MS LANGDALE: My Lady, the next witness is Ms Eardley and Mr De La Poer will be taking this next witness.
MR DE LA POER: My Lady, we are going to move from the grievance procedure now to consider the RCPCH and our first witness in that part of your hearings is Ms Sue Eardley.
LADY JUSTICE THIRLWALL: Thank you very much, Mrs Eardley, would you come forward, please.
MS SUSAN EARDLEY (sworn)
LADY JUSTICE THIRLWALL: Yes.
MR DE LA POER: Please could you give us your full name.
EARDLEY: Susan Joan Eardley.
DE LA POER: Ms Eardley, is it correct that you provided to the Inquiry a witness statement dated 6 June of this year?
EARDLEY: Yes.
DE LA POER: And are the contents of that witness statement true to the best of your knowledge and belief?
EARDLEY: Yes.
DE LA POER: Before I begin to ask you more questions, I understand that there is a statement that you wish to make.
EARDLEY: I would just like to talk particularly to the Families of those babies about how sorry I am and I cannot imagine what you must have gone through. This procedure has all gone on for so long, I can just hope that at the end of it there are some sufficient learning that other families won't have to go through what you have gone through.
DE LA POER: I begin my questions to you, Ms Eardley, by dealing briefly with your background. Did you qualify
EARDLEY: a chartered electrical and electronic engineer in 1985?
EARDLEY: Yes.
DE LA POER: And as a result of that qualification, did you end up working in project management?
EARDLEY: Yes.
DE LA POER: Did you come to be appointed as a part-time non-executive director and subsequently board chair of Mayday Healthcare NHS Trust in Croydon?
EARDLEY: Yes.
DE LA POER: Have you been a member of a number of national committees relating to the development of maternity standards?
EARDLEY: Yes.
DE LA POER: In 2005, did you join the Healthcare Commission latterly the Care Quality Commission, in a full time role leading on children, maternity and child safeguarding policy and strategy?
EARDLEY: Yes.
DE LA POER: And in that capacity, did you oversee inspections?
EARDLEY: Yes.
DE LA POER: Turning to the Royal College. Was it in 2010 that you joined the RCPCH as head of health policy?
EARDLEY: Yes.
DE LA POER: Two years later, did you begin in a new post, specifically to establish and run the Invited Review service?
EARDLEY: Yes.
DE LA POER: And in doing so, did you work closely with the Royal College of obstetric paediatricians and gynaecologists?
EARDLEY: Yes.
DE LA POER: If we come forward in time, past the dates that we are concerned with. Did you continue in that role until 2019?
EARDLEY: Yes.
DE LA POER: And in that role, did you oversee and/or directly conduct over 100 reviews of services, individuals and networks?
EARDLEY: Yes.
DE LA POER: And to bring us up to date, are you currently supporting the Royal College of radiologists to re-establish their Invited Review service?
EARDLEY: I am not doing that any longer, but I have done since 2019, yes.
DE LA POER: Just so we are clear, you are not and never have been a clinician; is that right?
EARDLEY: Correct.
DE LA POER: You clearly have a great deal of experience
working in the NHS and the healthcare sector. In your own words, in summary, how comfortable are you working with people and in environments which are clinical?
EARDLEY: I have, as you say, had a lot of experience in that so yes, I am very comfortable at board level and working with clinicians from all disciplines.
DE LA POER: In terms of the development of the service that you were appointed to create, by 2016, how well developed would you say that service was?
EARDLEY: We had developed the service initially building on the experience of the Royal College of Obstetricians and Gynaecologists and also Royal College of Surgeons, so we were developing a process not exactly from scratch but using their guidance. We had conducted a number of reviews and from each review there was some learning and we strengthened our processes and approach as we continued to do reviews.
DE LA POER: And as far as speaking in general terms the circumstances of the review that you conducted at the Countess of Chester Hospital was concerned would it be accurate or inaccurate to describe those as unique?
EARDLEY: With hindsight unique. Initially it was a further development in terms of an enquiry we received.
DE LA POER: We just need now between us to consider some
people, one person in particular, for you to introduce briefly and then to look at some Policy documents. Dr David Shortland you tell us had oversight of the Invited Review service in his capacity as Honorary Vice president for health policy; is that right?
EARDLEY: Yes, that's correct.
DE LA POER: Did he also have a role as clinical lead for Invited Reviews?
EARDLEY: Yes.
DE LA POER: We will come to look at how the clinical lead may have input and we will do so by going straight to the first of the Policy documents, which is the handbook for reviewers. It will come up on your screen in just a moment INQ0012822 and we will go straight to page 4, please. Now can I just make clear at this stage we are simply picking out key features of these Policy documents. We will come to apply them in due course, so that is coming. But I just want to invite you to identify with us one or two elements. Now this is described as a process flowchart and was it intended to be the template by which a review would begin, be conducted and conclude?
EARDLEY: Yes.
DE LA POER: We can see that the first step is the request
for assistance. At the second step, we see the clinical adviser so would that be Dr Shortland at the time?
EARDLEY: It would have been at the time, yes.
DE LA POER: So the clinical adviser decides the most appropriate action service design or individual performance review pre-visit may be arranged. Now, were you the author of this flowchart?
EARDLEY: Yes.
DE LA POER: So presumably when you created it you considered that that was an appropriate stage for the clinical adviser to become involved?
EARDLEY: Yes.
DE LA POER: Now, we can see an arrow to the right of that box leading to another text. "Advise to explore internal or external processes eg, NCAS, GMC, BMA, MHPS, no further RCPCH action." Now, this is a step away from the flow of the process, isn't it?
EARDLEY: Yes.
DE LA POER: Effectively it is a dead end?
EARDLEY: Yes.
DE LA POER: Indicating that one would not continue with the process if the advice of which examples are given is tendered at that very early stage?
EARDLEY: Correct.
DE LA POER: Was that designed by you as a recognition that sometimes people will ask the RCPCH to provide some form of help or review and it won't be appropriate for the RCPCH to become involved?
EARDLEY: Yes.
DE LA POER: The examples given include GMC, the General Medical Council, is that a reference to the possibility that some sort of regulatory action may be the appropriate response?
EARDLEY: Yes.
DE LA POER: If we just amplify that a little bit in terms of why you might have included the GMC. If what you are being asked about is effectively there is a concern that a doctor may have misconducted themselves, your view presumably would be, well, the GMC should be the ones investigating that, not the RCPCH?
EARDLEY: Yes. At the time I believe at the time the GMC was developing liaison with Medical Directors around the country and an enquiry about a specific individual doctor, we would have suggested they talk to their GMC representative, the Medical Director talk to their GMC adviser about next steps rather than necessarily going to the RCPCH for review.
DE LA POER: So you step off the process at that point?
EARDLEY: Yes.
DE LA POER: That conversation takes place, the regulator becomes involved, plainly if the regulator was to say: That is nothing to do with us, then you could potentially come back to this?
EARDLEY: Yes.
DE LA POER: Now, you haven't listed the Nursing and Midwifery Council, but they are just a list of examples. By mentioning the GMC, are you intending to imply, "and other regulators of a similar standing"?
EARDLEY: "Eg", yes.
DE LA POER: Yes, quite so. Now, one organisation who don't appear on your example list is the police.
EARDLEY: Correct.
DE LA POER: Just reflecting upon it, and recognising of course that this is not an exhaustive list, but as a means of focusing the mind, do you think perhaps the police should have been included on that list as being the most extreme and clear-cut example of where the RCPCH ought not to be trespassing?
EARDLEY: With hindsight of course the police should be there. At the time, there was such an unlikely occurrence it had not crossed our mind.
DE LA POER: So highly unlikely, but potentially would you agree the very worst example of a situation where the RCPCH should be becoming involved, if it is in fact
a police matter?
EARDLEY: Again, with hindsight, we would have expected the Medical Director would have gone straight to the police had they had suspicions.
DE LA POER: So that's the review process in a flowchart. Could we go to page 8, please. We don't need to look at all of this, I am sure that you will be able to confirm that, the title very much tells us what this is, the Handbook for Invited Reviewers, it's simply advice given to reviewers about how they should conduct themselves, what they should expect, that sort of thing?
EARDLEY: Yes.
DE LA POER: We can see at item 6 on this page: NHS policy briefing including child protection. "Reviews of services will always need to be considered within the local context of commissioning, planning and historical configuration. One of the criteria for reviewer selection is an awareness and understanding of recent national and strategic changes to the NHS and the opportunities and challenges these present together with the ability to contextualise these in relation to the service under review." It goes on to speak in relatively general terms referring to other policies, but my question really is, is this: included in that heading is, as an example,
child protection. Why was that as an example particularly picked out in bold as part of that title?
EARDLEY: Some of the reviews that we did were relating to community paediatrics and child protection was an issue in some of those reviews. The RCPCH had written guidance around child protection as well as clinical standards. It was in there because that was one of the elements that we covered.
DE LA POER: One reason to include it in the title in bold is because that is a particularly important and relevant policy or set of ideas that people need to be up to date with; is that fair?
EARDLEY: Yes. A separate set of web pages, up-to-date policy guidance on child protection issues and advice, yes.
DE LA POER: Now, one of the documents you didn't mention just now in what was I am sure a non-exhaustive list is of course Working Together?
EARDLEY: Yes.
DE LA POER: Was that one of the policy documents that you would expect reviewers to be aware of?
EARDLEY: Yes.
DE LA POER: The Inquiry has received evidence that it received periodic refreshes or updates, the version in force was dated 2015 as at the time of your review?
EARDLEY: Yes.
DE LA POER: Is that a document you would have expected your reviewers to be aware of?
EARDLEY: Yes.
DE LA POER: You have told us that you have a long-standing experience in safeguarding. Was that a document that you were very well versed in?
EARDLEY: Indeed, yes. When I was at the Health Care Commission and CQC I was involved in drafting previous editions of that document.
DE LA POER: This absolutely isn't a test so that we can bring it up on screen, but nor do I want to patronise you as you may well know what I am talking about. There is a passage in Working Together which talks about what an allegation is, I will just read it out for you, but we can bring it up on screen. An allegation may relate to a person who works with children who has behaved in a way that has harmed a child or may have harmed a child, possibly committed a criminal offence against or related to a child, or behaved toward a child or children in a way that indicates they may pose a risk of harm to children. Are you familiar with that sort of language when it comes to Working Together and safeguarding?
EARDLEY: Yes, yes.
DE LA POER: And so was it your understanding that when thinking about things from a safeguarding perspective, one isn't looking for definitive proof, one merely needs a suspicion before immediately everyone needs to be thinking about safeguarding?
EARDLEY: Yes, that is how it reads. Yes.
DE LA POER: So that is how it reads and it was a document you were very familiar with, I suppose the next question is: is that how you were thinking in 2016?
EARDLEY: At that time, no, I was not thinking along the allegation role. With hindsight I'm not sure why not but at the time I was aware of the allegation.
DE LA POER: You say with hindsight you are not sure why not. A possible implication of that is that you are recognising you should have been thinking in those terms; is that fair?
EARDLEY: Yes, knowing what I know now about what happened subsequently.
DE LA POER: But did you need to know that for that to be the correct way to have been thinking at the time, bearing in mind the language of Working Together?
EARDLEY: No.
DE LA POER: In all of your experience of safeguarding, had you yourself ever received or delivered any training about how people should react in a healthcare setting if
they suspected a colleague, so another member of staff, was harming or may harm a child?
EARDLEY: No, that was absolutely not something on my radar at all.
DE LA POER: Again, just taking the opportunity to draw on somebody who has had a very long-standing experience in safeguarding. Do you think that that should have been part of the training back in 2016 and earlier?
EARDLEY: Yes. Yes.
DE LA POER: Does it follow from that because you would recognise that that is a clear example of a safeguarding issue?
EARDLEY: Yes.
DE LA POER: Thank you. We can take that document down. We are next going to look at the Guide to Invited Reviews. INQ0010214. Now, whereas the previous version I think was an internal RCPCH document, for the benefit of those conducting a review, this was an outward-facing document for the benefit of those who might want to understand what the RCPCH could and couldn't do; is that right?
EARDLEY: Absolutely. Both were dynamic documents and we updated them as we went along as we learned new things as we explored new ways of doing reviews.
DE LA POER: But you would expect that a person who might
be interested in involving the RCPCH would be able to access this document, presumably online, in 2016, and familiarise themselves with what the RCPCH could or could not do?
EARDLEY: Yes, it was on the website, as I understand it.
DE LA POER: This, as we see, is the August 2016 iteration, so it slightly postdates the first contact from the Countess but represents the version in force at the time of the inspection?
EARDLEY: Yes.
DE LA POER: Just so we have got our dates straight.
EARDLEY: Yes.
DE LA POER: If we go and have a look at page 4, we can see some definitions which will help a person who is perhaps not familiar with the terms the RCPCH might use to understand it and the one to draw your attention to is paragraph 2.2, a service review which sets out what might occur, it is an invitation to visit and comment upon a current service. It can be broad, the whole paediatric service, or a specific element, including for example safeguarding. It involves meeting the clinicians and managers and then this: "The Terms of Reference will usually be rooted in the quality, safety and efficiency of the service."
EARDLEY: Yes.
DE LA POER: Just again, are these your words?
EARDLEY: Yes, the document will have been through a sign-off by members of the programme board, but yes.
DE LA POER: You will have proposed the original draft?
EARDLEY: Yes.
DE LA POER: Does that accord with what you understood the function of a service review?
EARDLEY: Yes. Again, working closely with other medical Royal Colleges that were providing similar services.
DE LA POER: And just if we take a step back and frame the situation at the Countess in a very general term. If it be the case that you were asked to try and understand why the number of deaths had increased, and we will look at the detail of the Terms of Reference and so on, how well do you think that fits with "usually rooted in the quality safety and efficiency of the service"? Do the two elide or are they in fact separate things?
EARDLEY: We were asked to provide a review, to, as I recall, see if there was any other factors that could explain the increase in mortality. And one of those -- the approach that I discussed with Ian Harvey was that a service review would explore
all the possible factors, organisational factors, cultural factors that may explain that increase in mortality. At the time of the initial conversation, I wasn't aware of the other reviews that had taken place to date. That was part of the whole service review.
DE LA POER: Well, we will come to the detail of your conversation with Mr Harvey and I am not looking to shut you down about that --
EARDLEY: No, no, that's fine.
DE LA POER: -- at this stage. But trying to understand why the rate of mortality may have increased, may be thought, so in other words what factors, may be thought to be different to looking at how good is this service? How safe is this service in general terms? How efficient is this service? Do you see the two -- one is a specific investigation into particular cases, the other is much broader?
EARDLEY: Yes.
DE LA POER: Do you at least see the point that I am making?
EARDLEY: Oh, completely. Yes.
DE LA POER: And do you agree with it or do you disagree with it?
EARDLEY: The -- looking at a service and eliminating any factors that could be causing an increased number of deaths is the purpose of a service review or one of the purposes of a service review.
DE LA POER: Had you ever before this been asked, in circumstances where there had been an increase in deaths, to see if you could identify why that death rate had increased?
EARDLEY: No.
DE LA POER: And since this, have you ever been asked up until 2019?
EARDLEY: No.
DE LA POER: So to that degree at least, this was unique in your experience?
EARDLEY: Yes, there had been reviews where -- where outcomes were less good, if I recall, where there had been tensions on units, where there had been a feeling that processes weren't as safe as they could have been. I can't name specific ones at the moment but this was of the nature of the kind of request that we had.
DE LA POER: Page 5, at paragraph 3.3. We can see: "Each review will have its own specific Terms of Reference and be uniquely designed within the scope of this guidance to be both robust yet fair to all concerned and to answer the questions and concerns
raised." Now, presumably, and we will come to the caveats later, you weren't meaning for people to understand when they read this that whatever concern that they came to you with, you would answer?
EARDLEY: Yes.
DE LA POER: If we have a look at page 7, paragraph 6.1, we see, "Where serious concerns are raised" and just so that we check that we are on the same page, the possibility that a member of staff may be murdering babies presumably falls at the very extreme end of the definition of serious concerns?
EARDLEY: Yes.
DE LA POER: "If issues of patient safety are raised at any time, the reviewers will advise the client immediately and discuss what urgent action should be taken if any. For concerns about an individual's practice for example the client may want to consider restriction of the doctor's practice as set out in the guidance [and I won't rehearse that bit]. For concerns about service safety beyond the scope of the review, the regulatory authority should be advised with consideration as to whether temporary suspicion of the service is appropriate." So again, just -- not looking at the detail of it now but dealing with it in relatively general terms, is that saying that if a doctor says in the course of the review, "I think there may be a serious patient safety concern", there needs to be a very strong and robust reaction from the RCPCH in response?
EARDLEY: This paragraph primarily referred to if on a review we came across some practice which the management was not aware of, which others were not aware of that we thought was a concern, and that has happened on some reviews where we would say -- there was one of an emergency service where we said, "We really suggest that you change practice immediately."
DE LA POER: Yes.
EARDLEY: For this situation, we were told at the beginning of the situation. So informing management about it was not so pertinent because management already knew.
DE LA POER: So certainly simply reflecting back what you have been told and that you know they already know may not have been what you needed to do. It's the advice bit?
EARDLEY: Yes.
DE LA POER: "The reviewers will advise the client immediately."
EARDLEY: Yes. Well, the client already knew. The
client advised us about the situation and how they were managing it at the time.
DE LA POER: Does that not tend to suggest that the reviewers will give advice immediately about what should be done in response to the concerns?
EARDLEY: Yes. This situation is if we come across something that management is not aware of during a review.
DE LA POER: Right.
EARDLEY: For example, poor practice or for example inadequate staffing, non-compliance with standards that was causing a significant safety issue.
DE LA POER: So when we read it as you intended its meaning --
EARDLEY: Yes.
DE LA POER: -- when we read: "If issues of patient safety are raised at any time ..." We should add in brackets, "... during the visit itself."
EARDLEY: Yes, that we -- that management are not already aware of.
DE LA POER: So was it not the role for the RCPCH to give advice about concerns that management were aware of?
EARDLEY: Our role in this review was looking at issues
apart from the situation which management had explained about the doctors' concerns. So we were looking at everything else. We were aware of the doctors' concerns. Our review role was to look at any other factors that could be there.
DE LA POER: Does that mean that you say that there was no obligation on any of the reviewers, yourself included, to give advice, on the basis of the information you had, about how that issue that you say is outside the review should be managed?
EARDLEY: We did discuss it. We discussed with the management how they were managing it.
DE LA POER: I understand that. But my question was about whether you think there was an obligation on you and the other reviewers to give advice to them about how they should manage it, not just discuss, "What are you doing?" but to say, "I understand what you are doing. You need to do this."
EARDLEY: Yes. Yes. And we did. We -- we recognised the situation that the Trust was in at the time, what steps they had taken and where our role was in the management continuing with their investigations.
DE LA POER: Now, one of the things that you didn't advise them to do is go to the police.
EARDLEY: Not directly, but we did discuss it and they explained why they hadn't.
DE LA POER: Well, again, you are coming at this from an independent perspective. It's one thing to say, "Oh, you have thought about it and you have decided not to do it." It's quite another thing to say, "Well, that doesn't matter. The right thing to do here is to call the police." The two are different. Do you agree that you didn't at any time say, "You need to call the police."
EARDLEY: Correct.
DE LA POER: And do you agree -- not with hindsight, but based on the information you were given at the time -- that that was advice that should have been given at least at some stage and we'll work through the chronology in due course?
EARDLEY: At the time we did discuss as a review team whether -- and we'll come to that I suspect -- whether to abort the review, whether to call the police. We did consider the totality of the risks of doing so and the implications of calling the police on the unit as well as the situation and the safety of the unit at that time, where the individual had been taken from clinical duties. So that was a consideration throughout.
DE LA POER: I am sure there were lots of factors to weigh up --
EARDLEY: Indeed.
DE LA POER: But I think the question is: ultimately, does it come down to this: was the correct balance of those factors at the time in fact the police should be called given what you knew at the time?
EARDLEY: Given what we knew at the time, we took the decision at the time which I -- was right at the time.
DE LA POER: Well, we will look at the various moments in time --
EARDLEY: Of course, of course.
DE LA POER: -- and explore it. Page 9, please, paragraph 8. 1. This really is by reference to the flowchart we have already looked at: "Once the clinical adviser has agreed for the College to proceed with the Invited Review, an early pre-review visit may be proposed to familiarise the College's representatives with the relevant individual." So two parts to that. The first part is that the process is anticipating that it is the clinical adviser who makes the decision about whether or not it would be appropriate to proceed, is that correct?
EARDLEY: Yes.
DE LA POER: The second is consideration of an early
pre-review visit. Now, you may be aware that the RCPCH have said in their opening statement that they think a visit to sit down and discuss with the Medical Director in person, as I understand it, what it was all about and what could and couldn't be done, should have occurred on the basis of this case?
EARDLEY: Yes.
DE LA POER: Do you agree with that or do you disagree with that?
EARDLEY: I agree with that, yes.
DE LA POER: Now, if we look at paragraph 9.5, which can be found at page 12. We see the expectation -- this really might be characterised as transparency: "It is expected that the client representative will share the final report amongst as many of those who contributed as possible. The RCPCH will endeavour to structure and phrase the report to reflect this. Occasionally where there are sensitive findings or concerns relating to an individual the RCPCH will write separately in confidence to the Medical Director or their nominee about those issues". And although not writing a separate letter, did in fact you produce one dissemination copy and one confidential copy?
EARDLEY: That's correct, yes.
DE LA POER: And was that with this paragraph in mind?
EARDLEY: Yes. There were other reviews that took place, where we in fact did write a separate letter or have a separate appendix. For this review, we produced a report and then we produced a modified report.
DE LA POER: Well, we will come to the --
EARDLEY: Of course.
DE LA POER: -- the merits and demerits of that in due course. But, really, if we think about the dissemination copy as it's been termed --
EARDLEY: Yes.
DE LA POER: -- was that produced in that way with a view to it being shared with as many people who contributed as possible?
EARDLEY: That was always our policy; that we would write the report so as many people could see it as possible and we would explain at the beginning of each interview that that would be the situation and that they would find within the report what they had said had been included, but it may be quite opaque or oblique to others.
DE LA POER: And those who contributed, I'm sure this is pretty obvious --
EARDLEY: Yes.
DE LA POER: -- everybody who you interview?
EARDLEY: Yes.
