a doctor perspective?
MURPHY: Yes. It was more from a nursing, although if, if the neonatal unit was busy then the paediatric nurses would go to help with the neonatal, with the special care element of the -- the neonatal unit. So we, we did share resources if there was a need.
DE LA POER: Now, the Inquiry has heard something about the change in divisional structure at the hospital before 2015, which placed the paediatric department into including neonates, into the Urgent Unplanned Care, whereas the obstetrics was in the Planned Care Division. From your perspective as the nursing lead for paediatrics, what was your view about whether that divisional structure worked or didn't work?
MURPHY: I think from my perspective, it -- it was difficult because we had been Women and Children's Directorate originally. But obviously it was a Trust decision to -- to then separate. It didn't have a major effect within paediatrics, but certainly from a neonatal perspective it -- it could have led to problems really being in two different directorates.
DE LA POER: So do you want to just help us, when you say "could", we are here not just looking for a list of every theoretical one, do you know of any difficulties that that change in division or structure caused for the matters that the Inquiry is investigating?
MURPHY: I think from a clinical incident perspective, the risk levels were -- were different. So there was a risk midwife, or I think it was classed as a risk midwife which -- which eventually she was also the risk lead for paediatrics as well. But from a paediatric perspective, we -- we didn't feel that that was the best for -- for paediatrics.
There was obviously a much greater link between neonates and the midwives because obviously they had a link to the central labour suite and the support was there. Should there be a delivery that needed assistance, they would get immediate help from the neonatal. So the risk element were in some respects more combined from a neonatal perspective with the midwives than it would have been from a paediatric element.
DE LA POER: We will be hearing from people who undertook that role I think tomorrow. As the Inquiry understands it, because of the separation of obstetrics and neonates into two separate divisions to try and keep those together in some forum, the Women's & Children's Care Governance Board was created; is that correct?
MURPHY: Yes.
DE LA POER: And you were an attendee of the Women's & Children's Care Governance Board; is that right?
MURPHY: Yes.
DE LA POER: Did you regard that as an effective forum for ensuring good governance?
MURPHY: Well, I think that there was quite a lot of issues that were very maternity-led discussed at that
meeting. But we did have the opportunity obviously to -- to take paediatric policies there for sign-off. All of the clinical incidents would then be discussed at that meeting as well, any investigations that had been carried out, things like that. But it was -- there was a lot of issues discussed at that meeting which were probably just, yes, yes, yes to -- you know that -- they had this incident and it was being looked at by the risk team. Things like that. So it was more of a sign-off committee than -- than very much a working party.
DE LA POER: Did you feel that it scrutinised problems which were raised at it?
MURPHY: I don't think scrutiny would have been the right word, no. So -- so possibly it wasn't. Paediatric or neonatal incidents weren't necessarily scrutinised, no.
DE LA POER: Just looking back on it, do you think that that was the place for them to be scrutinised?
MURPHY: Yes, perhaps it should have been the combined group that were scrutinising, but I -- I think that after the local level incident group meetings, they went to the risk management team and a lot of it was then decided what level the incidents et cetera were. So they would then come back to local level with it
being graded at whatever level.
DE LA POER: Then once -- so it's started at the local level, it's gone sideways to risk to have an assessment made, it's come back to the local level then it goes up to the governance board. What was the governance board then doing with that information?
MURPHY: From an incident perspective, I think they were just discussing it and looking at the data, how many incidents there had been, what effect there had been.
DE LA POER: If there had been concern about a particular member of staff, would it be appropriate to raise that concern, even if not naming the member of staff, at that governance board meeting?
MURPHY: I couldn't say that at some stage that that wasn't highlighted. I -- I can't really remember whether there was ever the time that that did occur. But there may well have been a time when we did take that to the governance board and say, you know, that because there had been a lot of neonatal deaths, it may well.
DE LA POER: So --
MURPHY: And, you know, I suppose by August -- December time, you know, the Consultants certainly were raising concerns.
DE LA POER: So by December of 2015?
MURPHY: Yes, sorry. Yes.
DE LA POER: Yes. So in your mind, because you think it may have been raised, it would have been appropriate to do so at that meeting?
MURPHY: Yes, it -- it probably should have been raised at that meeting at some stage.
DE LA POER: So we are going to look at specific meetings of that governance board as we work our way through the chronology. I would just like to start by, as we turn to look at it, working out just when it was that you first became aware of concerns about a member of staff. So obviously there are a number of concerns, you have already told us that by August after the death of [Child E] you had identified that it was unusual how many deaths there had been on the neonatal unit. So by August that was on your radar; is that fair?
MURPHY: Yes.
DE LA POER: We will start a little before that as we work our way through and begin at 29 June 2015. So INQ00036974 [INQ0036974] which, my Lady, is at your tab 4. I can give that again if that helps INQ00036974. It's Monday 29 June as you can see at the top and it's labelled as the senior clinicians meeting and you are identified on the list of those present at the third
entry. Do you see that?
MURPHY: Yes.
DE LA POER: If we go over the page, please, to the fourth paragraph, we can see discussed at this meeting: "There was also an issue raised around the fact that with the three recent neonatal deaths the Registrars had been quite worried and felt 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 that's being raised at that meeting following the deaths of [Child A], [Child C] and [Child D]. Those are the three deaths that are being referred to?
MURPHY: Right.
DE LA POER: Do you have a recollection of a discussion about those three deaths and the fact that the Registrars were concerned?
MURPHY: No, I -- I can't remember actually hearing that the Registrars were concerned, that any of the Registrars had been concerned. But it would depend on the context of -- of what their concerns were, really.
DE LA POER: Well, as recorded there --
MURPHY: To my -- to my knowledge it was the -- it was Dr Brearey who raised the concerns that -- that I was
aware of.
DE LA POER: Well, we have got --
MURPHY: But I was obviously at that meeting, yes.
DE LA POER: We have got these -- so, I mean, are you able to say that that record is wrong; that that wasn't discussed in your presence and that --
MURPHY: No, no. Certainly not. I am sure that that was actually factually correct at that time.
DE LA POER: I mean, just in terms of the approach that you would have taken to that sort of information, this is a concern being raised where there are Consultants present about Registrars. You were there as the lead nurse for children's services. Is that something that you would have paid attention to and been concerned about yourself or would you have thought "that's a doctor problem, I don't need to worry about it"?
MURPHY: I -- I think that it would have been -- the Consultants would have been dealing with that issue, but I would probably have gone back and asked if, you know, there were any concerns within the staffing element of the neonatal unit, had any of the staff voiced any concerns from a nursing perspective.
DE LA POER: Now, the Inquiry has received some evidence that the nurses were at the very least upset about the
three deaths that had occurred. Do you have any recollection of speaking to your nursing colleagues following this meeting and finding out whether they, like the doctors, were worried that not enough was being done?
MURPHY: I -- I can't recall speaking to the nurses personally. I would have spoken to Eirian and, you know, generally said to the nurses: are you all right? But I can't recall sitting down with any of those nurses. That would have been either Eirian or her deputy or the practice development nurse if -- if they were raising concerns themselves.
DE LA POER: So we can take that down and we can move forward a month to 20 July. INQ0017282. So this is marked as a paediatric specialty meeting. The list of invitees is rather longer than the previous meeting that we looked at which was the senior paediatricians and if we look down the list, about halfway down, we can see your name identified with you marked as being in attendance. Do you see that?
MURPHY: Yes.
DE LA POER: Now, as part of your preparation for today I hope you have had a chance to have a look at this meeting?
MURPHY: (Nods)
DE LA POER: I am sure you will accept it from me that there is no record within this meeting of those three deaths being discussed or raised; is that fair?
MURPHY: Yes, that's probably true.
DE LA POER: Can we have a look at page 3, just to understand something about the risk. "Governance Issues Summary". Firstly, it says "No representative present". Is that a reference meaning a representative from the risk department?
MURPHY: Yes.
DE LA POER: Then there is a reference to risk registers, "No risks to be added for paediatrics." Then the NNU. "Following QSPEC ROP will be added as currently there is only one clinician able to access this on the unit, there are implications to consider such as utilising other units, other clinicians, et cetera." Firstly can you help us with ROP?
MURPHY: It's -- it's a problem with neonates' eyes that's caused by oxygenation. I think it is retinal -- I can't remember.
DE LA POER: Don't worry about it. The point is there is plainly a discussion about that condition and how it might be relevant to the risk registers. Just helping us to understand this. We obviously
know that a month earlier there was a discussion about Registrars being concerned you had had three deaths on the neonatal unit in fairly quick succession. Was this an appropriate meeting to discuss those deaths or raise the fact that they had occurred?
MURPHY: I -- I think it may have been highlighted if there had been the risk nurse there. She may well have brought the data relating to the clinical incidents that had been put in following each of those baby deaths and there might have been discussion relating to those.
DE LA POER: But, I mean, I am not suggesting you were the only one who was present at this meeting and the meeting the previous month?
MURPHY: Yes.
DE LA POER: Obviously there were a number of doctors there but you were present at the previous meeting, you knew about the three deaths, you will have heard that the registrars were concerned about it and what needed to be done and a plan was required. Was this something that you could have raised and said: well, I think this would be a good forum for us to discuss this?
MURPHY: Well, because the nursing side had never raised any concerns to me personally, then if -- if there had been an issue then perhaps at that stage the clinicians should have raised it, the paediatricians.
DE LA POER: So you saw that because it was a concern on the medical side, on the doctor side, it would be for them to raise it but from your perspective as a nurse you didn't have anything to contribute on that point and so not for you to raise?
MURPHY: No, other than if -- if there had been -- I mean, we may have discussed it had the clinical incidents been highlighted at that meeting. The specialty meeting was more of a business meeting than a clinical meeting.
DE LA POER: But it did deal with governance issues because we --
MURPHY: It did, yes, it did deal with governance issues.
DE LA POER: We can see -- but is it your view that without having the risk nurse there, that couldn't be progressed in the way it might otherwise have been?
MURPHY: I don't think I can answer that whether it would have been or not, really.
DE LA POER: Just one other matter to ask you about this document. If we go to page 5, please, this is more of a general comment about what was being said at the time. In the second to last bullet point, about two-thirds of the way down the page, we can see a sentence beginning:
"General consensus that paediatrics is left to its own devices and is not considered in financial matters." The context is perhaps potentially relevant. But it is a general remark about the attitude from those outside paediatrics to it. Was that the view in 2015, July, that paediatrics was effectively left to its own devices and not taken into account in relation to the money?
MURPHY: I think there the -- the Consultants were obviously saying that they weren't given the opportunity to attend the divisional board and that the business case that had been put in, they didn't have the opportunity to actually go and speak specifically about the needs of -- of the paediatric service there, that it -- it looks as if what was being discussed is that we weren't involved in the financial side. That ...
DE LA POER: And is that how the paediatrics department felt generally, or is that just specific to this one issue?
MURPHY: No, I think in general we did feel at times that we were being let down in some way from the -- the, you know, sort of divisional side or, you know, the Executive side.
DE LA POER: So we can take that down, thank you very much. So we now come to the moment in the chronology that we have already dealt with, which is your recollection although you have told us you are not sure, that following the death of [Child E] in August, you in a meeting that Eirian Powell may have been present spoke to your line manager Jane Evans about the increase in the deaths on the neonatal unit. So that's where it fits in to what we are discussing. So clearly by that stage, you had concern that something unusual was happening; is that fair?
MURPHY: Well, it was unusual that there obviously had been a number of deaths. But there had been no high -- concerns highlighted by nurses.
DE LA POER: So we will now have a look at Women's & Children's Care Governance board meeting on 22 October and just so that we can absolutely understand what's been happening, we have had those four deaths that we have spoken about, all children named on the indictment, there were then two other deaths in September of non-indictment children and that's the background to the meeting that took place on 22 October. We will bring up the INQ, INQ0003223. Now, so that you understand where the other deaths fit into this, [Child I] died the day after this meeting, so that won't have been -- that death won't have been in
anybody's mind for obvious reasons although [Child I] had had a period of collapses prior to that. So that's the context. We can see that you are identified fourth from bottom in the list as being present at the meeting and again you have had an opportunity to refresh your memory from these notes and we can just move through it one page after another so everybody can see the sort of -- unfortunately every other page is blank, we can see pausing there, I am so sorry, neonatal is highlighted, 47 incidents reported, 44 of which were clinical, two moderate harm incidents relate to neonates that sadly died. So a reference to two deaths and the five top categories relate to seven babies with feeding problems, seven for delayed treatment, six deviation from policy, three equipment problems and three unexpected deaths. So we have got those there. As it's recorded there, that's just a list without any analysis or discussion or comment attached to the record of the meeting. Is that how those meetings went in terms of just a rehearsal of bullet points as opposed to a discussion about what it all might mean and whether people should be worried about it?
MURPHY: Yes, I think the -- it was more that these were the issues that were present at the time, what the clinical incidents had been and then in the background there would have been meetings taking place looking at the incidents themselves with the risk nurse, the neonatal unit. So Eirian, Dr Brearey, at that time I think it would still have been Debbie Peacock who was the risk for -- for women and children's, so each of the incidents would have been discussed at unit level but this was just highlighting how many incidents had been in the last month or so far that year, whatever it -- it actually may have ...
DE LA POER: Did anybody attending this governance meeting have any responsibility to say "that sounds like a lot" or "I need to know more about that" or "what's being done about that?" So in other words to think critically about the information that's being rehearsed and promote a discussion about it or does everybody just sit in silence, listen to the report and then move on?
MURPHY: I think that it would -- if there had been something that a particular member of -- of that board was concerned about, then there would have been the opportunity to raise it. But some of this was -- was
literally the figures being put up on a screen and how many incidents there had been. If there had been investigation carried out, then it -- it may well have been further discussed but the majority of the baby deaths were discussed at the morbidity and mortality group. So there were other groups that would have been concerned with literally looking at that specific incident.
DE LA POER: Absolutely and each of the baby deaths were the subject of at least one meeting considering them at a neonatal mortality meeting. But it's just trying to understand the governance role of this committee.
MURPHY: I -- I think it was more information gathering. I -- I don't think there was a lot of time for discussing individual things. I -- I think that the discussions had taken place at other meetings.
DE LA POER: Well, let's move forward, please, to the day after this meeting. We know that [Child I] died at 2.30 am on 23 October of 2015 and we are going to have a look at an email sent later that same day. This is INQ0005609. We can see that at the end of the first cc line your name appears and we are going to just need to unpack this email so we will go through the different parts of it. The first sentence: "Just to say that I have discussed the above with Anne Murphy ..." So a reference to you, do you agree, and a discussion that took place before this email was sent?
MURPHY: I was obviously copied into this email and if -- if she's put me in and named me, I am sure that Eirian did actually discuss that issue. But I can't recollect what that discussion was at this stage.
DE LA POER: Well, let's -- we can see when it says "I have discussed the above", people often use that convention to refer to the subject line of their email because that appears above the text of the email and we can see the subject line here is "Mortality 2015", that is the second line down?
MURPHY: (Nods)
DE LA POER: So do you agree it appears that what Eirian Powell is saying, she's had a conversation with you before she sent this email about mortality in 2015.
MURPHY: Yes, she will have, I agree there.
DE LA POER: The next part is: "... and on reflection it was decided to leave this until Monday." So again just trying to understand the ordinary language that is being used here. Eirian Powell seems
to be suggesting that following her meeting with you, it was decided to leave this, this topic, this issue, until Monday. Again does that accord with your understanding of what this email is saying?
MURPHY: Yes. I -- I can only assume that Eirian was in some way responding to a conversation or an email that she may have had with Steve Brearey. Otherwise I -- I don't know where I would have come into this.
DE LA POER: Yes. So to leave this until Monday, just so that you know, October 23 of 2015 was a Friday, so she is referring to leave this until Monday, 26 October?
MURPHY: Yes.
DE LA POER: If we just understand what seems to have happened here is because the email is sent to Steve, ie Dr Brearey, she seems to be have had a conversation with him at which it was agreed that something would be done that day. She's then had a conversation with you and it's been decided to leave it until Monday; do you agree that that's what this email seems to be saying?
MURPHY: Well, I can't definitely say what -- what was discussed in their conversation but it -- it obviously whatever our discussion took place, I can only assume that the information actually was given to me and because we weren't able to get hold of, I don't, Alison Kelly and Sian Williams, I assume that our
decision-making was that it was all right to leave it until the Monday.
DE LA POER: That's the natural reading of what this email means.
MURPHY: But that is -- my only recollection is from reading.
DE LA POER: Yes. So it appears just reading this email, do you agree, that there was a discussion with between Dr Brearey and Nurse Powell at which whatever it was was going to be taken to the Director of Nursing that day, there's then been your conversation. You have suggested that perhaps Alison Kelly wasn't available and we can see in the email that she wasn't in the hospital certainly and neither was her deputy Sian Williams and so the issue has been moved to Monday for resolution.
MURPHY: Well, because I can't remember what that discussion was, I can't really say whether it was something that had been agreed; that we would speak to the Executive team or not.
DE LA POER: Would it be normal for the unit manager, Ms Powell, to go straight to an Executive about an issue?
MURPHY: At that stage, probably not.
DE LA POER: Because she skipped out -- I mean, she is
including you in the conversation, but she's missing out Karen Rees, the head of nursing; she is missing out Karen Townsend, the director of the directorate, the Urgent Care, going straight to the very top of the nursing chain of command?
MURPHY: I agree with -- from there we have missed out Karen Rees. But it would not have been normal practice to go to Karen Townsend.
DE LA POER: But at all events, you have told us that that wouldn't be usual practice for somebody at Eirian Powell's level to go straight to the Director of Nursing. I am just bearing in mind the email strongly suggests, and you are copied into it as well, that you had a conversation about this issue, and it was unusual. Can you give us any help at all about what Eirian Powell was saying to you that she wanted to talk to Alison Kelly about that day?
MURPHY: I'm sorry, I can't -- I can't really answer that question. I mean, where she says "I have devised a document", that is the Mortality 2015 --
DE LA POER: Yes.
MURPHY: -- review that she did. And she's obviously saying that each of the baby deaths was different. So I really don't know what the conversation had been with Steve Brearey, unfortunately.
DE LA POER: I am not asking unless you were told about Dr Brearey; I am asking between you and Ms Powell?
MURPHY: I'm sorry, I can't specifically recall that incident.
DE LA POER: Well, we will have a look --
MURPHY: The discussion.
DE LA POER: We will have a look at that document in a moment. I just want to examine this idea of Alison Kelly was not in the hospital. As a director, would she have had a telephone number that you could find out from her PA to contact her when she is outside the hospital if it was sufficiently urgent?
MURPHY: I would assume that if Eirian had already contacted she would have contacted the Executive office and spoken to a secretary. But it wouldn't have been normal practice for one of us to pick up the phone and -- and ring Alison Kelly or Sian when they were outside of the hospital.
DE LA POER: But I think you have also told us it wouldn't be normal practice for Eirian Powell to go and see Alison Kelly about an issue directly?
MURPHY: Yes, she could well have.
DE LA POER: So whatever it is to be discussed with Alison Kelly is to be discussed on the Monday, do you agree that's what this email seems to be saying?
MURPHY: That's what the email says.
DE LA POER: So let's move on. "I have devised a document to reflect the information clearly and it's unfortunate that she was on. However, each cause of death was different. Some were poorly prior to their arrival on unit and others were [question mark] NEC or gastric bleeding/congenital abnormalities. I have attached the document for your perusal". Now, we know on the table that we will look at in a moment Letby's name was highlighted in red on that table, wasn't it?
MURPHY: (Nods)
DE LA POER: So is the "it's unfortunate that she was on" a reference to the fact that it is unfortunate that Letby was on?
MURPHY: Yes.
DE LA POER: Then finally before we turn and have a look at that document: "See you Monday, I will discuss with Debbie on Monday." So that's Debbie Peacock?
MURPHY: Yes.
DE LA POER: The risk midwife?
MURPHY: Yes.
DE LA POER: So two meetings to be had on Monday, on the face of it, one with the risk department, one with the Director of Nursing?
MURPHY: Yes.
DE LA POER: So let's have a look at that table very briefly. We have seen it many times. INQ0003189. Really, Mrs Murphy, to see if this further jogs your memory bearing in mind that this is a table that Eirian Powell appears to have created that very day, the day that [Child I] died, the day that she spoke to Dr Brearey, the day that she spoke to you and the day that she sent that e-mail, was that a document that she showed you before she sent the email?
MURPHY: Not to my knowledge.
DE LA POER: But --
MURPHY: But I don't know if the conversation that Eirian and I had was face to face or whether she telephoned me. I don't know. So I don't know if I actually saw that before it was circulated.
DE LA POER: But at 5.25 that day you received a copy of this table. Do you recall opening it and working your way through it and seeing Letby's name appearing in either of those two right hand columns for all but the first baby?
MURPHY: I'm sorry, I don't. I-- I can't remember when I first saw you know this document per se. But obviously, you know, it was one of many documents that was changed a number of times. But obviously because of the conversation she had had with -- with Dr Brearey he had obviously named that particular nurse, which is why Eirian has highlighted her name to show, you know, whether she was actually on the unit, where she was caring for that infant or not.
DE LA POER: Bearing in mind that conversation between Ms Powell and Dr Brearey took place before your conversation with Ms Powell --
MURPHY: Yes.
DE LA POER: -- and Dr Brearey and you are then -- forgive me, I will start that again. The conversation between Dr Brearey and Ms Powell took place between your conversation and Ms Powell. You are then copied into the email about the contact with Alison Kelly and the fact that this chart had been created. I mean, do you think it likely that it was in that meeting on 23 October that Ms Powell told you that Dr Brearey was worried about Letby?
MURPHY: I -- I'm sorry, I can't actually answer that. I don't know if in fact concerns had been raised before or whether it was actually in October that it was first discussed that he felt that she was there for the majority of -- of the instances.
DE LA POER: I understand. So this then -- if I have understood your answer correctly, this represents the very latest date that you would have heard about Dr Brearey's concerns but it may be that you heard about them before?
MURPHY: It may well. I -- I can't, I can't verify that, really.
DE LA POER: Whether it was this date or earlier in time, when you heard that Dr Brearey was concerned about a member of nursing staff and the fact that she was present when these various deaths occurred, did you have concerns yourself?
MURPHY: No, I -- I didn't have any concerns. You know, I -- I -- I know that I can't -- I don't know whether it was around about this time or when, but Eirian had obviously discussed the fact that the Consultant had raised concerns. But because the concern was literally that she was on the unit when all of the incidents had taken place, she wasn't looking after each of those babies. So, you know, was there coincidence in -- in this situation? It was supposition that, you know, she, she unfortunately was there on those days. But there was no
indication that she was causing any harm to those babies.
DE LA POER: Well, it's a serious concern that Dr Brearey had, do you agree?
MURPHY: Yes.
DE LA POER: Did you go and speak to Dr Jayaram, the Lead Clinician for paediatrics, to say: one of your Consultants, the lead for neonatal unit, has this concern, what do you think about it?