DE LA POER: We can see at 9.7: "The College has no statutory authority to require action following an Invited Review and can only give recommendations and advice to a client. Any action taken following an Invited Review is the responsibility of the client. Where concerns are raised over safety or staffing, the College would expect the client to notify the regulatory authorities promptly of the review recommendations and action plan. If during the review or follow-up period the College deems that action taken in response to concerns or recommendations is insufficient to mitigate safety concerns the Invited Review Programme Board reserves the right to authorise further action, which may include reporting the findings directly to the appropriate regulatory or commissioning authority. The Chief Executive of the client organisation would always be notified if this was being considered." So reserving the right, even though it's the client's report, if patient safety is engaged, to ensure that the right people see it if the response is inadequate?
EARDLEY: Yes.
DE LA POER: Now, in order for that to be practicable, doesn't that require the RCPCH to apply some degree of scrutiny over whether or not the recommendations that it's made have been implemented?
EARDLEY: Yes.
DE LA POER: Was there a recognised process for doing that, or was it very much an ad hoc on the facts of the review that you were doing?
EARDLEY: We would usually follow up three to six months after the review report was received.
DE LA POER: I think we see that at 9.8 --
EARDLEY: Yes.
DE LA POER: -- which is the next line?
EARDLEY: Yes. The follow -- follow up process was perhaps not as strong as it could be for a number of reasons which we can come to separately. On this review, I was following up regularly with the Medical Director about progress, but events moved on at a different pace.
DE LA POER: In terms of for a patient safety issue or other important issue --
EARDLEY: Yes.
DE LA POER: -- for that process to be effective, does it require the RCPCH to say, "We made this recommendation, number 1. What have you done about it?" Or is it sufficient simply to say, "How are you getting on?" and
for them to say, "We're doing well, thanks."
EARDLEY: We would usually write to an organisation three or six months later with a list of their recommendations and ask them to come back to us on how they had delivered against those recommendations. That was the usual process.
DE LA POER: And is that -- so that's three to six months after the final report.
EARDLEY: Yes.
DE LA POER: So if we think about our time frame here, that means that shortly after Christmas of 2017 into spring of 2017, that's your window, is it, for writing?
EARDLEY: The final report was the end of November. So it would be February/March.
DE LA POER: February/March?
EARDLEY: Yes. That would be three months; often it was six months to do a formal follow up.
DE LA POER: And the expectation is three to six months. Where there are very serious concerns, or potentially very serious concerns, was any adjustment made to the time period erring on the side of sooner rather than later?
EARDLEY: Well, I'd usually maintain contact with the Medical Director or client anyway throughout. So the formal approach would be between three or six months.
In this situation, the events took over.
DE LA POER: So if we --
LADY JUSTICE THIRLWALL: Mr de la Poer, just choose your moment.
MR DE LA POER: Thank you very much indeed, my Lady. I have got one more question about page 13.
LADY JUSTICE THIRLWALL: Yes, that's fine.
MR DE LA POER: We can see "Confidentiality".
EARDLEY: Yes.
DE LA POER: Is that really for our purposes -- it's a long paragraph, I'm not going to read it out -- reiterating what's been said earlier, which is that you are going to take a confidential approach but there are certain events which the College can breach that confidentiality effectively when patient safety is engaged?
EARDLEY: Yes.
MR DE LA POER: Now, there is one part that we have moved over, but I think, my Lady, that will be most appropriately dealt with after lunch.
LADY JUSTICE THIRLWALL: Very good. Thank you very much. So we will break now and start again at 2 o'clock.
(1.01 pm) (The luncheon adjournment) (2.00 pm)
LADY JUSTICE THIRLWALL: Yes, Mr De La Poer.
MR DE LA POER: My Lady, thank you. We are going to look at one final part of the document that we had on screen just before lunch, I wonder if that can be brought back up again, and we are going to go to page 8, please. Paragraph 7.5 provides list of situations which the College will not take on. If we look at the third bullet point down, where the expected scope includes behaviour or misconduct, bullying, harassment or possible mental health concerns. Now, do you agree, Ms Eardley, that engaging in any investigation into Lucy Letby herself was necessarily taking you down the path of considering behaviour or misconduct issues; is that right?
EARDLEY: No, no, I don't agree with that.
DE LA POER: You don't.
EARDLEY: No.
DE LA POER: Well, is the fact that a person may have acted criminally not something that could be characterised as behavioural or misconduct, albeit that's rather an under-description?
EARDLEY: All that we had heard was that she had been on duty at certain times and she had been taken off clinical duties.
DE LA POER: My question was about engaging in investigating her?
EARDLEY: We didn't do that.
DE LA POER: Well, you did add her to the list of people that you were to speak to in order to get her perspective?
EARDLEY: We did. That was within the -- at the time that was within the context of the service review.
DE LA POER: Yes, but the only reason that she was added to the list, and we will come to the detail of this was --
EARDLEY: Of course.
DE LA POER: -- was because of the allegations that were behavioural misconduct indeed potentially criminal?
EARDLEY: Yes. Yes, I accept that now. But that wasn't the -- that case wasn't the situation at the time when we took on the review.
DE LA POER: Well, let's have a look --
EARDLEY: So that element.
DE LA POER: Sorry, I spoke across you there. Please do tell me what you just said?
EARDLEY: So that element, item 3, the expected scope including behavioural misconduct, when we set up the review that wasn't in the scope.
DE LA POER: So then let's look at page 9, paragraph 7.7: "If any of the issues listed at 7.5 come to light during an Invited Review, the review should be completed
in relation to its original remit unless advised to the contrary in order to avoid prejudicing other investigations by a public authority or regulator but the reviewers cannot investigate or suggest solutions for any of the above." The first question about this is who is it that is envisaged to advise to the contrary?
EARDLEY: That would -- I would interpret that as being in discussion with the client, but I can't --
DE LA POER: One interpretation is that this is the RCPCH review?
EARDLEY: Yes.
DE LA POER: The RCPCH has a duty, do you agree, to not prejudice other investigations?
EARDLEY: Yes.
DE LA POER: So if a senior person within the review team decides that that is a risk then it might be them who were advising we must stop this?
EARDLEY: Yes, yes.
DE LA POER: Were you a senior person within the review team?
EARDLEY: Yes.
DE LA POER: Just so that we understand avoid prejudicing other investigations, were these your words "as approved by others"?
EARDLEY: Yes.
DE LA POER: So when you wrote those words, did you have in contemplation that if a situation may end up in front of police, they are most unlikely to be grateful to the RCPCH if all of their witnesses have already been interviewed and matters that they want to investigate have been discussed in that context?
EARDLEY: When you put it that way, yes, I agree.
DE LA POER: Is that what you had in contemplation when you wrote those words?
EARDLEY: I can't say I thought about it that deeply. But yes.
DE LA POER: That is the sense of it at the very least?
EARDLEY: Yes, yes, the sense of it.
DE LA POER: If it is not that specific as I have characterised it?
EARDLEY: Yes, yes.
DE LA POER: Police perhaps are the most extreme example, although the regulator is also mentioned, that it's a general principle when interacting with formal and serious matters like that that may interfere with a person's ability to do their job in the future, whether they are allowed to, or even their liberty, that it is absolutely imperative that that picture is not in any way muddied or confused by earlier investigations?
EARDLEY: I accept that.
DE LA POER: Do you agree with that?
EARDLEY: Yes, I agree with that.
DE LA POER: So we can take that down. You produced one final document which is a synopsis of the role of lead reviewer. I am not going to ask for it to come up but just simply to acknowledge that there was guidance but I am sure you can agree that there's nothing that's of particular relevance to the circumstances that we are dealing with within that document?
EARDLEY: Correct.
DE LA POER: Now, that's the lead reviewer role. There were other roles as well, a second reviewer; is that right?
EARDLEY: Yes.
DE LA POER: A lay reviewer?
EARDLEY: Yes.
DE LA POER: A nursing and other clinical reviewer, which is a broader category that may include more than one person?
EARDLEY: Yes, that depended on the nature of the service that we were looking at. We would find somebody who had the appropriate skills.
DE LA POER: So in terms of the Countess of Chester who was the lead reviewer please?
EARDLEY: David Milligan.
DE LA POER: Who was the second reviewer?
EARDLEY: Dr Graham Stewart.
DE LA POER: Who was the lay reviewer?
EARDLEY: Claire MacLaughlan.
DE LA POER: Who was the nursing reviewer?
EARDLEY: Alex Mancini.
DE LA POER: So what did that leave your role as being?
EARDLEY: I was head of Invited Reviews, I was administering the review and being the RCPCH staff representative supporting their team.
DE LA POER: Obviously on the one hand you are the head of the whole department under which this review is taking place, so that presumably is why you agree you were a senior person present in there?
EARDLEY: Yes.
DE LA POER: But on the other hand, is it right -- and I am not seeking to diminish the importance of the role -- you are providing administrative support, liaison and ensuring that all the logistics are going to work out so that the clinicians can do their part?
EARDLEY: Absolutely. They are clinically-led reviews, peer reviews, so they are led by clinicians. My role actually on the review visit was to ensure the process was followed as far as possible and to provide the
administrative support, yes.
DE LA POER: Now we have already seen reference to the Terms of Reference for a review and these govern, as the name would suggest, the scope of what is undertaken, is that right?
EARDLEY: Yes.
DE LA POER: And we have seen also that the draft Terms of Reference would usually be sent to the clinical lead, that is the process flow diagram that we looked at. In this case, were the draft Terms of Reference provided to the clinical lead for their review?
EARDLEY: I cannot recall doing that.
DE LA POER: Have you as part of your preparation uncovered any email, memo or other document which suggests that there was discussion or review by the clinical lead?
EARDLEY: Since I left the RCPCH I haven't had access to that information. It's not been provided in the documents.
DE LA POER: Has anybody shown you such a document?
EARDLEY: No.
DE LA POER: And acknowledging that you don't have a positive memory, so this question is not an easy one to answer, but is the reality in these circumstances that it's likely that you did not speak to the clinical lead?
EARDLEY: I was speaking to the clinical lead regularly. I would have mentioned the review as part of the regular communications.
DE LA POER: But in terms of the formulation of the Terms of Reference, is it likely that you did not speak to the clinical lead about those?
EARDLEY: Specifically, no, I don't think I did.
DE LA POER: So we are going to, as you would expect, look at what comes next in three parts, firstly the pre-visit, then the visit?
EARDLEY: Yes.
DE LA POER: And then the post visit. But let's just see if we can applying hindsight, and I am inviting you to do that now, knowing what you know now, do you agree with the suggestion that it was entirely inappropriate for the RCPCH to conduct a review in the circumstances that subsisted?
EARDLEY: At the time it was appropriate because we were excluding all other possible reasons for the high level of mortality. With hindsight, no there would have been other routes we should have taken.
DE LA POER: So does it follow from that that if you had been fully appraised of all of the facts, as they were known at the time by everybody across the piece, that the review wouldn't have gone ahead?
EARDLEY: Yes, that's correct.
DE LA POER: And do you agree that the fact that the review did go ahead gave rise to these risks, and I am stressing risks I am not suggesting that they did or didn't eventuate, but these are risks from the fact that your process went ahead, see if you agree: Firstly, it had the potential to delay other processes, do you agree?
EARDLEY: Yes.
DE LA POER: Secondly, it had the potential to provide false reassurance?
EARDLEY: Potential, yes.
DE LA POER: And, finally, and I stress this is potential, it was capable of prejudicing other investigations?
EARDLEY: With hindsight, yes.
DE LA POER: Pre-visit. First contact came from Ian Harvey to you on 28 June, is that right?
EARDLEY: Yes.
DE LA POER: We are going to bring up the email chain we are not in fact going to run through every email but I would like for us to bring it up on screen please INQ0009615. And we will go straight to page 5 because it is a thread so the start of it is at the bottom. And it begins there with Mr Harvey reaching out to you?
EARDLEY: Yes.
DE LA POER: And at that stage the issue is formulated in the general terms: where there are concerns?
EARDLEY: Yes.
DE LA POER: So that's where the conversation begins?
EARDLEY: Yes.
DE LA POER: You then refer him to the website and we get the URL there for I think the Invited Review document that we looked at, although it would be the pre August 2016 version.
EARDLEY: Yes.
DE LA POER: And then if we go up the page, to page 4, forgive me, that was an ambiguous statement so the bottom of page 4 we can see that two days after the initial contact, Mr Harvey is saying: "Further to our conversation" and apologising for following up so quickly. And it's that conversation that I want to ask you about so we have just anchored it in time it is between 28th and 30th. We can take the email down because you have had a chance to refresh your memory from that beforehand. That conversation did he phone you or did you phone him?
EARDLEY: He will have phoned me.
DE LA POER: And in summary, what did he tell you that he wanted the RCPCH to help with?
EARDLEY: When I receive phone calls like that I had I would quickly reach for paper to make handwritten notes I did have some forms that I would fill in as I went along. He will have set out the concerns they had.
DE LA POER: Can I just interrupt you there. Did you do that in this case?
EARDLEY: I have no record of it. I will have done.
DE LA POER: Yes?
EARDLEY: But my handwritten notes will have been lost somewhere.
DE LA POER: I understand. I just wanted to make sure there wasn't a way we could look at a contemporaneous document. I'm so sorry I interrupted you, please could you continue.
EARDLEY: That is fine. He will have outlined, as was often the case with a first contact with the Medical Director, what the concerns were from his perspective and seeking for the Royal College to explore whether a review would be appropriate.
DE LA POER: And was that the only telephone conversation you had with Ian Harvey before attending for the review or were there others?
EARDLEY: I haven't got records that there were others, but there was certainly a lot of email correspondence. There may well have been phone calls as well.
DE LA POER: The purpose of my question is to really just try and understand that was the extent of what you were told by Mr Harvey contained in those emails, which we believe we have, and just that conversation or might there have been subsequent conversations where you further understood the concerns which existed?
EARDLEY: There may have been other conversations but I normally would have made notes of those which would have come through.
DE LA POER: Well, let's deal collectively then with all of the things that you were told that aren't in the emails because we can all read the emails for ourselves.
EARDLEY: Yes.
DE LA POER: Whether it's just in that one initial call or over a number of calls, were you told about the fact that there was a rise in neonatal mortality?
EARDLEY: Yes.
DE LA POER: Were you told that concerns existed about the association of a member of staff?
EARDLEY: Yes.
DE LA POER: And was it made clear to you that those concerns were simply competence or whether they were
sufficiently ill-defined to include the possibility of deliberate harm?
EARDLEY: The concerns raised were explained as simply the correlation with being on shift at the same time as some of those deaths had occurred.
DE LA POER: And so --
EARDLEY: That was all that I was told. That there was a correlation. There was no, no other evidence, nobody witnessing anything. It was simply that paper correlation, so it wasn't given to me as a -- of significant importance.
DE LA POER: But?
EARDLEY: It was a piece of context.
DE LA POER: Well, it was a piece of information?
EARDLEY: Yes.
DE LA POER: -- that was shared as opposed to kept back?
EARDLEY: Yes.
DE LA POER: So it was sufficiently significant to mention to you, that must be inherent?
EARDLEY: Yes.
DE LA POER: And association could be one of three things couldn't it; either it could be pure chance, so coincidence; it could be that there was a competence issue and that there was a causative relationship but inadvertent, or it includes, doesn't it, the possibility that there is deliberate harm being caused?
EARDLEY: Yes.
DE LA POER: And at the time that you were told that, do you think you recognised that those three possibilities existed within what you were being told?
EARDLEY: Obliquely, but the focus was more on focusing on the standards and the practice and finding another reason.
DE LA POER: So I am going to just remind you of something that you said in your witness statement I will read it out, but if you want to turn it up please do. It is paragraph 52, the second sentence you say: "I do not recollect" -- in fact if you want to turn it up rather than listening to me read it out?
EARDLEY: I have it.
DE LA POER: You have it: "I do not recollect clearly the context of the fourth term of reference which was to identify any possible common factors linking the recent neonatal deaths. I had been told by Ian Harvey of the suspicions raised by the doctors."
EARDLEY: Yes.
DE LA POER: That is how you have framed it in your witness statement.
EARDLEY: Yes.
DE LA POER: So does it go a little bit further then than merely the fact that there was a correlation, but that it was the doctors who had identified the correlation and ascribed significance to it?
EARDLEY: Yes.
DE LA POER: And the words you use there is "suspicions." Does it follow from that also that by whatever words Mr Harvey is using, what he is communicating to you is the doctors are worried that this may be deliberate?
EARDLEY: Yes.
DE LA POER: And so at that moment in time, whether it's shortly after the initial contact or in a subsequent phone call but before you get there, does it follow that you knew that at least some of the doctors were worried that a member of staff was deliberately killing babies?
EARDLEY: That phraseology is very powerful. I'm not sure it struck me with that level of depth. I was aware that the doctors had suggested some correlation. But nothing beyond that.
DE LA POER: But it's not a suggestion if it's a suspicion is it, they are different things. One is to observe a state of facts. The other is to ascribe potential meaning to that state of facts and as you framed it in your statement that's what's being as a possibility --
EARDLEY: As a possibility.
DE LA POER: In the minds. No one is saying that there is a certainty here but that's -- So again you draw attention to the fact I have phrased it very powerfully. But in fact, is that just as a matter of ordinary language based on what you were told in fact what you were being told?
EARDLEY: Yes. Yes.
DE LA POER: And bearing in mind that you were told that more than one doctor was suspecting murder, was that not an appropriate moment to say: this is not something that the RCPCH should be coming involved in?
EARDLEY: With hindsight that's absolutely what we should have said.
DE LA POER: And did you in fact have enough information at the time reasonably to reach that conclusion yourself?
EARDLEY: I don't think so, no.
DE LA POER: Well, why not given what you have agreed you have been told?
EARDLEY: I think at the time, my view was that this was being managed by the senior management and our role as part of that was to see if there was another cause another reason to eliminate any other reason so then the management could then proceed with taking those suspicions further.
DE LA POER: If we put it in another way.
EARDLEY: Yes.
DE LA POER: And again you will be entitled to observe I am framing it in a particularly powerful way, but if you had been told that doctors were suspecting that a member of staff was sexually assaulting a patient, would that have been sufficient for you to say: the RCPCH shouldn't be getting involved in an investigation that engages with that?
EARDLEY: Yes, yes.
DE LA POER: And so what is the material difference, if any, between murder and sexual assault in this context?
EARDLEY: I absolutely accept that point. Looking at it now yes, we should not have proceeded. We should have gone back and said no this is not for us, explore those allegations further.
DE LA POER: You don't think that you spoke to the clinical adviser about the scope of this review in terms of the Terms of Reference?
EARDLEY: Correct.
DE LA POER: Do you agree that if you had had such a discussion that would have provided an opportunity to recognise the problem with what you were being asked to engage with?
EARDLEY: Yes.
DE LA POER: Why do you think it was that you didn't speak to the clinical adviser about the Terms of Reference and how they were framed and what you were being asked to do?
EARDLEY: From my recollection at the time, the Invited Review service was particularly busy. We were doing, we were receiving a large number of requests for reviews. There were two of us, plus an additional supporting member of staff and trying to keep up with the numbers of enquiries and deal with them effectively was challenging and that may have been why some of these formal procedures weren't fully followed.
DE LA POER: If I, seeking to assist you, remind you about something that you said in your witness statement, in relation to the discussions you had in person, with the Senior Management Team?
EARDLEY: Yes.
DE LA POER: We will get to those discussions in a moment but what you said was that the concerns were played down by the senior team?
EARDLEY: Yes.
DE LA POER: That is how you framed the way in which they were talking about the doctors' concerns?
EARDLEY: Yes.
DE LA POER: You don't make any comment in your witness
statement about the way that they were presented to you in the initial phone call. I want to give you the opportunity, if you have a sufficiently clear recollection, to comment upon whether the framing of the issue may have impacted upon you?
EARDLEY: Yes, it did. In my recollection at the time it is difficult with the benefit of hindsight, was that it was almost a passing remark that the doctors have noticed that a member of staff was always there. But it was not intimated to me that that was a serious allegation taken seriously by the Medical Director. That's my inference at the time.
DE LA POER: Yes. Well, did you ever think that the Medical Director, Mr Ian Harvey, thought it was a serious allegation, to use your phrase?
EARDLEY: I think if he had thought it was a serious allegation he would have called the police sooner.
DE LA POER: Did you ever think that Alison Kelly who you also spoke to thought it was a serious allegation?
EARDLEY: She was particularly supportive of Lucy Letby and in my recollection quite dismissive of the allegation.
DE LA POER: The third member of the senior management team that you spoke to on the last day was Mr Chambers, the Chief Executive?
EARDLEY: (Nods)
DE LA POER: Did you ever think that in the course of that conversation that Mr Chambers thought it was a serious allegation?
EARDLEY: My recollection of that conversation is not so strong but there appeared to be consistent response from the management team, that it was something the doctors were raising but not something they were taking particularly seriously in terms of evidence beyond that correlation of the -- of the rotas.
DE LA POER: We are going to have a look at the briefing and data collection sheet as it's referred, INQ0009590.
EARDLEY: Yes.
DE LA POER: It's only one part that we need to turn up which is the first page. It is in bold.
EARDLEY: Yes.
DE LA POER: Now, it is dated 27 June 2016 but in fact Mr Harvey didn't contact you until the 28th?
EARDLEY: (Nods)
DE LA POER: How contemporaneous to any conversation you had with him was this document?
EARDLEY: So this was a template. Most of the reviews were done by templates because it was a systematic way to carry them out. So after the conversation with Ian Harvey, I will have reached for this form online and
started completing it because this was the basis of my preparing proposal documents and establishing the review. So I started the document. The way I completed it was researching around the organisation to bring in as much information as I could. This is a very early draft. That piece in bold, the key issue, is the nub of the review. The rest was information -- was either guidance as to what to look for in case members of my team were completing it or it was information that I found from the internet.
DE LA POER: "Key issue".
EARDLEY: "Key issue".
DE LA POER: "Outlier for neonatal deaths over the last 12 to 18 months, done a thematic review and nothing highlighted -- no pattern. Neonatologists say they were not expected although some might have been." No pattern.
EARDLEY: Mmm.
DE LA POER: If it's right that you were told in this call -- and I appreciate your evidence doesn't go that far, it was at some point, but it may have been this call, but if it was this call that Ian Harvey told you that the doctors were suspicious because of the association, that those two words "no pattern" would have absolutely no place in this document; do you agree?
EARDLEY: So I am not quite sure I understand the question.
DE LA POER: If Mr Harvey told you that an association with a member of staff had been noted, before you filled this inn --
EARDLEY: That would have been a pattern.
DE LA POER: -- that would have been a pattern?
EARDLEY: Yes.
DE LA POER: In which case saying that there is no pattern would not be appropriate?