MURPHY: I can't remember having a conversation directly with Dr Brearey or Dr Jayaram at that stage and I know there were discussions that took place but I don't know, I couldn't give you the dates of those discussions.
DE LA POER: But as the lead nurse for children's services, didn't you have a responsibility to try and understand what was being suggested here, because of how serious it might be?
MURPHY: I -- I accept that it -- it was a serious matter and obviously on reflection even worse than we, we would have considered. But I was being informed by the unit manager that, you know, this -- this was literally just that she, she was actually present. What could she have done to those babies, especially those babies that she wasn't caring for, I --
you know. So -- so we could never find any evidence to support any wrongdoing and -- and therefore her literally being on the unit at that particular time, I don't think we felt as nurses that we could accuse her of doing some harm without actual evidence. And the fact that the babies appeared to die of, you know, varying conditions and there was nothing at post-mortem to -- to say that that was any different, and at that time I don't think we felt that it -- it was fair that a nurse should be accused, or anyone if you know I believe that if that had have been a member of the medical staff I would have felt the same thing; that, you know, what proof did we have that there was any wrongdoing?
DE LA POER: So we just need to unpack quite a lot of that answer, I will try and help you with what I am asking you. You said "a number of times as nurses". Did you view this as a doctors versus nurses situation?
MURPHY: I wouldn't say that we viewed it as a doctor versus nurses at all. I mean, Dr Brearey obviously had a concern, but he also had his own route to take that further if he felt his concerns was justifiable. I was being informed that to all intents purposes there, you know, there wasn't any indication to say that
this nurse had done anything wrong.
DE LA POER: So you had two competing points of view, Dr Brearey's concern on one side, Eirian Powell's view to you that there wasn't anything to be concerned about. Would it be fair to say that you chose to act on the basis that Eirian Powell was right, rather than that Dr Brearey may be right?
MURPHY: At that stage, yes.
DE LA POER: And that you did so without speaking to Dr Brearey yourself?
MURPHY: I cannot -- I cannot recollect speaking to Dr Jayaram.
DE LA POER: Or to the Consultant who sat above Dr Brearey, Dr Jayaram?
MURPHY: No.
DE LA POER: Again just reflecting upon this, bearing in mind how potentially serious it was, do you think that those were things you should have done at the time?
MURPHY: I -- I think the discussions that I also had with Dr Brearey and Eirian that none of us could come up with a reason why his thought process automatically went to her. So at that time, no, I really didn't believe that we should be actioning anything.
DE LA POER: Another thing that you said in your answer to my initial question was that you didn't think it was fair because you didn't have proof. I hope I have recollected that correctly?
MURPHY: (Nods)
DE LA POER: When it comes to keeping babies safe, do you need proof before you act?
MURPHY: I -- I think when a person is potentially going to be accused of some wrongdoing in that case, yes, I do think we should have had proof.
DE LA POER: So the fact that a senior Consultant who was in charge of the unit had a concern from your point of view didn't justify any action because you needed proof?
MURPHY: Well, I think we -- we were aware of -- that, you know, there was an -- an issue that babies obviously were dying. But not at that stage did -- did we as nurses, Eirian and myself, on discussion -- on discussion with Debbie Peacock, and then we didn't think there was an issue to address. Dr Brearey could have discussed it with his colleagues himself. I don't know if he did or not at that stage. He could have taken it to other members of the Trust.
DE LA POER: When considering child safeguarding generally, if you as a nurse suspected that a parent was causing harm, but you didn't have proof, would you act?
MURPHY: That would depend on what the reason for
that -- for that suspicion. You know, if a child came in with bruises, then obviously you are going to consider that that child has been harmed. It -- it didn't mean that it was the mother, the father or whoever it -- that would be an indication for alerting safeguarding. If a child said something that made you consider they may be being sexually abused or something, but there -- to me that is evidence from that child to say that something was wrong. So I don't think we would have gone to safeguarding without elements of some evidence.
DE LA POER: The final question just about this event in October is this: it clearly was thought serious enough to involve Alison Kelly, we can see that from the email, so no accusations being made to Letby, just going right to the Director of Nursing to get her support on what is undoubtedly a very difficult situation. Firstly, given that you knew about this and that you were Eirian Powell's direct line manager, was that something that you involved yourself in, so that you took this concern with Eirian Powell to Alison Kelly?
MURPHY: Well, I certainly could have. I -- I would have thought that my first port of call would have been to have gone to Karen Rees and I don't know what
Eirian's thought process was to go directly to Alison Kelly or to find out if Alison was in the Trust at that time or indeed what Dr Brearey had said to her, to make her feel like that.
DE LA POER: But she clearly discussed it with you and you agreed that seeing Alison Kelly on the Monday was a good idea?
MURPHY: Well, I think to leave whatever the issue was we -- we could safely leave until the Monday. I don't know if because if -- if it had been raised that they felt it was Lucy Letby causing harm to the baby that had died whether that indeed she -- she wasn't on duty again until the week after, then it -- you know, that issue could be left until the following week to be discussed.
DE LA POER: And so did you speak to Eirian Powell the following week to find out how her meeting with Alison Kelly had gone?
MURPHY: I'm sorry, I can't -- I don't know whether I did or not. I haven't had access to my own diaries for work so I -- I haven't been able to look at all of these dates and follow them up from my own information. So I really don't know whether that -- that did take place whether Eirian spoke to Debbie Peacock and was happy that, you know, it didn't need to go to Alison Kelly or if indeed Eirian got in touch with
Alison Kelly herself, I don't -- I don't know.
DE LA POER: But you have no recollection of having been told --
MURPHY: I have no recollection.
DE LA POER: -- whether the meeting did or didn't take place?
MURPHY: No, I'm sorry, I don't have a recollection.
MR DE LA POER: My Lady, would that be a convenient moment?
LADY JUSTICE THIRLWALL: Very convenient, thank you very much indeed, Mr De La Poer. Mrs Murphy, we are going to take a break now of 15 minutes and we will start again at half past 11.
MURPHY: Thank you. (11.14 am) (A short break) (11.30 am)
MR DE LA POER: Mrs Murphy, we are going to move forward from 23 October to 19 November. INQ0004271. This is a meeting of the Women's & Children's Care Governance Board and we can see under the "Urgent Care" heading Dr Jayaram is present, that is the first entry, and you are identified as being present four entries up from the bottom?
MURPHY: Yes.
DE LA POER: Dr Brearey has given his apologies that is item 1 on page 1. Now, as far as this meeting is concerned, the conversation that you had had with Eirian Powell on 23 October, the plan that Alison Kelly might be contacted, the discussion with Debbie Peacock, none of that appears to be recorded at this meeting. That was approximately three and a half weeks before this meeting took place. Do you know why that wasn't discussed or was it, and just not recorded?
MURPHY: I'm sorry, I don't know why.
DE LA POER: Do you think that sort of concern that had developed into thinking that Alison Kelly needed to be involved was something that should be raised at the Women's & Children's Care Governance Board?
MURPHY: I think, if we -- if we had discussed it then it would probably have been at the senior clinicians' meeting rather than at the governance meeting. But it may have been something that Debbie Peacock would have picked up on too, but I -- I can't really recall what the process would have been.
DE LA POER: So we know from page 5, right at the bottom, that the minutes were to be sent to Alison Kelly in her capacity as Director of Nursing?
MURPHY: (Nods)
DE LA POER: But looking through the minutes, it wouldn't be possible to discern those conversations that you had been having that level of concern following [Child I]'s death, the table with Letby's name in red, none of that would be apparent to somebody reading these minutes. I am just wondering whether that was something that should have been raised at this meeting in some form or other; that that concern had been had on the nursing side, in terms of the need to contact Alison Kelly?
MURPHY: I think the fact that no one raised a concern at this meeting, neither medical nor nursing, I -- I don't know whether it -- it should have been documented or not, really.
DE LA POER: We can take that -- sorry, did you want to add something? We can take that down. I would just like to ask you about an issue which is more generally applicable to children's services. As part of your preparation I think you were recently sent an extract from Alison Kelly's statement in which she talked about you and some Consultants raising staffing concerns about with her in December of 2015 or thereabouts. Do you recollect reading that as part of your preparation?
MURPHY: I am not altogether -- could you repeat that? I don't know if I didn't quite hear.
DE LA POER: Of course, I will see if I can help you. In her witness statement to the Inquiry, Alison Kelly says that you raised concerns about staffing levels within paediatrics --
MURPHY: Rights, yes.
DE LA POER: -- in December of 2015?
MURPHY: Right.
DE LA POER: She cites some other concerns that were raised and she says in her witness statement that she visited the department together with Sue Hodkinson and that she also was involved in a meeting with Lorraine Burnett and as a result of those meetings what Alison Kelly says is that that led to additional nurse recruitment, the upskilling of existing staff and new Consultants. So that's what she says about what happened in December 2015 which you were involved in and what the result of work that was done on the back of that. I am just wondering do you have any recollection of firstly being concerned about the staffing level on the paediatric unit generally?
MURPHY: Well, yes, we did have concerns about the staffing levels on both units. We certainly were not achieving the standards that -- from a paediatric perspective, that we did have standards of staffing levels.
December is a particularly busy month or the winter is very busy in paediatrics itself. So if -- if there were staff off sick or if there was a recruitment problem then, yes, I would have raised that, that issue.
DE LA POER: Do you have a recollection of a visit to the department by Alison Kelly and Sue Hodkinson as a result of you having raised concerns?
MURPHY: No, no, I can't recall. But I would not necessarily have been there if they went ad hoc to the units.
DE LA POER: After you had raised your concerns, did you see additional nurse recruitment by the Trust?
MURPHY: I can't answer that question either. At that time, without my records, I wouldn't be able to say definitely. But we certainly didn't get any additional doctors at that time, I know.
DE LA POER: We will move forward to 2016 and a paediatric specialty meeting that took place on 18 January. INQ0015284. So we can see a number of familiar names are present including Dr Jayaram first identified, Dr Brearey towards the bottom, Dr Mittal and Dr Isaac who worked in the community and had a safeguarding role and you -- thank you very much indeed -- in between those two.
MURPHY: (Nods)
DE LA POER: Now, we can see at this meeting if we go over the page, please, that there are a number of topics covered. We can work our way through, just to refresh your memory about it. I think we can probably turn to the next page. We see here, if we pause there, we have got that same heading "Governance Issues Summaries" we have got risk registers under discussion: "The Urgent Care board rejected the addition of the risks highlighted by NNU of staffing issues, transport issues, pseudomonas and gas analyser without an explanation. A representative of the NNU will attend the next session to explain the addition." So these are items that had been identified as going on the risk register that the divisional board said they weren't prepared to accept without more information. There doesn't seem to be in this context of governance any discussion about the increase in the mortality rate as at January 2016. Again, do you know why that topic wasn't being brought up in this context where there is a governance responsibility, and here please understand that I recognise that a number of doctors are also present, but I am asking you for your
reflections on it, please?
MURPHY: I am not altogether sure whether it -- it would have been highlighted. You know, the natural process would have been carried out behind the scenes, it may well then have been reported at this meeting if there had have been any discrepancies in, in the -- those incidents after being investigated, it may have been discussed. But it -- it obviously wasn't highlighted by Debbie herself as the risk lead for, for paediatrics.
DE LA POER: So we can take this down. That is the 18th. On the 19th, so the next day, Eirian Powell updated that table with the names including Letby's name in red. We will bring that up. Firstly, let's look at the email that she sent, so the email is at INQ0005643. If we scroll to the bottom we can see the start of the thread, 19 January. So just the day after that meeting, and if we look at page 2, please, we will see the body of it, it is addressed to Steve: "Hi, I have amended the last list to ensure that we have included all the babies that have died on the unit within this timeframe." If we go back up again, we can see that you are copied into that email. Do you see that, bottom right-hand corner?
We don't need to bring up the table unless you wish to see it again, Mrs Murphy, but the table had two additional entries on it, so it had gone from 8 to 10 and Letby's name was highlighted in red next to one of the two columns for both the additional deaths so that's how the table has changed since the version that was circulated in October. We can briefly take that down, but we will have a look at the email of 22 January. Just while we think about that table, do you have a recollection of receiving the updated version of the table and noticing the two extra deaths?
MURPHY: I think at that stage, you know, it was being regularly updated and reviewed. So I can assume that I did see that table.
DE LA POER: When you saw that there had been two more deaths and Letby's name was associated with both of those two further deaths, what, if anything, was your thought process?
MURPHY: I think at that stage it was generally looked at that everything had to be reviewed, you know, not just the fact that there was a nurse who they felt was potentially involved, but all other elements; you know, the care practices, the standards that were there, infection control issues.
I think these were also things that were being discussed behind the scenes, really, that because there still wasn't any actual evidence that she had done any wrong, no one had come forward to voice a concern, you know, from a colleague's perspective. It was still just the fact that she was present on the unit for the majority of these babies.
DE LA POER: You have mentioned things going on behind the scenes. What you say in your witness statement is that: "I can't say if I escalated to Alison Kelly ... or if indeed I was already reporting back to Karen Rees during our usual management monthly one-to-ones at this stage." So you said in terms in your witness statement you don't have any recollection of speaking to Alison Kelly about this. In terms of Karen Rees, we have heard about these one-to-ones which there are sometimes more people below you coming to that meeting. Do you have a recollection of telling Karen Rees about the fact that there was an increase in deaths and the fact that a nurse had been identified as being on duty or directly caring for the baby at the time of 9 out of 10 of the deaths?
MURPHY: I really don't, I can't answer that question. I would have thought that we would have been informing Karen of any updates but I -- I can't say that, you know, at what stage we did that. But because I have a recollection of informing Jane Evans originally, I think it would have been something that would have been discussed, you know, how were things going, had there been any more baby deaths, whatever, was there any extra information to be given? But I couldn't -- I mean, I cannot swear to that, really. That is just my assumption, really.
DE LA POER: Just looking back on it now, you say you may have raised it, you may not have, you assume that it's something you would have raised. Do you think it is something that should have been raised by this stage, with Karen Rees the Director of Nursing for that division, or the head of nursing rather?
MURPHY: Well, I certainly think that we were looking at all of the issues that could potentially be a problem within the unit. So, yes, I would have thought that we would have been informing our line manager about that.
DE LA POER: So we don't need to bring it up but that email from Dr Brearey in reply to Eirian Powell's proposes a meeting for half a day at which Dr Subhedar was going to attend and we now know that is the thematic review of neonatal mortality meeting. We don't need to bring up that email but that is his response to the table?
MURPHY: (Nods)
DE LA POER: If we just bring it up, the thematic review INQ0003217, really for the purpose of identifying that you are one of the participants at that meeting on 8 February, aren't you?
MURPHY: Yes.
DE LA POER: We can see from the bottom of the page that one of the objectives was any possible common themes. We know from this first version that the timing of the arrests was identified as one of the themes that six out of the nine deaths that were being looked at occurred between midnight and 4 am. Can you remember that theme being discussed at the meeting?
MURPHY: Yes, I believe I can remember that, yes, it was one of the issues that was highlighted.
DE LA POER: I am terribly sorry, I am sure it's me but can I ask you to keep your voice up a little bit. I just missed what you said there?
MURPHY: Yes, I think I can recall that.
DE LA POER: Yes. And we know that attached to this report was appendix 1 which had the columns that we have seen before with names of nurses on who were either on duty or who were allocated to the baby, so a version of the table that you had seen the previous month with a key
difference that Letby's name was not highlighted in red. Did you notice when this report was circulated that the table no longer highlighted her name?
MURPHY: No, I can't recall that. It certainly didn't come into the fact that it wasn't highlighted.
DE LA POER: In terms of the discussion before we look at what's actually said, do you remember whether Letby was discussed at this meeting, whether by name or by reference to a nurse?
MURPHY: I think there may have been reference to the fact that a nurse was present on the unit at all of these or the majority of the babies that we were going to review. Again, I couldn't really swear that that's right.
DE LA POER: So what you say in your witness statement is: "I believe [that] Lucy Letby's presence on the unit at all deaths was highlighted as it was on the Mortality 2015 report ... Letby's competence was never questioned. It was suggested, as no one wanted to accuse her of harm, that it may be a practice issue."
MURPHY: (Nods)
DE LA POER: So just thinking about that. Do you have a recollection of there being a discussion about whether Letby had a practice issue?
MURPHY: Yes, I -- I don't know whether we discussed it
at this particular meeting or whether I had previously discussed it with Eirian. But I do remember being told that she was a very good nurse, neonatal nurse, that she was up to date with all the competencies, she had done further training into neonatal care. So as far as I was aware there were no particular issues around that time that could sort of defer from that.
DE LA POER: So it may be a matter of some importance whether Letby was discussed at this particular meeting. So I appreciate it's a very long time ago but doing the best you can, do you think that she was discussed or do you think that it may have been a different meeting that you had a discussion about her competence or can you just not say?
MURPHY: I really can't remember whether we specifically discussed her at this meeting or not.
DE LA POER: Because one the things that is apparent from the record of this meeting is that there is no record of any discussion of Letby or a nurse or a potential practice issue or anything like that in this record. So is that a fact that you had appreciated before I pointed it out now?
MURPHY: Then I think that we obviously didn't discuss her directly.
DE LA POER: Because look at it another way. If -- if there had been a discussion about her potentially being a common theme and you had then received this record and that wasn't included in there, would that have stood out for you as well, this record isn't actually accurate?
MURPHY: Well, at that time then, yes, I probably would have queried it.
DE LA POER: So let's move forward to the paediatric specialty meeting. INQ0041363. This is on 15 February, so it's just seven days later. Again we can see that this is one of those meetings with quite a number of people who are invited, again Dr Jayaram is recorded as being present, as is Dr Brearey, and in the middle there you are recorded as being present at this meeting. If we go over the page, and again the usual comment applies here. There are other people who can raise these things, I am just looking for your perspective on it. We can see item 2 has just this comment under the "Performance, KPIs and Dashboards": "There are no problems in school health or NNU." Now, that is obviously under a specific heading which is "Performance, KPIs and Dashboards" so we have got to read it in its context. But given that the thematic review had taken place just seven days earlier was that something that should have been discussed at
this meeting, do you think?
MURPHY: Well, that was relating to performance. So they were really the -- the business side. So it was more like the appraisals that we had carried out, you know, so nursing competencies, mandatory training, they were the things that we would have been specifically talking about there. I don't know that someone's competence, unless it had been raised as an issue, would have been brought up at that.
DE LA POER: If we have a look at page 3 we will see that heading "Governance" is also there and the "Governance Issues Summary". Again what we don't see there is the fact that there was the thematic review just seven days earlier.
MURPHY: So, I mean, Debbie was saying that it would be shared, once it had been finalised and that was from a governance risk perspective for that.
DE LA POER: But we know it is not finalised until 3 March, but in terms of the content of -- sorry, 2 March, that is my mistake. But in terms of the content of the meeting, I mean, did that thematic review identify a clear explanation for the increase in deaths on the neonatal unit?
MURPHY: No, I don't think it highlighted any -- any
issues and I mean in fact Dr Subhedar at that meeting said that he was impressed on how many of the babies had had post-mortems because at the women's, he was never able to achieve that level of acceptance and agreement from -- from the families. So he put that forward as a good point from -- from, you know the perspective neonates. But I'm not sure sort of what, what you, you really want from that. Comment.
DE LA POER: Well, don't worry about that. It's really once you had had the thematic review, my question was: did you think that there was a clear explanation for why the number of deaths on the neonatal unit had gone up by so much?
MURPHY: No, and unfortunately I don't think we ever did get a clear review of that until obviously the police were involved. But I'm sorry, but looking at one set of minutes, I -- I can't think of what my thought process would have been at that time --
DE LA POER: Well --
MURPHY: -- or what conversations were going on behind the scenes.
DE LA POER: Let's just look at a slightly different point within these minutes the CQC. If we go to page 4. We can see the fourth bullet point under "Any Other
Business": "Anne Murphy asked if the junior doctors are ready for the CQC visit. Dr Jayaram said that they had all been given information relating to the visit and they had been advised that all PCs should be logged off when not in use, handover sheets should not be left in view and the notes trolley will not be taken on to the ward round." So the first question is: can you remember why you wanted to know if the junior doctors were ready?
MURPHY: Well, I think we were probably ensuring from a nursing perspective that things were, you know, all ready in preparation for the CQC visit and just to ask because, you know, it may be that, at that time, I know there had been an issue that one of the handover sheets had been found, so I think we just I think probably wanted to ensure that the doctors were also aware of the visit and the fact that, you know, a lot of things would be scrutinised at that time.
DE LA POER: Obviously striving to improve standards at all times is an important aspect of work within the NHS. But just help us to understand whether there was a culture here that the hospital would put its best foot forward when the CQC came just to try and satisfy the CQC, in other words for the sake of satisfying the CQC rather than because it was an intrinsically good thing to be doing, was there that culture?
MURPHY: No, I don't -- I don't think that you could say that there was a culture. I think it was more just to remind you know, the -- the nursing and medical staff at times would leave the room unlocked where -- where the notes were kept or where the computers were. They may well have left the computer on while they popped out to check on something or if, you know, they had had a call and were being asked to leave the room where all of their work was being completed. So I think it was just to remind people that, you know, we were reminding all of the nurses and it may well not have just been at that particular time but obviously the CQC were coming and it was, you know, what things may we sort of let ourselves down with and -- and it may be that they were the things that had been highlighted at that time.
DE LA POER: So I just want to draw your attention to something that Nurse ZC has said, there is a cipher list -- we are not using that nurse's name but there is a cipher list if you are not sure who I am referring to. She says -- and this was provided I hope in your pack: "Anne Murphy, the lead nurse of paediatrics,
attended one specific safety brief where the NNU was discussed. Following the briefing we had an impending CQC visit and Anne Murphy requested we fill out our appraisal documentation and sign them so we would appear compliant for the CQC visit, despite none of us receiving appraisals, or at least I know I did not receive an appraisal during my time at the Trust, but was requested to fill out this form at the time, again evidencing the operations between senior management across the Children's Division." So that's what she has said. Is that something that you did or is she wrong about that?
MURPHY: I certainly wouldn't tell someone to sign a form on an appraisal that they hadn't had. What I may have been saying is if you haven't had your appraisal then speak to your appraiser and, you know, get it sorted. Obviously at that time of year, we were just finishing a busy winter so appraisals may have been put on hold until after the rush that we have between October and February. But if I was going to say something like that, it would have been to the group of appraisers, not to the staff.
DE LA POER: Thank you. We can take that document down. We are going to move forward two days to the CQC meeting on 17 February 2016. You have had a chance to look at the notes prepared by the CQC recently about that meeting so hopefully that's helped to some degree. It was a meeting that Dr Brearey was also present at. We can bring up the INQ0017339 and we are going to go to page 207. So speaking entirely for myself, I have not found these notes the easiest to interpret. But it does appear if we look about three quarters of the way down, that the word "neonatal mortality times 2 last year", page 207?
LADY JUSTICE THIRLWALL: 207.
MR DE LA POER: That entry that I have just drawn particular attention to appears to be under a Mortality and Morbidity Meeting heading. "5 from NNU last year x4 this year." So in other words it does appear that there is some discussion about the number of deaths at that meeting?
MURPHY: Yes.
DE LA POER: Did the fact that there had been a thematic review feature in your discussion with the CQC? Is that something that was raised at the meeting that there had been a meeting just nine days earlier where all of these deaths had been looked at and that no clear explanation had been identified for the increase?
MURPHY: I can't remember exactly what was said at that meeting. But, you know, we have talked about the mortality/morbidity meetings and, you know, we -- we probably said the same to the CQC; that we couldn't find a reason for any of the mortality being increased. But I can't remember the, you know, everything that happened. I mean, there was a lot of conversations taking place. But, I mean, we clearly told the CQC, you know, about the raised mortality but I -- I can't remember what was actually discussed.
DE LA POER: I mean, it appears that from the notes that you told them about the number of deaths which may or may not be the same thing as telling them that you had had, comparatively speaking, very many more deaths than you were used to. Do you see? Just identifying the number of deaths, which is what we have recorded here, doesn't necessarily mean that you are saying this is many more than we are used to and we haven't been able to find a clear explanation for why. So it's just important, doing the best you can, we can see what the notes record as having been said. That second part namely that this was a very significant increase and that you there had been an investigation looking at all of them and that no clear explanation had been found, it's that second part. Do you have a recollection of that being said by either you or Dr Brearey to the CQC?
MURPHY: I'm sorry, I -- I can't recall what, what exactly was discussed, whether it was highlighted in those particular themes.
DE LA POER: Given the meeting that you attended, was that the sort of thing that you should have been saying you and Dr Brearey to the CQC, to help them do their job?
MURPHY: I am not altogether sure, really. I mean I think one -- one of the participants in this was actually Lucy Letby herself. So I don't know whether we were actually withholding that information or whether it was something that just didn't come up. I -- I really don't recall what the context was of, of all of the meetings that -- that we had over those couple of days.
DE LA POER: Thank you, we can take that down.
LADY JUSTICE THIRLWALL: Sorry, just before you take it down.
MR DE LA POER: My Lady, of course.
LADY JUSTICE THIRLWALL: Mr De La Poer may have missed it but the line immediately below the yellow highlight, are you able to tell us, it looks as though it says "Neonatal mortality x2 last year" and then I couldn't work out the last part.
MR DE LA POER: It may be, my Lady, we will have to ask the author.
LADY JUSTICE THIRLWALL: Yes. Are we going to hear from the author?
MR DE LA POER: I believe so but I don't want to give that answer with certainty.
LADY JUSTICE THIRLWALL: No, all right. Just in the light of the questions you were asking, I wasn't sure whether that line was the information about the previous year, although they both say "last year". Anyway, we hope to hear from the author.
MURPHY: I -- I think that was the fact that there had been two neonatal mortality meetings held --
LADY JUSTICE THIRLWALL: Ah, meetings?
MURPHY: -- in the previous year but I don't really ... I can't decipher.
LADY JUSTICE THIRLWALL: Depending on cases to be discussed, that is what the last one says --
MURPHY: Depending on cases to be discussed, it depends, the mortality meetings were held if there were cases to be discussed. So they weren't a regular two monthly or three monthly event. It was if there were cases to be discussed and there had obviously been two in the previous year.
MR DE LA POER: I think perhaps to be distinguished from the perinatal mortality and morbidity meetings, which we can see are referred to in the first part of the highlight which were regularly scheduled events, weren't they? Or it may be that you don't know that but we have certainly heard that from other witnesses. Thank you, we can take that down. The next event that we are going to consider -- so that was 17 February -- is the 2 March when Dr Brearey circulated the final version of the thematic review and we will just bring up the email, INQ0003114. We can see that in his email Dr Brearey, which is right in the centre, thanks Nim, Dr Subhedar, Dr V, Eirian and Anne for contributions. That may be a reference to contributions at the original meeting or subsequent contributions. Can you help us with whether after the meeting you had any further contribution to make to Dr Brearey finalising this report?
MURPHY: I think after the meeting the action plan was further updated, so I think that that was what he was -- first it was thanking them for actually coming to the meeting, but because Nim didn't have anything to do with sort of updating the actual mortality table, I don't know if there was any further issues.
That was then going to be sent on to the Executive team for them to review and look at, which would obviously have included the mortality tables that had been carried out.
DE LA POER: Now, the second version the finalised version contained a new theme, it was the first theme: "Sudden and unexpected deteriorations and no clear cause in some cases for death deterioration identified at post-mortem." So did you, Mrs Murphy -- it is not in the email, on that later version of the thematic review, did you notice the fact that there was an additional theme that was identified? We can probably take that email down. I can show it to you, if that would be helpful?
MURPHY: I am sorry, I can't -- I can't think what had been added.
DE LA POER: Let me just --
MURPHY: Or whether it was the learning points to take forward.
DE LA POER: So make sure I get the right version for you. Forgive me for a moment. (Pause) So it is INQ0003251 and we will go straight to page 7. 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 [the post-mortem]."
MURPHY: (Nods) Yes.
DE LA POER: So was that a theme that you were aware of that emerged from the thematic review?
MURPHY: Well, it had been discussed, certainly at -- at -- I don't know if at neonatal level or at some of the senior clinicians meeting. They obviously weren't expecting some of those babies to deteriorate. But I -- I don't know at what stage we would have got the post-mortem reports back and they would normally have been discussed at the Morbidity and Mortality Meetings which I didn't attend.
DE LA POER: But --
MURPHY: But it -- I don't know if that was something that the themes -- whether that was added after the original document had been --
DE LA POER: It wasn't in the original document; it was in the document that Dr Brearey sent you --
MURPHY: Yes.
DE LA POER: -- and others on 2 March of 2016?
MURPHY: Okay.
DE LA POER: Because that's this document that we are looking at now. So my question really was: was that as at March of 2016 something that you were aware of, that
not only had the death rate increased, but that for some of the babies there were sudden and unexpected deteriorations with no clear cause for deterioration or death identified at the post-mortem?
MURPHY: Well, yes, I suppose I did know, was aware, you know, sort of at that time that the concern was that these were unexpected deteriorations. I don't know whether I could have equated the post-mortem results to -- to you know, the reason those babies were deteriorating.
DE LA POER: But so that's what the doctor, Dr Brearey, is recording and presumably you would defer to him --
MURPHY: Yes.
DE LA POER: -- in terms of the accuracy of that?
MURPHY: Yes.
DE LA POER: So two days later -- we can take that down -- you had another meeting with the CQC. INQ0017339 at page 262. I believe that records the 4 March 2016 at the top. We can see that the inspector is identified as Ms Cain halfway down and there is a meeting. The attendees include you. Now, this was two days after the finalisation of the thematic review. You can look through the notes if you want or you can take it from me it doesn't seem to
be the case that you are raising with the CQC at that meeting what had been circulated two days ago. Do you have a recollection of telling the CQC in March about the thematic review and the fact that there was sudden and unexpected deteriorations some of which had no explanation at post-mortem?
MURPHY: No, I don't recall telling them that, this was specifically relating to the children's ward, but -- so I don't think neonatal came into it at that stage. I think this was their review of the actual children's ward itself.
DE LA POER: Thank you, we can take that down, thank you. Continuing to move forward, 15 March INQ0005697. Again we see you copied into the top right-hand corner. This is an email from Eirian Powell in which she sets out how many deaths there had been on the neonatal unit from 2010 to 2016 and she also points out that Letby had commenced working on the NNU in January 2012. Did these numbers come as a surprise to you?
MURPHY: No, I don't think they did at that stage because there had been a number of discussions about these babies and -- and that that was sort of how, Eirian put it into perspective, I suppose, by highlighting previous years to -- to sort of everyone.
I mean, I believe that there was another bit of that email or a response or whether it was in response to an email. I think it was still at that time we were trying to pull out any issues regarding it and I believe at this stage this was when the Consultants were getting together and discussing the fact that, you know, they -- they were genuinely concerned about it. And I think it was from there that we or Eirian specifically but with my knowledge emailed Alison Kelly with the thematic review. She didn't know whether, you know, it had been sent to Mr Harvey for -- by Steve Brearey or not which I -- I would have assumed Steve would have sent it up to Ian Harvey anyway. But I think this was in addition to that just to highlight the fact and at that stage Eirian asked for a meeting to discuss or had, you know, it may well have been just afterwards, to ask if we could have a meeting to discuss the thematic review.
DE LA POER: So we are going to come to that email which was, you are absolutely right, two days after this email but I would just like to go back to what you said about the Consultants. So to your recollection it was around this time, so just after the thematic review was finalised, that Consultants in addition to Dr Brearey were expressing their concern; is that right?
MURPHY: Yes, yes.
DE LA POER: And are you able to say which of the Consultants you have a recollection of having such a concern?
MURPHY: I mean, the -- the Consultant that I know who definitely voiced that was Dr Jayaram. But I think Dr Gibbs was also -- although he speaking to Dr Gibbs he couldn't give us a reason for any of these babies having a sudden deterioration, I think because they were obviously discussing it amongst themselves, then he was also feeling that at that time, you know, there had to be something and I mean -- I don't know whether we were still looking at other elements. You know, could it be something else or at this stage I think we were all just getting a bit upset about it all and discussing whether it should be put into the police hands, really. We were -- we had investigated as much as we possibly could and couldn't find a reason for it. It -- it could be coincidence that this particular nurse was there all of the time but there was nothing then to accuse her of doing. So I think we were really wanting support and advice from our Executive team by this stage.
DE LA POER: So it could be coincidence but was it also
within your contemplation that it could be something that she was doing, you just couldn't say what?
MURPHY: Well, I don't know that I personally felt that she was doing harm. I -- I couldn't personally consider what, what it was that she could be doing to these babies that would present in different ways. I -- what -- what could she be doing? I really don't know.
DE LA POER: So in the state of mind that you had taken it as far as you could, you sought help from the Executives and in particular Ms Powell. Let's just bring that up INQ0003089, again we are very familiar with this but let's just mark that moment in the chronology. If we scroll to the bottom. Forgive me, there we are. 17 March, Ms Powell -- you are not in fact on copy of this first email but you become aware of this, come on to this thread later we will have a look at. We can see she sent that message but that message was sent with your knowledge and approval, was it?
MURPHY: Yes, yes, it was.
DE LA POER: And bearing in mind all of the individual reviews, the thematic review, had this situation now reached a point where it was urgent?
MURPHY: Well, I think at this stage we felt that we
needed some support from -- or, you know, different eyes to be looking at it. We were, apart from the thematic review which involved one of the regional Consultants, I think it had always been an internal women and -- well, children's neonatal reviews with our risk assessor, who couldn't really -- I mean, she didn't at that time I don't think she didn't voice any concerns either about the nurse's presence. But I think at this stage I think Eirian was getting frustrated that the doctors kept saying that it had to be her, Lucy Letby, that was somehow causing this. They couldn't give us a reason or, you know say how this could be happening, what exactly she could be doing to any of these babies. And we still didn't have any reports from nursing colleagues to say that they had -- they were upset that these babies were dying because it was different, you know, this was different. But could it just be a blip that there had been a lot of babies born with problems and, you know, subsequently deteriorated? No one could answer those questions for us. But, you know, at that stage, I think we had discussed you know that we needed support from outside.
DE LA POER: So if we just run through this email. We can
see that Alison Kelly replies four days later asking for the report, that is 21 March. If we then scroll up to the next page, we can see that the same day Eirian Powell sends the report to Alison Kelly and then the next email is 14 April, you are now put on copy at this stage and it's Eirian Powell chasing Alison Kelly?
MURPHY: Yes.
DE LA POER: Now, given the apparent lack of response, that's certainly what this email tends to suggest, should action have been taken before 14 April to get input from the Executives? In other words, was it acceptable to wait a period of over three weeks before following this issue up?
MURPHY: Well, perhaps not. Perhaps we should have been chasing. But I -- unfortunately we obviously didn't and, you know, I can't really say why that, why we wouldn't be doing that.
DE LA POER: Because back in --
MURPHY: Perhaps we just -- you know, we weren't always on duty at the same time, you know, there were things that were happening within the various units, I really don't know why we left it until that stage to -- to then question it again.
DE LA POER: Because back in October the plan had been to go and see Alison Kelly that day, in person. And I am just wondering if you can help us with why, that having been the thought process back in October that at this stage we see a period of over three weeks passing before an email is followed up?
MURPHY: I'm sorry, I can't answer that. I don't know why we didn't.
DE LA POER: At all events we know that by the beginning of May, there is some further action. INQ0003393. If we go right to the bottom. Thank you very much indeed. We can see on 3 May there is a cancellation, and that's in the subject line of a planned meeting. So we know from other evidence that it was planned that Dr Brearey and Ms Powell would meet with Ian Harvey and Alison Kelly on that day but it was cancelled. We can see Dr Brearey asking for alternative times, so that is the start of this conversation. Then we have Alison Kelly saying we will advise on an alternative date and then the next day, Dr Brearey -- you are not on copy to this but it's nothing that you didn't know, I don't believe. "There is a nurse on the unit who's been present for quite a few deaths and other arrests. Eirian has sensibly put her on day shifts at the moment but can't do this indefinitely." Can we just pause there and just ask you a couple
of questions about the day shift move. Did you know that at the beginning of April Letby had been moved on to day shifts?
MURPHY: Yes.
DE LA POER: Was that something you were told about after it had happened or something you were consulted upon?
MURPHY: I think Eirian and I had discussed that because she had been involved with so many of the deaths that it would be better for her mental health really to come on to days for a period of time. But because there were also more staff around during the day she would then not necessarily have to look after the sickest babies. So it -- it was -- I think it wasn't done because people were pointing the finger per se, that she was the person that was causing these babies to deteriorate, but it -- it would have been better for her and obviously if there was something happening at that stage then it could well be prevented if -- if that was the case. So I don't know whether it was to appease the doctors or -- but to me it was a good suggestion to actually bring her on to days.
DE LA POER: We know the thematic review identified that six of the nine collapses took place between midnight and 4. We also know that within two days of Letby being
moved to day shifts there was a sudden and unexpected collapse, [Child M], during her day shift. Did anybody notice that at the time or comment upon it that you were aware of?
MURPHY: I can't remember anyone commenting that to me at all. I mean, I obviously wasn't involved in some of these emails either.
DE LA POER: No, we will -- if we --
MURPHY: I was involved in the initial one, but I wasn't copied in to the others.
DE LA POER: We are going to move up and I am just going to ask for your comment on one particular thing, because Alison Kelly then in an effort to get an interim meeting it would seem, we will hear from her what she says her explanation is, asks for you -- asks for you and Ms Powell to meet Karen Rees, she is sending that to Karen Rees, do you see that at the bottom? "Can you please look into this with Anne M and Eirian? If there is a staff trend here and we have already changed her shift pattern because of this then this is potentially very serious". Now, absolutely I accept you are not on copy to this but this is the Director of Nursing describing what's being reported to her. I mean, was she right to describe it as
"potentially very serious"?
MURPHY: Well, I think at that stage we all felt that it was quite serious that people were pointing the finger and, you know, I mean I -- I am not aware at that stage that there was any sort of discussions outside of sort of the senior staff on neonates and paediatrics so the clinicians and Eirian and myself. I really don't know how many people were aware that the Consultants had suggested that, that there was this definite link if it was indeed a definite link. But you know, it was serious. I think at that time, the Consultants were talking about going to the police or who could we -- who could we get to support us through this?
DE LA POER: Did you agree with the suggestion that the police should be involved?
MURPHY: I think I did by this stage, not -- not that I thought that it was the nurse who was actually doing anything, but we weren't in a position to investigate this any further. We -- we had looked at everything we thought we could possibly look at and -- and, you know, I think by this stage, we were all, well certainly within, I mean I can't vouch for Eirian, but I think you know because the Consultants were definitely -- there was nothing that we could say was the nurse's fault. But there was -- you know, these babies were still dying.
DE LA POER: On 5 May you met with Karen Rees. Did you say to her that you thought the police should be involved?
MURPHY: In actual fact I can't remember meeting with Karen that day. But -- so I don't know you know what we actually discussed at that meeting.
DE LA POER: Do you -- and maybe you have already answered this -- have any recollection of telling Karen Rees that the thematic review had identified as its first theme that there were sudden and unexpected deteriorations and that the post-mortem in some cases had not explained either the collapse or the death? Was that information that you were telling to Karen Rees?
MURPHY: I mean, I -- I don't know if -- if Karen Rees had had a copy of the thematic review. I don't really know sort of what had been shared with Karen other than, you know, sort of what Alison Kelly has said in -- in the emails. I really don't -- I can't remember what was discussed. I am really sorry, but, you know, there was so many meetings around that time that without minutes, I -- I don't know what we did.
DE LA POER: We do have a record of that meeting. INQ0003243, page 2. It's just very short. If we go to the second page:
"Discussion with Dr Brearey, Anne Murphy and Eirian Powell. "Karen Rees requested that we discussed exactly what the issues, if any, were other than coincidence that was evident. Despite highlighting the usual factors, there was not real evidence or statement that could confirm whether there was an issue here." And then it goes on to give a list and identify the advice sought.
MURPHY: Yes. I mean, I have obviously seen the minutes, I was -- if I was there then I will have seen all of this. So obviously they were all discussed and, you know, they were the issues that had been looked at and the advice that had been sought prior to this meeting taking place. You know, I mean, that was internal and external because obviously there was network involvement there. While Eirian and Dr Brearey went to the network meetings, Nim had come to do the thematic review. So you know, the network were aware of sort of all of those deaths within -- presumably they knew that what our normal death rate was. I don't know whether they ever highlighted that they were concerned or, you know, that that there could be issues or whether they discussed that. I'm not sure.
DE LA POER: The next meeting I want to ask you about is the meeting with Alison Kelly and Ian Harvey on 11 May of 2016. What you tell us in your witness statement is that you don't have a memory of that meeting but you think that Alison Kelly's handwritten note is correct?
MURPHY: Yes, I mean --
DE LA POER: Or at least no reason to think that it's incorrect?
MURPHY: I have no reason to believe that it wouldn't be incorrect.
DE LA POER: Now, Dr Brearey has suggested that in that meeting Eirian Powell was very defensive of Letby. Do you have any recollection of how Letby was spoken about and how Eirian Powell presented herself in that meeting?
MURPHY: I think Eirian was defensive about the nurse because no one could give us any other reason and why -- why should it just be her? You know, we had highlighted in another table that one of the Registrars had also been present on a number of -- of occasions. But for some reason it was only the nurse that was being sort of pinned as being someone that potentially had created all of this. So, yes, Eirian probably was getting quite upset at the fact that -- or frustrated that the only thing any of the Consultants would look at was the fact that she
was present. You know, in retrospect, yes, they were completely right but do you ever want to accuse someone? We couldn't accuse someone of murder without any sort of background or sorry -- I don't think any of us wanted there to be an "us and them" situation.
DE LA POER: Did you agree with what Eirian Powell was saying or did you disagree with it at that meeting?
MURPHY: No, I think I had to agree with Eirian. You know, there was no proof that if -- if someone had come and said, you know, that she had witnessed anything untoward or if anything had been brought up in the babies's postmortems then that probably would have made a difference. But, you know, to all intents and purposes this was an excellent neonatal nurse. Why on earth would she be doing something, what could she be doing? I couldn't get my head around what could she be doing to harm these babies?
DE LA POER: On that point, presumably you were aware of past cases where nurses had and indeed doctors had harmed patients. Did any of those come to your mind as you thought about the situation that you were confronted with?
MURPHY: I'm sorry, could you repeat that?
DE LA POER: Yes, of course I will give you the names. Beverley Allitt, Victorino Chua. These are nurses who have harmed their patients, we have obviously got Harold Shipman?
MURPHY: Yes.
DE LA POER: There are past cases?
MURPHY: Yes.
DE LA POER: My question was just really whether those cases crossed your mind as you were trying to navigate this particular situation?
MURPHY: I- I don't think I did think about Beverley Allitt. I don't think I really thought that any harm was being carried out by a particular person. So no, I didn't consider -- and, I mean, I was very aware of the Beverley Allitt.
DE LA POER: You were very -- I'm sorry, did you say you were very aware of that case?
MURPHY: I mean I was aware of -- my previous manager had been the nurse involved with the report. So -- the investigation. So, you know, she had actually come to back to the Countess to get information about resuscitation trollies from us. So I was very aware of Beverley Allitt and so.
DE LA POER: Doing the best you can, why do you think you didn't draw that connection?
MURPHY: I'm sorry, I didn't. I didn't. I didn't think about child protection at all at that stage.
DE LA POER: Can I just ask you about a couple more matters. We are going to move past the deaths of [Child O] and [Child P] to two meetings on 27 June, we can deal with fairly briefly. The first is the lunchtime meeting involving the paediatricians. I think you have say that you have a recollection -- I believe it is of that meeting of Dr McCormack saying something. Doing the best you can, what is it that you recollect Dr McCormack as saying?
MURPHY: I don't -- I may have been wrong in what I wrote in my statement because I'm not sure whether that was an urgent meeting that had been called at half past 7 that morning or whether it was the official senior clinicians meeting which always took place at half past 12 on a Monday, well, three Mondays of the month. But the only thing that did stand out in my mind was that it was a meeting where there were obstetricians there as well as our Consultant paediatricians and I think there were other members, I don't know if Julie Fogarty was there, whether there was a risk person there. There was obviously Eirian and myself, I don't know if there was anybody else from paediatrics or from
the neonatal unit as anyone could really come to the senior clinicians. But, I mean, the only thing about that meeting that did stand out was when Mr McCormack we had obviously were discussing the fact that people were starting to get upset and that there was a nurse involved and Mr McCormack then shouted down the table, "Are you telling us there is a murderess on the neonatal unit?" And I think that was like a slap in the face. Eirian retaliated and said, you know, that he couldn't say that, there was no evidence but I think that is the only sort of thing that has been retained in my head about that meeting.
DE LA POER: The other meeting I wanted to ask you about which you don't give a date for in your witness statement is a meeting in late June of 2016 which you say Stephen Cross attended.
MURPHY: Well, I am not -- I'm not sure about the timeline. Certainly I only remember that at some time there was a meeting in which there was a number of the chief execs, and risk, safeguarding, senior management. I don't know if Karen Rees was there or not. I think Julie Fogarty was there as Head of Midwifery. But -- but there was a meeting where, which was pulled together to discuss the --
DE LA POER: Obviously don't worry about the timings. What is your recollection about what Mr Cross said?
MURPHY: My recollection of that was after discussion Stephen Cross saying that that there was no, there was no evidence to involve the police and the police would sort of disregard what we were actually asking for. He didn't think the police would entertain an investigation. So -- but as I say, I really don't know what the timeline was for that meeting, whether it was round about that time. I feel that it was but I may be completely wrong.
DE LA POER: The final event to ask you about is the meeting you had with the RCPCH on 2 September 2016. It is just one thing that you are recorded as saying. You describe the doctors in that meeting as being tunnel-visioned about her presence, that is what the note of the meeting says. Would you like to see it?