EARDLEY: Correct.
DE LA POER: I'm sorry that I didn't frame that as clearly as you have just helped me to. So does that help at all with the question of whether or not in that call Mr Harvey told you about this in that first call?
EARDLEY: It helps enormously. I cannot recollect when I found out about the allegations, concerns from the doctors. This does indicate that I wasn't told in that initial call.
DE LA POER: Well, arguably it indicates that you were told the contrary. Again, this is based upon --
EARDLEY: (Nods)
DE LA POER: -- I accept an incomplete recollection on your
part and Mr Harvey will have an opportunity to give his evidence about it. But a number of possibilities. If he did tell you that, you have written something that you shouldn't have written, do you agree?
EARDLEY: Yes. If -- if he had told me, I would have recorded that.
DE LA POER: So from your point of view, you would not have written that if he had told you about it?
EARDLEY: Correct.
DE LA POER: The proposal for the Terms of Reference was sent by you on 30 June.
EARDLEY: Yes.
DE LA POER: So when he sought to chase you following the conversation and in that, and we will bring it up, INQ0009595, page 2, you reflect back, in paragraph 3, the problem.
EARDLEY: Yes.
DE LA POER: "In recent months the unit management team have been concerned the neonatal service appears to be an adverse outlier. The individual cases have been examined by the Coroner and expert from the network about there appears to be neither evidence link nor specific cause which could account for this level of mortality." Now, this is on the 30th so it follows your call?
EARDLEY: (Nods)
DE LA POER: You appear to be asserting in terms that it's your understanding that there is no evidence link, nor specific cause.
EARDLEY: Yes.
DE LA POER: Now, I appreciate that whenever it was that Mr Harvey told you he did so in passing, I think was your phrase, but that would render this misleading, wouldn't it? To talk in those concrete terms where -- if you did know?
EARDLEY: Yes, I cannot recall at what point I knew about the allegations.
DE LA POER: If we go to pages 3 and 4, so we will start at page 3, section 3, we don't need to look at the detail of it. But we can see it starts with "What the RCPCH's Invited Review service is"?
EARDLEY: Mm-hm.
DE LA POER: Now, you can you should correct me if I am wrong about this, but as we turn over the page, and we are not going to read every line of it but you will be familiar with it, nowhere does it say what the service cannot do and shouldn't do; do you agree?
EARDLEY: Yes.
DE LA POER: So those caveats that we see in that publicly available document haven't made their way into this to
make it clear to the client, in the letter, this is what we can't do?
EARDLEY: Yes. I --
DE LA POER: And do you think -- I'm sorry?
EARDLEY: My recollection is that I would refer to the Guide to Invited Review somewhere within that proposal and the Guide to Invited Review does have those caveats.
DE LA POER: But all of that is a secondary step for somebody who needs to chase it down?
EARDLEY: Yes.
DE LA POER: But it is a pretty important part of what you do to be clear what you don't do, isn't it?
EARDLEY: Yes, yes.
DE LA POER: Do you agree that that is of sufficient importance to make it into a letter, so that the parameters are absolutely clear in a single place that you would expect the client to read carefully?
EARDLEY: Yes.
DE LA POER: Again, just why do you think that those caveats aren't in here?
EARDLEY: We were developing -- we were continuing to develop the service. We had not come across a situation where those caveats had been imposed during this process. Following that, they would have gone in there as we learned and developed the templates.
DE LA POER: Now, you have no doubt followed that -- and I am characterising it I hope fairly and accurately -- that the senior Executives appear to have derived some reassurance -- they certainly say they provide, receive reassurance -- from the RCPCH report?
EARDLEY: (Nods)
DE LA POER: Knowing that now, do you agree that it's essential that the client is told in writing at the start what the report cannot be used for or understood and what won't be investigated?
EARDLEY: Yes.
DE LA POER: If we look at the bottom of the page: "The concerns outlined in the client brief are not uncommon and the RCPCH proposes the following approach to this review ..." Now, again, if you had been told by the time you sent this letter about the doctors' suspicions, that sentence really shouldn't have been there, do you agree?
EARDLEY: That sentence was an error. The concerns outlined were uncommon, that is a standard part from the template which I had failed to remove.
DE LA POER: Again having sat on a board yourself and understanding how these things work --
EARDLEY: Yes.
DE LA POER: -- it is not beyond comprehension that
a letter like this will end up in front of people who sit on the board and give them reassurance; is that fair?
EARDLEY: Yes.
DE LA POER: So when assessing the significance of that error and the fact that a template was used and not altered, do you agree it had the potential at least to give false reassurance to anybody outside of the conversation that you were having with Ian Harvey about the nature of the problem?
EARDLEY: Again with hindsight, yes, it did have that potential.
DE LA POER: Page 5, section 5, we have the start of the draft Terms of Reference and we can move through them, we don't need to look at the detail of them, but bullet point 1 at the very bottom of the page, is that a standard Term of Reference?
EARDLEY: Yes.
DE LA POER: Over the page, please. Is that second bullet point a standard Terms of Reference?
EARDLEY: Yes.
DE LA POER: The third bullet point, is that also a standard Term of Reference?
EARDLEY: In essence, yes. These Terms of Reference will have been specifically designed for this review but
that those were the issues that we would generally cover yes.
DE LA POER: I am sure it didn't formalise into a pick list, which is a phrase we have heard?
EARDLEY: No.
DE LA POER: But there will be certain forms of words that you regularly import, bespoke to the situation, and that's when I say standard is what I am meaning, these are ones that if we look through all of the letters that you sent out during this period, we would see those time and time again?
EARDLEY: Similar, yes.
DE LA POER: Yes. The final one, and we will come back to the penultimate one, "Are there areas of concerns of potential development?" Is that also a standard term of reference?
EARDLEY: The gist of it, yes, we did tend to keep the Terms of Reference fairly fluid because when there were concerns about a unit, sometimes the review team would visit and discover things that perhaps hadn't been articulated by the client at the time.
DE LA POER: Yes.
EARDLEY: It gave us some scope to explore other areas if we came across them.
DE LA POER: It is a catch-all to give you flexibility?
EARDLEY: To some extent, yes.
DE LA POER: So then we come to the fourth one: was that entirely bespoke for the situation that you were presented with?
EARDLEY: Yes. I think it would have been.
DE LA POER: So bearing in mind that we have gone through some standard ones and nothing may turn on it, but if that's the bespoke one, why isn't that one first?
EARDLEY: Because the way we had approached it was as a service review looking at the whole service. But the trigger for that was that rise in neonatal deaths, I don't know why it wasn't first.
DE LA POER: Now, when you wrote that --
EARDLEY: Yes.
DE LA POER: -- made that proposal, did you know about the doctors' suspicions?
EARDLEY: I really cannot recall.
DE LA POER: So you might have but you might not have?
EARDLEY: Yes.
DE LA POER: Let's consider the circumstances that you did know. If it be right that you did know, do you agree that that could be read as suggesting that that is something that you are going to investigate?
EARDLEY: It could be read that way, yes.
DE LA POER: Because if you did know, then if it wasn't something you were going to investigate but would otherwise be caught by the language, you might indicate "other than" or put an exception or an asterisk or some caveat to it to say: we are not investigating that?
EARDLEY: Yes, because we wouldn't investigate that.
DE LA POER: Exactly so.
EARDLEY: Yes.
DE LA POER: But as the Royal College, you are best placed to know what you do and don't investigate?
EARDLEY: Yes.
DE LA POER: When Mr Harvey, whenever it was, mentioned in the way that he did the suspicions of the doctors, did you say to him: "we can't look into that"?
EARDLEY: No.
DE LA POER: Should you have said that to him?
EARDLEY: With hindsight, yes.
DE LA POER: Well, again you have caveated "with hindsight".
EARDLEY: Sorry we, we -- in my view we weren't looking into those particular allegations. We were looking at everything else.
DE LA POER: But he's told you about the allegations. You haven't said: we are not going to look into them and then you have proposed a term of reference which is capable of including them.
EARDLEY: Yes.
DE LA POER: So does it need hindsight or does it just need: actually I had enough pieces of information at the time to know that I needed to make it absolutely clear in writing what we were not looking into?
EARDLEY: I think that is the situation. I think we were in a pressured environment. Had I had the time to sit back, reflect, discuss with people it may have been different.
DE LA POER: Now, we can take that down, thank you very much indeed. We are going to -- Mr Harvey comes back with a counterproposal, 7 July. INQ0009615, page 3. If we -- I do beg your pardon, bear with me a moment, please. Forgive me, my mistake. INQ0010256, this is the email that he sent, in fact, but the actual draft Terms of Reference I think should appear against the INQ I have just given. Yes. Now, to all intents and purposes, the four standard ones, 1, 2, 3 and 5, appear as they were; do you agree?
EARDLEY: Yes.
DE LA POER: But the one bespoke one at number 4, he's come back and he's said this: "To consider concerns about the neonatal unit with specific reference to: are there any identifiable common factors or failings that might in part or in whole
explain the apparent increase in mortality in 2015 and 2016?" Now, in your witness statement I think you say that you didn't think this made any difference to the meaning?
EARDLEY: Correct.
DE LA POER: Did you wonder to yourself, if it didn't make any difference to the meaning, why it was that Mr Harvey had apparently gone to the trouble of redrafting it?
EARDLEY: I can't say that went through my mind.
DE LA POER: Again, just thinking about it, do you think that if a client adds in some more words, uses words like "specifically" and so on, that that was -- at the time wasn't a trigger for you to say: well, I had probably better speak to the client about why he's doing that and whether we both understand each other?
EARDLEY: Yes, it should have been.
DE LA POER: You see because if we have a look at the changes that are made, common factors or failings: now, a failing is always capable of being a factor, I mean that's a tautology in one way.
EARDLEY: Yes.
DE LA POER: But one thing that murder will never be is a failing.
EARDLEY: Yes.
DE LA POER: So that appears to be directing attention at things which might not be murder; do you agree?
EARDLEY: I am not quite sure I follow about the -- your previous comment but that --
DE LA POER: Well, we can see that he's added "in part or in whole", so in other words recognising the possibility that there may not be a single explanation for the increase?
EARDLEY: From my recollection how I may have taken that would be: have the staffing levels decreased? Are they accepting infants that are very early in gestation that should have been at a more senior unit? Is the transport service not picking them up quick enough? There are many other factors that could have led to rise in mortality over that period of time. So whilst we know now that that was what was being implied, in my mind there were a number of other things that we could have been looking at. As I recall, that section wasn't specifically focusing on: was there a nurse involved? That wasn't in my mind at the time. That was a piece of background information. My understanding when this was being discussed was that there may have been a whole range of other factors, including practice by -- you know, including clinical practice, including transport, including gestation, including environment, a range of things.
DE LA POER: The final addition is the insertion of the word "apparent". Now --
EARDLEY: Yes.
DE LA POER: -- that's capable of having an insidious effect in the sense that it is capable of being read as suggesting that there may not have been an increase in mortality. I mean, that is how it operates in the sentence?
EARDLEY: Yes.
DE LA POER: Did you notice that at the time? Do you know why the increase in mortality had become the "apparent" increase in mortality?
EARDLEY: I can't say I picked that up. No. I mean there are fluctuations in mortality. Numbers are usually quite small. There can be fluctuations, they are whole numbers, but I didn't pick that up in the sense that you are implying at the moment.
DE LA POER: We can take that down. We just pause at this moment. The Terms of Reference, you adopted the revised wording telling us as you do that in fact you didn't think it really changed anything. What the Royal College has said in their corporate statement is:
"The time period for developing the proposal and Terms of Reference for the review was unusually short as it normally takes a number of weeks to draft a proposal and there is often correspondence between the commissioning organisation and the RCPCH to agree the Terms of Reference." Is that a fair observation?
EARDLEY: It wasn't -- it wouldn't take that long. Normally we would put a proposal together within -- probably within a week, 10 days. At that time that's how the process was working. So it was fairly swift because most of the enquiries we had for reviews were quite straightforward.
DE LA POER: There is the suggestion that I would just like you to consider and comment upon in light of the evidence that we have just been through. If we take a step back. It might be suggested that this has the hallmarks of being rushed and there is insufficient care and let me give you the factors for you to consider. You have told us about the fact that you were under an enormous amount of pressure at the time?
EARDLEY: Yes.
DE LA POER: Which is a situation in which such things can occur. You have told us that the expected process of
consultation about the Terms of Reference with the clinical lead as a result of that didn't occur?
EARDLEY: (Nods)
DE LA POER: We have got the possibility of a misunderstanding, the possibility we will see whether it's right or not in due course, or a mismatch. We have got no record by you in any of the documents we have looked at that you have been told about the suspicions and we have got standard wording that shouldn't have gone in the letter that made it through. So those are all potential indicators that insufficient care has been taken over the process. I would like to give you an opportunity to comment upon that, please.
EARDLEY: I hear those comments. I -- with reflection back, it was a very busy time. I was perhaps over confident in terms of putting reviews together and focusing on that. There was a gap between me saying to Ian Harvey the proposal will come out and me sending it to him and I will have sought agreement to that proposal from it will have been from then the Director of Finance to check the -- the costing put on it for sure. I accept some of those comments, that it was rushed. There was not the level of care that I would
normally have put into a proposal.
DE LA POER: You then assembled a team.
EARDLEY: Yes.
DE LA POER: There was a pre-visit meeting by telephone; is that right?
EARDLEY: Yes.
DE LA POER: Do you have any recollection of that pre-visit meeting over the telephone?
EARDLEY: Normally we would try to have a pre-visit meeting if we could. Back at that time, people didn't do online teleconferences. We would have telephone conferences which were quite difficult to manage. I think we had one for that we normally had something a few days before. We certainly would make sure that the review team met the night before the review.
DE LA POER: We will come to that.
EARDLEY: Yes.
DE LA POER: If there was a telephone meeting, do you have any recollection of telling the team about the suspicions of the doctors?
EARDLEY: I don't have that recollection.
DE LA POER: Do you think that's because you didn't tell them?
EARDLEY: Yes. It could be.
DE LA POER: If it be right that at the time of that conversation you knew that from Mr Harvey, is that something you should have told them?
EARDLEY: Yes.
DE LA POER: Do you agree that that would have been an opportunity before you had made the commitment of time and effort and everybody turning up and starting the process, it would have been an opportunity as a team to realise that this was not an appropriate course for you to continue upon?
EARDLEY: Yes, it would have been that opportunity.
DE LA POER: Email from Mr Milligan. 26 August, we are now closing with the visit. INQ0012748, page 3. This is in a chronology you have prepared. I don't think we have the original email, but we have got the text of it thanks to your chronology so we will just have a look at that now. We can see right in the middle of the page: "I have had a look at most of the documentation but not yet all the individual baby files and we have much of the workload data I was looking for plus a more in-depth analysis of what happened with the indexed cases. But a number of questions arise from that, not least that one individual appears to have been present for all but one of them." Was that an email that you received from your lead
reviewer?
EARDLEY: Yes. That may have gone to the whole team, or it may have come just to me.
DE LA POER: Now, what, by 26 August, did you know about the suspicions of the doctors?
EARDLEY: I think I will have done, yes.
DE LA POER: Put it another way, did Mr Harvey tell you it in the days before? If not then you must have known?
EARDLEY: Yes, I knew.
DE LA POER: So as far as you are concerned, do you agree that email has a potentially greater significance for you than anybody who didn't know?
EARDLEY: Yes.
DE LA POER: One aspect of the significance is that from a completely independent, cold start your lead reviewer has identified the very basis of the suspicions of the doctors in the hospital; is that fair?
EARDLEY: Yes.
DE LA POER: Did that strike you at the time as being a concerning thing?
EARDLEY: I'm not sure I reflected fully on it at the time as I was preparing for the review. But yes, it should have done.
DE LA POER: It should have done. Now, we are going to have a look at the documents
and I think Mr Milligan may have got early access to the documents because he's sending that email on the 26th. If we have a look at your email of 30 August, INQ0012846. This is the email where you provide access to the wider team for the documents. So --
EARDLEY: They will have had access before that normally about at least a week beforehand.
DE LA POER: They would have had access?
EARDLEY: 12 August.
DE LA POER: I am so sorry that is my -- my mistake, I don't know how I have made that, it is probably because I read the top email but that is entirely my error. So 12 August, so before Dr Milligan's email. We can see as you introduce the team to this you say this: "Rather an enthusiastic set so, please don't be dismayed." Is enthusiastic a euphemism for they have given us quite a lot?
EARDLEY: A huge amount of documents, yes.
DE LA POER: A huge amount and are you judging that huge amount of documents in the context of your wider experience of what you usually get from hospitals?
EARDLEY: Yes. Reviewers are clinicians full time. They don't have a lot of time to spend on the review. I write to the client organisation with a fairly
detailed list of the information that we would like to receive and instructions to tailor it as far as possible. Many organisations just put everything on the list, so it was harder to process it to make it more focused for the reviewers.
DE LA POER: What you do draw out for the team is in the third paragraph: "Key things to look at are probably the mortality reviews and there are some concerns coming out over transport service."?
EARDLEY: Yes.
DE LA POER: "Please keep the Terms of Reference in mind"?
EARDLEY: Yes.
DE LA POER: Now we have already looked at the Terms of Reference and I have invited you to consider it from the point of view of the client. Your team at this stage don't know anything about Mr Harvey's concerns, I think that's right?
EARDLEY: Yes.
DE LA POER: The Terms of Reference don't in themselves exclude the investigation of the doctors' suspicions, do they? We have looked at that.
EARDLEY: (Nods).
DE LA POER: And so can you see that there's also a problem so far as your team is concerned about the lack of clarity in what this review was and wasn't supposed to be engaging in?
EARDLEY: Yes. The review was to look and to see if there was anything else affecting the mortality.
DE LA POER: Well, in fact, the chronology might make a bit more sense now that I have got my dates right because having you drawn attention to the reviews and the Terms of Reference, it would appear that your colleague Dr Milligan immediately looks at the mortality review and spots that Letby is associated with nine out of the 10 deaths?
EARDLEY: That was a specific document which the doctors had put together.
DE LA POER: Yes?
EARDLEY: And submitted, yes.
DE LA POER: But to your mind, that's not what your review is there to do?
EARDLEY: Yes.
DE LA POER: And yet, Mr Milligan, reading the Terms of Reference, no doubt as you have encouraged him to, reading the thematic review as you have encouraged him to do, that is where his mind immediately goes?
EARDLEY: When he saw that document prepared by the doctors, yes.
DE LA POER: Yes so if we just circle back to that document having set the groundwork here, quite aside from whether
the significance of what he said should have had a greater impact upon you, do you think that was also an opportunity for you to say to Dr Milligan: "We need to be very clear we are not here to do that. That's the one thing we are not looking at."?
EARDLEY: Yes.
DE LA POER: Let's have a look at the documents briefly in list form. INQ0012847. Now this is a 13-page document although in fact only the first 12 are really populated just one line on the 13th page, which sets out in a structured way the documents that you have received and there is a review process, I think it's somebody providing administrative support "MA" in your unit.
EARDLEY: Yes.
DE LA POER: Has had a look at them. And we can see that there are a large number of staffing rotas?
EARDLEY: Yes.
DE LA POER: Was it usual for clients to be sending you staffing rotas to this degree?
EARDLEY: That was the standard that we asked for.
DE LA POER: That was a standard thing?
EARDLEY: One of the other documents in the pack is the letter that we sent to Ian Harvey saying this is how to prepare for the review and there is a list within that of the kind of documents that we requested. So this was
not inappropriate to receive that.
DE LA POER: So this isn't the extra material that you were talking about when describing them as enthusiastic. You had asked for this and you got it?
EARDLEY: We had asked for it. There was a comprehensive set sent to us yes.
DE LA POER: Page 4, please. We see a document entitled "Mortality review February 2016." And a little bit of detail around it, "Mortality review draws out themes around night cover delayed clamping" and then it says this: "Six out of nine review cases had arrests between midnight and 4 am and an area to probe filled in blue explore night cover." Now, that very amply fits the description of the thematic review of neonatal mortality completed by Dr Brearey in February because that is one of his conclusions.
EARDLEY: Yes.
DE LA POER: Was that a document that you read?
EARDLEY: I'm not sure if I read that in detail because Melissa was doing the reviewing. She highlighted it yes, so I will have read it at some point.
DE LA POER: At the time that you read it did you have in mind Dr Milligan's comments, in other words was that after he had sent you the email drawing attention to the
commonality of a particular member of staff, or was it before or can you not say?
EARDLEY: I don't recollect correlating those two, no.
DE LA POER: And in terms of the "Six out of nine review cases had arrests explore night cover", if we jump right to the end and the report you produced, did the RCPCH find any explanation for why six out of the nine deaths occurred in those four hours?
EARDLEY: No.
DE LA POER: So that was a question going into it?
EARDLEY: (Nods).
DE LA POER: And one which was not answered at the end?
EARDLEY: Correct.
DE LA POER: Now there is one other document which has attracted some significance I am just going to bring it up briefly, INQ0010072 and just help us to the degree that you can. This is not the thematic review. This is instead a technology fail which I hope will be... Yes. It may be there is a difficulty showing this. There we are. Thank you very much indeed for that. Is this a document that you believe was within the pack?
EARDLEY: I don't recall seeing it.
DE LA POER: No well if it helps you, Ms MacLaughlan has pointed to the fact that this document doesn't appear on the list so far as she can tell and so you wouldn't have any reason to say positively you think that was included?
EARDLEY: Mmm.
DE LA POER: So we can take that down. The final event before the visit begins is the night before in the hotel.
EARDLEY: Yes.
DE LA POER: By this stage, there can be no doubt but that you knew about Mr Harvey's concerns.
EARDLEY: Yes.
DE LA POER: Did you tell any of the team then?
EARDLEY: I don't know from looking at previous notes. Possibly not.
DE LA POER: I mean, if, if they say we were not told --
EARDLEY: Then I didn't tell them.
DE LA POER: Would you have any basis to say that they are wrong about that?
EARDLEY: I think they would be correct then they weren't told.
DE LA POER: Again do you agree that was another opportunity for as a group to discuss this now in light of what Dr Milligan has pointed out so you have got another piece of information and say: we must stop?
EARDLEY: Absolutely, it was an opportunity to discuss it, yes.
DE LA POER: Yes, and did it present an opportunity to say: stop?
EARDLEY: It could have done. My recollection is at the time perhaps it was so, so, so very unlikely that it wasn't high on my radar as being an issue because it was so unthinkable.
DE LA POER: But that of course is an explanation for why you didn't mention it. But if you had mentioned it, it's possible it would have had a greater significance to one of the people that you were mentioning it to and of course we know that Dr Milligan had done his own analysis and it is possible, can't be known, that he would have said "That is exactly what I spotted and it seems like there can't be something in it." We can't know?
EARDLEY: I don't know why I didn't mention it. I do not know.
DE LA POER: No. Now, we come to the visit. There are notes about all of this and we have two other witnesses coming to deal with it, so you will forgive me if I don't go through every line of every one. Many of them speak for themselves. The first meeting that you had was with Alison Kelly and Ian Harvey?
EARDLEY: Yes.
DE LA POER: That's right and Dr Milligan is recorded as saying we may not be able to explore the details of the deaths not doing a Casenote Review."?
EARDLEY: (Nods).
DE LA POER: Was that in the context of a discussion about the Consultants' suspicions?
EARDLEY: I would need to see my notes but yes, I wrote notes pretty much verbatim handwritten notes, probably quite hard to read, but they are pretty much verbatim what was said, so --
DE LA POER: We know -- sorry.
EARDLEY: Depending at what point Ian Harvey mentioned it would be around the Casenote Review so I suspect it would be -- I haven't got it in front of me -- that it was raised by Ian Harvey and then David Milligan would have said we are not doing a Casenote Review because we never were. That was never the situation.
DE LA POER: So far as you can remember, I appreciate there are notes, but impression is important here. When Dr Milligan said we may not be able to explore the details of the deaths", did that strike you as being a surprise to Ian Harvey or Alison Kelly? Something that they were comfortable with, something that they were uncomfortable with? So far as you can remember did
they have any appreciable reaction to being told the detail of the deaths would not be explored?
EARDLEY: It had always been my assumption that we wouldn't be doing a detailed Casenote Review so I didn't note any particular reaction. We were there to do a service review not a Casenote Review.
DE LA POER: And so does it follow that what didn't happen at that point is them saying well, "I thought that is what you were here to give us reassurance about" -- no conversation like that?
EARDLEY: I don't remember it as clear as that, no.
DE LA POER: One of the notes that you made attributed to Ian Harvey, is he stated he having talked about the correlation of one nurse, so it's in that context, wanted to think the worst but nothing else is pointing to it. Do you remember that phrase. It is one that you specifically mention in your witness statement?
EARDLEY: Yes, yes.
DE LA POER: I just wanted to try and understand just what you thought he was meaning by "wanted to think the worst". Who wanted to think the worst?
EARDLEY: It's an unusual phrase to use. I would suspect that there was that correlation of being on shift. But nobody saw anything happening. It was only simply that they had been on shift, which -- and without any other evidence apart from being on shift and everybody else thinking that she was such a good nurse and always available, and very competent. He was expressing his dilemma about the only correlation he had was being on shift. Nobody appeared to have seen anything, nobody appeared to have any other suspicions about practice. Things that came out later obviously.
DE LA POER: Generally speaking the idiom is that people want to think the best, but?
EARDLEY: Yes I don't know why.
DE LA POER: But your note is "wanted to think the worst"?
EARDLEY: I know.
DE LA POER: And that is why I am just -- I mean, was he saying that he wanted to think the worst or was he saying that somebody else wanted to think the worst?
EARDLEY: I -- I can't answer that one.
DE LA POER: You also record that Ian Harvey asserted he had been through all evidence. Was it your understanding that he conducted his own review of all of the information?
EARDLEY: I inferred from that that he had, he had explored it in some detail, yes.
DE LA POER: You also record and I will just read it out
for you: "Ian Harvey then mentioned that he had to intervene with a neonatal lead as the junior doctors had been referring to Letby as nurse of death with ripples through the team. He could not see how to conclude without calling the police. He stated that unless there is something to satisfy the medical staff from this review then they will call the police." The phrase "Unless there is something to satisfy", could be thought to be quite a loaded one "Unless this happens, this result will occur." I mean is that how you took it at the time or was it just an ordinary conversation?
EARDLEY: I took that to mean unless the review can find some other reason for the deaths, then the doctors then we would call the police.
DE LA POER: Did the review find some other reason for the deaths?
EARDLEY: No.
DE LA POER: And, bearing in mind that you knew that that was the doctors' mind that if your review didn't find anything to explain it, should you not have been thinking well, it's really important that we get the police involved at this stage?
EARDLEY: I think because of that conversation we felt we were on site, it wouldn't -- we felt we can spend
two days to see if there's anything else and if there isn't, then we had the assumption that the management team would call the police because they would have the information to do so.
DE LA POER: So understanding that reasoning. You are envisaging one of two things happening?
EARDLEY: Yes.
DE LA POER: (1) that the review will find an explanation, no need for the police, or (2) the review won't find an explanation, the police will become involved. Is that --
EARDLEY: Yes, yes, at that time that was my inference.
DE LA POER: Well bearing in mind what you have told us about the risk of prejudicing police investigations, was that the right way to be thinking about it?
EARDLEY: We did discuss that as a review team. We were on site with interviews lined up. We were aware of the issues. We agreed, at that time, that we would continue with the review bearing in mind that we were, we would not compromise any subsequent Inquiry.
DE LA POER: Because the thing that came out of that meeting was that Letby was added to the list?
EARDLEY: Yes.
DE LA POER: And so you were leaning into the allegations rather than staying away from them, weren't you?
EARDLEY: We did discuss that in some detail as a team and members of the team felt it was very important to interview her and collectively as a team we agreed that that would go ahead.
DE LA POER: More important than the risk of prejudicing any police investigation?
EARDLEY: As a team we discussed that and at the time considered that proceeding with the interview in a limited way would not be unhelpful. That was our view of the team at the time.
DE LA POER: I will just circle back to my question where we started this?
EARDLEY: Yes.
DE LA POER: Was that the wrong way of thinking about it?
EARDLEY: It may well have been, yes.
DE LA POER: Did in their first discussion with you, Alison Kelly or Ian Harvey, tell you that the pattern of deaths had changed when Letby was moved only to day shifts?
EARDLEY: Yes.
DE LA POER: They told you that?
EARDLEY: It was very early.
DE LA POER: Yes.
EARDLEY: Early days they didn't have full information we knew that she had been taken from clinical duties but it had only been a month or two.
DE LA POER: So we are moving now from a position, do you agree, of just an association because there is an additional factor which is you know the thematic review has said an unusually high number of proportion, that is the implication, are happening at night and you know she is taken off nights and you know that the pattern has changed. That is what you are telling us you have been told?
EARDLEY: Sorry, is this the pattern moving from nights to days?
DE LA POER: Yes?
EARDLEY: Oh okay. I don't think we were aware of that.
DE LA POER: You weren't aware that the pattern of sudden and unexpected collapses stopped happening at night?
EARDLEY: I don't recollect being aware of that. We knew that she had been taken off clinical duties at about the same time as the unit had been downgraded.
DE LA POER: I'm sorry I jumped ahead and it may be you didn't in fact know because of my poor question what I was telling you. In April?
EARDLEY: Yes.
DE LA POER: Letby was moved from night shifts to day shifts?
EARDLEY: I am aware of that now yes.
DE LA POER: You are aware of that now. In July right at the beginning of July, she was moved away from clinical facing role?
EARDLEY: Yes.
DE LA POER: That I think was what you were answering?
EARDLEY: Yes.
DE LA POER: Were you aware at the time the fact that she was moved to day shifts and that the collapses at night had then stopped?
EARDLEY: I don't think we were aware of that detail.
DE LA POER: Now obviously you spoke to a number of people including Dr Brearey and Dr Jayaram and it would follow from your answer that they didn't tell you that either if that's right. But just thinking about it now, if you had been told that by the Executive Directors in that first meeting, would that have been a relevant consideration for you at that stage as to whether you should continue or not?
EARDLEY: I think it probably would. I'm not sure that came up in our conversations.
DE LA POER: The next people you spoke to were Dr Brearey and Dr Jayaram and I will summarise I hope accurately what they told you: that they were concerned about the
way in which collapses occurred and that these were sudden and unexplained, that they had conducted some investigations and included the network?
EARDLEY: (Nods).
DE LA POER: That they could find no adequate explanation, that they noted Letby's association, that they had gone so far as to investigate if she might have used air embolism to murder the children, and they told you that they had expected the Executives to call the police?
EARDLEY: Yes.
DE LA POER: So is it fair that you had an opportunity at that stage for yourself to assess the level of their concern?
EARDLEY: Yes.
DE LA POER: Because, all new to you was that they had gone so far as to conduct research into how she might have done it?
EARDLEY: Yes.
DE LA POER: So that isn't just a passing thought implicit in that; that is a high level of concern, do you agree?
EARDLEY: Yes.
DE LA POER: And did you form the view that Dr Brearey and Dr Jayaram were entirely sincere in that concern?
EARDLEY: Yes.
DE LA POER: And was that another opportunity to say: we
must stop now"?
EARDLEY: It was an opportunity, yes.
DE LA POER: And should you have taken that opportunity?
EARDLEY: I think so.
DE LA POER: Now, we will take a break if my Lady agrees in just a moment. I just want to finish off this area. What Dr Jayaram and Dr Brearey were telling you was, to put it one way, they had a safeguarding concern; do you agree?
EARDLEY: Yes, it wasn't put like that, but yes.
DE LA POER: No, but you have got -- I appreciate you were limited by the training you did or didn't receive?
EARDLEY: Sure.
DE LA POER: But you have got huge experience in safeguarding?
EARDLEY: Yes.
DE LA POER: And that is the effect of what they are saying?
EARDLEY: Yes.
DE LA POER: That you have two senior clinicians sitting in front of you saying, "I think that person poses a threat to children."
EARDLEY: Yes.
DE LA POER: In particular babies?
EARDLEY: Yes.
DE LA POER: Did you ever -- and we will come to this later -- that day when you spoke to Dr Mittal and Dr Issac who were representatives of the safeguarding unit -- did you ever ask them, "Do you know anything about the concerns of these two senior Consultants?"
EARDLEY: It -- we did not feel it was our place to share those concerns within the organisation.
DE LA POER: One of the things you were there to investigate was how robust the policies and procedures were?
EARDLEY: Yes.
DE LA POER: One of those procedures was the safeguarding procedure?
EARDLEY: Yes.
DE LA POER: A way of testing whether the safeguarding procedure was robust was to find out whether safeguarding concerns arrived in the safeguarding department?
EARDLEY: That is a very accurate point, yes.
DE LA POER: In those circumstances, should you have been asking whether those serious concerns were on the radar of the safeguarders?
EARDLEY: What we were asking was about the unexpected deaths whether they were recorded as Serious Incidents, whether the procedure was being followed in terms of
Serious Incident Review.
DE LA POER: Yes?
EARDLEY: And we concluded that not all of them were. There wasn't a consistent process. If the doctors had those significant concerns we couldn't see that they were systematically being followed through.
DE LA POER: So undoubtedly your report ultimately concludes that the SUDiC procedure as referenced in Working Together --
EARDLEY: Yes.
DE LA POER: -- not followed. That's a recommendation?
EARDLEY: Yes.
DE LA POER: So you spoke to them about that. But we have heard from Dr Garstang, who tells us that SUDiC is not one and the same thing as safeguarding, it is an associated process?
EARDLEY: Yes.
DE LA POER: So I'll just go back to my question. Should you have checked with the safeguarding department that the safeguarding concerns that you were told about had reached them?
EARDLEY: Yes, I recollect we didn't see them as safeguarding concerns in that sense at the time. Obviously with clarity now, they would have been, but it was so difficult to contemplate that might be
happening, I guess.
DE LA POER: The final thing before I ask my Lady to take a break will be the lunch time discussion. It was at this stage, I think, that you as a team reflected upon whether you should continue or not?
EARDLEY: (Nods)
DE LA POER: You had an opportunity to sit in private and to discuss the things that you had been told that morning.
EARDLEY: Yes.
DE LA POER: Did some of your colleagues seem surprised to have learned what they learned?
EARDLEY: Yes.
DE LA POER: Now, you have told us already about the decision-making process and what you decided to do and I'm not going to go over that. But one thing that we haven't touched upon in relation to that discussion is: is it right that there was a discussion between those present about how a person might murder babies using different methodologies? I will just -- I don't want to give too much away. It's a sensitive subject. But this is already in the public domain. The discussion included insulin injection as a possible methodology. Does that -- do you remember that discussion?
EARDLEY: I think so. I think that was -- that was
found at the Inquiry about Stepping Hill. That was --
DE LA POER: Yes.
EARDLEY: -- an issue that came up in that situation.
DE LA POER: There were other methods used. I am not going to say them out loud.
EARDLEY: Yes.
DE LA POER: But you record them in your notes, in fact --
EARDLEY: Yes, yes.
DE LA POER: -- that there were others. So the discussion was insulin, that's in the public domain.
EARDLEY: Yes.
DE LA POER: Air embolism, that's in the public domain?
EARDLEY: Yes.
DE LA POER: And other methodologies?
EARDLEY: Yes.
DE LA POER: So what we have here, is this right, that we have a group of very senior and experienced people actively engaging with the possibility that murder had been committed in relation to the deaths that were the subject of the review; is that right?
EARDLEY: Yes.
DE LA POER: In and of itself, at that moment, was that not a very clear moment to say, "If we are having this conversation, we need to walk away, the police need to come in"?
EARDLEY: Yes.
MR DE LA POER: My Lady, would that be a convenient moment?
LADY JUSTICE THIRLWALL: Yes, thank you very much. So we will take a break now and we will come back in at 20 to 4. Thank you.
(3.22 pm) (A short break) (3.40 pm)
LADY JUSTICE THIRLWALL: Yes.
MR DE LA POER: Ms Eardley, having spoken to Dr Brearey and Dr Jayaram, the other Consultants were also spoken to; is that correct?
EARDLEY: Yes.
DE LA POER: Were they broadly supportive of the position of Dr Brearey and Dr Jayaram?
EARDLEY: As I recall, yes.
DE LA POER: So another piece of the puzzle for you was that Dr Brearey and Dr Jayaram were not outliers within the Consultant body, but in fact that this was a shared concern?
EARDLEY: Yes.
DE LA POER: Again a question I have asked you already, is this another opportunity to recognise the weight of reasons to stop at that point?
EARDLEY: Yes.
DE LA POER: Now, so far as Letby herself was concerned, we have already covered that she was not originally scheduled. What you say in your witness statement is: "The review team felt strongly that LL should have the opportunity to give her perspective."
EARDLEY: (Nods)
DE LA POER: Now, who was it within the review team who first proposed speaking to Letby?
EARDLEY: I think it was Claire MacLaughlan but as a whole team we agreed.
DE LA POER: The phrase "Opportunity to give her perspective", what was meant by that?
EARDLEY: It seemed unusual that she was not included in the -- in the list of people to interview. I'm not sure what we meant by that beyond what it says.
DE LA POER: Why was it unusual for her not to be in the list in circumstances where you were not speaking to every nurse and in circumstances in which you say you were not investigating her?
EARDLEY: I can't recollect our thought process at the time, I am sorry.
DE LA POER: Now, as the head of the Invited Review service, was it within your power at that point to say: we are not doing that, we are not investigating Letby.
EARDLEY: It would have been, yes.
DE LA POER: You didn't do that; is that right?
EARDLEY: I didn't do that. We were all equal members of the review team so it was a discussion that we had between us.
DE LA POER: But some are more equal than others. You are the head --
EARDLEY: Yes.
DE LA POER: -- of the Invited Review service?
EARDLEY: Right, I acknowledge that.
DE LA POER: Is that something that you should have said at that stage?
EARDLEY: Yes, I think so.
DE LA POER: Why is it that you think that you didn't?
EARDLEY: In that context, I recognised that Claire had particular skills and competencies around nursing, around the legal system. She felt it was important, so I deferred to her expertise on that.
DE LA POER: What did you understand Ms MacLaughlan's experience of legal process was?
EARDLEY: She was a qualified barrister and she had worked as a nurse in the Royal Navy.
DE LA POER: She tells us that she has never worked as a barrister?
EARDLEY: No.
DE LA POER: She is not practising?
EARDLEY: Correct. Correct.
DE LA POER: And has never practised?
EARDLEY: Correct. She had also conducted a number of reviews of clinical staff when she worked in her previous role.
DE LA POER: Was there any discussion at that stage about, "This could all end up with regulatory or even the police, we really shouldn't be going anywhere near it"?
EARDLEY: I think there was some discussion amongst the team, everybody had a view and we concluded that we would proceed with the interview.
DE LA POER: I think you have already told us that that was a wrong turn at that point.
EARDLEY: Yes.
DE LA POER: Now, the interview with Letby was conducted by Ms MacLaughlan, and I am sure I am pronouncing this incorrectly, Mr Mancini?
EARDLEY: (Nods)
DE LA POER: We understand that the decision so as not to intimidate her, that two women were chosen from the group of the five of you; is that right?
EARDLEY: It was the particular skills that they brought, the nursing skills, the nursing knowledge, understanding of nursing practice.
DE LA POER: Was there any other person who you interviewed who you treated in that way?
EARDLEY: When we assigned people to interview sometimes on a review we would have two streams of interviewing and we would always -- for a doctor we would always make sure there was a doctor; for nurses, we would always make sure there was a nurse. So the choice of those two individuals was appropriate.
DE LA POER: So it wasn't unusual that it wasn't all five of you?
EARDLEY: It wouldn't have been all five of us, no.
DE LA POER: Now, we can hear from Ms MacLaughlan and Mr Mancini about what took place and they are our best evidence for that.
EARDLEY: Yes.
DE LA POER: But we understand that Letby was provided with Ms MacLaughlan's mobile telephone number, were you aware of that?
EARDLEY: No.
DE LA POER: Would it be appropriate for a mobile telephone number to be given to an interviewee?
EARDLEY: It wasn't unusual. When we conducted other reviews, they were very much peer reviews so we were working alongside the clinicians and if they needed support and advice usually we would provide
EARDLEY: opportunity to make contact. Didn't usually give telephone numbers, that was unusual.
DE LA POER: Just thinking about it now. The only reason Letby was chosen to be spoken to was because the Consultants suspected her of murder. Looking at it through that lens?
EARDLEY: Yes.
DE LA POER: Might that not be even greater reason not to provide your number to such a person?
EARDLEY: It may well be I wasn't aware at the time. That was a decision made by Claire on grounds that she has given her evidence on.
DE LA POER: Well, even if there were welfare grounds, would the more appropriate course not be to ensure that she was properly connected with the network of support that the hospital provided?
EARDLEY: Yes.
DE LA POER: I mean, although it's a peer review, you are people who have come in, speak briefly and then leave?
EARDLEY: Yes, I wasn't aware of the -- of the passing -- the sharing of the telephone number until I saw the papers for this Inquiry.
DE LA POER: Now, Letby says in a message to a doctor that she had been given to understand following that meeting that there was going to be a recommendation by the RCPCH
about some sort of HR procedure. We will come to it. There was in fact a recommendation about an HR, but at the time, Letby appears to know that. Would it have been appropriate to tell her about that recommendation on what was day one of the visit?
EARDLEY: I don't think it would, no.
DE LA POER: Day two. Mr Harvey and Ms Kelly, we will bring this one up INQ0014605. We will go to page 6, please, just so there is absolute clarity about this particular issue based upon what you record. We can see: "Saw lots yesterday, lots of new info. Not sure if the review will give you the answers you are looking for. Considered aborting and starting again but ToR to be important to get the background. Need independent Casenote Review of all deaths by two independent people. Big concerns about Lucy plus need formal process to be started so she knows where she is, HR Director been involved on leave, has HR advice legal to support Lucy and protect as an organisation." So that is what the note records.
EARDLEY: These notes are ...
DE LA POER: If we scroll up, so "Reviewers all"?
EARDLEY: Okay, yes.
DE LA POER: Then an arrow saying "Claire Davies" --
EARDLEY: These are taken from my handwritten notes, yes.
DE LA POER: So really just the takeaways here is that you said in terms as a team that active consideration had been given to aborting and by that were you communicating that you had contemplated that the RCPCH review was not appropriate? Is that inherent in what you are saying? You wouldn't have considered aborting unless you shouldn't have been there?
EARDLEY: Can I just read it, please?
DE LA POER: Of course, by all means. (Pause)
EARDLEY: Okay. So I think these will be my handwritten notes from the feedback team meeting. Yes, I think we knew quite early on that we needed an independent Casenote Review, yes.
DE LA POER: Yes, what you appear to be saying, just filling in the gaps, as a team we have thought about stopping --
EARDLEY: Yes.
DE LA POER: -- and starting again, but we think that it's important that we continue, but you are going to need another process, in fact two more processes; one --
EARDLEY: Yes.
DE LA POER: -- Casenote Review, one HR process?
EARDLEY: Yes, yes.
DE LA POER: So in other words the RCPCH review isn't the end of the story, that is what you are saying --
EARDLEY: That's right.
DE LA POER: -- on --
EARDLEY: Yes.
DE LA POER: -- day two, but in particular -- and this may be an issue, we will see later -- it was communicated according to these notes that there had been consideration of stopping?
EARDLEY: Yes. That was early on. That was on day one, after we had met with Ian Harvey and Alison Kelly and the doctors.
DE LA POER: But here you are meeting with them at the beginning of day two --
EARDLEY: Yes.
DE LA POER: -- telling them what the thought process?
EARDLEY: Yes.
DE LA POER: -- was?
EARDLEY: Yes.
DE LA POER: You also spoke to the senior nurses later that day. We can take that down, thank you very much indeed. You found them, according to your witness statement, to be very supportive of Letby?
EARDLEY: Extremely. Yes.
DE LA POER: So, I mean, the very fact that you are talking
about it, about her specifically, might be thought to be an indication that you are investigating whether she was responsible?
EARDLEY: Yes, that was certainly communicated to us by the nurses.
DE LA POER: When the nurses were saying that Letby was a good nurse, or whatever it was that they were saying, did you say look, well, we are not here to understand whether she killed these babies or not; that is not what we are here to do? Or did the conversation just continue in a natural way?
EARDLEY: It continued in a natural way.
DE LA POER: Again, looking back on it now, shouldn't that just have been shut down to show that that was not what you were interested in?
EARDLEY: Yes.
DE LA POER: Do you think by this stage, that lines had become quite substantially blurred?
EARDLEY: Yes.
DE LA POER: Now, there was a feedback session at the end with Tony Chambers, Ian Harvey and Alison Kelly?
EARDLEY: (Nods)
DE LA POER: You record in your witness statement that: "[Mr] Chambers asked 'were the deaths expected or not?'..."