MURPHY: I mean, I -- I can't say that I didn't say that certainly. And in some respects we did feel that the doctors were very sort of tunnel-visioned about the fact that it had to be a nurse. But, I can't -- I can't recall seeing it that late in the process because I thought the police had already been involved by 2 September.
DE LA POER: The police were not involved until April 2017?
MURPHY: Right. I think well, I can't, I can't really remember. I think we were asking for external reviews and external investigations at that point and I may well have said that I thought the Consultants were -- had tunnel vision about it. But we weren't the ones that could do anything more to prove or disprove that.
DE LA POER: The very last matter which is not about any particular meeting, it's just a comment that you make in your statement is that you describe Tony Chambers and Ian Harvey as being confrontational and threatening in your witness statement. Was that behaviour that was reported to you or behaviour that you witnessed yourself?
MURPHY: I -- I couldn't say about Tony Chambers. I don't -- I can't remember whether he got confrontational at the meeting with, with the Executives. I think Ian Harvey we felt was confrontational at times but I think because after we had the RCPCH review, we were asking for -- to see the report and we kept being told, no, no, no and eventually he agreed to show us the report and I think there was just Dr Brearey, Dr Jayaram and myself who went to have a look at this
report which was supposed to be going out to the public. But it was heavily redacted and certainly the Consultants were not happy about that. I mean, you know, it was just literally covered in black ink, we couldn't see what half of what the RCPCH had said, never mind trying to decide what lessons we could learn from it or whether, you know, they had found anything else of concern and -- and I think Ian Harvey got quite, he gave us something like 15 minutes to actually look at this document which was inappropriate really especially when it was so heavily redacted and the Consultants asked for the -- the full copy which I don't know that we ever really got, I don't know if we did get it before it was published or whether we got it the morning it was going to be published, so I think that there were heated comments certainly with the RCPCH review. But I don't know that I was present at any other meetings.
MR DE LA POER: Mrs Murphy, thank you very much for answering my questions. There will be some more questions which I hope we can accommodate before lunch, my Lady, from Mr Skelton?
LADY JUSTICE THIRLWALL: Very good. Mr Skelton.
LADY JUSTICE THIRLWALL: Take the time you need, Mr Skelton.
MR SKELTON: Thank you. I will try and be fairly swift, my Lady. Mrs Murphy, I ask questions on behalf of some of the families. I am going take you back to October 2015 and the death of Baby I [Child I], do you remember her?
MURPHY: Well, I'm sorry, you see I don't know any of these babies. I didn't work on the neonatal unit so I had nothing to do with the babies' care or their families. So, you know --
SKELTON: I understand that, but it has been nine years since she was murdered and you are at a Public Inquiry into the death into her murder and other things?
MURPHY: Yes.
SKELTON: Have you refreshed your memory about the care that was given to the individual babies on the units which you had responsibility for?
MURPHY: Yes.
SKELTON: You have refreshed your memory?
MURPHY: Yes, I have looked at ...
SKELTON: Baby I [Child I] died on 23 October 2015 and we now know she was murdered by Lucy Letby, do you recognise that?
MURPHY: I have looked at all of the reports, so yes.
SKELTON: Do you recognise that she was murdered by Lucy Letby?
MURPHY: Well, she's she been found guilty by a court of law, so yes, I do.
SKELTON: And in your opinion?
MURPHY: I mean ...
SKELTON: Do you accept that verdict?
MURPHY: Yes, I accept that she has been found guilty. You know, there's -- and you know in some ways we were wrong for it going on so long. So yes, I would half -- you know, I am so sorry for the Families who have had to deal with this for the last seven, eight years. You know, it, it's awful for them. So yes, I do accept, you know, that Lucy Letby obviously has murdered or had a part in all of those babies' deaths.
SKELTON: Just going back to what was going on in October 2015. The death of the child was unexpected, Dr Gibbs, the Consultant who was called to help the resuscitation was unsettled by her death. He hadn't expected it to occur. Do you understand, do you remember that?
MURPHY: Well, I have obviously read what has been said. I don't know that I had a discussion with Dr Gibbs about any of that, but --
SKELTON: The --
MURPHY: I accept that --
SKELTON: Mrs Murphy, sorry to cut across you. The reason I am asking you this is that Eirian Powell just after the death was in contact with Dr Brearey in respect of a mortality table which you were copied in on.
MURPHY: Yes.
SKELTON: So there must have been things at the time that you must have remembered or you must have been involved with for you to be copied in just after Baby I [Child I] died. Can you remember that, that mortality table with Lucy Letby's name in red?
MURPHY: I obviously remember that a baby had died and it will have been reported to me. But -- but that -- that was my, my only involvement in any of those babies.
SKELTON: Well, just trying to put -- I am trying to understand what you might have been thinking when you were involved in October 2015 because you were copied in on the email with the table and because you were a manager, a senior manager to Ms Powell; that's right? Yes?
MURPHY: Well, the manager was telling me that she didn't think that -- that the nurse was involved in any of those babies's deaths. But you know, I accept that obviously you know in retrospect, yes, we were aware.
SKELTON: She thought it was an unfortunate coincidence?
MURPHY: Yes.
SKELTON: She thought Lucy was a good nurse?
MURPHY: Yes.
SKELTON: You accepted those two things?
MURPHY: Yes, I did.
SKELTON: And you didn't investigate the matters yourself?
MURPHY: No, I was involved in some of the investigating work but I didn't investigate anything myself. I -- you know, I was aware of the qualifications of Lucy Letby, you know, the courses that she had done since qualifying.
SKELTON: You have mentioned repeatedly in your evidence the seriousness of the allegation or the accusations to be put to Lucy Letby, had it been true?
MURPHY: I don't think we ever made an accusation.
SKELTON: No, that wasn't my question. Today you have talked about how serious it was to accuse someone?
MURPHY: Yes.
SKELTON: It's right though that that's nothing compared to the seriousness of the death of the children?
MURPHY: Right.
SKELTON: Correct?
MURPHY: Yes.
SKELTON: And the seriousness for their Families?
MURPHY: (Nods)
SKELTON: I am trying to compare the seriousness of what you needed to think about, the seriousness of the acquisition against Lucy Letby, but the seriousness of the death of the children, the effect on their families and do you recognise that the latter far outweighs the former?
MURPHY: Well, obviously it's devastating. It's devastating to lose any child, any baby. But, was that an indication that some harm was being done? And that I think that was what we were thinking. You know, how: what was happening? What could have been done to those babies? And you know I mean, I -- I can't answer that.
SKELTON: Well, you accepted Ms Powell's view that it wasn't Lucy Letby that had caused the deaths.
MURPHY: Well, I don't know at that stage. I accept now but I didn't know at that stage and no one could give me any proof that any wrongdoing had been done to those babies.
SKELTON: But you know -- and I won't take you through all the children for obvious reasons -- but they were stable for the most part, their deaths were unexpected and they were unexplained for the most part; in other words, there wasn't a clear cause of death, which is why the Consultants were concerned, because they couldn't
understand why the children had died. So that in itself is concerning, isn't it, children dying unexpectedly, obviously?
MURPHY: But I'm sorry, you know, I -- I -- I didn't think any differently at that stage.
SKELTON: Did you think about the consequences if you were wrong?
MURPHY: Of course I think about it.
SKELTON: No, at the time --
MURPHY: Well, no --
SKELTON: So let me finish the question.
MURPHY: -- at the time, I -- I didn't think about the consequences. You know, things do happen. Coincidences do happen and the fact that she was present, you know. And I think if she had been caring for each of those babies and not just being on the unit then, then that may well have, have been slightly different; you know, the fact that only babies in her care were dying. But that wasn't actually the case.
SKELTON: But did you ever check that she had had any contact with any of the babies that weren't in her care? Did you actually check that?
MURPHY: Well, no. In fact we couldn't check that element --
SKELTON: So why --
MURPHY: -- because the -- the -- there was no -- none of the staff came forward and said, you know, that there was interference with the care of their baby. In the neonatal unit, they -- the nurse allocated tended to do everything for those babies and -- but I don't know whether they did sort of document if someone else took over for lunches or their breaks. I really don't know, but --
SKELTON: Sorry. Did you try and check that?
MURPHY: No, I did not personally check.
SKELTON: Just going back to my original question. You thought Lucy Letby was a good nurse, that is what Ms Powell had assured you, and you thought it coincidence, which is what she thought as well.
MURPHY: Yes.
SKELTON: Did you think about the consequences if you were wrong; that she, in fact, wasn't the nurse you thought she was and that this wasn't a coincidence. Unlikely as you might have thought it, but did you ever think about the consequences that you were wrong?
MURPHY: No, I don't think I did.
SKELTON: Do you recognise that the consequences were extremely serious, in fact it couldn't be more serious?
MURPHY: Yes.
SKELTON: In those circumstances, if you can't be
certain that children aren't being harmed, isn't the obvious step to take action urgently to protect children?
MURPHY: Yes. In retrospect, yes, we would -- we should have.
SKELTON: Not in retrospect. Based on the information that you knew at the time, you couldn't be certain that Lucy Letby was not harming the children and therefore you needed to investigate urgently?
MURPHY: No.
SKELTON: Do you accept that?
MURPHY: Yes.
SKELTON: Can I just ask you about Karen Rees. I think she became the head of nursing in the Urgent Care Division in August 2015. You may not remember that date, but do you remember her becoming a manager above you?
MURPHY: Yes.
SKELTON: Was it at that point that you would have started having regular contact with her?
MURPHY: Yes.
SKELTON: Straight away?
MURPHY: With Karen Rees, yes.
SKELTON: Could you just describe the frequency of the meetings and how they took place and if they were
structured?
MURPHY: It was generally a monthly meeting. It may have stretched or if there was issues it may not have occurred on a monthly basis, but it was a meeting where the four managers of the children and neonatal unit would go and speak with the head of nursing for our area.
SKELTON: Did you meet her, apart from those formal meetings, the monthly sort of fixed meetings? Were you in regular contact to discuss things with her?
MURPHY: No, I don't think I was.
SKELTON: Going back again -- and I appreciate your memory isn't perfect about these events in 2015, it was some time ago -- but after [Child I] died and you and Eirian Powell were thinking about what might be causing the increased mortality, did you raise that concern, either your concern on behalf of the nursing team or the Consultants' concern, with Karen Rees in 2015?
MURPHY: I really can't say for definite that either myself or Eirian did. I thought that it was -- at least the mortality on the unit was discussed. But I -- I really couldn't swear to that.
SKELTON: Doing the best you can, if you think about those monthly meetings --
MURPHY: Well, I -- I think that we did discuss it, but
I -- I really don't know.
SKELTON: In 2015, at some point, or are you taking us into 2016?
MURPHY: No, I -- I think -- I think that we started to inform earlier in 2015 and when Karen took over I think that we would have continued to -- to inform her if there was a baby death. I don't know if we did say that the neonatal Consultant was concerned and had raised concerns about it.
SKELTON: So doing the best you can, do you think that you or Eirian Powell will have told Karen Rees, some time in 2015, that there were concerns about increased mortality in the neonatal unit?
MURPHY: I -- I do believe that we had informed about the raised mortality. I really can't say at what stage we did do that. My recollection was that it had started earlier in 2015 with the previous head of nursing.
SKELTON: And when those discussions started, were you also raising the concerns that had been raised with you or Ms Powell about Lucy Letby?
MURPHY: I don't -- I don't know at what stage that was raised as a concern. I think that that may have been in the June or July. I'm sorry, I really can't think -- I can't remember.
SKELTON: Lastly, Mrs Murphy, in your statement you don't mention The Families of the children and in your reflections you don't talk about your own responsibility for the hospital unit, for the nursing team, during the period in which the children were killed. Is there anything you would like to add in this evidence now before you go in respect of that?
MURPHY: From my reflections from this is that, you know, all of those babies died and obviously some of them could have been prevented. Some of them could have been prevented from ending up with, with, you know, lifelong problems and, and, yes, from my perspective I should have done something earlier myself. But I -- I really didn't --
SKELTON: Thank you.
MURPHY: I couldn't understand why, you know, it was happening. So, you know, I have to apologise to all of those Families from my perspective that, you know, I feel that I certainly failed those children by not doing something sooner. So I am sorry for that.
MR SKELTON: Thank you, Ms Murphy. Thank you, my Lady.
LADY JUSTICE THIRLWALL: Thank you very much, Mr Skelton. Mrs Murphy, that's the end of your evidence so you
will be free to go in just a minute, but I just wanted to thank you for coming.
MURPHY: Thank you.
LADY JUSTICE THIRLWALL: I appreciate it has not been easy, but it's been helpful. Thank you.
MURPHY: Thank you very much.
LADY JUSTICE THIRLWALL: I know we finished a little bit late, but we are going to start again at 2 o'clock. (1.10 pm) (The luncheon adjournment) (2.00 pm)
LADY JUSTICE THIRLWALL: Ms Langdale.
MS LANGDALE: My Lady, may I call the next witness.
LADY JUSTICE THIRLWALL: Ms Rees, would you like to come forward.
MS KAREN REES (sworn)
LADY JUSTICE THIRLWALL: Do have a seat.
REES: Thank you.
MS LANGDALE: Ms Rees, you have provided the Inquiry with a statement dated 14 June 2024. Do you have that with you?
REES: I do.
LANGDALE: And can you confirm for us that the statement
IS true and accurate to the best of your belief?
REES: It is.
LANGDALE: You tell us, Ms Rees, at paragraph 7 that you commenced the role of head of nursing within the Urgent Care Division later referred to as Associate Director of Nursing in August 2015 and stayed in that position until 2018 at the Countess of Chester?
REES: That's correct.
LANGDALE: What was your experience before that position?
REES: Before what, Sorry.
LANGDALE: What was your experience before taking up that position in nursing and managing generally?
REES: Okay. Sort of my career path?
LANGDALE: Yes.
REES: Prior to taking up my post as head of nursing I was theatre manager for eight years, my background is cardiology. But I wanted to gain experience within the surgical division as well as the Planned Care Division so I could get an overview, which I think that's what helped me get my head of nursing post eventually. I had responsibility for eight wards at the Countess of Chester Hospital, three wards at Ellesmere Port Hospital, I also had managerial responsibility for the emergency department, all specialist nurses within the Urgent Care Division but I was supported and of course
neonates and paediatrics came under that umbrella too but I was supported by four matrons and one lead nurse.
LANGDALE: Before you took that role, was all of your other experience related to adult patients?
REES: Yes.
LANGDALE: So when you began this Director of Nursing role or head of nursing, did you receive any particular training or go on any course in relation to safeguarding or child protection as it used to be known?
REES: We all have safeguarding training to do within the environment obviously, but mine was majority adult, being in the adult. When I took over as head of nursing, I made it my business to become accommodated with the neonatal unit and paediatrics because clearly I never had any nursing experience. So I did rely heavily on the senior nurses in both those departments but I didn't have any basic training in paediatrics or neonates, no.
LANGDALE: So when you say you relied heavily on the senior nurses, which ones were those?
REES: Okay predominately Eirian Lloyd Powell and Anne Murphy.
LANGDALE: What did you at that time think should be done if you were suspicious, only suspicious or concerned that a child may have been harmed deliberately by an adult, what did you think should happen where there is just mere suspicion?
REES: It should have warranted an immediate investigation.
LANGDALE: By whom? I am not talking specifically now, just generally what was your understanding, if there's a baby in hospital and there's concerns that someone may have harmed that baby, we don't know who, a family member, a member of staff, someone might have harmed a child, a baby: what should happen next?
REES: Okay. I think initially the safeguarding team should have been brought in immediately to have a look, an overview, and then make some recommendations if it needed a further deep dive into an investigation where the appropriate personnel who have got the appropriate qualifications, somebody like myself obviously couldn't investigate. So we would have to make sure that we appointed somebody with those relevant -- that relevant knowledge and skills.
LANGDALE: So if somebody was concerned on the neonatal unit that an adult, a parent or a family member had harmed a child, and you were told there is some concern, at that time would you have said "go to safeguarding" or would you yourself go to safeguarding?
REES: Yes, that would be -- I would have, yes, suggested that we bring safeguarding in immediately as an initial look.
LANGDALE: Right. So as an initial thought, if it was a family member, "bring in safeguarding" is what you think you would have said?
REES: Yes.
LANGDALE: What would you have done if it was a member of staff, just a mere suspicion, do you think the same or should have done the same?
REES: I think initially, yes, the same. And then it -- I would then rely on that safeguarding team to have a look at the situation or the allegation and then make some recommendations if a further deep dive was necessary.
LANGDALE: Paragraph 9 of your statement, you say: "In August 2015 the culture and atmosphere on the NNU was good ... a small cohesive team who appeared to work well together ... [and] the nursing team appeared happy and well-supported by Eirian Powell and her two deputies?
REES: Yes.
LANGDALE: Was that your impression?
REES: That was, because like I said to you earlier I made a big effort to spend quite considerable time in
and out of there so I could understand how that the neonatal unit run, so yes, that was my impression initially, yes.
LANGDALE: And you say at paragraph 11a when we have asked you about culture amongst different groups, you say: "Clinicians and managers: initially the relationships between the clinicians and managers were good. They appeared to communicate effectively and supportive of one another." What tier of management do you mean when you are saying that, that they appeared to communicate effectively?
REES: Okay, well obviously myself as first line, Eirian and myself, and then the clinicians and with the Executive team.
LANGDALE: Mr Chambers, Ms Kelly?
REES: Yes.
LANGDALE: Others?
REES: Yes, because Sian Williams was the deputy Director of Nursing at the time, obviously Alison Kelly then you have got Ian Harvey who was the Medical Director, Tony Chambers. Yes, they were our Executive team members, and Sue Hodkinson.
LANGDALE: So at the beginning you thought that
communication was good?
REES: Yes, nobody -- I didn't notice anything and nobody reported anything different.
LANGDALE: At 11b you say: "Nurses, midwives and managers." You say: "The nurses on the NNU worked closely with the midwifery team supporting each other when the need arose"?
REES: Yes.
LANGDALE: That was your impression. Did Eirian Powell ever say anything different to you? She's told the Inquiry that there were some issues with the midwifery team but was that ever discussed with you?
REES: Not to -- not that I can recall. In fact, my recollection was the midwifery team and the neonatal team worked quite well together because they did cross boundaries with care. So no, I don't recall Eirian ever informing me of anything.
LANGDALE: And 11c, in terms of the relationship between medical professionals, doctors, nurses, midwives and others, how would you describe the working relationships between doctors and nurses on the NNU at that time?
REES: Initially I thought they worked quite well together, my observation was that. I think things became a little strained as time moved on and when circumstances started to unfold. I do think there then was an element of trust, I did feel that there was a change.
LANGDALE: And when you say "element of trust", what was the issue?
REES: Well, my observation was that obviously the nursing team had one view and the medical team had another. What I think it's fair for me to comment that communication could have been better.
LANGDALE: In what way -- in what way could it be better?
REES: Well, meetings and reporting of incidents were going on and it wasn't cohesive. You know, it took me a while to realise that the clinicians, the paediatricians had raised concerns with the Executive team and I knew nothing about it. I wasn't involved, I wasn't told about it. So these alleged meetings that I have later found out that the Consultants said they had with the Executive team, I wasn't informed of them and I certainly wasn't invited to them. So it was -- it was a little bit cloak and dagger. You know, I didn't know who had been reporting to who and who had been ... so I do think that was a little bit of a breakdown in an element of trust. Nobody -- my
observation was nobody knew who was talking to who.
LANGDALE: About what?
REES: About the concerns raised.
LANGDALE: And do you think things were getting repeated by people or misstated sometimes in that practice?
REES: Possibly, again I can't give you an example of that. But as time unfolded, and I got informed of meetings that had taken place between the clinicians and the Executive team, I was surprised nobody had mentioned it and I also think it's important for me to say I would have expected Ravi Jayaram and Steve Brearey to highlight their concerns initially with Eirian if you are following hospital policy and procedure. If you have got concerns --
LANGDALE: I will come to that later. I am just talking about generalities at the moment.
REES: Okay, sorry.
LANGDALE: If we go, please, to INQ0003057, page 23, it's the end of an interview you had with Facere Melius, Ms Rees?
REES: Who, sorry?
LANGDALE: Facere Melius, it was a company that were doing a review for the hospital and you were interviewed by somebody called Kay Boyle, I think, asking you the questions?
REES: Yes, I've seen that.
LANGDALE: You have seen the document?
REES: Yes.
LANGDALE: The general point I want to ask you about is page 23 at the bottom, if we can enlarge the last two paragraphs. You are thinking about the grievance and one of the outcomes that they wanted was mediation with Dr Brearey and Dr Jayaram. So if we look at the last two paragraphs, just expand or explain to us. You see here: "Well, my thoughts about the way that it was or it really didn't need happening because I don't see the point, I know these are notes. "I can't follow that. Can you just explain whether you thought that mediation between the doctors and Letby was a good idea or not?" What are you saying at this point? Take your time to have a look at it. I know you have seen it but have a look again.
REES: Yes, please. (Pause)
LANGDALE: Darren Thorne says: "Did you think mediation was the right thing in the first place? "Now we know what we know, probably not, but I think to be fair to the Execs, whoever, because it was
an external person ..." You go on and say further down that paragraph: "Come on, Executive team, you had an outcome, why aren't we driving it forward? If it had been a nurse, she'd have been told you're doing it and I did and it just saddens me. I think we are in this day and age, I just think we [if we go to the next page, page 24] perhaps have to be careful about what outcomes we put as a grievance if not going to be followed through and I suppose it reiterates maybe that perhaps things haven't changed that much, that Consultants have got the power and organisation. That's how I feel." So as a generality you are clearing expressing there the relationship between nurses and Consultants, you think the Consultants have the power?
REES: That's how I felt at the time because I thought a lot of effort had gone in with Lucy Letby's grievance and then to make recommendations that then weren't fulfilled and I felt that, yes, initially mediation was a good idea to try and move things forward in order for us to allow to get Lucy Letby back on the neonatal unit there had to be some mediation because obviously, like I have said to you, the amount of trust had, you know, fallen. And then I think the frustration was that those mediations, or not all of them, went ahead and it didn't and that seemed to me which is why I made that comment, is that the Consultants can say no, I don't want to do it.
LANGDALE: And do you think where they had raised concerns she was deliberately harming babies it was entirely understandable that they said no?
REES: Yes, I understand what you are saying. But the grievance was -- was upheld and at that time, if my memory serves me correctly, there was still no evidence tabled pointing everything at Lucy Letby.
LANGDALE: What do you mean "tabled"?
REES: Well, discussed or highlighted or presented. I think that was a frustration from us all particularly as time went on.
LANGDALE: Let's have a look at paragraph 7, if we may, so paragraph 7 is when you tell us in your statement: "I first became aware of the increased mortality rate on the NNU in February 2016. This was when the internal Thematic Review took place and Eirian Powell sent me an email outlining the findings of that review." We can't find that email. I don't know if you remember the email now. Do you remember the table, do you remember the review table that she sent or spoke about?
REES: The table with the -- following the thematic review?
LANGDALE: Yes, yes, did you see that?
REES: Yes.