You say you are not clear who responded but likely Dr Stewart: "Some were expected, cannot say if there is a link between them at the moment." You go on to say there was mention of a forensic paediatric pathologist?
EARDLEY: Yes.
DE LA POER: Now, in what circumstances do you understand that a forensic paediatric pathologist will be relevant?
EARDLEY: Normally there would be a -- a pathologist involved in every unexpected death that didn't always happen because of the shortage of paediatric pathologists generally, certainly from those unexpected deaths. Because we didn't have a clear reason, we were suggesting that for those ones there be a full pathology review.
DE LA POER: One word that I am particularly focusing on, let me make it clear: forensic. When would a forensic paediatric pathologist normally be appropriate?
EARDLEY: That would normally be if there was a concern about somebody -- some foul play.
DE LA POER: So it does rather appear, do you agree, that at that stage, you are encouraging investigation --
EARDLEY: Yes.
DE LA POER: -- of a crime or potential crime without
involving the police?
EARDLEY: Can I perhaps clarify. It may be that when I used the word "forensic" I wasn't meaning it in the context that perhaps we have inferred today. It would have been a very detailed and thorough pathological review.
DE LA POER: I mean, that is the word that you chose in your witness statement?
EARDLEY: Yes.
DE LA POER: It is a term of art, is it not, the forensic?
EARDLEY: Yes.
DE LA POER: -- paediatric pathologist?
EARDLEY: Yes.
DE LA POER: Do you know whether the gentleman you named, Tony Beswick, is in fact a -- whether or not he is, I am not suggesting he is or he isn't, but do you know whether he is?
EARDLEY: I'm not sure he was -- I think named by somebody from the review team.
DE LA POER: I understand. You suggest that he may be able to assist in the case note or postmortem examination?
EARDLEY: There was a significant shortage of people who could conduct Casenote Reviews in the country. There are no many who could do it so that was a name that came at that time.
DE LA POER: Two more issues about the review and then we will just move on to the aftermath. The first is in relation to the conversations you had with the Executives about the reasoning behind why the police weren't called. What you say in your witness statement is: in discussions about calling the police, the Medical Director had clearly made up his mind and cited advice from colleagues within the Trust. He requested a review be completed before any police contact."?
EARDLEY: Yes.
DE LA POER: Largely it speaks for itself. Firstly, is that your recollection of --
EARDLEY: Yes.
DE LA POER: -- his presentation?
EARDLEY: Yes.
DE LA POER: Cited advice from colleagues?
EARDLEY: Yes.
DE LA POER: What advice did he cite?
EARDLEY: I can't remember the exact position of the individual. But he said there was somebody working within the organisation who had been a senior police officer who had given him advice that to call the police would be such a massive impact on the organisation that they had to be very careful before they did that because
of the reputational risk, because of the other concerns about what that would do for the organisation as a whole. That was my recollection of the conversation at the time.
DE LA POER: And that was reported to you, that is obviously one side of the balance.
EARDLEY: Yes.
DE LA POER: The other side of the balance is there may be a murderer who needs to be detected and stopped?
EARDLEY: Yes.
DE LA POER: At the time, did you find it an inappropriate way of reasoning to not calling the police or did you think that that was a reasonable approach?
EARDLEY: At the time that was the judgment that the senior management was making within that organisation. It was that organisation's role to call the police, but I accept that us coming from outside could have had a stronger comment on it.
DE LA POER: But you are not sitting there as an entirely passive person you will have a reaction to --
EARDLEY: Yes.
DE LA POER: -- what somebody is telling you is their reasoning in relation to a very important decision. Do you have any recollection of thinking, well, "That sounds fine to me" or, on the flip-side, "That's
a terrible approach to take"?
EARDLEY: I remember thinking the situation has been mitigation at the individual that they had concerns about was no longer working in clinical practice. Therefore, at that time the reasoning seemed appropriate.
DE LA POER: So your reaction to being told that was "That sounds reasonable to me"?
EARDLEY: Was if our review couldn't find anything else then the police would be called.
DE LA POER: The second point you have touched on already when I inadvertently confused you about April and July. You know that Letby was moved out of the clinical role?
EARDLEY: Yes.
DE LA POER: At the same time the unit was downgraded.
EARDLEY: Yes.
DE LA POER: Did you investigate whether or not the increase in the mortality had persisted past that point?
EARDLEY: That had only been a fairly short period, I think it was 7 July, and revisited in September so it was less than two months.
DE LA POER: Two months?
EARDLEY: Yes.
DE LA POER: But nevertheless, was that something that you enquired into?
EARDLEY: We did and we noticed that there had not been any further unexplained deaths.
DE LA POER: And did you ascribe any significance to that at the time or potential significance in the context of weighing up what the right thing to do was?
EARDLEY: We certainly noticed it and continued to monitor, yes.
DE LA POER: I mean there are two obvious explanations that might spring to mind one because the unit has been downgraded which some people have cited?
EARDLEY: Yes.
DE LA POER: The other is that Letby's been moved off the ward?
EARDLEY: Yes.
DE LA POER: Was a thought process that you engaged with at all trying to understand why there had been this change?
EARDLEY: We considered it, but also we would be aware that the unit would be considering it as well and other staff in the unit will have noticed that as well.
DE LA POER: We are going to bring up your letter which you sent on 5 September, INQ009611 [INQ0009611], we are in the final part of my questioning for you. If we go to the second page, we can see two action requires, these were both immediate actions, is that right?
EARDLEY: Yes.
DE LA POER: Because you had jumped ahead of the report?
EARDLEY: Yes.
DE LA POER: To get these processes undergoing immediately?
EARDLEY: Yes, I think from, from after this review we instigated the process of a two-week letter where we would send a letter swiftly after review with any immediate actions.
DE LA POER: And in fact you had foreshadowed both of these in the meeting on 2 September?
EARDLEY: Yes.
DE LA POER: HR investigation, "It is important that the Trust takes immediate steps to formalise the actions you are taking with the nurse. Our understanding is that an allegation has been made and therefore a process of investigation needs to be put in place which sets out the nature of the allegation and the process you follow to investigate it." Are you there envisaging a disciplinary process?
EARDLEY: The process we suggested was an NHPS which is an independent investigation if allegations have been made against an individual about clinical practice.
DE LA POER: But does it have the effect of a disciplinary, in other words "You are accused of doing something wrong, we are investigating whether you have done something wrong"?
EARDLEY: I suppose it could be put like that, yes.
DE LA POER: Because you have used the word allegation?
EARDLEY: Yes.
DE LA POER: Which generally is reserved for suggestions that somebody has done something they shouldn't have done?
EARDLEY: Yes, yes.
DE LA POER: So you have recommended that this process is undertaken. I mean, can we be frank. The allegation was she may be murdering babies, is that fair?
EARDLEY: Yes, yes.
DE LA POER: And so your proposal is that whether or not she is murdering babies should be undertaken in accordance with the NHPS process?
EARDLEY: The issue behind this was that she returned from leave and was moved to non-clinical duties and a process wasn't followed for doing that.
DE LA POER: This was a protective measure to try and stop the Trust being sued for constructive dismissal?
EARDLEY: Yes. It could be seen as that.
DE LA POER: Yes, so that is its origin but what you are in fact saying is you need to ask, to follow the NHPS process to investigate whether she has been killing babies?
EARDLEY: When you put it like that yes, I can see that.
DE LA POER: But that is what it means isn't it?
EARDLEY: Yes, yes.
DE LA POER: That should have said, do you agree. You need to phone the police"?
EARDLEY: Yes.
DE LA POER: And whilst that may be a pragmatic solution to a potential employment claim, do you agree that that is not in fact appropriate?
EARDLEY: Knowing now what I know now, yes, that's not appropriate.
DE LA POER: Knowing what you knew at the time, bearing in mind you knew what the allegation was that you put in your letter?
EARDLEY: Yes, it did not feel as strong as that at the time. I know how that sounds. It did not feel as strong as that at the time.
DE LA POER: Do you see how that might, might give the Chairman of the Board of Directors or somebody else who reads it false reassurance?
EARDLEY: Yes.
DE LA POER: Because it's all framed in quite oblique language, allegation?
EARDLEY: Yes.
DE LA POER: And somebody who's not aware of all the circumstances might read that and think oh we just need
some kind of disciplinary process to sort all this out?
EARDLEY: Yes.
DE LA POER: In terms of the Casenote Review, you describe this as a detailed forensic Casenote Review. What does the word forensic mean in that context?
EARDLEY: I think a detailed Casenote Review was what I meant.
DE LA POER: Yes. Tautology?
EARDLEY: Yes.
DE LA POER: Is it right you didn't actually mean anything by the word forensic that wasn't imported by the word detailed?
EARDLEY: Correct.
DE LA POER: You contemplate the following minimum elements. Were you expecting that the hospital would turn its own independent mind to your proposal and consider whether additional measures might need to be added?
EARDLEY: I think including all interventions and details of nursing and medical observations and activities -- we had expected that may uncover some of the issues around who was there and who did what and some of the findings.
DE LA POER: I am sure it's me and the resonance of the room, can I just ask to you keep your voice up very slightly?
EARDLEY: Sorry.
DE LA POER: No need to apologise. It is a large room and I have been asking you questions for a long time. I am really just focusing on the word "minimum" here. You seem to be allowing for the possibility that if the hospital thinks about it, it might come up with other things it needs to do too?
EARDLEY: Yes.
DE LA POER: Option 3 is examination with relevant paediatric pathologist of the postmortem findings and any additional information. Now, the run-up to this is at least two senior doctors, we see that in the body of the paragraph, whether neonatology or pathology. So are we just understanding what you are saying needs to happen, as far as you are concerned it could be that they choose two neonatologists which would fulfil that first criteria but if they did they are also going to need a pathologist as well in order to satisfy your third criteria?
EARDLEY: Yes.
DE LA POER: Or, they might choose a neonatologist and a pathologist in which case they probably don't need an extra pathologist for your option 3?
EARDLEY: Correct.
DE LA POER: Is that how you had in mind, what you need is for everyone's of these cases pathology input?
EARDLEY: If possible, yes.
DE LA POER: Well, I mean, what you are not saying is if possible -- I appreciate it is a recommendation?
EARDLEY: We were expecting pathology input, yes.
DE LA POER: This is the minimum is what you are saying?
EARDLEY: Yes, yes.
DE LA POER: And you include in your list rare conditions such as air embolism?
EARDLEY: Yes.
DE LA POER: I mean, that is contemplating in the context of what you were told by Dr Jayaram and your own internal discussion at lunchtime that these children may have been injected with air?
EARDLEY: Yes.
DE LA POER: But your recommendation is that that's all done before there's any question of involving the police?
EARDLEY: I'm not sure that air embolism is only by injection, I don't know.
DE LA POER: No, of course not. But in the context of the discussions you have had air embolism has come up because Dr Jayaram has told you?
EARDLEY: Yes.
DE LA POER: That they investigated?
EARDLEY: Yes.
DE LA POER: As to whether that provided an explanation for the mottling?
EARDLEY: Yes.
DE LA POER: Deliberate administration of air. You have had a discussion at lunchtime where a number of chemicals and insulin and air embolism are discussed as a method of murder.
EARDLEY: Yes.
DE LA POER: And here we are, four days later, and you are encouraging that that is one of the things that their investigation looks for?
EARDLEY: Yes.
DE LA POER: And is that not another clear indication to you that this has taken a wildly wrong turn and if those are things that need investigating the police need to be called?
EARDLEY: Yes.
DE LA POER: Recommendation 4: "Details of all staff with access to the unit for four hours before the death of each infant." Now, you are not here asking who was allocated to care for the baby who was on duty. You have used this phrase: staff with access.
EARDLEY: Mmm.
DE LA POER: That isn't actually something for a neonatologist or a pathologist to be looking into is it?
EARDLEY: True.
DE LA POER: Do you agree?
EARDLEY: Yes.
DE LA POER: I mean that's something that a police officer would be investigating, you would expect that to appear in a list of lines of investigation, do you agree?
EARDLEY: Yes, yes.
DE LA POER: I mean at this point, do you think that you have slightly put yourself in the position of an investigating police officer as to the sort of things that need to be investigated?
EARDLEY: That is certainly how it reads, yes.
DE LA POER: Do you think that that is in fact in part how you were thinking?
EARDLEY: I think it may be, yes.
DE LA POER: Because that, would you agree, is another recommendation that as you were writing it you should have thought this is a police matter --
EARDLEY: Yes.
DE LA POER: -- do you agree? Thank you, that can come down. You had contact with Jane Hawdon in the context of finding out if she would be available to conduct the review; is that right?
EARDLEY: I'm not sure I would only have had that very initial contact. The -- Ian Harvey emphasised it was important to keep it very separate.
DE LA POER: Yes.
EARDLEY: I think my recollection is because of the very public nature of the whole process, that the names of those people doing the case reviews would be kept private.
DE LA POER: Dr Hawdon says that she didn't know at any stage prior to producing her report that there were allegations against a member of staff.
EARDLEY: That is possible.
DE LA POER: You weren't the only person she spoke to, she also had contact with Ian Harvey?
EARDLEY: I don't --
DE LA POER: But so far as you are concerned --
EARDLEY: I would have only spoken to her about her availability and her willingness to have her name put forward to the Countess of Chester Hospital.
DE LA POER: Bearing in mind what was sitting in the background --
EARDLEY: Yes.
DE LA POER: -- and had been the subject of so much of the visit --
EARDLEY: Yes.
DE LA POER: -- do you think that's something you should have alerted to her to?
EARDLEY: Yes.
DE LA POER: So that if she agreed to do it she did so understanding the situation she was getting involved in?
EARDLEY: Yes.
DE LA POER: And what she might need to be alert for?
EARDLEY: Yes.
DE LA POER: I mean, she's the person doing the forensic Casenote Review, isn't she?
EARDLEY: Well, we put four -- there were four names I think put forward of whom two were available?
DE LA POER: Yes.
EARDLEY: I don't recollect what my contact with them was beyond saying "are they available?" And then I passed them over.
DE LA POER: Now, when it comes to drafting the report, see if we can do this at a relatively high level. There is a suggestion that the Consultants said it was a gut feeling. I don't know whether you had a chance to look back over the notes, but that was something that the nurses said?
EARDLEY: Yes, it is.
DE LA POER: But it was attributed to the Consultants --
EARDLEY: Yes.
DE LA POER: -- via the report and can you see that by attributing that to the Consultants it might be thought that their allegations are perhaps less well-founded than they might otherwise have been?
EARDLEY: Yes, I accept that.
DE LA POER: If we look at the close out form, INQ0010170 [not found] -- no, forgive me, that's the wrong reference. We can take that down. Maybe I can deal with it this way. That includes the phrase "unsubstantiated allegations"; I don't know if you recall that?
EARDLEY: I think so, it was a very early close-out form, it wasn't completed it was just the first part.
DE LA POER: Yes. Again, the fact that that was even written might be thought to suggest that not much was thought of what was being suggested in terms of its cogency?
EARDLEY: Yes.
DE LA POER: Do you think that does -- I mean, we have got a misattribution of gut feeling, we have got an unsubstantiated allegation. Do you think in fact a fair representation of your state of mind was you didn't
think there was much in this?
EARDLEY: At that time, I think, yes, there was such a strong feeling from management that there was not much in it.
DE LA POER: When you sent the draft, you included the phrase "it does contain some fairly strong recommendations"?
EARDLEY: Yes.
DE LA POER: Is there any particular recommendation you have in mind or do you think that perhaps overstates it rather?
EARDLEY: I am just trying to recall all the detailed recommendations. There wasn't a particular one in mind, no.
DE LA POER: Dr Shortland sent an email the report went out in Dr Shortland's name?
EARDLEY: Yes.
DE LA POER: INQ00012748 [INQ0012748]. I hope I haven't added an extra digit there. I think I might have. Put in 12748, thank you, page 4. Dr Shortland's email right in the middle, 28th: "Quite an interesting and complex review. Good to have David M leading that one, almost felt a bit like Grantham situation 30 years ago and my only question was why they didn't involve the police if they had those suspicions, otherwise looks like a good report with very clear recommendations." Now, we know that Dr Shortland a was a junior doctor at a Nottingham hospital at the time that Beverley Allitt carried out murders in Grantham nearby?
EARDLEY: Yes.
DE LA POER: And that he retrieved sick infants from Grantham Hospital. Did you understand that when he said "the Grantham situation" he was referring to Beverley Allitt?
EARDLEY: Yes.
DE LA POER: Is this not an extremely significant moment when Dr Shortland is saying that? That he's actually saying that having read your report and not taken any part in the review at all, he can see similarities with a murderous nurse?
EARDLEY: Yes.
DE LA POER: Is that another occasion when you should have hit pause on the report and said: we need to make sure the police are brought in?
EARDLEY: Yes.
DE LA POER: "When the report was sent it came with the sentence "will not distribute or share it more widely without your permission". That sentence is in breach of or contrary to the
policy in that you have made it clear in the policy that you will share it without permission in the event it contains recommendations that go to patient safety that aren't followed?
EARDLEY: But we would always inform the Chief Executive first.
DE LA POER: You will always tell them but that is not the same as asking permission.
EARDLEY: Okay. The sharing with them would be the result of a dialogue. We wouldn't -- in practice we would share it if we had I think three times asked for evidence that action had happened or that the Trust had reported and if they hadn't then we would go ahead and report it to another body.
DE LA POER: There were two versions of the report as we have already covered?
EARDLEY: Yes.
DE LA POER: Whose idea was it to create two versions?
EARDLEY: I think it might have been mine. I wrote the original version with all the information that we had. I wrote it in a way that those paragraphs that are in green could be removed for wider dissemination because of the sensitivity of the allegations that had been made.
DE LA POER: Just thinking about it now. Do you think it
was a good idea to do it in that way?
EARDLEY: What I had done subsequently was to write the full report and then let the organisation redact it as needed.
DE LA POER: And perhaps for it to be clear that redactions have been applied?
EARDLEY: Yes.
DE LA POER: We are going to look briefly at three areas of the report.
EARDLEY: Yes.
DE LA POER: The first one is your conclusion about leadership, INQ0009618 page 13. Forgive me a moment. It must be over the page, please. Paragraph 4.3. "Does the unit have clear and engaged leadership and good team working?" "Yes generally, but there are some areas where communication could be strengthened." I am not going to read it all out now but the next paragraph is positively glowing isn't it with the quality of the leadership of this department?
EARDLEY: Yes.
DE LA POER: And?
EARDLEY: That is the generally.
DE LA POER: It is just significant because if it's being suggested by anybody at any time that the explanation
for the increase in neonatal mortality was because of a lack of good leadership, they would not find support for that in your report would they?
EARDLEY: Correct.
DE LA POER: In fact, they would find quite the contrary?
EARDLEY: Yes.
DE LA POER: We don't need to bring it up but you also identify that the SUDiC guidance was not being followed, is that right?
EARDLEY: Not completely, yes not completely followed.
DE LA POER: And the third matter is at page 24, could we go over the page, please. "Are there any identifiable common factors or failings" -- this is the crux of the report in the sense that this is the single bespoke factor that you were asked to consider. The first paragraph doesn't reach any conclusion about that?
EARDLEY: Correct.
DE LA POER: It just gives a list of facts. And then it says a number of recommendations. You point out that staffing levels were inadequate although you are not judging those by reference to how they were before the spike occurred or anything like that. You are just making an observation that they weren't good enough at the time?
EARDLEY: Yes.
DE LA POER: There is a comment about how there had sometimes been delay, but again you are not saying that every case that you were looking at fell into that category or that that was a common factor or failing?
EARDLEY: Mm-hm.
DE LA POER: And then you say most infants had undergone a postmortem but didn't include systematic tests for toxicology. So that isn't in fact a potential cause. That's a recommendation for how there might be better detection of the reasons; do you agree?
EARDLEY: Yes. Yes.
DE LA POER: And fourthly over the page, you suggest that an independent reviewer for unexpected deaths would be an improvement which is again not a potential cause but a way in which potential causes might be identified in the future?
EARDLEY: Yes.
DE LA POER: You say the personnel issues cannot be resolved formally until this is completed. What is that a reference to?
EARDLEY: I'm not sure.
DE LA POER: But does it come to this, as you told us before but this is an important point: the RCPCH went in
being asked to identify an explanation or explanations for the increase in neonatal mortality and you did not identify any?
EARDLEY: Correct.
DE LA POER: We can take that down. Six of the recommendations were under the heading of immediate. Was it your expectation as per the guidance that that report would immediately be shared with those who participated?
EARDLEY: I had thought the report had been shared particularly -- the full report had been shared in the middle of November with the senior team, with the senior doctors, with Alison Kelly, with Eirian. I thought they had all seen the report with the green sections in it.
DE LA POER: But if changes are going to be made for example SUDiC?
EARDLEY: Yes.
DE LA POER: You were concerned that if there was another sudden and unexpected death that the right protocol, and that could happen in theory at any time?
EARDLEY: Yes.
DE LA POER: Any Consultant, any doctor any nurse involved in that would need to know what your recommendation was?
EARDLEY: Yes so we recommended that the report be circulated as soon as possible as soon as the final
report was issued.
DE LA POER: Did you subsequently exchange email correspondence with Dr Brearey and with Mr Harvey, where firstly you were informed that the report wasn't in wider circulation and, secondly, that you were encouraging Mr Harvey to make sure that all of those who made allegations against Ms Letby saw the full version?
EARDLEY: Yes, I had thought that they had seen it in November, because the response back on 15 November from Ian Harvey was that it included comments from the two doctors and those other nurses who I have mentioned. It emerges from looking at the subsequent papers that they had seen it in his office for an hour without being able to take it away which is insufficient.
DE LA POER: Well, if departmental change is going to take place, everyone needs to see it and consider it at their leisure?
EARDLEY: Absolutely. And that was our recommendation from the beginning from the proposal that we would write it in a way that it could be shared.
DE LA POER: And is it overstating the matter to suggest that bearing in mind these were patient safety recommendations that you were making, that it put patient safety at risk for that report not to be given to everybody in that unit?
EARDLEY: Yes.
DE LA POER: But is that overstating or is that a fair --
EARDLEY: Yes, to withhold sharing that report would have increased the risk or the risk would have been reduced by sharing that report.
MR DE LA POER: Ms Eardley, thank you for answering my questions. My Lady, there are some Rule 10 questions.
LADY JUSTICE THIRLWALL: Very good. Mr Baker.
MR BAKER: Mrs Eardley, I ask questions on behalf of the Families of 12 children. I am going to ask you some very specific questions about candour and the role of candour in these investigations.
EARDLEY: Yes.
BAKER: Now first of all as of 2016, the Royal College would have understood the importance of the duty of candour?
EARDLEY: Yes.
BAKER: And the role that it played in ensuring that affected individuals were kept informed about safety critical issues that were relevant?
EARDLEY: Yes.
BAKER: Was there any system in place at the Royal College in 2016 to ensure that candour issues were formalised and an agreement was reached in relation to them of any service users?
EARDLEY: Not directly from the Royal College but there was as part of my correspondence with Ian Harvey at the beginning there was a conversation, email conversation.
BAKER: We will come on to that in a moment.
EARDLEY: Okay.
BAKER: But it would be right to say there was no formal agreement as part of a contract that's formed when a service review was undertaken that specified a duty to agree a structure when it came to informing people or being candid with affected patients for example?
EARDLEY: Correct service reviews were usually carried out without specific patient case note detail.
BAKER: But a service review had the potential to reveal issues that involved individual patients?
EARDLEY: Yes.
BAKER: And so trigger a duty of candour obligation?
EARDLEY: Yes.
BAKER: And so would you agree that it would have been sensible to have some formalised process in place so that individuals who were entering into contracts with the Royal College for service reviews understood how material and information would be used in respect of
a duty of candour?
EARDLEY: Yes, that would be helpful.
BAKER: Now in terms of the actual type of agreement, the client, so the individual in this case or organisation, the Countess of Chester Hospital, would own the report that you created?
EARDLEY: Yes.
BAKER: And so you would lose all control of that report once it was finalised and provided to the client?
EARDLEY: We would obviously retain our copy but the agreement usually was how that report was used as a responsibility of the client.
BAKER: So in reality you had no control about how it would be used?
EARDLEY: No.
BAKER: And had you encountered issues in the past where Trusts had not been entirely upfront with the College about how material would be used other than this case?
EARDLEY: Not that I can recall. I usually maintained a good dialogue with my client contact, usually the Medical Director and we would discuss dissemination.
BAKER: Had you encountered problems with Trusts being honest and open with the College other than the Countess of Chester?
EARDLEY: Not generally as I can recall. It was some time ago but I can't remember any specifics. There was one other case which --
BAKER: So if we could look at the chronology you created, INQ0012748. And if we could go, please, to October 2016, which is on page 4. Can you see an entry just dated October 2016, programme board written update, where it says "Two recent reviews have become much more complex than initially anticipated mainly due to the management our clients not being open and honest with their paediatric team and/or not responding to our requests for data." Now I assume that one of these is referring to the Countess of Chester, is it?
EARDLEY: Yes.
BAKER: So it wasn't unique was it for Trusts not to be entirely upfront with the College about what the College was being asked to do or indeed, I would suggest, how those reports were going to be used?
EARDLEY: Those were the only two situations that I can recall.
BAKER: So save for, and of course I don't ask you to identify the other Trust, but one of them is the Countess of Chester?
EARDLEY: Yes.
BAKER: These two Trusts were unique in all of your experience of Royal College service reviews?
EARDLEY: As I can recall, yes, they stood out.
BAKER: But it is easy to see by November of that year if we look down 11 November from "Paeds", there is a reference here to Dr Brearey contacting you. The paediatricians have seen a redacted report and made some comments which were forwarded to the RCPCH on 15 November confirming draft report had been seen by the Execs and they were comments that had been taken into account. Did that not start alarm bells running or ringing about how the Countess of Chester was using the report, if it was providing redacted versions or not providing full versions to affected individuals?
EARDLEY: Yes, that did concern me.
BAKER: Because if we go to INQ009595 [INQ0009595], which is the review proposal, and we look on, please, to page 4 of that, this is a review proposal that was sent to Ian Harvey on 30 June and signed off by him?
EARDLEY: Yes.
BAKER: Can you see under 3.3, you say: "Each review we conduct is tailored specifically to the service or individual in question but will always be conducted using tested principles including ..." Item 2 is: "A commitment that findings will be shared as far as possible with those involved."
EARDLEY: Yes.
BAKER: That had been effectively a term of the agreement from the outset?
EARDLEY: Yes, yes.
BAKER: Now, "shared as far as possible with those involved" doesn't extend to patients who might be affected?
EARDLEY: No, would be all those interviewed. Sometimes an organisation would -- would limit some of its circulation, would sometimes redact copies before they disseminated them, but we would expect the whole report to be disseminated to all those involved.
BAKER: Yes. So it may that be very sensitive material --
EARDLEY: Yes.
BAKER: -- is omitted and one can assume there might be exceptional reasons for doing that in some cases?
EARDLEY: Yes.
BAKER: But generally the expectation was that in terms of the individuals working within the Trust who would be affected it would be provided to them and they would be allowed to see the outcome?
EARDLEY: We would write the reports with that in mind.
BAKER: Yes.
EARDLEY: So we would write them appropriately with the kind of language that would be suitable for dissemination for those that were interviewed.
BAKER: It isn't a part of this proposal or indeed the terms that the Royal College enters into with the Countess of Chester that there be an expectation that it be disclosed to Families who might be affected we are going to come on to your email to Ian Harvey in a moment, but in terms of the agreement there is no section that specifies the need to be candid with the affected Families, is there?
EARDLEY: Not -- these terms are core terms for our reviews. We knew from the first conversation that the report was likely to be published. We would encourage organisations to put it in their board papers, we knew this one was highly sensitive in terms of media interest.
BAKER: You didn't mean to give the impression that this is a sort of boilerplate contract, but just to be clear, if you look at page -- if we go back to page 2 of this document --
EARDLEY: Yes.
BAKER: -- it is quite clear that it is a bespoke
document to the Countess of Chester --
EARDLEY: Yes.
BAKER: -- hospital. So it sets out the terms of the agreement with them. Now, if we go then to your emails with Ian Harvey, if we turn first of all to, forgive me a moment, so it's INQ0009599. Now, the proposal that we have just been to is dated 30 June and it is agreed. So the contract in effect is formulated on 30 June. So here we are just having discussions with Mr Harvey about mechanics and what's going to be happening and you say in this email: "Finally, I was just wondering what the position is regarding the parents of the infants who died. Would they be expecting to meet us? I have not included for that and we wouldn't usually meet them in a review like this as we are not intending to go over every case again in detail but we just need to confirm the duty of candour arrangements are in place." Mr Harvey responds to you on the following day, so 13 July, and if we go to INQ0009615, and to page 2, so at the top of the particulars of claim is the main body of an email from Ian Harvey it says: "Re the parents, we made every effort to contact
the parents of every baby who had died due to the increased incidents period before the story was in the local paper. Address and phone number changes mean that we couldn't contact all. Part of the conversation was that we would share the findings of the review with them. To my knowledge none has requested seeing the review team." What did you take that to mean?
EARDLEY: I took that to mean that the duty of candour was being followed by the Countess of Chester Trust, there was dialogue with the Families, and that yes, our report would be shared with them.
BAKER: Is that --
EARDLEY: At that time we obviously hadn't done the review, we hadn't got the details and information so ...
BAKER: I mean, what it's saying that they have not been able to contact everybody. I mean, do you know -- did you go back and ask how many they had actually been able to contact?
EARDLEY: No, we didn't -- we didn't pursue it beyond that.
BAKER: I mean insofar as the Families who I represent are concerned, the Mother of [Child C] is the only one who actually finds out about this review at or about this time and she finds out about it through a leak in the newspaper rather than being contacted?
EARDLEY: Okay.
BAKER: None of the others were contacted who I represent.
EARDLEY: That is concerning.
BAKER: Yes. But if you --
EARDLEY: Because that is not what this email says.
BAKER: This is as of I should say July 2016; they find out about it later.
EARDLEY: Yes. As I say, usually within the RCPCH's remit at the time we would -- depending on the nature of the review we would seek to talk to patient family representatives but that was not when we were looking at something like this.
BAKER: But, you see, one of the issues and I think on reflection the fact that it isn't a contract term that candour is followed, the fact that really it's dealt with in a very informal way by you, you raise it, it is a good thing you raised it?
EARDLEY: Yes.
BAKER: But it is in an informal way, it is not part of the terms of the agreement?
EARDLEY: Yes.
BAKER: It does leave the Royal College to be potentially fobbed off, doesn't it, about candour?
EARDLEY: It -- reading that, it appears as such, yes. It is the responsibility of the Trust to liaise with the Families under duty of candour requirements.
BAKER: Yes.
EARDLEY: So my email was double-checking they were doing that. I had that confirmation that that was being done. So we left it there.
BAKER: But you don't have a list, for example, of: I have contacted this number of patient Families, these remain uncontacted, we are making ongoing efforts to contact them. It's all very loose, isn't it, actually on reflection what Ian Harvey says?
EARDLEY: It is, yes. I -- I hate to say that was outside our remit but we weren't focusing on that at the time but reading that assurance, yes, that is very loose.
BAKER: I mean, you may have been misled by it, that is one thing. But again, if there had been a formal arrangement in relation to the duty of candour within the proposal and the contractual documents --
EARDLEY: Yes.
BAKER: -- it would have put the Royal College in a much stronger position, wouldn't it, when it came to issues like this?
EARDLEY: As I say, I accept that this was not intended
to be a Casenote Review. Had it been a Casenote Review there would be a whole issue about communication with Families, this was not intended to be.
MR BAKER: Thank you, my Lady, I have no further questions.
LADY JUSTICE THIRLWALL: Thank you very much, Mr Baker. Mr Skelton.
MR SKELTON: Ms Eardley, I ask questions on behalf of one of the other Family groups.
EARDLEY: Okay.
SKELTON: You have been asked in detail about the pre-review phase where you were in contact with Ian Harvey.
EARDLEY: Yes.
SKELTON: I just want to revisit that briefly, please, and then I will turn on to your review and your decision-making there?
EARDLEY: Yes.
SKELTON: The Terms of Reference which eventually were agreed left it open for you to identify any identifiable common factors or failings that might in part or in whole explain the apparent increase in mortality?
EARDLEY: Yes.
SKELTON: So everything was on the table for the College
reviewing team. Wasn't it obvious from the start that when you are coming to look at mortality of specific children, that you had to look at their notes?
EARDLEY: It was not -- we were looking at the whole, the numbers. We weren't intending to look at the individual children.
SKELTON: But --
EARDLEY: I hear what you say.
SKELTON: How could you scientifically -- your background as an engineer I think?
EARDLEY: Yes.
SKELTON: Even medically which you were very familiar with?
EARDLEY: Yes.
SKELTON: How could you identify why more children than expected had died without understanding why each child had died and looking to identify in their notes and in discussion with their treating professionals, the common factors medically which would link them. You couldn't do that, could you?
EARDLEY: No. That's why we recommended a specific case note review to look into that in detail.
SKELTON: Yes, I think the key point really was that from the start that issue, that very issue at the heart of the Terms of Reference that I have quoted --
EARDLEY: Yes.
SKELTON: -- required a Casenote Review?
EARDLEY: Yes.
SKELTON: And you were given some information by Ian Harvey. I have sensed a great degree of discomfort throughout your evidence about the way in which this review was set up and conducted. Is that fair?
EARDLEY: Looking back absolutely, yes.
SKELTON: Well, as soon as he raised concerns about suspicions of potential murder, that must have raised some degree of concern and alarm in your mind as to whether or not you were in a zone where you could assist meaningfully?
EARDLEY: Yes. Yes.
SKELTON: And they were, as I think Mr De La Poer put to you, of the utmost gravity; the murder of babies in a hospital couldn't be more serious?
EARDLEY: (Nods).
SKELTON: So, in those circumstances, the only appropriate course really was to say "We can't do this and you need to get someone else to look at this properly" from the start.
EARDLEY: I agree.
SKELTON: And if the concerns were at that level, the only organisation that really is equipped and
experienced to look at these sorts of things is the police. They have the full panoply of investigative powers which others don't. So, for example, they can get whatever expert reports they want, they can interview people, they can seize documents, notes, et cetera. None of those things is within the power of an independent pathologist or an independent clinician who may be brought in. Is that correct?
EARDLEY: Yes.
SKELTON: Did you pick up at the beginning before you went there that Ian Harvey's view was that the Consultants were misplaced in their concerns? That somehow they had got this wrong and that he needed help to demonstrate that?
EARDLEY: I think that's a good summary of our perceptions at the time, yes.
SKELTON: Do you think that's an appropriate use of the College? The Consultants, for example, are members of your College, Ian Harvey is not, and of course corporately the Trust is not, but you were put in a position where your members, two of your members, well as it turned out more than two of your members, are concerned about deliberate harm to children. You are brought in by the hospital who employs those Consultants to disprove their concerns.
That isn't an appropriate situation to get yourself into, is it?
EARDLEY: I think the -- the issue round them being members of the College is an important one but it's a different role. We are not a College coming into represent or support members. We have to be objective and independent. But yes, we heard their concerns, we should well have acted differently.
SKELTON: Yes, leaving aside the membership point?
EARDLEY: Yes.
SKELTON: I can see you have to be independent. Just because your members think something doesn't mean you have to agree with them obviously. But leaving aside that, you were being used to some extent weren't you in a way which wasn't appropriate for an independent review?
EARDLEY: With hindsight, yes, I would agree.
SKELTON: In fact based on what Mr Harvey told you; he wanted to use the Royal College to disprove the Consultants' concerns without addressing them directly?
EARDLEY: He wanted to see if there was any other factor that could possibly have been a cause.
SKELTON: Why is it then that the Terms of Reference don't say that because on the face of it the Terms of Reference I have read out to you, which Mr De La Poer
went through, open up everything. But in fact you in your head, and repeatedly in evidence today, have said you were in fact excluding that concern deliberate harm, from your review.
EARDLEY: Yes.
SKELTON: So why is that not apparent from the Terms of Reference?
EARDLEY: I can't say. I can only think it was too awful to contemplate. Knowing now what I know, which we didn't know then.
SKELTON: You have used the word "hindsight" a lot and similar phrases. I would like to kick away that crutch to some extent I am afraid because actually based on what you were told, you were being told there were concerns that potentially with criminality your Terms of Reference which you put in your report include that as a possibility because they don't exclude anything?
EARDLEY: Yes.
SKELTON: That isn't a rational position to find yourself in, is it?
EARDLEY: No.
SKELTON: Day 1 of the review you already knew about the increase in mortality, that is baked into the Terms of Reference?
EARDLEY: Yes.
SKELTON: And likewise the unexpected nature of the children's deaths?
EARDLEY: Yes.
SKELTON: And you already knew that a nurse was alleged, or at least thought to have been connected to the deaths?
EARDLEY: Well, she had been on duty at the time.
SKELTON: Yes correlated?
EARDLEY: Correlated.
SKELTON: And there were concerns by the Consultants that she was in fact connected, there was a causal link?
EARDLEY: Yes, yes.
SKELTON: As you are speaking to Ian Harvey you start to be given more information, I presume this must have led to a degree of discombobulation on your part, that in fact the situation was far more complex than you had previously envisaged?
EARDLEY: (Nods).
SKELTON: In that very first discussion with him and Alison Kelly?
EARDLEY: Yes.
SKELTON: The pattern isn't a normal pattern for deaths. The babies didn't respond to resuscitation in the normal way. The only common denominator is the single nurse and the clinicians had threatened to go to the police.
This is all more information and it is all significant isn't it?
EARDLEY: Yes.
SKELTON: And when you thought about who you were talking to, you are talking to the Director of Nursing and the then Medical Director who's an orthopaedic surgeon. Were you aware of their background?
EARDLEY: Yes.
SKELTON: And neither of them was qualified to express a view on neonatal medicine, were they?
EARDLEY: At their level of authority I thought they would be, they would have had a view on that. They were not qualified clinically but they would have management responsibility to understand the issues.
SKELTON: Well, they had management responsibilities and they had their own healthcare training and experience?
EARDLEY: Yes, yes.
SKELTON: One is an orthopaedic surgeon and one is nurse?
EARDLEY: Yes.
SKELTON: But they are not neonatal doctors either of them?
EARDLEY: No.
SKELTON: So the specialist knowledge, the experience the judgment rests with a different specialty?
EARDLEY: Yes.
SKELTON: And did you consider that as a factor. You have two senior people they are senior managers, but neither of them in fact had a specialism in neonatology who are dismissing the concerns of the people who do have a specialist knowledge in neonatology. Did that factor in?
EARDLEY: Not in such an articulate way, no.
SKELTON: Does it make sense as I put it to you now?
EARDLEY: It does.
SKELTON: Did either of them offer an alternative explanation to you, an alternative hypothesis? So there was only one working hypothesis which had been raised by the Consultants that connected the deaths, this was the nurse, and as Mr De La Poer put it to you that it could have been just a statistical anomaly, a failure of inadequate care and/or deliberate harm. Was there any other hypothesis put to you that you needed to look at?
EARDLEY: There were some concerns about the transport service. There were some concerns as I recall that being a Level 2 unit was perhaps over extending in terms of its capability to look after the very, very premature infants. Those were the factors that we were looking at,
whether the staff and the expertise was appropriate, whether the transport came on time, whether the Consultant cover was sufficient, those were the areas that we were focusing on.
SKELTON: But I think you have accepted, haven't you, that you couldn't determine whether those factors in fact --
EARDLEY: Correct.
SKELTON: -- had led to the increased mortality; that was beyond the scope of your review?
EARDLEY: Yes.
SKELTON: And indeed objectively implausible?
EARDLEY: Yes. At the end of the review we concluded that those factors weren't accounting for the increase in mortality specifically.
SKELTON: I think in fact you, although you did make a very clear finding about the understaffing of the unit, number one, that is a common problem with district general hospital neonatal units, so this wasn't unique to Chester?
EARDLEY: Correct.
SKELTON: Number two, it didn't cause the increase in mortality, as far as you found?
EARDLEY: Correct, we couldn't find a correlation there.
SKELTON: No, and without correlation there can't be causation. So what did they think had caused this increase, if anything?
EARDLEY: They? Senior management?
SKELTON: Ian Harvey and Alison Kelly, who you spoke to on the very first morning of your review.
EARDLEY: I don't know what they thought was causing it.
SKELTON: So you had an open field to look for anything?
EARDLEY: I think they wanted us to disprove that it was Nurse Letby.
SKELTON: Which you accepted was an inappropriate use of the Royal College?
EARDLEY: Yes.
SKELTON: I am going to ask you briefly -- I am very conscious that I am treading into the sort of time when we should have finished --
EARDLEY: This is important.
SKELTON: Can I ask you about the interviews that you had with Dr Jayaram and Dr Brearey, please.
EARDLEY: Yes.
SKELTON: Is it easier for you to look at your handwritten notes or your typed notes?
EARDLEY: Handwritten notes.
SKELTON: It might be easier for you. If it proves problematic for others who are looking at them, can we
change?
EARDLEY: I am very happy, yes.
SKELTON: I don't think there are any major discrepancies?
EARDLEY: No, that is fine.
SKELTON: I have not correlated it?
EARDLEY: They just look familiar to me, that is all.
SKELTON: Okay fine. In that case it is INQ0010124. Just picking up finally before I move into the detail of this, the police are mentioned as a possibility by Ian Harvey on a number of occasions and you were asked by Mr De La Poer about the consequences of calling in the police. It seems to have been dealt with in a way which sounded rather apocalyptic as if the unit would suddenly become a crime scene, or at least it would lead to its closure or such reputational catastrophe that it would close its doors to patients. Do you think that is a fair and realistic view or well-informed view?
EARDLEY: I think it's such a rare occurrence there was -- there was uncertainty, there was certainly a perception that we picked up from Ian Harvey and Alison Kelly that to call the police because of the media interest and the perception that everything would have to stop and there would be alarm raised amongst
patients, that was their driving concern.
SKELTON: Did you test that though?
EARDLEY: No.
SKELTON: Because in one sense Lucy Letby had gone, she had been gone for months. In another sense the actual crimes that she might have or she was alleged to have committed were even further back?
EARDLEY: Yes.
SKELTON: They started, as we now know, in June 15 and ended in June -- or thereabouts -- 16?
EARDLEY: Yes.
SKELTON: So to some extent there isn't any need for the police to close the unit, for example, because the perpetrator is not there and the crimes took place many months ago?
EARDLEY: Yes.
SKELTON: On the other sense the police can in fact do things rather discreetly, can't they? Was there any reason to think that wouldn't be the case?
EARDLEY: No, no reason at all. I think I recall the perception in my head was that that would be such a major step and I think that's reflected in the notes that it was considered to be such a major step to call the police because it would be, I guess, an admission that they had a murderer amongst their staff and that
seemed too big to contemplate.
SKELTON: Do you know what in fact happened when the police were called?
EARDLEY: I know it was reported but it was relatively low key.
SKELTON: But it didn't cause a catastrophe in terms of the service?
EARDLEY: No, no.
SKELTON: So in fact that concern might have been rather alarmist?
EARDLEY: Yes.
SKELTON: Page 6, please, and towards the bottom where I think it says -- can you see -- I think it's Steve?
EARDLEY: Yes.
SKELTON: Can you see that? "Things all okay until last June" Do you see that?
EARDLEY: Yes.
SKELTON: So this is the narrative that you are now getting the full story in fact of exactly what happened and I think this is the Consultants really are unfurling everything to you?
EARDLEY: Yes, yes.
SKELTON: That they are worried with and that they think has happened?
EARDLEY: Yes.
SKELTON: Right from the beginning?
EARDLEY: Yes.
SKELTON: The story in brief was that babies start to die unexpectedly in June and they begin to investigate or think about what the cause is. And the key issue at the start is that they can't find a medical explanation?
EARDLEY: Yes.
SKELTON: So they start to see if there is another explanation and they identify a member of staff?
EARDLEY: (Nods).
SKELTON: That in itself is significant?
EARDLEY: Yes.
SKELTON: And the staff member that they identify is a nurse, we now know it's Lucy Letby, and that became readily apparent to you. Those are two of the factors to start with. If we go further on to page 8, please.
EARDLEY: Yes.
SKELTON: This is Ravi -- I think it is Ravi at the top?
EARDLEY: Yes.
SKELTON: Can you see about a third of the way down, it says "Ravi"?
EARDLEY: Yes.
SKELTON: Stephen crossed out and then it is "Ravi" and then he says -- do you want to read out those three
lines if you can?
EARDLEY: "It is how the babies collapsed, no indication, didn't respond physiologically how they should have done. Seven of them [that was seven paediatricians] so not always the same one talk to each other." So it was a while before they realised that they were all experiencing these collapses.
SKELTON: Yes, but several there are several things here. So it is how they collapsed?
EARDLEY: Yes.
SKELTON: These babies aren't expected to collapse in this way?
EARDLEY: Yes.