LANGDALE: Shall we put that on the screen to help you see if it -- INQ0003251, page 1 is the front sheet. This is dated February but this is the one that was sent out in March. There is one in February and one in March. Does this ring a bell if we go to page 2, "Purpose of Meeting". Did she send you this?
REES: I did -- I do recall seeing that, yes, I have got --
LANGDALE: Okay. So we see there: "There was a higher than expected mortality rate on the NNU in 2015. An obstetric thematic review did not identify any common themes or identifiers that might be responsible for the rise in mortality. The aim of the neonatal meeting was to review the cases again as a multi-disciplinary team with an external review and tertiary level neonatologists to assess where all actions points completed, any new areas of care improvement, any possible common themes discussed if further action is required." And then attached to that we know there was a list
of babies and outcomes written down. When you received that, what did you make of it? What did you think was going on?
REES: I think we all had concerns when we -- when we read that. I certainly did when I read it and I did rely heavily on Eirian Lloyd Powell to discuss these things, this was her area of expertise. So yes, I think I would have discussed that definitely with Eirian.
LANGDALE: Did she tell you whether there had been discussion about, for example, the time of day or night that a number of babies had died, was that raised?
REES: I do recall being informed that predominantly a greater number of the mortalities happened on night shift. I'm not sure when it was -- if it was at the same time I received this.
LANGDALE: You received one in May again, didn't you?
REES: Yes.
LANGDALE: With Letby's name in red, so it could have been then?
REES: It might have been sorry but yes, it was definitely and the reasons why I do recall that is I think Eirian made the decision to bring Lucy Letby on days.
LANGDALE: Yes, we will get to that.
REES: Sorry.
LANGDALE: She does, you are right, but this is March time?
REES: Okay.
LANGDALE: But when you received this you realise there's increased mortality. Do you appreciate that some of these babies have suddenly and unexpectedly deteriorated? It's not simply they have died, in some cases it is that it is unexpectedly died, was that discussed between you and Eirian Powell?
REES: I am sure it was because I can recall Eirian giving me assurance saying that a number of these babies had been born with congenital abnormalities, that might have explained the sudden collapse, that I think if I am right there was a sepsis issue. That's all I can recall without looking at it, sorry, but I do recall us having that conversation and she was giving me assurance saying, well, because of these things that that might explain the sudden collapses.
LANGDALE: Did you question whether she had the expertise to tell you how particular babies had collapsed or why they had died?
REES: I didn't question Eirian's expertise because she had been a long time in that role and I did, like I say, rely heavily with her experience and her knowledge. So I never questioned her experience because she was a senior nurse, running the neonatal unit and had been there for quite some time. So no, I didn't question.
LANGDALE: Identifying cause of death is a very complex process --
REES: Yes.
LANGDALE: -- isn't it?
REES: Yes.
LANGDALE: Particularly where deaths occur in suspicious circumstances?
REES: Yes.
LANGDALE: Did you understand that of itself was forensic and difficult and required scrutiny?
REES: Absolutely. Yes.
LANGDALE: And you were taking responses from Eirian Powell about causes of death and being reassured about that. Do you think you should have been reassured about what she said about unexpected deaths or specific deaths?
REES: I suppose in hindsight, which is a wonderful thing, but at that time and I think there were rumblings of infection -- potential infection control issues. So there were other few -- if my memory serves me correctly, if it was the right time, so perhaps not but
I did rely heavily on her.
LANGDALE: When you say "rumblings of infection control" that's again something that was repeated, wasn't it, we have heard about pseudomonas in taps infection?
REES: Yes.
LANGDALE: You sat on QSPEC?
REES: Yes.
LANGDALE: The Quality Safety and Patient Experience body, it was never suggested that babies were dying as a consequence of infection on the ward, was it?
REES: No, not at QSPEC, no.
LANGDALE: And if that was happening, whether it was any infection on that unit or across the hospital that would have been an issue attacked by a number of wards, wouldn't it, and considered?
REES: Yes. But I think -- I think at that time we were all looking to see could there be -- what could be the reasons that are causing these collapses.
LANGDALE: Were you looking hard for an innocent explanation because you didn't want to look at the more difficult explanation?
REES: I think all of us that were involved and certainly as it unfolded were really keen to try and find if there was a cause or causes that could account for the number of mortalities.
So I think we were trying to cast the net widely to see was there anything else. Because yes, I accept Lucy Letby was on duty for a large number of those, although she wasn't allocated all of the babies under her care, but she was present on the unit at the time and I think we were just -- it was just an awful thought when I think about it to think that somebody could purposely be doing this --
LANGDALE: Pausing there, why did it matter whether she was allocated to the babies when she was on shift?
REES: What tends to happen in an intensive care environment, which obviously neonatal unit was, when I used to manage coronary care, which was obviously adult, but you got allocated a patient to care for while you were on shift and the same thing happened on neonates. Now, that doesn't mean to say even though you have been allocated a patient, whether adult, child, baby, if you are present on the unit and responsible for looking after another patient, that didn't mean to say that you wouldn't come in and help if for whatever reason that was required. But I suppose at the time we were thinking, right, if she would have been allocated all of those babies, that might have put up a bigger red flag. It was
something we -- Eirian and I discussed and, you know, we did consider.
LANGDALE: Did Eirian Powell tell you that Nurse W, who had been running a shift, complained that Letby didn't look after her allocated baby and kept gravitating to Baby C [Child C], one of the murdered infants? So she wasn't playing by the rules that you have just described about looking after her own baby. Nurse W reported this to Eirian Powell who suggested she raise a Datix in relation to the baby Nurse W was worried about at the time, the one that Letby was supposed to be looking after in a different nursery. When you had this conversation about the significance or not of being a shift or allocated a baby on a shift, did Eirian Powell tell you of that complaint what that had been made to her about Letby?
REES: No, I don't recall that at all. But I think the other side of that is if that particular Nurse W had put a Datix report in about that, I am sure that would come to my attention as a head of nursing at some point once it had gone through the system and I can't ever recall seeing a Datix with that issue being raised neither. But definitely I can't -- I do not recall Eirian highlighting that to me, no.
LANGDALE: Would you have been interested to know that when you are looking at everything?
REES: I think -- I think Eirian would have -- well, I would have expected her to have raised that with me at some point when we were having conversations because clearly this -- as it unfolded, this got bigger and bigger and obviously --
LANGDALE: Did you ever with her talk specifically about specific babies that had died, Baby A [Child A], Baby C [Child C]?
REES: No.
LANGDALE: Baby D [Child D], or did you deal with these generalities?
REES: It was more generalities because clearly, like I have said, neonates is not my area of expertise, so I had nothing to do with the care of those babies but clearly I liaised a lot with Eirian about obviously the whole neonatal issue. But no, I wasn't aware who Baby A [Child A],B,C -- no, I wasn't, it was more general.
LANGDALE: So you never sat down with her and said, "Right, this baby, what reports have you got, what are you thinking, where are you at with this one?"
REES: No.
LANGDALE: That wasn't your remit?
REES: No.
LANGDALE: Who did you think was doing that?
REES: I thought the team as a whole certainly following the thematic review and on the attachments that Eirian sent I would have thought that the clinicians and Eirian and the senior team would have discussed that there between themselves because they are the ones with the expertise.
LANGDALE: There's an email I would like you to go to now, I have got two INQ reference numbers. INQ0003138, page 1. So 0003138, page 1. It's an email to you, Ms Rees, the second one down. 4 May. "Hi Karen, please see attached. Not sure you will have had previously sight of this. Lucy Letby highlighted in red. I have not noticed this when I first reviewed. Can you please look into this as per my previous e-mail. Thanks." And you say: "Dear Alison, I am meeting with Eirian tomorrow." And we see below, not that she sent it to you, another email that Alison Kelly has sent. "Please look into this with Anne Murphy/Eirian. If there is a staff trend here, we have already changed her shift patterns because of this. This is potentially very serious." So she does send that one to you as well, doesn't she, 4 May?
REES: Yes, she does.
LANGDALE: "I will check the report they send through, I didn't notice there was a staff trend." That is a report again with a list of babies and Letby's name very clearly in red. First of all, who did you think had put her name in red and what did you think when Alison Kelly asked you to look into it, that you were supposed to be doing?
REES: I can't say for certain, but I would have assumed it would be Eirian and Steve Brearey would have highlighted Lucy Letby's name in red because following the thematic review they were looking into all aspects of that, which is why when Alison had sent me that then obviously I would have had a discussion with Eirian about it, as I said there, although I have got no evidence of that discussion but clearly that put on my radar would have been something I would have discussed with Eirian.
LANGDALE: They can go down now please, thank you. It is paragraph 16 of your statement. You say: "I did read the schedule I had been sent by Alison Kelly ... [and] I was aware prior to receipt of these emails of an increase in the mortality rate ... I cannot recall enquiring as to what the usual mortality rate was for the NNU. I relied on Eirian Powell to
update me". What did she update you with following receipt of this new table with her name in red?
REES: I think she just went through the table with me. I can't absolutely recollect, but I know we would have sat down and discussed obviously Lucy Letby and her allocation of babies and her presence on the unit.
LANGDALE: We know you weren't copied into the email so there is no need to put it up but Dr Brearey, 4 May, emails Alison and says there is a nurse who's been present for quite a few of the deaths and other arrests, Eirian has sensibly put her on day shifts only at the moment but can't do this indefinitely. So you appreciated at this time she was on day shifts as you mentioned earlier. What did you make of that?
REES: My understanding when I asked Eirian about that because it was obviously a decision she made, I do remember her saying to her "Okay, what is the rationale then?" And if my memory serves me correctly, I remember her informing me that it was a neutral act to bring her on to days. It wasn't deemed as a punishment or a finger-pointing exercise. It was because there are more staff on days than on nights and because of what you alluded to earlier about predominantly a lot of these mortalities were happening on the night shift, she wanted to check her competencies and bring her on to days so she could be more supervised if, I remember correctly.
LANGDALE: So she was suspicious that she may have been doing something whether it was deliberate harm or incompetence that impacted on the deaths at night and she would be better off in the day, is that the position?
REES: I don't think, I think it was more checking her competencies.
LANGDALE: Right.
REES: Because it goes without saying if you have got more staff on days, then you can allocate somebody to check those competencies because there's obviously more people around, whereas you have a limited number on night shift, it is harder to do that.
LANGDALE: And what did you understand checking her competencies meant?
REES: Well, looking at exactly that; I am led to believe that Lucy Letby had the extra qualification in specialty and she was one of a number, there is only a small number of Eirian's team, if I remember rightly, had that qualification. So it was extra training I am led to believe in ITU
care of the neonate, so it will be the competencies that will be attached to the roles and responsibilities of that nurse, with that qualification and also her basic competencies as well. You know, nursing observations, all the additional roles and responsibilities that comes with that qualification, I would have thought that's what would have been checked.
LANGDALE: And when you say "been checked", who was going to be told, who should be doing the checking, you need to know you are checking on someone, don't you, if you are checking?
REES: Well, I would have thought, although I can't say for sure, the neonatal unit had a practice development nurse within their team and I would have assigned it to her.
LANGDALE: You would have?
REES: Yes.
LANGDALE: Do you know if it was and is that Yvonne Farmer you are talking about?
REES: Yes.
LANGDALE: So you think someone like Yvonne Farmer should have been doing that or supporting her with her work at that time?
REES: Yes, I would have expected her to be doing that, yes.
LANGDALE: At paragraph 22, you set out that you were aware that Letby had this qualification. Were you also aware there were many Band 6s on the ward and many nurses more experienced in terms of years than her?
REES: Yes.
LANGDALE: She was a young nurse at the beginning of her career really, wasn't she?
REES: Yes.
LANGDALE: So she may have done this course but the notion she was highly experienced or a Band 6, 7 or advanced neonatal practitioner, nothing like that, we are talking about a Band 5 who has done one course, important, but it's an important perspective isn't it, to bring to bear to this issue?
REES: Yes, absolutely.
LANGDALE: And you say at paragraph 22: "The sickest patients are often allocated to the most qualified nurse. This was the reason that Letby could have been allocated the sickest babies to care for." Was that something you were told by anyone?
REES: No, that's why I have said "could have". And if I go back to when I was ward manager of coronary care, I would give my sickest patient on that unit to my most experienced nurse to care for.
LANGDALE: Well, there were a lot of Band 6s, so this is a young Band 5. So if you just stand back for a moment --
REES: Okay.
LANGDALE: -- she's not a highly experienced or advanced qualified neonatal nurse or anything like that, is she, at this point?
REES: She wouldn't have had the length of experience that some of those nurses on the neonatal unit would have had clearly because of their length of service. But what she would have obtained, I would have thought, by doing that extra qualification is that she would have been taught additional -- what can I say? -- competencies to care for a sicker baby because that surely is the whole purpose of doing a course.
LANGDALE: When you say "sicker baby", you hadn't sat down you said earlier and done a review of the unexpected deaths, you didn't know whether any of those babies were sick or not presumably, did you?
REES: No, I didn't.
LANGDALE: So that is a generalisation rather than --
REES: Yes.
LANGDALE: -- specific to the unexpected deaths?
REES: Yes.
LANGDALE: You tell us that you had a meeting on 5 May and in fact if we go to INQ0006890, page 77, we see an email to you from Eirian following on from that meeting.
REES: Sorry, it's not come up on my screen.
LANGDALE: Don't worry, it will in a moment. You tell us that these are the documents that Eirian sent you after the meeting. Just to be clear, Dr Brearey doesn't recollect being at this meeting. It says it is yourself, Yvonne Griffiths, Anne Murphy and Dr Brearey. Might it be the case that he wasn't present at this meeting on 5 May? Let's refresh your memory with the documents that are sent. It might help bring it back to you. Lucy's shifts, you were sent documents relating to her shifts from Eirian Powell. You were sent the table again with the names of the babies. Can you remember?
REES: Yes.
LANGDALE: There's a suggestion in this email: "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". She also produced -- and let me ask you if you saw this -- INQ0006690 [not found], page 93. At some point this has been produced.
I will just wait for a moment. Sorry, that's not right page. Yes, there is 6890, page 93. Did you see that?
REES: Let me just read it.
LANGDALE: It is a two-page document produced by Ms Powell. And over the page, 94, next page, if possible, do we see there: "Karen Rees requested we discussed exactly what the issues, if any, were other than coincidence that was evident. Despite highlighting the usual factors there is not real evidence or a statement that could confirm whether there was an issue here." These are Eirian Powell's summary?
REES: Yes, I do recall seeing them.
LANGDALE: Yes, you see it? If we go back to the previous page, if we may, I just needed to you see that second page first. There is a whole list of factors 1 to 15 that Eirian Powell has listed. Were those discussed with you at that meeting on the 5th?
REES: Yes. Yes, I do recall. I remember Eirian discussing those points with me, yes.
LANGDALE: And do you see number 2 she's recorded: "There are no performance management issues and no members of staff that have complained to me or others
regarding her performance." Did you know about her being involved or setting a morphine rate 10 times the dose it should have been for a baby in 2013, did she mention that?
REES: Never.
LANGDALE: That she had had a one-to-one and had to be checked, did you know about that?
REES: No. Never.
LANGDALE: Would you like to have known about that performance issue --
REES: Yes.
LANGDALE: -- at the time?
REES: Yes. Honestly I -- I wasn't aware of that fact. When was that, sorry, did you say?
LANGDALE: In 2013.
REES: No, no.
LANGDALE: So a couple of years previously that she had a one-to-one with Yvonne Griffiths, also with Eirian Powell and had further training with Yvonne Farmer, you weren't aware of that?
REES: No, I mean appreciating that it was at least two years before I came into post, but no, I was not aware of that.
LANGDALE: Were you made aware that in fact Nurse Lightfoot -- do you know Nicola Lightfoot?
REES: I remember the name.
LANGDALE: Did you know that she had failed her in her final year and she had to do a retrieval placement?
REES: I didn't until I got the Inquiry outline. But no, I wasn't told.
LANGDALE: Again, would you have thought that was relevant if someone was telling you there were no performance issues and she had excellent standards within the clinical area?
REES: I probably wouldn't have expected to be told that because if that was at the end of her training, it's quite some years before. And people do fail placements during their nurse training so no, I wouldn't have expected to be informed of that.
LANGDALE: There is a reference at 6: "Cheshire and Mersey Transport Service have been involved in a few of these mortalities." What did you think that meant, what was the suggestion being made there?
REES: I think there were delays, if my memory serves me correctly, between a clinician requesting the transport service. I am sure that's what Eirian meant or that number 6 meant, that because there were delays in the transport service getting to the Countess, and then transferring the baby to the appropriate tertiary centre, might have been attributable is my understanding of that.
LANGDALE: Number 7, the same about if there had been a bed sooner the infant may not have died. Did she ever link this to any child or unexpected death that you were considering?
REES: No, no, I think it was just a general overview that these issues were obviously present at times, but I don't recall Eirian really laying them to a particular baby.
LANGDALE: Some of the issues related to midwifery problems, any idea what that referred to in relation to the unexpected deaths of babies?
REES: I could only assume that that was perhaps a delivery issue but I -- I can't comment. Sorry, I can't recall that one.
LANGDALE: Then we have, as you described earlier, recording two of the babies diagnosed congenital pneumonia, four babies congenital abnormalities, two with necrotising enterocolitis, one overwhelming sepsis, transport team issue. On its face it looks as though this is some kind of specific analysis, but it was not, as far as you are concerned; it is a generalised commentary of issues facing the unit rather than anything specific to any
unexpected death?
REES: Well, I am assuming from point 10 to 15 that was in relation to the mortalities because there's numbered there -- there's numbers there, isn't there, there's four babies had congenital abnormalities, one -- if it had just said congenital abnormalities might have been an issue with maternal syndrome. So I am assuming that is in relation to the babies that ...
LANGDALE: Nevertheless, if we can just go back to INQ0006890, page 77, this is the first email sent to you on 5 May. If we look there: "We would like to have a meeting as a matter of urgency primarily for reassurance and to ensure we have covered all the relevant actions." So whatever she's produced as the ward manager, she's looking for reassurance. What did you take that to mean and why did you think she was requesting it?
REES: I think she was requesting that to gain reassurance from the Executive team that they hadn't missed anything, hence the request for a meeting with Alison Kelly and Ian Harvey. Because obviously they had done the thematic review, these documents showed varying bits of information and I think Eirian just wanted to make sure that she had ticked all the boxes or was there
anything else they could look at?
LANGDALE: When you saw it, did you think there's something else you could do? Like link to specifics of the babies in the table that you had seen and give a bit more forensic scrutiny to it? Or alternatively, "Get someone else to look at this, Eirian, it's too complicated for you and it's too complicated for me"?
REES: Maybe that's what Eirian -- I can't really answer for Eirian but I am looking at that. I would have thought, right, well, we have done A,B,C and D, is there anything else we need to do or should we hand it to somebody else to look at? Obviously the concerns were still there because there was no answers specifically found at that time.
LANGDALE: Let's move now to Friday, 24 June. Karen Townsend has provided a statement to the Inquiry that says she met Dr Jayaram the morning of Friday 24th at 11 am and she bleeped you immediately afterwards to speak to you.
REES: (Nods)
LANGDALE: She called you and couldn't get hold of you so she bleeped you. Do you remember that now, her contacting you on the Friday?
REES: Oh I do, yes, clearly.
LANGDALE: Was she right, it was Friday morning after she
had seen him? She said she saw him at 11 so when they had finished she said she immediately contacted you; is that right?
REES: My recollection was it might have been a bit later but it might have been me delaying my response to get to her because Fridays, as you can appreciate, in an acute general hospital very busy. So she might have -- I recall her bleeping me, but I can't put my hand on my heart and say exactly what time, but she definitely bleeped me and said "I need to discuss something urgent with you. As soon as you are free can you come over to my office?" And I was clearly busy with other things so I got there as soon as I can which might be the reason for the difference of opinion of the time.
LANGDALE: When do you think the time was?
REES: It was I am sure it was after lunch by the time I spoke to Karen, in fact, I know it was. It was -- it was early, early to mid-afternoon when we had that conversation in her office, yes.
LANGDALE: And do you get urgent bleeps like that regularly?
REES: All the time.
LANGDALE: Right. So you go and speak to her and you pick this up at paragraph 28/29 of your statement but you may remember it. Tell us in your words what she said to you.
REES: She Karen Townsend informed me that she had met Ravi Jayaram for a coffee over in the Comfort Zone, which was a cafe in the Women's and Children's building where she had discussions about any issues and it was at the end of that conversation that she told me that Ravi Jayaram had said to her: I just need you to be aware because we have got concerns about the clinical practice of one of the neonatal nurses. My recollection is that she then asked him what were those clinical concerns of which he wasn't forthcoming with. But obviously it alerted her and concerned her enough to bleep me about it. Do you want me to go on and tell you what I --
LANGDALE: Yes, he's -- well, before we go to him, did she say to you, you say at paragraph 28: "I was called to the office of Karen Townsend who informed me of allegations from Dr Jayaram that Dr Jayaram and Dr Brearey both thought Lucy was purposefully harming babies on the neonatal unit." That is what you say at paragraph 28 of your statement. Do you have that in front of you? You say that in your statement to the police, sorry?
REES: Yes.
LANGDALE: You say that in your statement to the police?
REES: Sorry, I am just trying to recollect. Yes, well, if I -- obviously it's in my police statement that is what was said to me because that's what I have reported to the police and it did cause me -- I was absolutely horrified when she told me that. So -- and particularly when there was no forthcoming rationale to support these allegations. So I informed Karen Townsend that I needed to go and find both Ravi Jayaram and Steve Brearey to ascertain what exactly did they mean. So I immediately went over to the Women's and Children's building because Ravi Jayaram and Steve Brearey shared an office together. I clearly remember Ravi Jayaram being present in his office, so I knocked on his door and went in to see him. I said: you know why I am here, I said: because of what you have just said to Karen Townsend and I need more information of what on earth are you alluding to. And again he just said to me: Steve Brearey and I have got concerns about the clinical practice of a nurse. I said: well, I need to understand what those clinical concerns are and if she's purposely harming babies, you need to give me more information than that. I then asked him where Steve Brearey was and he
said to me: well, he will have been in clinic this morning, not sure where he is this afternoon. So I asked him to bleep, phone him because I said I really need to talk to him. Fortunately for me, Steve Brearey's clinic had overrun so he was still in clinic in the Women's and Children's building and so I made my way over there and sat outside his clinic until he had finished his clinic. When he came out I said: I need to discuss something important with you, but clearly not in this environment, so we went back to his office. Ravi Jayaram had left, he wasn't in the office. So I said to Steve Brearey, I said: look, I said you need to share with me why you have got these concerns and why and how do you think that she's purposefully harming babies and his answer to me and I remember it clearly because he says: I have got a gut feeling and I have got a drawer of doom, and he pointed to a drawer in his desk so I said to him: well, share the contents of that drawer of doom with me, of which he refused. And he just said: she needs to be moved off the neonatal unit, I am aware that she is on this weekend. So I said to him: I can't remove a nurse from a clinical practice just because of gut feeling and a drawer of doom of which contents you will not share with me. So I wasn't getting anywhere with him. He just kept insisting I remove her, remove Lucy Letby. So I told him I was going over to the Executives' suite immediately because I was really concerned at this point.
LANGDALE: Are you sure he spoke about this that day and not in the phone call in the evening?
REES: No, this was this afternoon. He did ring me later. So I went immediately over to the Executive suite by this time, it's late Friday afternoon and I was just conscious that everybody would be going home and I was getting really worried. So Alison Kelly, my Director of Nursing, was the only Executive in the office at that time. So I relayed to her the events of that afternoon what Ravi had said to Karen and my subsequent actions. And she listened to me and then said: right, I need to speak to Ian Harvey about this. He wasn't in the Executive office, I don't know where he was, whether had he gone home or -- but she said she was going to make contact with him. At some point, and I can't remember whether I left the Executive office then, I thought I had gone over to speak to Eirian Lloyd Powell but I think it was Yvonne Farmer, I think I made that mistake, I thought it was Eirian, to ask if she had got any concerns about any, I didn't mention Lucy Letby's name at this point. I just said: your nurses that you have got on unit this weekend, have you got any concerns about their clinical practice? Of which she gave me assurance saying: absolutely not. I then --
LANGDALE: Just pausing there.
REES: Yes.
LANGDALE: So paragraph 31 you say in the Inquiry statement: "Dr Jayaram informed me that both he and Dr Brearey had concerns about the clinical practice of one of the NNU nurses and that she may be purposefully harming babies." So he, as you have said earlier, did say "may be purposefully harming babies". When you asked Yvonne Farmer if it was Yvonne Farmer; have you got concerns about clinical practice, why didn't you say: have you got concerns any nurse may be purposefully harming babies, because that is the whole of what you had been told, wasn't it, why did you just say "clinical practice"?
REES: Because I -- I suppose I didn't ask that because if Yvonne Farmer had had concerns or anybody any
senior member of that nursing team had concerns about somebody purposely harming babies I think that would have been brought to my attention rather than wait for me to ask it.
LANGDALE: You had been sent tables with her name in red?
REES: Yes.
LANGDALE: Was that a way of bringing it to your attention these -- even if you say they weren't expressed as clearly as you might have liked to have done, but Eirian Powell produced that table, the nursing manager who liked Letby, thought highly of her?
REES: Yes.
LANGDALE: But she had produced that table and put the name in red. So when you say they hadn't brought concerns to you, what did you think when you saw that?
REES: I suppose I -- when I went to speak to Yvonne Farmer, I did want to see if there was any response from her because I think it's important, in my nursing career, certainly latterly in my last years, on a number of occasions I have had Consultants demand I remove nurses either from their team or from their ward or unit because personal and professional relationships have broken down for varying reasons and initially, I thought because both Ravi Jayaram and Steve Brearey were
reticent to give me further details, I thought at that time it was personal. Rightly or wrongly, I admit at that time I thought there's a personal issue going on here.
LANGDALE: Because you weren't getting more information?
REES: Yes, yes. Because, without me going into details of what's happened previously with other Consultants, yes, I did initially. But that's the reason. I was still concerned which is why I went immediately over to escalate to Alison Kelly, my Director of Nursing. That's what we do, that is hospital policy and procedure, if we think, you know: we are not getting anywhere here or you are concerned about an issue.
LANGDALE: So you wanted to be sure about a motive or think about whether there could be another motive, a personal reason. You tell the police, in fact I can read it to you: "As I got to know Lucy I did ask her certain questions in these meetings. I did ask her about her working relationships with the two Consultants. Lucy was quite shocked, particularly with Dr Jayaram. She thought she had quite a good working relationship with him. I asked her either of them had ever made a pass at her. She replied 'absolutely not'. I got the feeling
she had no idea either of them felt like this. The distress this has caused to both Lucy and her parents has been terrible to witness." So you did explore that with Letby at the time, didn't you, is there anything they have got against you, and the answer was no and it was nothing?
REES: It wasn't at that time.
LANGDALE: A bit later?
REES: Yes, it was not on that Friday because I had never even met Lucy Letby.
LANGDALE: Of course.
REES: Yes.
LANGDALE: But looking back now, you know that there was no personal motive having had those conversation with her later, she couldn't give you one and didn't have one --
REES: No.
LANGDALE: -- and you didn't see one; is that right?
REES: Yes.
LANGDALE: But your first thought on the Friday was: is there something else?
REES: Yes, yes.
LANGDALE: Did you ask anyone else about that before you asked Letby further down the road about that?
REES: Ask anybody about what?
LANGDALE: Ask anybody on the Friday: could there have been a personal agenda here or not?
REES: No.
LANGDALE: You didn't have anyone to ask?
REES: And the reason why is because we were under pressure, it was late on Friday and I had other things to do. So no, the only person I spoke to, which I thought was Eirian at first, was Yvonne Farmer, yes, that was she was the only person.
LANGDALE: So you spoke you say to Alison then you went home and got a telephone call from Dr Brearey later, didn't you? Can you tell us about that call?
REES: Yes. We have a difference of recollection of that telephone conversation. It was early evening and my mobile phone went and obviously I didn't recognise the telephone number and I answered the phone and Steve Brearey said to me "Hi Karen, it's Steve" and I remember saying "Steve who?" not imagining for one minute he would be ringing me at home. So he said: I need to understand what actions you are going to take to take Lucy Letby off the neonatal unit. So I reiterated to him again, I said: I can't take a nurse off a unit without just cause, appreciating the severity of your allegation and your concerns, but you
are not sharing anything with me. I told him -- I recall him saying, I said: I've been in to see Alison Kelly and she is discussing the whole episode of that afternoon with Ian Harvey. Steve Brearey inferred I was lying, he didn't believe that I had been into the Executive suite and the reasons why I remember this so much because I said to him: if you don't believe me, then contact Alison Kelly or Ian Harvey yourself. When that phone call was terminated, I -- this is why I remember this, I called Alison Kelly back to inform her again of the conversation I had just had with Steve Brearey on the telephone and to say to her to expect a telephone call from him because he didn't believe that I had been in to speak to her.
LANGDALE: Looking back, the fact that they had both raised and he was repeating in that call, enough to phone you on a Friday night, he was concerned she maybe purposefully harming babies, wasn't that enough? What else did you need, really, you couldn't investigate it if he did give you anything else, could you? A serious concern had been raised.
REES: Yes, but I thought -- the feeling I got rightly or wrongly at that time I -- I felt I was being bullied and intimidated to make a decision about moving
a nurse that nobody else had been prepared to do until that point. I also -- we have to remember that employees, because at that time employees have got rights equally and like I have said to you, because I initially thought it was personal, I had to have good reason. I couldn't just walk on the unit and say: right, I am moving you, because of a gut feeling and a drawer of doom. There has to be specific reasons to action.
LANGDALE: We know at this point you had received the mortality review, you had received it a second time with her name in red, there had been concerns and Eirian was asking for reassurance. Wasn't that enough at this point for you to say: actually, the babies come first, we don't know why particularly, but we must keep them safe, it's not about employer and employee rights, it's about the babies at this point?
REES: I fully appreciate that. But then why? My question: why did Steve Brearey not give me something else?
LANGDALE: They have given you that they thought she may be deliberately harming babies. What more did you want? Did you need the mode of attack, what did you want? How could they give you that without the pathology, forensics that were required?
REES: I don't know. I just -- because I thought because they are not willing to give me anything else to support my decision whether to exclude or remove, I honestly thought it was personal and perhaps I was slighted by that.
LANGDALE: And the fact they couldn't give you something else didn't mean there wasn't something else to find?
REES: No.
LANGDALE: Did it?
REES: I appreciate that.
LANGDALE: Unexpected, unexplained, they couldn't give you medical causes. That was their contribution, they didn't know why these babies had died, couldn't be clear about that. So it needed proper investigation?
REES: I fully -- I fully appreciate that. But then why tell me he's got a drawer of doom and won't share the contents of it with me?
LANGDALE: From the moment Karen Townsend had used those words to you, that she may have deliberately been harming a baby, do you think you should have gone straight to safeguarding as you would have done if a member of staff told you: I am worried this parent has harmed this baby that they walked in with? You wouldn't know whether that was right or wrong but you know you couldn't answer the question?
REES: No, I have reflected upon that and perhaps that is what -- that's an action I should have perhaps taken on Friday. But equally neither Consultant did neither. I just think yes, on reflection, I perhaps should have done and I am sorry for that. I am sorry.
LANGDALE: And when you refer again to the Consultants, it does come across that you have an antipathy, as you said in the interview with Facere Melius about Consultants and they are in charge and they have the power. Do you have a natural, or did you have then, an antipathy to them as a group?
REES: No, not, not immediately. It was just I feel that they could have -- both Consultants, Ravi Jayaram and Steve Brearey could have involved Eirian and I at a much earlier stage and we could have worked together. I -- I feel looking back that the alleged meetings that they had with the Executive team about their concerns I wasn't aware of them, I certainly wasn't invited to them and that's not what I would have expected of a senior clinician. I would have thought he would have gone to his unit manager Eirian first, and then she would have involved me.
LANGDALE: That's the point, isn't it, Eirian was invited to a lot of the discussions with the Consultants and eventually some of the more Senior Executives suggested
there had been a rift between them and you knew that Eirian was asked to sign something to say there wasn't a rift, they regarded her as part of the group, didn't they, in their discussions?
REES: Yes, because like I say, at the beginning they were a cohesive team and it's just as all this unfolded, like I said previously, the element of trust had gone and it was, it appeared like an "us and them" situation where the nurses thought one thing and clearly the medics thought another.
LANGDALE: And the nurses Eirian Powell expressed in a document 100% thought Letby hadn't done anything. Did you think the same at that time?
REES: Say that again, sorry?
LANGDALE: Had you formed a view that Letby was innocent at that time, innocent of any causing any harm at all?
REES: I don't think that that was a question that I needed to answer. Was she innocent, was she guilty? I just thought that I -- I wasn't given enough to act upon and honestly on reflection, you know, and we have all done that, I am sure, I should have called safeguarding in and I am sorry for that.
LANGDALE: On 27 June, you sent an email, INQ0005745, page 1. Sorry, you didn't send it, Alison Kelly sent it. Sorry, Ms Rees. And it follows a meeting that had
been had between all of the Executives. Have a look at that to refresh your memory of it. We can see there is an action plan. So this is following the weekend, the murder of two triplets?
REES: (Nods)
LANGDALE: The Consultants are not at this meeting when an action plan is being drawn up. Do you know who sorted out the invitation list for this meeting to discuss concerns and an action plan?
REES: I honestly can't, I'm sorry. I don't know.
LANGDALE: When you look at it now, does it strike you as odd that an action plan was being devised in the absence of any input from the Consultants who had the concerns?
REES: Yes. Yes.
LANGDALE: And does this already fall into the "us and them" category?
REES: It appears so, doesn't it? Yes.
LANGDALE: And we see: "Ian Harvey to identify Royal College lead to facilitate external review." Did you know much about what that review was about and what it was going to look at?
REES: No, I wasn't involved with setting the terms of reference or anything like that, but clearly I saw it at some point on completion. But I wasn't familiar who
had set the Terms of Reference and what they were at that time.
LANGDALE: And we have here the penultimate -- in italics -- paragraph: "Eirian, can you also review staff competencies re skills and knowledge to support sick babies at varying levels of dependency. I know you will have this but it would be good to undertake a review." Another review, another generalised review of everyone's competencies?
REES: I know, I know.
LANGDALE: A lot of work and totally unnecessary --
REES: I know, I know.
LANGDALE: -- at this point?
REES: I am sorry, I don't know who requested that, I assumed it was Alison. I don't know.
LANGDALE: You say at paragraph 56: "I agreed with the decisions taken at the meeting ... [Although] neither Consultant was present Alison Kelly and Ian Harvey were to meet with them both to discuss their concerns and the actions listed." Again looking back I think, as you just have, and reflecting, it was divisive, wasn't it?
REES: It was.
LANGDALE: How might that have been better managed at the time just speak of your role, what would you -- if you could now, what would you input at that point?
REES: I think you are right, I think both Consultants should have been at that meeting. It's like I said to you earlier, I wasn't aware of these alleged meetings that the Consultants had had with the Execs. I wasn't involved with any of them, so I -- obviously it appears there's been a breakdown in relationships at some point. But, yes, I think the whole team should have been together at that meeting, including the clinicians.
LANGDALE: You say then -- Letby's removal from the unit in your statement, you say at paragraph 58: "I did not play any part in the decision to remove Letby from the unit. I recall I was on annual leave ..." When I was on annual leave: "... a meeting took place on 14 July when she was informed of the decision that she was to be put under clinical supervision pending the completion of an external review by the Royal College of Paediatrics and Child Health." Do you think there was transparency with her at that point about what was actually going on?
REES: No.
LANGDALE: No. And why was that?
REES: I really don't know. I mean, I was tasked on return from my annual leave to remove Lucy Letby off the unit with my HR business partner. I had just come back from leave, I had come in early. I checked A&E, I checked the neonatal unit come back and my HR business partner was waiting outside for me and said: we have been given a management instruction --
LANGDALE: Would is that business partner?
REES: Linda Guatella, she is like my HR wingman and so she said to me: Karen we have got to go and remove Lucy Letby off the unit now. So I said: what are we saying, what's gone on?" because clearly whatever decision, meeting, whatever had taken place had clearly taken place when I was on leave.
LANGDALE: Shall we see the letter you wrote that will help you I am sure --
REES: Yes.
LANGDALE: -- with your memory of this INQ0002458, page 1. It is a letter of 18 July from you.
REES: Yes.
LANGDALE: If we read the third and the fourth paragraph you are telling her: "Since the meeting on 14 July it has become apparent not possible to provide you with full time
supervised practice because of staffing levels on the NNU. Currently a number of members of staff are absent from work including sickness which has impacted upon the availability of senior clinicians who are able to provide support." And then you refer to temporary redeployment. Did you think it was because there was an inability to have the staff to supervise or was it something else that led to this letter?
REES: I couldn't say for sure because I wasn't involved in the meetings and the decision-making, but obviously staffing levels weren't the best on the neonatal unit -- well, across the Trust, to be honest, at times. So to put somebody under clinical supervision you do have to have an acceptable number of staff for that to continue because you can't let that fall down if somebody goes off sick the next day and then there isn't a staff member to closely supervise. So I took that as, yes, that was the reason.
LANGDALE: If we go over the page, your second paragraph: "You raised with me the issue of personal support and stated that your friends are work colleagues. I advised you that the purpose of the redeployment was not to stop the usual social contact but you should be mindful of discussing any matters which may be sensitive
in nature relating to the review of the NNU." So you are not telling her she can't speak to her friends or anything like that, are you?
REES: No, I think it was misunderstood.
LANGDALE: Well, we note at paragraph 85 -- we don't need to turn it up -- in your statement you are criticised within the grievance process, I think, for effectively preventing Letby -- you tell us: what were you accused and what did you accept, in fact?
REES: I think -- and it was my fault because I clearly didn't communicate effectively. I think Lucy took it upon herself that she thought I had stopped her going to the neonatal unit as well as having any social contact with her friends and team members and that wasn't my intention.
LANGDALE: You say that very clearly there, though, in the letter, don't you? You haven't said that, so why do you say that is your fault? You hadn't prevented it?
REES: Also --
LANGDALE: She did continue to communicate with people on the unit?
REES: Yes.
LANGDALE: What had you done to prevent that? What was the criticism that had come?
REES: I think she misunderstood when I said that she wasn't to go back on the neonatal unit whilst she had been redeployed, even though it was temporarily until investigations had taken place. I think it was Lucy misunderstanding what I had said. I probably didn't make myself clear at the time.
LANGDALE: We know if we go to INQ0002746, page 3, Tony Millea writes to you on 2 September 2016. We see at the bottom of that email --
REES: Yes.
LANGDALE: -- over the page complaining about the process that the hospital is now engaging in?
REES: (Nods)
LANGDALE: The RCPCH, at the top of the page: "The investigation centred around procedure, culture, staffing levels and what was it like to work on the NNU. No question of our members' involvement was discussed. In fact, it was imparted by the panel that the review will not solve the issues for Lucy personally. As a result of this I now believe our member has grounds to action a grievance." What did you understand the RCN officer was saying there was need for a grievance at this point, why was there such a need?
REES: I think -- I think, if I remember correctly, that somewhere along the line Tony Millea had us under
the impression that the Trust had decided to move Lucy Letby off the neonatal unit and redeploy her while this investigation was going on from RCPCH. And then obviously somewhere along the line, he's -- he's found out what the Terms of Reference are and he was alluding to then the Trust not being open and honest with Lucy Letby and felt -- and this is hence why he advised her to have grounds for a grievance. He thought -- I recall him saying to me that he didn't think the Trust were being open, honest and being upfront and telling her the true reason why she had been redeployed.
LANGDALE: You also sent an email, 9 September, it is a bit later, a week later, to Alison Kelly INQ0002860, page 1. You say in the second paragraph: "The decision to delay transfer back to the NNU. In my opinion this decision is wrong and immoral based on a senior clinician having a gut feeling with no evidence except that LL has been present at a number of these neonatal deaths." The last but two paragraphs: "There is also the impact not only for the NNU but for the rest of the organisation and the message that this sends out a clinician is being listened to and supported with potential devastating consequences for
a nurse. How are the nurses on the NNU going to react?" What would you like to say about that email?
REES: Sorry?
LANGDALE: What would you like to say about that email?
REES: I was clearly very frustrated and emotional at that time. We were planning to put Lucy Letby back on the neonatal unit, then we weren't, then we were, then we weren't. And at that time I had been given a management instruction following Lucy Letby's removal from the neonatal unit into the risk team was to meet with her on a weekly basis with two of my other senior colleagues to support her health and well-being during all of this and to give her feedback from any investigations that were going on.
LANGDALE: Just pausing there. Feedback from investigations. So you were to meet her every week it was you, Hayley Cooper and?
REES: Kathryn de Berger.
LANGDALE: And you were supposed to be telling her what the hospital were doing, what investigations, whether it was the RCPCH, the Hawdon Review, she was getting the hotline with what was happening?
REES: Yes, yes. And during that time, clearly I got to know Lucy Letby and that email came because we had had a meeting with Lucy and Hayley I think was present,
Hayley Cooper, and Alison Kelly and Sue Hodkinson I think the day before and they didn't mention anything about delaying Lucy Letby's transfer back to the neonatal unit at that meeting but they called me back afterwards and said to me: I have got to tell her she can't go back on the unit yet. And at that time, I was emotional and frustrated because I was witness to her -- she was absolutely devastated and I suppose I was looking at her and she kept crying and saying: why are they doing this to me, I have done nothing wrong? I -- I am not going to let them run me out of the job that I love. Why are they letting me say it and go back on the unit, then they are saying they are not? And I suppose months of that witnessing that, her being distraught, rightly or wrongly, where we are now, I understand that, but at that time and I remember looking at her thinking: oh, this is dreadful, because -- and I appreciate the enormity of the allegations and everything, but I suppose I sent that email because I was witnessing the anguish, the absolute -- she was absolutely -- it was hard to keep witnessing that week in, week out and promising her one thing and promising her another. I am just trying to explain why I sent that email.
LANGDALE: You actually say in there: why have the police not been called?
REES: Yes.
LANGDALE: Paragraph 2?
REES: Yes.
LANGDALE: Why weren't they? Why didn't you say they should be called? Why did you not think that they were being called?
REES: I think they should have. You know, I was at fault. I didn't go to the police neither. But I -- I just thought we are having this investigation, that thematic review, this, that, nothing's proven and the issues weren't going away. I recall, and I can't absolutely tell you what, what the date and time was, but I do recall Sian Williams, who was the deputy Director of Nursing at the time, and myself going into to see Alison Kelly.
LANGDALE: Sian Williamson, is that?
REES: Pardon?
LANGDALE: Was that Sian Williamson?
REES: Yes, Sian Williams. She was the deputy and we both went in to see Alison saying: Enough is enough, you have got to be calling the police in now. This is -- we are getting nowhere. So the relationships were breaking down all over the place in the neonatal unit between the clinicians,
the Execs, we weren't getting any answers and so Sian and I pleaded with Alison to bring the police in.
LANGDALE: Do you agree that the last but one paragraph of your email is very factionalised there as well where you say "devastating consequences for a nurse". You make it about nurses and doctors rather than actually --
REES: Yes, perhaps.
LANGDALE: -- somebody making a very serious complaint --
REES: Yes.
LANGDALE: -- for babies actually?
REES: Yes, yes, I accept that. Yes.
LANGDALE: That can come down now, please. If we go to INQ0002879, page 33 is the first page. This is the grievance interview that you have at the time with Dr Green in October 2016. If we go to the next page, page 34, in that top box, you say: "KR went straight to see Alison Kelly. Wasn't happy to exclude LL, felt no grounds to exclude. In the evening KR received a call from SB at home." So this is the night you get the telephone call. "Felt SB tried to bully me putting pressure on. Felt he was exhibiting passive aggressive behaviour. Remained professional but gently powerful." "Remained professional". So he wasn't shouting or
anything?
REES: No, he wasn't shouting. He never shouts.
LANGDALE: But it was urgent tone. He wanted you to --
REES: Insistent, I would say.
LANGDALE: If you go page 35, the next page of the grievance interview note, in the first large box there: "I have heard SB is adamant LL is not going back to the unit. I feel very strongly we need to get LL back on the unit." So you two are completely polarised?
REES: Mm.
LANGDALE: Yes: "I raised with AK and SH if we can get a deadline of date. Also questioned why haven't brought police in. KR [that is you] hasn't because of LL."
REES: (Nods)
LANGDALE: "Would we like our daughter to be treated like this? I don't think so. In the meeting with Stephen Cross it was mentioned about if we call the police the unit will be shut down and people may be arrested." So was that your reservation about the police not being called because of LL, because she may be arrested? How does that --
REES: I think that might have been part of it. But like I say, we were all at fault, none of us went to the
police, did we? And I think you know on, you know, when I look back on all of this, I didn't because I thought what am I going to go to them with, obviously Consultant concerns. But I think also because they hadn't neither and the Executives hadn't, it was hard. But I -- I was -- I was -- I have never been so relieved when they eventually did.
LANGDALE: But you do appear to be saying here you don't -- you haven't because of Letby and you refer to Stephen Cross. Did you hear Stephen Cross say: if you call the police the unit will be shut down and people may be arrested or had someone told you he had said that?
REES: I honestly can't remember, I don't know whether Stephen Cross might have said that.
LANGDALE: Did you ever have a meeting with Stephen Cross, were you there at the same meetings with him or not?
REES: I've been at meetings with Stephen Cross, one in particular was a Consultant meeting we had at the end of January, where I read out -- I was asked to read out Lucy Letby's statement. I think Stephen Cross was present then --
LANGDALE: Yes.
REES: -- and he might have inferred something to that degree. But I can't honestly say absolutely.
LANGDALE: Dr Tighe gave evidence to the Inquiry that the reading out of that statement was the last thing the meeting needed, it was a serious situation and he described it as a melodramatic dissertation from Letby. When you look back now about reading that out and how you read that out, do you have anything to say about that?