SKELTON: And they then don't respond to the usual medical interventions?
EARDLEY: Yes.
SKELTON: The various drugs and things that are intervened?
EARDLEY: Yes.
SKELTON: So another two red flags here?
EARDLEY: Yes.
SKELTON: As to something clinically unusual that he's mentioning to you?
EARDLEY: Yes.
SKELTON: And then the next point is that this is an independent view so it's not just the two that are talking to you, Steve and Ravi, it is the other Consultants are all starting to come to this view independently?
EARDLEY: Yes, yes.
SKELTON: There is no problem of group think, it is individual thinking?
EARDLEY: Only when they start talking to each other they realise they had all experienced the same, each individually thought it was a one-off I suspect, yes.
SKELTON: Yes, so they are not conspiring to make up an allegation?
EARDLEY: No.
SKELTON: They are all independently coming to it and pooling their thoughts?
EARDLEY: Yes.
SKELTON: And by definition becoming even more concerned?
EARDLEY: Yes.
SKELTON: Because they probably second-guessed their own judgment and now in fact it proves that they are all having the same thoughts?
EARDLEY: Yes.
SKELTON: If we go a bit further down you can see it
says that -- I'm sorry to the bottom of the page, the very last bit, do you mind reading that out as well for those that can't understand your writing?
EARDLEY: "Nurse on shift at all times. Spoke to Ian and Alison. CQC is in the place of delay." That would have been in February.
SKELTON: So it is just the bit?
EARDLEY: "Nurse on shift at all times. Spoke to Ian and Alison" -- that being Ian Harvey and Alison Kelly -- "CQC is in the place so delayed." So that would have been around February when CQC was doing a visit so my inference is from what they said that they weren't listened to because CQC were visiting.
SKELTON: Yes, so they tried to do something about it?
EARDLEY: Yes.
SKELTON: They couldn't find a medical explanation, they looked for another explanation and they found the nurse that was on shift. They raised it with the Executives. It didn't go anywhere and your impression is in fact it's because the CQC were looking at the unit?
EARDLEY: That is obviously what they were told, we are too busy with CQC at the moment.
SKELTON: Yes. So they had been fobbed off?
EARDLEY: Yes.
SKELTON: If we go on to the next page, please. Just underneath the box, so do you want to if you could just read about the first sort of seven or eight lines?
EARDLEY: Yes, of course. "At the time of talking to Ian and Alison, Eirian had decided to put the nurse on day shifts not nights as staff member had been through all the harrowing episodes. Pastoral care. Six out of 9 mortalities at night midnight to 4 am. Outcome of the conversation then to keep a watch. No one expected collapses at night when she was on days but collapses happened in daytime."
SKELTON: If you could stop there?
EARDLEY: Yes.
SKELTON: So the last bit of information, I think you said earlier that you weren't told about the --
EARDLEY: It's there.
SKELTON: Not only the correlation with the nurse but the correlation with her shifts?
EARDLEY: Yes, it is there.
SKELTON: In fact, you were told that?
EARDLEY: Yes.
SKELTON: The collapses occurred at night when she was there, they stopped when she left, they moved to the day when she started the days?
EARDLEY: Yes.
SKELTON: So another piece of information --
EARDLEY: Yes.
SKELTON: -- that you are getting. If we go on to, please, page 9, sorry, further down. I will just read it out for you. Dr Jayaram starts to say to you: they wondered if they were missing something. So this is the point at which they are really opening up to you about what they are trying to think about and this is when they start to raise the possibility of an air embolus. So they are trying to work out that if it was this nurse, how she had actually done it?
EARDLEY: Yes.
SKELTON: The possibility of air embolus is raised. And I think at one point Dr Jayaram describes the sort of chill that came over him when he thought about this. Do you remember that?
EARDLEY: I think so, yes, I remember him saying that.
SKELTON: I'm afraid I haven't got the reference for that particular bit but I can read out the bit from the transcript of it. He says: "When thinking forensic, what happens with air embolism? Looked at the case studies. Last observations? Chilling."
EARDLEY: Yes.
SKELTON: He says.
"Just like what happened. Babies unresponsive to any inputs, list of them, odd skin discolouration, blue with eyelids of pink. [Query] injecting air into babies. Went to see new Execs." Then it says: "OB and S as have to cancel ..." I don't quite know what OB and S means?
EARDLEY: OB and S?
SKELTON: Observation?
EARDLEY: Obstetrician? Yes.
SKELTON: So as far as you were concerned, what is being raised with you is another factor that they did?
EARDLEY: Yes.
SKELTON: That he identified and discussed?
EARDLEY: Yes.
SKELTON: Which was this odd skin discolouration?
EARDLEY: Yes.
SKELTON: Having looked at the air embolism and correlated that. So you have a potential cause of murder --
EARDLEY: (Nods)
SKELTON: -- and they are unable to exclude it. It's beyond a Consultant paediatricians' toolkit --
EARDLEY: Yes.
SKELTON: -- to assess this, isn't it?
EARDLEY: Yes.
SKELTON: Someone else has to?
EARDLEY: Yes.
SKELTON: So stepping back and obviously the Stockport issue is also raised with you at one point and you discussed that with Mr De La Poer?
EARDLEY: Beg your pardon, sorry.
SKELTON: The Stockport?
EARDLEY: Yes.
SKELTON: The murders in Stockport --
EARDLEY: Stepping Hill, yes.
SKELTON: -- by a nurse?
EARDLEY: Yes, I wasn't familiar with that at the time, but yes.
SKELTON: Did you know what they were referring to when Stockport was mentioned?
EARDLEY: Dimly. I knew there had been some issues. I have obviously looked it up since.
SKELTON: You have been given a lot of information in this meeting over a very short period of time, almost all of which was new?
EARDLEY: Yes.
SKELTON: And it's very detailed?
EARDLEY: Yes.
SKELTON: And it must have been rather heartfelt from them, they must have been rather -- it must have been quite an intense experience to listen to all of that?
EARDLEY: (Nods)
SKELTON: Isn't it obvious at that stage that this is far beyond the capabilities of the Royal College and in fact this is an urgent situation that needs intervention?
EARDLEY: Yes.
SKELTON: The upshot, as we know, leaving aside the advice that you gave is that you recommend further investigation. Now, I have to put to you that that recommendation was not an appropriate thing to do and the reason for that was that the time had passed; that many babies had died; that in fact at this point the opportunity could have been taken -- well, it could have been taken months and months before to have a forensic pathology review or a forensic medical review. It was going to add extra time in a situation which required immediate intervention. Do you accept that?
EARDLEY: We absolutely should have encouraged the police to be called, yes.
SKELTON: You should have advised the Trust in no uncertain terms that it had to occur straight away?
EARDLEY: Yes.
SKELTON: One of the reasons that that was required was that appreciating that there were knock-on effects, potentially a police investigation which may have been significant and certainly Dr Brearey was concerned about that, as you may know. But Lucy Letby had been suspended, she hadn't been dismissed and she hadn't been struck off the nursing register?
EARDLEY: Yes.
SKELTON: So there was the risk, a real risk, that she could be reinstated?
EARDLEY: Yes.
SKELTON: There was a real risk that she could seek employment at another hospital?
EARDLEY: Yes.
SKELTON: At any time?
EARDLEY: Yes.
SKELTON: If she in fact was the murderer, patients would have been put at real risk?
EARDLEY: Yes.
SKELTON: That, I put to you, should have been on your mind and the minds of your fellow reviewers when you thought about the appropriate steps that needed to be taken and the timeliness of those steps?
EARDLEY: Yes.
SKELTON: Can I ask you just lastly about Dr Brearey and his evidence. He hasn't given his evidence to this Inquiry yet orally but he put in a statement. In his statement, in a number of points, he is critical of the College for not helping him and his colleagues --
EARDLEY: Yes.
SKELTON: -- when they needed help?
EARDLEY: Yes.
SKELTON: The reason, I think you already understand why he must be feeling like that, is because he explained everything he had to you --
EARDLEY: Yes.
SKELTON: -- with Dr Jayaram --
EARDLEY: Yes.
SKELTON: -- to try to go to those that should have helped him?
EARDLEY: Yes.
SKELTON: His bosses, the Executives, it hadn't worked, and so they were running out of options. Arguably they should have called the police, but that is a matter for him. But do you see why he felt let down by the College and what is your response?
EARDLEY: I completely accept they both had a horrible time, particularly having seen the documents that I have
seen for this Inquiry. The conversations that happened within the management team and how hard they strived to get this situation resolved quickly. I can only apologise for the fact that we weren't able to support them as they had asked.
SKELTON: I have taken you through most of the sort of salient bits of information that you were given by the two Consultants and indeed by Mr Harvey?
EARDLEY: Yes.
SKELTON: If you think about all of those factors, and what they told you, would you characterise that as being no evidence that Lucy Letby was connected to the deaths or would you characterise it as being a serious basis for suspicion?
EARDLEY: I think with all those factors put together and without the overarching stress and pressure that we were under at the time it is clear there was enough evidence there.
SKELTON: It certainly isn't something that should conceivably have been dismissed by anyone, is it?
EARDLEY: I beg your pardon?
SKELTON: It should not have been dismissed by anyone, that information that you were given on the first day of your review?
EARDLEY: I agree. I agree and particularly the two doctors have behaved with such dignity as well and politeness throughout. They have -- yes, they have done very well.
MR SKELTON: Thank you. Thank you my Lady, I'm sorry ...
LADY JUSTICE THIRLWALL: Ms Scolding, I see you there, it is very nice to see you. Do you have any questions?
MS SCOLDING: No, I don't have any questions. Thank you very much, my Lady.
LADY JUSTICE THIRLWALL: Very good to hear that also, given the time, thank you. Mr de la Poer, is that the end of the evidence for today?
MR DE LA POER: It is.
LADY JUSTICE THIRLWALL: Thank you all very much I know we have run over time three times, we will do our best to do a bit better next week. But thank you again and we will start at 10 o'clock on Monday. Thank you for your evidence.
(5.10 pm) (The Inquiry adjourned until 10.00 am on Monday, 11 November 2024)
Witnesses:
Claire McLaughlan: Lay Reviewer, RCPCH
Alexandra Mancini: Nurse Reviewer, RCPCH
Dr David Shortland: Paediatrician & Clinical Lead for Invited Reviews, RCPCH
Dr Nicholas Wilson: Consultant Neonatologist & instructed as Quality Assurance Reviewer, RCPCH
LADY JUSTICE THIRLWALL: Mr De La Poer.
MR DE LA POER: My Lady, thank you. Our first witness today is Ms Claire McLaughlan and I wonder if she might come forward, please.
MS CLAIRE McLAUGHLAN (affirmed)
LADY JUSTICE THIRLWALL: Thank you, do sit down.
McLAUGHLAN: Thank you.
MR DE LA POER: Please could you give us your full name?
McLAUGHLAN: Claire-Louise McLaughlan.
DE LA POER: Ms McLaughlan, is it correct that you provided the Inquiry with a witness statement dated 23 May of this year?
McLAUGHLAN: Yes, that's correct.
DE LA POER: In terms of its content, I think you have identified that you made an error in relation to an interview which you were not present at but that you had thought you were --
McLAUGHLAN: Yes.
DE LA POER: -- when the phrase "gut feeling" was used?
McLAUGHLAN: That's correct.
DE LA POER: Does it come to this: you have realised that
you thought you were present because "CM" was used, but in fact that is a different CM to you and you were not present?
McLAUGHLAN: That's correct.
DE LA POER: Save for that correction, which I think applies in two places, is the content of your witness statement true to the best of your knowledge and belief?
McLAUGHLAN: Yes, it is.
DE LA POER: I am going to run through your background. Did you qualify as a nurse in 1983?
McLAUGHLAN: That's correct.
DE LA POER: Did you gain qualifications in intensive care and teaching in 1998?
McLAUGHLAN: That's correct.
DE LA POER: Between 2002 and 2008, were you an associate lecturer with the Open University?
McLAUGHLAN: Yes.
DE LA POER: What subject did you lecture in?
McLAUGHLAN: It was a foundation course in healthcare.
DE LA POER: During that period, that is to say in 2004, did you cease practising as a nurse?
McLAUGHLAN: Yes.
DE LA POER: I believe you stayed on the NMC register until 2016?
McLAUGHLAN: I think that's correct, yes.
DE LA POER: Now, broadly concurrent with the period that you were an associate lecturer at the Open University, so here I am talking about 2001 to 2005, did you complete a law degree?
McLAUGHLAN: Yes.
DE LA POER: Did you complete the Bar Vocational Course?
McLAUGHLAN: Yes.
DE LA POER: Were you called to the Bar in 2005?
McLAUGHLAN: That's correct.
DE LA POER: We will come back to that topic in more detail in a moment. But just in terms of qualifications, is it right that you never undertook pupillage?
McLAUGHLAN: That's correct.
DE LA POER: And that you never practised as a barrister?
McLAUGHLAN: Correct.
DE LA POER: In your witness statement, you describe yourself as an unregistered barrister?
McLAUGHLAN: (Nods)
DE LA POER: At the time, looking at the CVs that were circulated, did you describe yourself as a non-practising barrister?
McLAUGHLAN: That's correct. Yes.
DE LA POER: Just tell us briefly, please, why the change in description?
McLAUGHLAN: I understand that "non-practising" wasn't
being used any more, and that the term was "unregistered".
DE LA POER: Returning to your background. Did you become the Head of Fitness to Practise at the NMC in 2005?
McLAUGHLAN: I think so, yes.
DE LA POER: And did you undertake that role for two years?
McLAUGHLAN: That's right.
DE LA POER: Did you then move to the National Clinical Assessment Service?
McLAUGHLAN: Yes.
DE LA POER: So that we understand what that organisation is, is that a service that provides impartial advice to healthcare organisations?
McLAUGHLAN: It does.
DE LA POER: And whilst there, did you rise to the position of Associate Director?
McLAUGHLAN: I did.
DE LA POER: So does that account for the period approximately 2007 to 2014?
McLAUGHLAN: It does. Could I just add that it only provides advice about doctors, dentists and pharmacists.
DE LA POER: Yes. Thank you. In 2014, were you made redundant and did you start work as an independent consultant?
McLAUGHLAN: I did.
DE LA POER: So that I describe this accurately, I am just going to read out from your statement what you say about yourself, as a consultant: "[You] provided bespoke holistic services and access to resources relating to performance management including investigations and reviews, revalidation remediation, reskilling and rehabilitation for individual and teams of health professionals and organisations that they work in"?
McLAUGHLAN: That's correct.
DE LA POER: In as succinct a summary as you can give, what did that mean in practice?
McLAUGHLAN: I was contracted by a number of organisations to look at the dynamics within a team, perhaps, or an individual's performance within a team, so it could be the whole team or within a team and help them, the organisation, to better -- better work with the team or the individual and vice versa. I did some investigations around complaints about doctors and dentists and pharmacists and sometimes nurses, mainly about their behaviours and attitudes.
DE LA POER: So not competence?
McLAUGHLAN: No.
DE LA POER: What you say in your witness statement is you've worked with over 300 NHS and private healthcare
organisations and people?
McLAUGHLAN: That included my time with the National Clinical Assessment Service which did look at competence and as well as behaviours.
DE LA POER: Whilst holding yourself out as an independent consultant, did you begin work with the RCPCH --
McLAUGHLAN: Yes.
DE LA POER: -- as lay reviewer?
McLAUGHLAN: Yes.
DE LA POER: And did you begin in that role in 2014?
McLAUGHLAN: I think so, yes.
DE LA POER: Again we will come back to the RCPCH but just to complete what you tell us about yourself. Did you also work for NHS England as a lay panel member for the Performance Advisory Group?
McLAUGHLAN: Yes.
DE LA POER: And as a lay chair of the Performance List Decision-Making Panel?
McLAUGHLAN: Yes.
DE LA POER: And finally as a lay member of the Royal College of Veterinary Surgeons?
McLAUGHLAN: Correct.
DE LA POER: Now, before we go further, I just want to ask you a little bit more about what you say about yourself as a barrister.
Now, to set the scene, and it's not important that you have seen this but Dr Gibbs when he read your CV said in an email that he noted that you had trained as a barrister and that was one of the features of your CV that he pointed out, no doubt that will be because you included what you told us in your CV that was sent by the Royal College?
McLAUGHLAN: Okay. Sorry, I don't know who Dr Gibbs is.
DE LA POER: Dr Gibbs is one of the Consultants that you spoke to upon the visit?
McLAUGHLAN: Okay.
DE LA POER: So far as Ms Eardley is concerned, it would appear that she attributed some significance to that qualification. On Thursday, I asked her about what she thought about your experience of legal process was and the first part of her answer was to describe you as a qualified barrister?
McLAUGHLAN: (Nods)
DE LA POER: And in her statement, she says this about you as a lay reviewer, that you had: "... vast experience in objective investigations from her barrister training and career at NCAS"?
McLAUGHLAN: (Nods)
DE LA POER: Do you recognise that it's important that everybody that you interacted with understood what your
qualification as a barrister meant and what it didn't mean?
McLAUGHLAN: (Nods)
DE LA POER: Do you agree with that?
McLAUGHLAN: Yes.
DE LA POER: At the time, did you identify that there may be a risk that people would read too much into the fact that you had been called to the Bar or was that not something that you considered at the time?
McLAUGHLAN: I was always very careful to make sure that everybody knew, at the time, that I was non-practising. It's only in the last, I don't know, year or so that I came to understand that I should -- should now say I am unregistered to make it clear to people that I am not a practising barrister, but right -- right from the very beginning I always made it very clear I was non-practising.
DE LA POER: Now, in terms of that phrase and I am not -- do not understand that I am criticising you for using that phrase in and of itself, but by saying that you are non-practising may leave open the question that you practised in the past, do you see by saying "I am non-practising today" might allow for the possibility in somebody's mind that you had practised in the past; do you see that that's a possibility?
McLAUGHLAN: I -- yes, yes.
DE LA POER: To what extent was that in your mind at the time; that people might think: oh she is not practising now but she has practised?
McLAUGHLAN: If anybody ever asked me about it, I would say that I had never practised and people did ask me. So it was in my mind, I suppose, that that's -- I -- I never tried to hide that I had never practised and I was very clear about it if people asked me. Otherwise I wouldn't have thought about it.
DE LA POER: If we just think about what Ms Eardley's perception, and this is very much in her mind but she interacted with you. She appears to have ascribed some considerable significance, bearing in mind it was the first part of her answer, to the fact that you were a qualified barrister when being asked about your experience of legal process. In fact, is this fair: your experience as a barrister would not have involved you engaging in any legal process, you have academic training as law degree --
McLAUGHLAN: (Nods)
DE LA POER: -- and you undertook the Bar Vocational Course which is an academic qualification --
McLAUGHLAN: Yes.
DE LA POER: -- not even involving placements --
McLAUGHLAN: Sure.
DE LA POER: -- albeit that you may occasionally go to court as part of that course?
McLAUGHLAN: Sure.
DE LA POER: So to what degree do you think the fact that you were a qualified barrister was relevant to your experience of legal process?
McLAUGHLAN: That's not how I would have described it.
DE LA POER: Similarly, Ms Eardley says that you had vast experience in objective investigations from your barrister training and career at NCAS. NCAS aside, plainly that did give you very considerable experience, but did you in fact gain experience of objective investigations from your barrister training?
McLAUGHLAN: No.
DE LA POER: So again would you say that's not a way that you would have described it?
McLAUGHLAN: I wouldn't have described it.
DE LA POER: So again acknowledging that this is Ms Eardley's perception and her words, but she's somebody that you had interactions with and spoke to, are you able to shed any light on how it may be that she placed that level of emphasis on something that you yourself wouldn't say it justifies?
McLAUGHLAN: No, I cannot answer that.
DE LA POER: And do you think there's any possibility that you overstated or overemphasised the relevance and significance of your barrister training?
McLAUGHLAN: No.
DE LA POER: We are going to move now to your role with the RCPCH and you have told us that it was as a lay reviewer and you had approximately two years' experience before the Countess of Chester inspection?
McLAUGHLAN: I think that's right.
DE LA POER: Or review, rather. You describe that role as having a number of functions: to represent patient and public interest is one part of it?
McLAUGHLAN: (Nods)
DE LA POER: We will come back to that. It's also to stop there being too much jargon being used, is that right, particularly in the final report, to make it more accessible?
McLAUGHLAN: Yes.
DE LA POER: To stop the tendency of professionals who all know each other to talk in a cosy way but to recognise that there needs to be proper boundaries; is that another part of it?
McLAUGHLAN: Yes, I think I call it critical -- being
a critical friend.
DE LA POER: Yes.
McLAUGHLAN: Yes.
DE LA POER: Yes, and if it was just as a friend, you would sit there passively and let them get on with it. Being a critical friend involves you needing to challenge people and say: hang on a minute, I am sitting here as a layperson, this doesn't feel right to me, can you explain it?
McLAUGHLAN: Yes.
DE LA POER: Now, in terms of representing patient and public interest, does that mean that in the context of the Countess of Chester review, you were there representing the interests of the Families of the children who died?
McLAUGHLAN: I can't, I don't, I don't -- it was broader than that. It was -- I think is also the patients who were still there.
DE LA POER: So I have drawn it too narrowly. It includes the category that I have spoken about, but you say it --
McLAUGHLAN: Wider.
DE LA POER: -- is wider than that. In terms of your conduct of that role representing the bereaved families and patients who are still alive and on the unit, how do you say you discharged that particular function of your role as lay reviewer when it came to the Countess of Chester inspection?
McLAUGHLAN: I was there as part of the panel to try to decipher. So to go into -- into the final report what was going on and how -- how it was going on. I was involved in a number of interviews separately from the main group. I can't answer any more than that.
DE LA POER: Speaking generally, is there, in your experience, a risk that sometimes in an NHS setting, people become very focused upon internal disputes, internal politics, internal relationships and that sometimes they are not thinking about the patient first?
McLAUGHLAN: I think that can happen.
DE LA POER: Yes. So would your role be to, when that is happening in front of you, say: hang on a minute, everybody, this is about the patients. That's who we should be thinking about first?
McLAUGHLAN: It could be. Yes.
DE LA POER: Do you think that in the course of the Countess of Chester inspection -- or review, forgive me, my mistake, in the course of the Countess of Chester review, you ever said: I know we have got this two sides of this issue, but don't we need to take a step back, everybody, and think about the patients?
McLAUGHLAN: I don't remember.
DE LA POER: You don't remember?
McLAUGHLAN: No.
DE LA POER: By saying that, are you allowing for the possibility that you did say it?