REES: I was asked to read that statement out. I didn't volunteer. I suppose at that time I was happy to do so because, again, we weren't getting anywhere and I think obviously Lucy Letby wanted to -- she had had a grievance upheld, if I remember, if I have got this right in chronological order.
LANGDALE: That can come down now. Carry on, sorry?
REES: Sorry. And she just wanted to let the Consultants know because at that time we were still planning to put Lucy Letby back on the neonatal unit. I think as for it being melodramatic, it was emotional certainly from what I recall, what I read out. Yes, it was a hard meeting regardless.
MS LANGDALE: We have been going for 90 minutes, so shall we stop for a break now, Ms Rees?
LADY JUSTICE THIRLWALL: Very well. I will take a break now, Mrs Rees, until a quarter to 4. 15 minutes. (3.31 pm) (A short break) (3.44 pm)
MS LANGDALE: Ms Rees I want to ask you about where Letby was working and what happened subsequently in terms of placements anywhere and if we go to a series of documents. If we can have first, please, INQ0003273, page 2. This is an NNU action planning meeting, 30 June, and it's Alison Kelly, Dee Appleton-Cairns, Sue Hodkinson, Julie Fogarty, yourself, Sian Williams and others. On page 2 we see a reference with KR, your initial next to it: "LL not working anywhere else, ie at another Trust or agency. Trained at Leicester, lives alone, has elderly parents. Clarity with LL working in other units and query bank hours." In June 2016 what were you tasked with, if anything, in relation to that clarity Re working on other units or bank hours, can you remember?
REES: I don't recall being tasked with anything from there. I think it was a question that was raised just
in case Lucy Letby was working for an agency outside the organisation.
LANGDALE: Yes, whether she was.
REES: Yes.
LANGDALE: So what clarity was sought, what did you understand the position was?
REES: For Lucy Letby or for?
LANGDALE: Yes for Letby then, what -- not working anywhere else, is that what you understood was the position or not?
REES: Yes. I think the concerns were raised that what they didn't obviously want while this was going on couldn't remove her from the clinical placement in our Trust for then to be found out that she had been working for an agency elsewhere.
LANGDALE: Did you have to check with agencies or just check with her that there was no concern about that?
REES: I didn't have to check. But I can't remember whether Dee Appleton-Cairns, somebody from HR might have checked but I certainly didn't. I wasn't tasked with that.
LANGDALE: INQ003529 next, please, page 3. A meeting 26 January at the bottom, 2017, with Letby, Kelly Hodkinson, yourself, de Berger. If we go over the page, please, to page 4, at the
bottom: "Karen asked on you behalf if we could continue with fortnightly meetings with both Sue and Alison which we both confirmed by advising absolutely. "Alison added it was a good opportunity to think about the type of messages you may want Alison to say on your behalf when having meetings with the nursing teams as we are looking to arrange a meeting with them. It is important the nursing team are there to support you and need to be clear on how they will wrap around you when you go back. "Karen agreed for you, Hayley and Kathryn to discuss this further with you the following week." So what was that about nurses needing to wrap around her when she went back to support her, what conversations were happening?
REES: If my memory serves me rightly, I think there are obvious concerns because of the breakdown in working relationships between the clinicians and the nursing team and particularly with the failed mediation following the grievance. I think I was just trying to I think at that time to try and find a way to put Lucy Letby back on the neonatal unit with her full nursing team support there.
LANGDALE: At this point, you knew from her that she did not think there was any personal acts from either Dr Brearey or Dr Jayaram. We have seen you told the police you asked her about that, there was no personal concern. Were you still thinking that there was in some way bad faith in the allegation that she was deliberately or may deliberately be causing harm to babies? Or did you think it was a reasonable and well held belief, a genuinely held belief?
REES: Yes, I suppose it was. It's hard to absolutely recall. But yes, I think the intention was to make sure she had enough support if we would have been successful in returning her to the neonatal unit and to try and help build those working relationships again.
LANGDALE: If we go, please, to 0003529, page 5. We see in the meeting on 31 January, the last paragraph: "Finally, you advised how you had been liaising with a colleague based at Alder Hey to view theatre lists to have an observational contract. We agreed you would work with Karen to come back with a plan around this within the next week. Meeting closed at approximately 12.30." So she is speaking with you about Alder Hey and her plan about working there. What did you understand the position was?
Pleases be careful to use the cipher if you are going to mention any names here.
REES: If I recall, Lucy Letby had a friend, a medical colleague that worked -- she had obviously worked with him prior and he was currently based at Alder Hey Hospital and I recall her arranging to have this observational contract with this particular medic, so she could sit in his clinic and just observe. There was no hands-on clinical contact as far as I was aware, made aware. But I do recall once that had been -- Lucy had set that up with this particular medic, that Alison Kelly then on hindsight retracted it and stopped it.
LANGDALE: But you didn't contact Alder Hey at any time to either confirm or prevent that placement either way, you didn't get involved in that or what's the position?
REES: No, no.
LANGDALE: If we can go to INQ0003529, page 9, this is a meeting on 8 March, if we go to the next page, page 9, sorry, we concluded -- you see at the top: "We concluded the meeting by discussing your plans for transition back to the NNU. You had been working with Karen on dates of 3 April and 10 April. You would have support from a number of buddies and Karen had spoken to the senior team around your competencies.
"Karen, Hayley and yourself spoke about how you had gone on to the unit on your own last week and this was a big step. "Karen reiterated she would be guided by you with shifts." What had she done on her own on the unit in March?
REES: Sorry, say that again? Sorry, can you repeat that?
LANGDALE: What had she done on her own on the unit? You see it says she tells you she's been on --
REES: I think she just -- my recollection is that she just went to visit the unit to see how she felt, so it was -- she didn't actually work on the unit that I can remember. I think she just went because she had obviously been removed from there for quite some time and she was anxious about it. I think it was just a visitation.
LANGDALE: We know there was some tea party or some welcome event organised. Did you get involved in that, sorting that out?
REES: No, I wasn't aware of that and I certainly didn't get invited.
LANGDALE: If we go to INQ0004697, page 3, and the last box 13: "Provide continuous professional development to LL
to support her ongoing development and refresher re her clinical skills. Alison Kelly delegated to Karen Rees. Initial discussions with Alder Hey Hospital re: observation placement." So was that seen as her keeping her skills, the observational placement? I think she was subsequently sent on a course as well, wasn't she?
REES: Was she? Definitely it was just to get her back in renewing her knowledge and skills. I don't recall her going on a course. I don't recall that at all.
LANGDALE: If we go, please, to INQ0003479 [not found], page 1, we see here by 27 April 2017 the Trust decision, paragraph 4, was that you could not return to the unit as this had been paused. Now, you, Hayley Cooper, Kathryn de Berger and Letby were all working towards this, weren't you, her to be going back on to the ward?
REES: Yes.
LANGDALE: So what did you make of this?
REES: I'm trying to think at the time. April. I think that was around Easter time, if I remember rightly, and so her return to the unit was paused yet again I think because the mediation with the two Consultants, Ravi Jayaram and Steve Brearey, hadn't taken place and I think there were concerns about her going back on the neonatal unit without having that rectified.
LANGDALE: Did you support the decision that that should be paused? Did you think it was important there should be a thorough forensic investigation into the unexpected deaths or not?
REES: Absolutely. It was just so difficult when there was a plan and then there wasn't a plan, and then there was a plan and then there wasn't a plan. But, yes, I think -- I think it would have been really hard to put Lucy Letby back on that neonatal unit without having some sort of mediation with the two Consultants and, you know, a satisfied investigation.
LANGDALE: To complete the working INQ0002796, page 1., the working picture, if we look at this 2796, page 1. The third paragraph: "Karen Rees has just informed Lucy that both have advised Lucy does not go to Alder Hey for the time being like she has been." It looks as though that was in May 2017. "Would like to know why this is the case and is this a management instruction and if so on what grounds?" Can you see?
REES: That was what I was alluding to --
LANGDALE: Yes.
REES: -- just before --
LANGDALE: May 2017 when that instruction, looking at that letter --
REES: Yes.
LANGDALE: "Dear Alison and Sue" from Hayley: "Following the meeting we have just all attended Lucy has asked ... on behalf of the following conversation with Karen Rees." You were the one to tell her, weren't you, in the conversation?
REES: Yes. We had had a meeting and then I got called out of that meeting to ask to go back in to her, Lucy Letby, to tell her that we couldn't proceed and obviously Hayley Cooper wrote that email because she was clearly upset saying: Why didn't they be open and honest and tell her why we were in that meeting, and hence that, you know, I'm assuming that's why Hayley Cooper sent that email.
LANGDALE: Whatever you chose to tell her it's apparent looking at the meetings that she had worked out for herself by then that the Consultants were saying there was an issue with her, yes?
REES: At some point, yes.
LANGDALE: And she in particular wanted apologies from four people, didn't she, not all of the Consultants? She wanted them from four people. Can you remember that?
REES: I thought it was three.
LANGDALE: Who did you think she wanted apologies from?
REES: Ravi Jayaram, Steve Brearey, and Jim McCormack was my recollection. I can't think...
LANGDALE: In the meeting, does Dr V ring a bell as well, Dr V? I can't give you the name.
REES: Sorry, I don't recall.
LANGDALE: So Drs Brearey, Jayaram and McCormack in particular you remember that she wanted apologies from and she didn't know why all the Consultants were apologising, is that right, in one meeting?
REES: I -- oh, God -- I don't think she wanted or expected an apology from other clinicians. I think it was -- just what I recall is it was those three in particular.
LANGDALE: So if we go to INQ0005810, page 1. We see at the bottom a letter from all seven Consultants. It's from Tony Chambers: "An apology from the whole Consultant team will be done as a group." She says:
"Why is that?" Tony Chambers says: "It's thought to be the most sensible. We have recognised some of their behaviour was not appropriate. This is acknowledged and we need to get into a position where we can move forwards." If we go over the page, to page 2, she says: "I expect four apologies. SL..." Is that her mother?
REES: Ah, right.
LANGDALE: "It's unacceptable if not." And then they say: "As a family it's easier to do a collective apology. They made it very personal again so personal allegations are redeployed. She's not been told about it." And it repeats: "We were expecting four apologies." If we go to the next page, page 3, Mr Chambers: "I am trying to advise you. The last thing we want is sensational press. This is about sick poorly babies. The story in The Sunday Times is about families saying we are keeping them in the dark." What did you think the parents of the babies who had been killed and harmed were being told about the investigations?
REES: I think there should have been a lot more openness and transparency with certainly the parents. Everybody.
LANGDALE: If we go to the last page of this document, page 7, we see: "We want a mediation from her parents of ... or not we want her back on the unit. We can forget about individual. Mr Chambers' report will be published next week. There may be interest from media outlets. This is not about you. There was an increase in mortality, the review and recommendations. There will be a flurry of interest. Parents saying we appreciate what's been said. If her name comes up in the press we will take advice." Lucy Letby says: "Do all you can to avoid this." You end the meeting: "Important to have the mediation and to move forwards." Whose needs were paramount in that meeting? That can go down now, thank you.
REES: Clearly Lucy Letby's and her parents.
LANGDALE: There is no reference to the safety of babies at all in that meeting, is there?
REES: No.
LANGDALE: Do you think looking back you, in common with Eirian Powell, got too close to Lucy Letby and her position?
REES: I can only answer for myself. I think the answer to that is, yes, because I was tasked to meet with her on a near-weekly basis for nearly two years and as I said previously witnessing her distress, yes, I acknowledge that.
LANGDALE: She had support from a number of sources, didn't she? She had Dr U, who was messaging her?
REES: I don't know. I don't know about that.
LANGDALE: You made reference to her having a connection with a clinician who was helping her -- you mentioned it to the police -- keeping her competencies, keeping her expertise, that she spoke about stuff. You know about that at the time, didn't you, that she was messaging Dr U as we know him in the Inquiry?
REES: Messaging him?
LANGDALE: Yes, messaging. Texting, Facebook messaging. She was not messaging you. Between each other, they were messaging each other. So she had support from him.
REES: Okay. I don't know about that, sorry, but...
LANGDALE: You say something to the police --
REES: Did I?
LANGDALE: -- about him you knew that she was -- had, as you mentioned, a placement arranged?
REES: Was that the one, sorry?
LANGDALE: Yes.
REES: Yes.
LANGDALE: So that person.
REES: But I didn't realise they were...
LANGDALE: The extent of messaging?
REES: Yes. Yes.
LANGDALE: Understood. So she had support there. She was also messaging and in contact with a couple of the nurses who she'd worked with on the unit, wasn't she? You nod, but, did you know that? She had support from some friends?
REES: I don't -- I really don't know about that. I know she had a close friend on the unit and one would assume she'd still. But, I can't comment. I really don't know about that.
LANGDALE: And she turned up at the Christmas party, didn't she, in December 2016 -- sorry, December 2017. She was able to go back to -- it was combined with Eirian Powell's retirement. She felt able to do that. Did you go to that party?
REES: No, I did not.
LANGDALE: Okay. So she wasn't short of sources of
support at that time, was she, and she had the three of you on the WhatsApp group?
REES: (Nods)
LANGDALE: Hayley Cooper, Kathryn de Berger and yourself. So she had a number of people she was messaging in support, didn't she?
REES: Yes.
LANGDALE: Were you aware at the time the number of people and avenues of support that she did have?
REES: No, no, no.
LANGDALE: Because if we go, let's go to INQ0108337, page 1. This is a message from you that is on that group between the four of you, 24 May: "See, hang on in there girl. Something I need to share with Alison and Sue. Your nursing team are fully behind you. We will get through this lol, K." That's a very personal message, isn't it?
REES: Yes.
LANGDALE: If we go to INQ0108337, page 2 [not found]. The 1st of the 1st: "Happy New Year to all. Lucy let's hope we get closure this year. I'm really proud of you and the professional way you have presented yourself throughout is admirable. We will continue to support you and I promise I will do all I can before I leave. All have a great day. See you in the week." You were fully committed to her position, weren't you?
REES: I was at that time, yes.
LANGDALE: And again 108337, page 3 [not found], the last message. I'm not sure if you received it. This is 18 December 2018: "Just to let you know we are constantly thinking of you and hope you can try and have a pleasant xmas with your family during this continuous stressful time." When you say you were at the time, what did you learn since about her that questions your interaction with her at the time if anything?
REES: Sorry, say that again?
LANGDALE: What have you learned, either at the criminal trial or subsequently through documents you have been sent, about Letby that you didn't know at the time when you were supporting her so fully?
REES: It's certainly -- obviously when I've read all the stuff that I have been sent, you know, in regards to the public Inquiry it was quite enlightening to read all of that because you do forget things and you are not aware of things. So, yes, I take it on board. I think for me personally, yes, professional and personal boundaries blurred because of my -- the amount
of involvement I had tasked, you know, with meeting with her regularly and perhaps on hindsight that wasn't as necessary as it was made out to be.
LANGDALE: Who was the first person who asked you to meet her that regularly?
REES: It was Alison Kelly and Sue Hodkinson.
LANGDALE: It was originally weekly, wasn't it, and then it went to fortnightly?
REES: Yes.
LANGDALE: Is that right?
REES: It was weekly for me and then I asked Alison and Sue to -- Alison Kelly and Sue Hodkinson, sorry -- to join the meeting so they could give full explanations about progress or lack of it and the reasons why, which is then they agreed to do and that's when they came monthly.
LANGDALE: And another email, I don't need to put it on the screen, 21 December 2017: "We will continue to fight for you and as I promised, whoever takes over from me will continue to give that support I promise." If we can look though at INQ0057499, page 1. This is a message from Letby to Ian Harvey. Can you see? "Karen Rees informed that a junior doctor openly
tabled at a meeting when discussing the increased mortality rates there might be a possible connection involvement with this. When Karen asked, the details of the doctor and the meeting were not provided. Is there an agenda or minutes which could be traced? I am interested to know who tabled this and who was present as they are potentially professionals that I will be working with in the future and feel that it's only fair for me to know." Do you remember now which junior doctor that was who had raised the links with her?
REES: No, I am sorry, I can't. I don't know whether I was aware of which junior doctor it was.
LANGDALE: Did you know she was going to write to Mr Harvey and ask for that information? She cc'd you. Did you know before?
REES: Not until I had read it after she cc'd me, but she didn't tell me of her intent.
LANGDALE: But would you have supported that? I mean, you are still writing her messages of support at this time so presumably you did support her with that request.
REES: Well, I think she had already done it before she had informed me she was doing it. Hence when I read it when she had cc'd me, it had already been done.
I don't recall supporting her or her informing me she was going to do that; send that email to Ian Harvey. I don't remember that.
LANGDALE: That can go down now, thank you. Paragraph 123 of your statement. We referred you to appendix 6 of the Trust disciplinary policy which is entitled "Consideration of Referral to the Local Authority Designated Officer" and it refers to if there is a concern raised or an allegation made about a person who works with children, whether a professional staff member, foster carer or volunteer that they may have behaved in a way that has harmed a child or may have harmed a child, possibly committed a criminal offence in a way that indicates they are unsuitable to work with children then the process outlined below should be followed. The disciplinary, you say you were aware of that?
REES: Yes.
LANGDALE: At any point, did you think she should be being investigated for what this allegation represents in terms of what the doctors had said about her?
REES: If I remember correctly, referral to the LADO -- I am trying to recall it now -- because it's in the disciplinary policy that you, your first port of call is to inform your line manager and then I think referral to the LADO has to -- well, the recommendation is it 24 hours she should -- it should have been reported to. Well, this was over 12 months. So I didn't even question. I thought perhaps whoever had already reported it to the LADO because my understanding was these concerns were raised well before I was in post. So I -- I didn't even give that a thought, I am sorry, I thought it would have already been done.
LANGDALE: At paragraph 128 under reflections you say: "On reflection if Eirian Powell and I had been approached by the Consultants when they first had their suspicions in relation to Letby, we could have worked together and monitored Letby's clinical practice more closely."
REES: Yes.
LANGDALE: Eirian Powell was working closely with Dr Brearey right from the moment when the review into A, C and D had been conducted.
REES: Right.
LANGDALE: She was communicating with you and you were aware that they were doing that work, weren't you, around the thematic reviews, increased death rates and links to a member of staff?
REES: Yes, I was. But what I am referring to in my
comments made there was my understanding was concerns had been raised in January '15. I came into post in August 2015. I would have -- on reflection I thought if, if and I wasn't aware that they were meeting with the Execs or anything like that, but I thought when I came new into post it might have been of benefit -- and hindsight's a great thing, I get that -- but if, if Ravi Jayaram and Steve Brearey had called a meeting with me and Eirian and said: Look, we have got concerns, we don't know exactly what those concerns are... But that's a cohesive way of working with a team. If I put myself back in coronary care when I was ward manager there years ago if any of my Consultant cardiologists had had a concern about a nurse, I would have expected their first line of concern to be raised with me, not jump immediately into the Executive suite. So yes, I was aware. I was made aware of the thematic review and all the other things that were going on later on. I just think we had a missed opportunity. As the unit manager and the head of nursing we could have sat down and worked closely and perhaps that would have prevented the divide between the clinicians and the nurses and the lack of trust moving forward. That's what I meant by that.
LANGDALE: When you were both told that she may purposefully be harming babies, that's you and Eirian Powell, you did not believe it, and you in fact questioned their motive.
REES: When did I do that, sorry?
LANGDALE: When they first mentioned that to you, that she was suspected of purposefully harming babies back on 24 June, when that was said in the clearest terms --
REES: Right, sorry, yes.
LANGDALE: -- you didn't believe it. So, what difference would it have made, even if it had been expressed in the loudest terms to you, three months earlier?
REES: Because if they would have come to me -- I went to find them on that Friday. At no time did either Consultant bleep, telephone, knock on my office door to tell me about their concerns. I wasn't one of -- the first port of call and I think that's -- that's lacking is what I'm trying to explain. I didn't know they were having meetings with the Executive team. I just thought I would have expected them to sit down with me and Eirian and that's just my opinion.
LANGDALE: Dr Brearey did telephone you the night of 24 June?
REES: He did.
LANGDALE: But it made no difference. He very clearly made his concerns aware to you?
REES: Yes, but I have explained about the content of that conversation, that I felt like I was being bullied and intimidated. I didn't find it a very professional conversation and I'm not making excuse. I, you know, this is why I phoned Alison Kelly straight back and said: Look, Steve Brearey is still agitating so you need to know this.
LANGDALE: You did an interview, didn't you, with ITV on August 22 --
REES: God, yes.
LANGDALE: -- 2023?
REES: Yes.
LANGDALE: And you said in that interview: "If I had been given a little bit more information, if it had been inferred insulin had been used but neither of them gave me anything other than they were concerned about her clinical practice. I would have acted differently." And you said there they were concerned about her clinical practice. You didn't say in that interview that they had also said, certainly in June, she may purposefully be harming babies as you have told the Inquiry. There is a difference, isn't there --
REES: There is.
LANGDALE: -- between people saying, "They didn't tell me other than they were concerned about her clinical practice" and saying, "She may purposefully be harming babies." Why didn't you say in that interview that that is what you had been told?
REES: I don't know. I'm sorry, I don't know.
MS LANGDALE: Those are my questions, thank you.
REES: Thank you.
LADY JUSTICE THIRLWALL: Thank you very much indeed, Ms Langdale. Mr Baker.
MR BAKER: Good afternoon. I ask questions on behalf of some of the Family groups.
REES: Okay. Thank you.
BAKER: Part of your remit was patient safety?
REES: Yes.
BAKER: And as part of that duty towards patient safety, one of your jobs was to be aware of the risk that members of staff may harm patients? That's correct, isn't it? It wasn't an entirely novel concept in 2015 that a member of staff may cause harm to a patient?
REES: I think in all of my career, I have never had
anybody say that a member of staff has been purposely harming patients. You know, yes, part of my role, as is any nurse, you know, patient safety is paramount but for the reasons that I have explained today.
BAKER: We don't have to encounter it personally and directly, do we, to be aware of the risk?
REES: Sorry, say that again to me?
BAKER: We don't have to encounter a risk personally to be aware of it?
REES: No, true.
BAKER: You know from nursing practice that there are many risks and conditions that you may only ever see once in your career?
REES: Yes, I appreciate that.
BAKER: And if we are thinking about the proximity of risk in 2015 someone had been convicted of murdering patients less than 40 miles away a nurse in a hospital. So can I ask you this: as of 2015, what level of proof did you think was necessary in order to act on the idea that somebody might be harming a patient?
REES: I think it's like I previously explained, I thought it was personal at first and I appreciate what you are saying, that what -- but I just feel that if I had have been given something more, bearing in mind I wasn't aware that the Consultants had raised concerns
with the Executive teams well before I was in post, and then not to come anywhere near me but I hear what you say yes, it was -- it was, it was an awful allegation and for that I am sorry.
BAKER: Well, these were two doctors who were --
REES: I know.
BAKER: -- sensible, they were senior, they weren't people who would inherently denounce other members of staff for serious crimes, were they?
REES: I would hope not, no.
BAKER: No. And in fact they were right, as it turned out?
REES: As it turned out.
BAKER: Looking at when you became aware of things going on, is it true that hearing about Ravi Jayaram talking to Karen Townsend came completely out of the blue, is it really true that you were unaware of any issues of Letby before then?
REES: No, because I think at the beginning I thought that was the first time that I had heard about Lucy Letby or her name. But clearly evidently because it was such a long time ago, when I got all, all the information sent to me, clearly there was a thematic review that I was emailed after they had done that. So you are right, no, it wasn't the first time.
BAKER: No, what you say in your Facere Melius interview is that you had been involved in discussions regarding mortality from the end of 2015 onwards. So if I -- it's INQ00012991 [INQ0012991] on page 3. So if we look here on page 3, you can see there in December 2015, there was the thematic review discussed at the QSPEC meetings and you ask: "Was that the internal one, the initial internal one? "Yeah." And you say: "Yes, I think it's the one Jane Fogarty developed." Darren Thorne says: "... and Sian Williams were involved in. "Yes, I do recall. "Can you remember what was discussed at that meeting at all? "All I can remember is I believe there were some concerns raised by -- just think, some of the concerns if I remember rightly, so apologies, that were raised by the Consultant paediatricians with the Exec team." You are describing there discussions taking place in December 2015 that you are aware of?
REES: Yes. Yes, and I think that's alluding to Julie Fogarty and Sian Williams I think that was the first internal investigation and I do recall that looking at off-duty, you know, the simple internal things first, so I do recall that, yes I am sorry, yes.
BAKER: And as head of nursing, if there were discussions about mortality and in particular a link between a nurse and mortality, you would expect to be informed about that, wouldn't you?
REES: Yes.
BAKER: So Eirian Powell should have told you about it and kept you up to date on anything that was going on?
REES: Yes.
BAKER: So by the time we come on to May 2016, you receive an email which is headed in terms "Concerns about nurses" or "Nurse concern NNU thematic review" is the title of the email that you receive in May, 4 May 2016. You must have understood from what was within it and what had gone before that there were concerns about the connection between Lucy Letby and an increase in neonatal mortality; that is correct, isn't it?
REES: That is correct.
BAKER: And what you say in your witness statement at paragraph 20 is that you went off to see Eirian Powell about this and you say that Eirian Powell told you in terms that Lucy Letby was -- she assured me that
a number of these babies were born with congenital abnormalities, maternal syndrome, necrotising enterocolitis and sepsis and she told me about the lack of cot availability in Alder Hey. She said Lucy Letby had been on shift for the babies listed on the schedule but had only been allocated three of them and I did not consider there was a potential safeguarding risk to patients. Eirian Powell was defending Lucy Letby at this meeting you had with her, wasn't she?
REES: Yes, and I suppose I listened to her because as a unit manager or a ward manager you know your team best. You know their strengths, their weaknesses, their capabilities and so, yes, I trusted Eirian's judgment in that regard.
BAKER: Stephen Brearey in his statement describes attending a meeting with Anne Murphy and Eirian Powell on 11 May 2016 and he put his concerns at that meeting and he said with Eirian Powell countered those concerns "forcibly and with great emotion" is how he describes it. Is that a fair description of how Eirian Powell was defending Lucy Letby when you met her, forcibly, strongly, with emotion?
REES: I wouldn't say forcibly. But she was
persistent with that view.
BAKER: Persistent?
REES: Yes.
BAKER: You were given some reasons as to or some background descriptions of how these babies were. But were you told that they had all been -- the deaths had all been unexpected and unexplained or were thought to be unexpected and unexplained?
REES: Sorry, can you say that again?
BAKER: So in your witness statement at paragraph 20 you describe Eirian Powell describing the background conditions?
REES: Yes.
BAKER: The comorbidities for these babies including necrotising enterocolitis and sepsis.
REES: Yes.
BAKER: Did Eirian Powell tell you that is why those babies died or did she say to you that despite those background conditions, the deaths were unexpected and unexplained?
REES: No, she didn't say to me that was the reasons for the death. I think it was just information given to say that they weren't deemed the stable babies that was first alluded to at some point from Eirian.
BAKER: Would it not have been important, though, in
trying to understand neonatal mortality to understand why those babies died?
REES: Sure.
BAKER: So did you ask her why the babies died?
REES: Well, we had discussions when she went through the paperwork that identified each baby and what -- whether it was sepsis, congenital abnormality or whatever, but I can't recall us having a conversation to say is that definitely what they died of, no, I don't recall that.
BAKER: And did you seek any reassurance from the doctors, for example, as to the cause of death for these babies or whether what had been said to you was accurate?
REES: No, I did not.
BAKER: Because the form that you saw with Letby's name in red --
REES: Yes.
BAKER: -- describes [Child C]'s cause of death as NEC?
REES: Yes.
BAKER: But in fact a post-mortem had been done months before that form was completed --
REES: Right.
BAKER: -- which did not give NEC as a cause of death?
REES: Okay, I am sorry, I wasn't aware of that.
BAKER: But do you think the way in which Eirian Powell defended Letby and what she said to you influenced your reaction to the allegations?
REES: Maybe. Maybe. Certainly at the beginning, yes.
BAKER: Do you think in hindsight, some degree of tribal allegiance was working here and that you tended to accept her word because she was a nurse and perhaps had a bias against what the doctors might be saying?
REES: I think -- I think obviously I believed what Eirian was telling me for the reasons that I said just before is that a unit manager knows her team members better than anybody, better than the doctors, so yes, I did believe Eirian.
BAKER: You assume that Eirian Powell as a serious senior nurse --
REES: Yes.
BAKER: As a senior nurse, sorry, would have carried out her own serious research before saying those things to you?
REES: Yes.
BAKER: Did you ask her or indeed carry out any of your own investigations as to the background to any of these collapses? Or, sorry, any of these deaths?
REES: No, I did not.
BAKER: I mean of course you know now that if you had carried out investigations of your own you would have found out that doctors had been concerned in June 2015 about a grouping of deaths and collapses?
REES: Yes.
BAKER: You would have found out that [Child E], one of the children who had died, had a twin who had also had an unexpected collapse?
REES: Yes.
BAKER: And you would have found out if a doctor had reviewed those notes that [Child F] had an abnormal level of insulin in his system?
REES: If it was known at that time, yes.
BAKER: Yes. So the issue, and do you accept this, is that you accepted a superficial description delivered by somebody who was shouting a defence for Lucy Letby rather than carrying out a sufficiently thorough investigation as to what was actually behind all of this?
REES: Well, I didn't feel that I had to personally carry out another investigation because there were a number of investigations already going on that one would hope would have looked at those things that you have highlighted.
BAKER: I mean, what really should happen though is if
somebody, the senior doctor, says to you in good faith: I think this nurse may be murdering babies, is that you should call the police, shouldn't you?
REES: On hindsight perhaps I should, but then I questioned as to why neither Consultant did that also. If they were so convinced, why did they not? But I acknowledge yes, yes.
BAKER: Doesn't that reveal a bias because you don't apply the same level of scrutiny to what Eirian Powell tells you, you just accept her word?
REES: No, but I felt like I hadn't got any absolute evidence to go to the police. What was I going to say to them? Yes, two Consultants have raised massive allegation but weren't prepared to go to the police themselves.
BAKER: Well, you are not encouraging any sort of investigation at all, are you? I mean, there is no sense of: we need to go off and scrutinise the records or ask the doctors what the basis of this and how we might scrutinise the records. All Stephen Brearey is asking you to do is to take Lucy Letby off the ward so she doesn't harm another baby, that is all he was asking, wasn't it?
REES: Yes, he was demanding. He wasn't asking, he was demanding, yes.
BAKER: Did that put your back up, that he was demanding it?
REES: I wouldn't say put my back up but why wasn't he working with me? You know, like I have said previously just because a Consultant makes a demand, as senior nurse, you -- you don't -- when they click their fingers you don't jump how high. I mean, I accept, and looking back at all of these things, yes, and that is why we are here today so we can learn lessons and I am sorry for all of that.
BAKER: Well, it's this serious, isn't it, because when you have a conversation with him on 24 June by telephone, he says to you: would you be happy to take responsibility for Lucy coming back on shift if she harms another baby?
REES: I don't recall him asking me those questions. But I can say this because apparently he said I said yes, I would take responsibility. I certainly wouldn't have answered yes and that's evident for me to phone Alison Kelly directly following that conversation to inform her that Steve Brearey had been back on the phone to me and is pushing for us to take Lucy Letby off her clinical practice.
BAKER: Do you think though that where an otherwise senior sensible Consultant is saying to you that they have serious concerns that if Lucy Letby comes into work tomorrow that she will murder a baby, which I presume is a fairly novel conversation to be having with a Consultant, does that not immediately start alarm bells ringing from a patient safety point of view that maybe we should just take some safeguarding action?
REES: Yes, and I have acknowledged that I wish I had now brought the safeguarding team in. But equally, and I will keep saying it, why did Ravi Jayaram or Steve Brearey not call the safeguarding team in if they were so insistent that she was doing? Why did they continue to work along side her? I am not making excuses, I acknowledge I should have done it too.
BAKER: I am sure they will be asked that question. But again, Ravi Jayaram talking to Karen Townsend in a coffee shop, that irritated you, didn't it?
REES: No, it didn't irritate me. If I would have been working with any healthcare professional that I thought was purposely harming a patient I wouldn't have declared it in a hospital cafe over a cup of coffee and that was the point I was making. It didn't irritate me, I was just trying to make the point that there is not a chance I would have tabled that concern over a cup of coffee in a cafe she was the divisional director. What I couldn't understand is why
did he not call an urgent meeting right there and then and ask for me, ask for Alison Kelly, Ian Harvey, safeguarding, on that Friday afternoon?
BAKER: What he did do, though, and what Ravi Jayaram did as well is to ask you not to let her come in for another shift so that this could be investigated. They were unhappy about the risk that she created for patients and your reaction to that was to effectively say: she's coming in to the unit?
REES: I don't recall saying that.
BAKER: You refused to take her off the shift the following day. As a consequence she attacked Baby Q [Child Q], didn't she?
REES: Yes.
BAKER: Can I ask you what you understand the duty of candour to mean when it comes to patients, and I ask you this because of something you say in your police statement. So if we could go, please, to INQ0014005 at page 3. So the second paragraph down beneath the "drawer of doom" paragraph begins: "We have a duty of candour to both clinicians and nurses. So as Dr Brearey was pushing me to take some action even though he was not prepared to share with me the evidence of his allegations, I went to speak with
Alison Kelly." Can I ask on behalf of the parents of all of the children who I represent why there is no mention of a duty of candour to patients in this?
REES: I don't know why I never said that. I don't know. Sorry.
BAKER: Because nobody told them at all about the suspicions or the investigations and they had to find out in quite horrible and upsetting circumstances?
REES: Well, I wasn't aware of that, I am sorry, and of course that did not fall within my remit. But I wasn't aware of that.
BAKER: Who is responsible for telling the parents?
REES: I would have thought the clinician that was caring for that patient in the first instance.
BAKER: What, Lucy Letby?
REES: Sorry?
BAKER: Lucy Letby?
REES: No, no, no I am talking about the Consultants, the Consultant team that were looking after that patient I thought, yes. They would have been first line to speak to those parents, surely. I didn't realise that they weren't informed and had to find out in a horrible way as you say. I didn't know that.
MR BAKER: Thank you, my Lady I have no more questions.
LADY JUSTICE THIRLWALL: Thank you very much, Mr Baker. Mr Skelton.
MR SKELTON: Ms Rees, I am going to ask questions on behalf of the other family group.
REES: Thank you.
SKELTON: Can I just go back to the timings of your knowledge, please?
REES: Yes.
SKELTON: Just to be absolutely clear --
REES: Okay.
SKELTON: -- when were you first told that the mortality on the neonatal unit was higher than usual?
REES: When was I?
SKELTON: When?
REES: My recollection was it was either the end of 2015 or the beginning of 2016. It certainly wasn't June or July 2015 because I was not in post at that time as Head of Nursing.
SKELTON: You came in in August?
REES: Yes.
SKELTON: It was in October -- I think you were here this morning, sat in the hearing -- when Eirian Powell produced a mortality table --
REES: Yes.
SKELTON: -- after the death of Baby I [Child I]?
REES: Okay, yes.
SKELTON: That was shared with Dr Brearey who had raised a concern with her, so at that stage Dr Brearey is speaking to Eirian Powell, Eirian Powell is copying in Anne Murphy?
REES: Yes.
SKELTON: Were you involved in that knowledge circle at that stage in October?
REES: In what -- in October? I can't honestly recall it being October but, like I say to you, I think I was made aware either at the end of it, more December or the January. It was somewhere around that time but I do not recall being made aware of that in October.
SKELTON: Who made you aware of it?
REES: Pardon?
SKELTON: Who spoke to you?
REES: Made me aware of it?
SKELTON: Yes?
REES: Eirian Lloyd Powell at the time.
SKELTON: And we have had a lot of evidence about her views. She at that stage rejected the suggestion that Lucy Letby had harmed children, did you accept her view?
REES: Well, clearly at that time I did, didn't I?
SKELTON: Did you go and speak to any of the Consultants?
REES: No, I didn't.
SKELTON: Because you have obviously said the onus was on them to bring things to you. They had brought things to her, she had rejected it --
REES: Right.
SKELTON: -- you yourself didn't feel the need to get a personal grip on this.
REES: Well, as a head of nursing I would have expected to be told, as soon as, if there was a concern about a nurse.
SKELTON: You would have expected to have been told by the Consultants as opposed to being told by the nursing manager of the unit?
REES: Well, the nurse manager, yes.
SKELTON: Can I infer from that you would have expected to have been told by Ms Powell sooner than the end of 2015 to early 2016; in fact, as soon as she was aware?
REES: Well, she was aware, wasn't she, in June 2015.
SKELTON: Yes.
REES: And I was working in another division then, so ... But I don't -- like I say to you, yes, she might have been aware there, but I don't recall her mentioning
it to me in October. I was fairly new in post. Whether we just didn't get the opportunity, I don't know, but I don't recall her telling me in October 2015.
SKELTON: But you would have expected her to have raised it with you?
REES: Yes, yes.
SKELTON: I won't go over the phone call in any detail with Dr Brearey. You have been asked about it a number of times. But what I would like to understand is in your earlier interview with Facere Melius, and indeed in your Inquiry statement, you don't mention being bullied or intimidated by Dr Brearey. In fact, you have described him as rather softly spoken.
REES: Yes.
SKELTON: So he was being more assertive than usual?
REES: Yes.
SKELTON: But you don't mention being bullied or intimidated?
REES: Well, perhaps that's -- but that's how I felt on the phone. I felt he was trying to push me to remove Lucy Letby off the neonatal unit when nobody had been prepared to do that before. So there was a difference this his, in his voice and his tone. He doesn't raise his voice. Steve Brearey never does, but because he phoned me up at home, you know, and
was pushing me to do it again that's why I phoned Alison Kelly immediately after and said: This Consultant is still on the phone to me agitating.
SKELTON: Well, he was being assertive.
REES: Assertive.
SKELTON: He wasn't bullying you really, was he?
REES: Okay. That's how I felt. I felt like he was trying to push me take an action that nobody else had been prepared to do. So you can call it assertive. That's how I felt.
SKELTON: Well, I think you said in your interview he was assertive.
REES: Okay.
SKELTON: Were you cross about that? That's another thing you said in the interview.
REES: Was I cross? Maybe I was. He had phoned me up at home, despite us having a conversation, despite me telling him I'd escalated to the Execs. He inferred I was lying. So, yes, probably I might have been a bit cross. Yes, maybe.
SKELTON: Did it occur to you that he might be desperate, that this was a desperate situation requiring -- effectively he had to get your number from the switchboard. You were being called out of hours as the sort of Exec responsible for responding to emergencies or serious issues --
REES: I wasn't the Exec.
SKELTON: I had understood that you were, as it were, the hotline as a senior manager for that weekend?
REES: No, no. There's levels. This is -- clearly people are labelling me as an Executive nurse. I never have been, never was. So that's a mistake because obviously that's Alison Kelly and we always have an Exec on-call and then a clinical manager like myself.
SKELTON: Leaving that aside, the status issue, he clearly felt there was a desperate need to call someone to get a nurse removed. That's a highly unusual step to take.
REES: Yes, I get that. But I honestly believe if I hadn't gone to find him on that Friday, he never came anywhere near me, I went to seek him out because I was concerned. As a senior nurse, I do not walk out of the organisation when you have got an allegation like that on the table. Absolutely not. And the whole time I had been in post as head of nursing not one time. And I honestly feel if I hadn't had gone to find him -- and I accept all what you say -- if I hadn't have gone to find Steve Brearey on that Friday afternoon, I wouldn't have had that conversation, he wouldn't have rung me at home.
SKELTON: Well, leaving that aside. You had known by this stage, for at least six months or so, that there were concerns about Lucy Letby possibly harming children?
REES: Okay. Yes.
SKELTON: For a long period of time. This wasn't news to you?
REES: No, it wasn't.
SKELTON: Two babies had just died out of a family of three that had just been born?
REES: I know.
SKELTON: And you were being called by a Consultant saying: In order to protect children on the unit you need to get rid of this nurse off the shift. It's an extraordinary situation to be in.
REES: It is.
SKELTON: But your response was to be cross and not to take that step. Can you actually justify that?
REES: Right. I have just explained why I possibly was cross. I escalated again, the second time that day, to my Director of Nursing. I was following hospital policy and procedure. I was unsure what to do because he wasn't giving me anything else, so I picked up the phone immediately and told my Director of Nursing that he had been back on the
phone to me.
SKELTON: Did you have the power to remove Letby from that shift?
REES: Yes, I did.
SKELTON: Without --
REES: Not -- not in isolation. I would have had to have discussed it with my Director of Nursing and then involve human resources. You can't just do it in isolation.
SKELTON: And what was your recommendation to Alison Kelly?
REES: I didn't have --
SKELTON: Presuming she was reliant on you.
REES: I didn't make any recommendations to Alison Kelly. I was just informing her of the events that afternoon and the events of Steve Brearey calling me.
SKELTON: Isn't the reality that you didn't want to remove Lucy Letby?
REES: If I'd've had good reason, I would have done.
SKELTON: And --
REES: If I had been given sound reason, I would have discussed it with Alison Kelly and we would have brought in HR and we would have removed her.
SKELTON: You said in answer to questions from
Ms Langdale, and indeed in your statement, that you felt the Consultants might have had a personal issue?
REES: I did. I did initially. I have admitted that. I thought it might be personal because I have had incidents before where Consultant clinicians have demanded me move nursing for varying other reasons -- not this allegation clearly -- because there's been a breakdown in personal or professional relationships.
SKELTON: Were you --
REES: So you have to have more than a gut feeling and a drawer of doom to remove somebody.
SKELTON: But there hadn't been a breakdown in the personal relationships, had there, in terms of there was no question about Lucy Letby's competence, there was no personal dislike between her and the Consultants?
REES: Sorry, I'm not following that one, sorry?
SKELTON: There was no personal reason in this case in fact. It was purely a professional decision they wanted to make --
REES: Well, okay then, yes.
SKELTON: But you didn't investigate that personal reason?
REES: I didn't investigate. I escalated.
SKELTON: And calling someone and speaking to them about a potential nurse murdering patients is of a very different order from a breakdown of personal relations, isn't it?
REES: Mm-hm.
SKELTON: Do you recognise that you may have brought a degree of bias to your decision-making in assuming that there was a personal problem?
REES: Possibly. Possibly.
SKELTON: Did you think to enquire with the other Consultants? Dr Gibbs had treated the children who had just died. Did you think to ask him: Is this safe?
REES: No, I did not.
SKELTON: Prior to -- well, at any point really, did you speak to any of the other Consultants --
REES: No, I did not.
SKELTON: -- Dr Holt, for example, who was a relatively new and female Consultant who had come to the unit, she explained that she was concerned by high mortality within weeks of arriving on the unit in 2016. Did you ever speak to her?
REES: No and I wasn't aware she -- she had got concerns at that time neither.
SKELTON: So do you think looking back that what happened was that you dug in in a certain mindset quite early on, you and Ms Powell, and never really re-examined your own conclusions as to whether Letby in
fact may have harmed children or not?
REES: I hope not. I -- it's -- I don't know. I don't know. I'm sorry.
SKELTON: Can you give one example of you testing your own assumptions, asking questions, checking investigations?
REES: Well, obviously I had numerous conversations with Eirian. I didn't commence any investigation because there were internal investigations already going on. My main conversation about all of this was definitely with Eirian Powell.
SKELTON: Well, Ms Langdale took you to the email that you were writing in which you were greatly supporting Lucy Letby in September 2016 --
REES: Mmm mm.
SKELTON: -- just after the Royal College had come in and done their review for two days. You, I think, were aware that the Royal College were not looking at increased mortality or indeed Lucy Letby, is that right?
REES: I wasn't involved with setting the Terms of Reference and I hadn't seen them at that point. But I think I recall somewhere in the Terms of Reference it certainly didn't mention Lucy Letby. But if my recollection is correct there is
somewhere in those Terms of Reference that said if you can highlight any possible causes or whatever in regards, there was something that was written, in regards to the mortality rates, I don't think it was very specific, and certainly I know Lucy Letby's name wasn't. But like I say, I -- I didn't see them. I wasn't involved in setting them until well after the investigation had taken place.
SKELTON: As far as you were concerned, throughout this period of time, how did you understand the truth was ever going to be determined about whether or not she had or had not murdered the children?
REES: It needed to be -- to call the police clearly because we weren't getting anywhere, with no amount of investigations, internal/external thematic reviews, post-mortems whatever, it wasn't moving anything on. So, yes, the only way we could determine was to bring the police in.
SKELTON: And as far as you're concerned, I think you accepted this earlier, that it was the responsibility of everyone involved --
REES: Yes, and I hold my hand up to that as well.
SKELTON: -- to call the police?
REES: Yes.
SKELTON: -- as soon as the suspicions became
apparent --
REES: Yes.
SKELTON: -- and when it was clear that you couldn't handle them internally?
REES: Yes.
MR SKELTON: Thank you.
REES: Thank you.
MR SKELTON: Thank you, my Lady.
LADY JUSTICE THIRLWALL: Thank you, Mr Skelton.
MS LANGDALE: No further questions, my Lady.
LADY JUSTICE THIRLWALL: Thank you, Ms Langdale. Mrs Rees, thank you very much indeed. That concludes your evidence. Thank you for coming to help us today. You are free to go.
REES: Thank you. I am sorry for everybody's loss.
LADY JUSTICE THIRLWALL: Thank you. Can you just remind us of the timetable?
MS LANGDALE: I would like to be able to but, I can't actually. It's 10 o'clock tomorrow, I know that much.
LADY JUSTICE THIRLWALL: Very well, that will do for now. We will resume tomorrow at 10 o'clock. Thank you all very much.
(4.54 pm) (The Inquiry adjourned until 10.00 am, on Tuesday, 22 October 2024)