McLAUGHLAN: (Nods)
DE LA POER: You are?
McLAUGHLAN: Yes. Either I did or I didn't, I don't recall.
DE LA POER: Well, have you seen any note or record of you having said that or anything to that effect?
McLAUGHLAN: No.
DE LA POER: Does that indicate to you that that is unlikely to have happened then, or would you not draw that conclusion?
McLAUGHLAN: I -- I couldn't draw that conclusion. I -- I haven't got a note of it.
DE LA POER: You haven't got a note?
McLAUGHLAN: I haven't seen anybody else's note of it either but that doesn't mean it didn't happen but, but it may not have done. I just don't know.
DE LA POER: No. Well, just examining that for a moment. You didn't make a note of you saying that, nobody else has made a note of you saying that --
McLAUGHLAN: That I have seen.
DE LA POER: -- that you have seen, of the notes that you
have seen, you have no recollection of having said it? It would be quite a significant moment in any meeting, wouldn't it, it is a big challenge to people participating to say: everyone, just stop for a moment, let's think about the patients. Do you agree?
McLAUGHLAN: It's hard to say because it was such a long time ago. There are -- having looked through all of the information that I was given in preparation for this, there were lots of things I didn't recall. So ...
DE LA POER: Well, in terms of your recollection, and granting that we are now 2024 and it was 2016, in fact this was a unique experience for you in all of the reviews that you had conducted; is that fair?
McLAUGHLAN: In retrospect, yes.
DE LA POER: But at the time it's the only time you tell us that they had any issue raised about the possibility of criminality being committed by a member of staff?
McLAUGHLAN: Yes.
DE LA POER: There are other reasons for it to be unique which is that you thought it was going to be one kind of inspection?
McLAUGHLAN: Yes.
DE LA POER: When you turned up, you found it was rather different?
McLAUGHLAN: It was a review.
DE LA POER: A review, forgive me, thank you, I welcome that correction, please ensure that I get that right?
McLAUGHLAN: Yes, you are right.
DE LA POER: But, yes. It was: you thought it was going to be one kind of review and it turned out to be another?
McLAUGHLAN: Yes.
DE LA POER: So there were reasons at the time for it to be memorable, do you agree?
McLAUGHLAN: Yes.
DE LA POER: Then it's not just that we are looking back from 2024, because presumably you will have heard about the arrest or charge or trial of Letby?
McLAUGHLAN: Yes.
DE LA POER: All of which were some time ago now. Presumably that would have caused you to bring to mind your involvement in this review?
McLAUGHLAN: Of course.
DE LA POER: Your thoughts at the time, so we aren't just looking back over eight years, in fact there have been opportunities in the past for you to think about it. So again just doing the best that you can, with those opportunities and the fact that it was memorable in the way it was, do you think that you did give that challenge at any point about thinking about patients or do you think it is likely that you didn't?
McLAUGHLAN: I can't recall.
DE LA POER: In terms of your overall experience of the RCPCH inspections, I think you believe that you did 14 in total over the time?
McLAUGHLAN: I -- I think so.
DE LA POER: That this was number 6; is that right?
McLAUGHLAN: I think that's what I said, yes.
DE LA POER: In terms of the RCPCH training, did the RCPCH give you any safeguarding training?
McLAUGHLAN: I don't think it was done directly through the RCPCH. No.
DE LA POER: Did they have any requirement of you that you had a minimum level of safeguarding training in order to participate?
McLAUGHLAN: I don't recall. But I was always in date for the required level of training that I would -- that I needed for the other jobs that I was doing so I will always have been in date as I am now.
DE LA POER: Did the training that you had received give you a familiarity with Working Together?
McLAUGHLAN: No, it didn't, I don't think.
DE LA POER: In terms of what amounts to a safeguarding allegation; in other words, an allegation that should trigger safeguarding concerns. We will just bring up
what Working Together says about it and see whether it accorded with your definition at the time. INQ0013235, and we are going to go to page 54. So the third bullet, although it's the widest indented bullet towards the top, talks about clear policies being required and then it says this: "An allegation may relate to a person who works with children who has behaved in a way that has harmed a child or may have harmed a child, possibly committed a criminal offence against or related to a child, or behaved towards a child or children in a way that indicates they may pose a risk of harm to children." So before I ask you to agree or disagree with this as being consistent with your understanding at the time, just to pick out some things, we are here framing things in terms of possibilities. So "may pose a risk" or "possibly committed a criminal offence". So that is what Working Together in 2015, which was the current version of the statutory guidance, said. Was that consistent or inconsistent with your understanding of the threshold for safeguarding?
McLAUGHLAN: At the time?
DE LA POER: At the time.
McLAUGHLAN: I can't recall but the training was provided by, I think, the NHS at the time so I am sure that it
will have included that.
DE LA POER: So your expectation is that that you would have been operating on --
McLAUGHLAN: Under this.
DE LA POER: -- the basis that we see there?
McLAUGHLAN: (Nods)
DE LA POER: Thank you. We can take that down. Now, the Invited Review guidance published by the RCPCH talks about when a review may not be appropriate. We can bring it up, INQ0010214 and it's page 8 and we are looking at paragraph 7.5. We can see that the College will not take on cases where the expected scope, the third one down: "Includes behaviour or misconduct, bullying, harassment or possible mental health concerns." Does that accord with your understanding at the time that that's not what the College would be investigating as part of its review?
McLAUGHLAN: Yes, yes.
DE LA POER: Do you agree that the suggestion that somebody may, a member of staff may be murdering babies falls four square within behavioural or misconduct issues?
McLAUGHLAN: Yes.
DE LA POER: If we go over the page to 7.7, we can see that:
"If any of the issues listed in 7.5 come to light, the Review should be completed in relation to its original remit, unless advised to the contrary, in order to avoid prejudicing other investigations by public authority or regulator." Now, you had experience working for a regulator, the NMC, in their Fitness To Practise Directorate?
McLAUGHLAN: Yes.
DE LA POER: No doubt as part of your legal training you gained some understanding of the powers of police and investigating, it is a standard part of law degrees and Bar Vocational Course?
McLAUGHLAN: Sure.
DE LA POER: So just drawing upon that experience, do you recognise that there is a risk to both regulatory and police investigations if the Royal College continues to investigate in a space which is rarely their remit?
McLAUGHLAN: Yes.
DE LA POER: What would you say the risk of prejudice is to those investigations if the College carries on?
McLAUGHLAN: That it's going to slow things down, it's going to put -- give false assurance to people.
DE LA POER: In fact the very process of interviewing people can muddy the waters, can't it?
McLAUGHLAN: Yes.
DE LA POER: It can involve for example getting lots of people into a room as you would without a problem in an Invited Review and have them all share their perspectives?
McLAUGHLAN: Sure, of course.
DE LA POER: But in principle, that's not a good way of conducting a regulatory or police investigation, is it --
McLAUGHLAN: No.
DE LA POER: -- when taking accounts? So, again, that exists as a possible prejudice?
McLAUGHLAN: Yes.
DE LA POER: Do you think that in 2016, based on your experience with the NMC and the training you got on your law degree and in the BBC, that you understood those risks?
McLAUGHLAN: I did. However, if I may --
DE LA POER: Of course.
McLAUGHLAN: -- could we go back to 7.5?, please.
DE LA POER: Yes, of course. It's the page preceding.
McLAUGHLAN: The preceding. In taking on the review, I had personally believed that we would not have been taking on the review if this was the case. So I -- I assumed that this work had been done before --
DE LA POER: Absolutely.
McLAUGHLAN: -- we got there.
DE LA POER: If I can give you this reassurance: Ms Eardley has accepted that she did know that the issues in relation to Letby, although her position was that that was not going to be part of what was going to be considered and she has suggested that she doesn't think she told any of the rest of you --
McLAUGHLAN: No.
DE LA POER: -- about that. So that is not a disputed fact; it accords with your recollection as well. Absolutely, 7.5 is about taking on a review. What 7.7 is about the situation you found yourself in which is that once it has started, if we go back over the page --
McLAUGHLAN: Thank you.
DE LA POER: -- if it comes to light, is how it's framed, during an Invited Review, then it should be completed; is what the language says?
McLAUGHLAN: (Nods)
DE LA POER: Unless it's advised to the contrary in order to avoid prejudicing, so it's understanding that?
McLAUGHLAN: And we weren't advised to the contrary.
DE LA POER: Well, did you offer any advice based upon your experience?
McLAUGHLAN: That was not my place. I was not there in a legal capacity.
DE LA POER: No, but you had an understanding unique to the team about the particular potential damage to a regulatory or police proceeding, you had that in your mind. You have told us that; that you knew that?
McLAUGHLAN: Okay.
DE LA POER: Would it not be the right thing to do, to draw that to people's attention so that they could consider that as part of whether the review should continue?
McLAUGHLAN: I think in the -- in the moment, we were under the impression that no red flags had been raised by a number of different organisations in relation to the allegations that had been made and I suppose we were given a -- a false assurance that that had been considered and dealt with, I suppose.
DE LA POER: We are going to get to the detail of when that assurance was given and what you recollect. But at any point in this process, did you contemplate the police might need to get involved?
McLAUGHLAN: As I say, we were given -- we were on a -- you know, given false assurance, I think, so --
DE LA POER: If I can just ask you to focus on my question.
McLAUGHLAN: Sure.
DE LA POER: At any point in this process, did you anticipate that the police might need to get involved?
McLAUGHLAN: I don't recall the conversations.
DE LA POER: Well, we can go to it in your witness statement. But what you tell us is, jumping all the way to the end, that you thought that by recommending an HR investigation, a disciplinary investigation, that the police would quickly get involved after that. So that's what you tell us in your witness statement?
McLAUGHLAN: Well, if, if -- if they then found that they needed to get involved.
DE LA POER: Yes. So does it follow that the answer is that you did anticipate that the police may need to get involved during this process?
McLAUGHLAN: Yes.
DE LA POER: Understanding as you did at the time about the potential risk to the police investigation, do you think that you should have said, "I think we should all consider the possibility here of stopping because this might damage a police investigation that may happen"?
McLAUGHLAN: No, I didn't.
DE LA POER: Do you think you should have?
McLAUGHLAN: I think I probably should have, in retrospect. But it didn't occur to me at the time.
DE LA POER: Well, you have added two caveats to that "probably" and "retrospect". Just thinking about the question. At the time, with the information you had, bearing in mind you foresaw the police might get involved and you knew from your previous experience about the potential prejudice, do you think you should have spoken up and said, "I think we should stop because of that risk"?
McLAUGHLAN: I wish I had. But, again it's a different -- you are -- I am answering a different question. I understand that, but In --
DE LA POER: You --
McLAUGHLAN: Yes, I should.
DE LA POER: We will turn now please to the beginning of your involvement. You have looked at your records and you think the first contact you had was at the end of June of 2016?
McLAUGHLAN: I think so.
DE LA POER: Is this how it worked, that effectively you told the RCPCH you were willing to act as a reviewer but that was subject to your diary and other commitments so it would be entirely unremarkable for them to reach out to you and say: are you free to agent as a lay reviewer?
McLAUGHLAN: That is how it worked.
DE LA POER: That is essentially what happened here?
McLAUGHLAN: (Nods)
DE LA POER: What you say in your witness statement about your understanding at the start of this process was: "It was my understanding that ahead of the Countess
of Chester Invited Review taking place there were no known circumstances or allegations highlighted to the Review Team."
McLAUGHLAN: That's correct.
DE LA POER: That's your very clear understanding, is it?
McLAUGHLAN: Yes.
DE LA POER: Could you turn up paragraph 36, because it should be in the witness statement in front of you. Do you have that?
McLAUGHLAN: Yes.
DE LA POER: What you say in paragraph 36 is: "Had I been aware of the concerns about Ms Letby prior to the visit during the preparatory stage, or even the evening before, I would not have participated in the review." Then you go on to say: "I would have advised the RCPCH that in the circumstances the Terms of Reference, especially the fourth bullet point [and you go on to quote it] were misleading and that it was inappropriate to start a service review until these matters had been dealt with and the situation clarified." We will just pause there for a moment. Why do you describe the term of reference as "misleading", what was it that caused you to describe it in that way?
McLAUGHLAN: Because they had already identified something that linked the death, or they thought they had identified something that had linked the deaths.
DE LA POER: Yes, and so you read that fourth term of reference as implying that no link had been identified yet?
McLAUGHLAN: Yet. Yes.
DE LA POER: You say: "I would have advised the Countess of Chester to follow its own internal processes for dealing with such serious allegations made, I believe, in good faith such as clarifying the concerns, taking them seriously, seeking HR legal advice, considering a formal restriction of practice or exclusion from practice was required and following that process. That would have included beginning a conduct or capability investigation and appointing an independent investigator as well as discussing the matter with the police and with the NMC."
McLAUGHLAN: (Nods)
DE LA POER: So if we understand what you are saying here is, if the night before you had been told "the Consultants have identified that there is a nurse who is on duty for most of these deaths" and we will just limit it to that, "and they are concerned that she may be deliberately harming babies", if that was said to you,
you would have said number one, we mustn't do this review?
McLAUGHLAN: (Nods)
DE LA POER: Is that right?
McLAUGHLAN: Yes.
DE LA POER: Number two, we need to tell the Countess of Chester that they need to engage some kind of HR process and/or take legal advice; is that right?
McLAUGHLAN: Yes, yes.
DE LA POER: Three, that they should consider whether or not it is necessary for that nurse to be excluded from practice?
McLAUGHLAN: Yes.
DE LA POER: And four, that they should discuss the matter with the police and the Nursing and Midwifery Council?
McLAUGHLAN: Yes.
DE LA POER: That's the night before.
McLAUGHLAN: Or previous.
DE LA POER: Or earlier than that?
McLAUGHLAN: Yes.
DE LA POER: 12 hours or so later, you were given that information, weren't you?
McLAUGHLAN: Yes.
DE LA POER: At that stage, did you say: we should stop?
McLAUGHLAN: No.
DE LA POER: At that stage, did you say: you should consider some formal restriction or exclusion from practice?
McLAUGHLAN: No.
DE LA POER: At that stage, did you say that they should undertake an HR process and/or take legal advice?
McLAUGHLAN: No.
DE LA POER: At that stage, did you say: you need to discuss this with the police and the NMC?
McLAUGHLAN: No.
DE LA POER: So I suppose the question really is --
McLAUGHLAN: Why.
DE LA POER: -- what changed over those 12 hours that you were -- you are so clear, if I may say so, about the precise steps that would have been taken the night before, you accept you didn't take any of those steps 12 or so hours later when you were possessed of that information. Why not?
McLAUGHLAN: Again we were given a false level of assurance and we were hearing about -- it was sort of dropped into the conversation as a "by the way" ... it wasn't given any level of importance or credence and it was given to us as part of almost a breakdown in relations.
DE LA POER: But what -- that was what the Executives were
saying?
McLAUGHLAN: Yes.
DE LA POER: But you immediately went to speak at some length with Dr Brearey and Dr Jayaram who gave you their perspective?
McLAUGHLAN: Sure.
DE LA POER: What was being said was an allegation of the very most serious type?
McLAUGHLAN: (Nods)
DE LA POER: Do you agree with that?
McLAUGHLAN: Yes.
DE LA POER: I would just like to -- I asked Ms Eardley this same question, I would just like to reflect on it. If it had been, to use your phrase, just dropped into the conversation, that doctors were worried about a member of staff sexually assaulting a patient, and if you then went to see the doctors and they said, "Yes, that is what we are worried about", do you think you would have reacted any differently?
McLAUGHLAN: I don't know. I don't know.
DE LA POER: I am just trying to unpick what you say here because you have accepted that --
McLAUGHLAN: Yes.
DE LA POER: -- it is an allegation of the most extreme type, albeit played down or whatever phrase, "false
assurance" given by the Executives. But the doctors weren't giving you that assurance, were they?
McLAUGHLAN: Well, they gave us a mixed picture because they told us in one breath about their concerns and the allegations they were making. But in the next breath they were telling us what a good nurse she was.
DE LA POER: Well, it's possible to be a good nurse and a murderer?
McLAUGHLAN: I am not saying it isn't and I am not downplaying this.
DE LA POER: They weren't suggesting to you that their worry was that through incompetence she was killing the babies?
McLAUGHLAN: But they found it hard to believe as well.
DE LA POER: Well, but they still entertained in good faith, to use your phrase, that suspicion?
McLAUGHLAN: They did.
DE LA POER: That is that --
McLAUGHLAN: But they hadn't called the police either.
DE LA POER: Well, they can answer for that.
McLAUGHLAN: Sure. But that was -- that was part of the false assurance that we were given. The whole picture of the false assurance.
DE LA POER: But they -- on the subject of the police they
had told the Executives in the expectations the Executives would call the police and so in the doctors' minds, do you agree, the police should be called, but they were following a process, tell the Executives, and at that point what they had thought would happen didn't happen. So it wasn't as if they were telling you: we don't think the police need to be involved. They told you they thought the police should be involved but the people they thought should call the police were the Executives and the Executives weren't doing it. So again is it fair to describe that as a false reassurance?
McLAUGHLAN: Yes, I think so because they had -- they had the ability to call the police themselves individually. So this was all a pattern of -- of having looked at the information, this one piece of information that we were given which was uncorroborated against all the other information that we had been given as a package that looked at the Coroner's reports and the CDOP reports and the network review, looking in, in the whole of the context that there were no red flags, that this was the only piece of evidence that we were -- well, the only piece of information, I wouldn't at that stage even have called it evidence, that there was something else going on.
DE LA POER: Well, you have described it as uncorroborated and that is a phrase you use a number of times in your witness statement?
McLAUGHLAN: Yes.
DE LA POER: So let's just see if we can understand what you mean by that. So if we go to paragraph 108, that is an occasion where you use that phrase. Do you have paragraph 108?
McLAUGHLAN: I do, yes.
DE LA POER: What you say: "In my opinion I cannot speak for the whole team. This was the personal view, feelings, interpretation of one person regarding Ms Letby, it was not based on fact and was uncorroborated. Even now I would not consider his view as objective or impartial as he was too involved, too close to the situation and had a conflict of interest." I just want to look at some of the language you have used there to try and understand it. You start by using the word "personal". You don't say it was his view or his professional view or his expert view or his view as a Consultant. You say "personal". Why did you choose the word "personal" there?
McLAUGHLAN: My understanding was that that the -- it was one person who I -- it was one person who had put the information together.
DE LA POER: We will come on to the one in a moment. Why personal?
McLAUGHLAN: Because he -- that, that's how it was presented; this is what I have done ...
DE LA POER: Can I invite you to reflect on this. Within a professional setting, it's quite common to distinguish between personal views and professional views. A professional view is somebody offering their opinion, which is just their opinion, based upon their professional knowledge and expertise. A personal view is usually understood to mean a view that they are giving outside of the parameters of their professional expertise or outside of their job. Are you familiar with the distinction?
McLAUGHLAN: I can understand where you are coming from, yes.
DE LA POER: Now, you have used the word "personal" here?
McLAUGHLAN: Sure.
DE LA POER: Do you not think that giving that opinion the appropriate respect that it was entitled to, that actually it was a professional or expert view?
McLAUGHLAN: The information we were given was of --of the
duty rosters and --and an interpretation of the duty rosters for the doctors and nurses that were present during the period that the babies died. It's not normally the role of somebody of that doctor's status and experience to have any involvement, is my understanding, in the rostering of staff. And therefore I would not have -- I wouldn't have called it his professional role for him to take on the analysis that he apparently did of those rosters.
DE LA POER: Wasn't what you in fact were told rather more complicated than that; that what you had was a Consultant, the head of the neonatal unit if we just talk about the one individual you are referring to, who using his professional expertise looked at the deaths and could not understand, applying all of that medical knowledge, why there had been an increase in the deaths. So that is absolutely 100%, would you agree, his professional expertise being exercised?
McLAUGHLAN: Absolutely.
DE LA POER: That he as any reasonable person would start from the fact there could be any number of possibilities for this, but I need to work my way through to exclude the ones which it definitely isn't? And that he had undertaken that process and that he had using that expertise excluded lots of common explanations, again
all exercising his professional judgment, would you agree?
McLAUGHLAN: Yes.
DE LA POER: And it was absolutely part of that exercise of his professional judgment to consider whether staffing may have been responsible for the increase in the deaths, do you agree?
McLAUGHLAN: I agree.
DE LA POER: When he came to look at that area, he found what he thought was a surprising state of affairs in the first instance which was that there was one person, unexpectedly in his mind, associated with every single one of the deaths bar one?
McLAUGHLAN: Yes.
DE LA POER: In addition, the cohort of babies he was considering he knew, based upon his professional expertise, were not expected to die and so we weren't just talking about an increase in the deaths. He was looking at babies who he expected to survive and so he was dealing with an unexpected cohort and he didn't have an explanation beyond the commonality that he had identified. Is that all fair about the information you were told?
McLAUGHLAN: That's fair.
DE LA POER: So do you see that or do you think that in fact it might in fact be absolutely his provisional judgment that is being involved here?
McLAUGHLAN: I -- yes.
DE LA POER: The fact that you used the word "personal", do you think that that is a reflection of the fact that perhaps even until this very moment, you had not seen what you were being told in those terms?
McLAUGHLAN: Yes.
DE LA POER: Again, do you think that's a reason why you might have used for example the word "feeling" in your list of three personal attributes where you said this was the "personal view/feeling/interpretation"?
McLAUGHLAN: Yes.
DE LA POER: Because if we are going to be real about it, describing something as a personal feeling is not terribly persuasive; describing something as a professional interpretation is rather more persuasive? Do you agree?
McLAUGHLAN: I agree.
DE LA POER: But you were -- when you wrote this, which was in fact I think only in May of this year, your take on it was that this was capable of being described as a personal feeling?
McLAUGHLAN: Yes.
LADY JUSTICE THIRLWALL: Now, Mr De La Poer, is that a convenient moment?
MR DE LA POER: It absolutely is, my Lady. Thank you very much.
LADY JUSTICE THIRLWALL: I should have mentioned earlier, I hope you have been told. We are going to take the break now. There is a service going on outside and obviously we will be observing the two minutes' silence and it seemed to me more appropriate that if we break now and we will come back in at 10 past 11.
(10.49 am) (A short break)
(11.10 am)
LADY JUSTICE THIRLWALL: Yes, Mr De La Poer.
MR DE LA POER: Ms McLaughlan, we are looking at paragraph 108 and we have dealt with personal and feelings and we are I think agreed that the correct analysis is "professional opinion", and then we read on, "of one person". Now, in fact, Dr Brearey who I think is the one person you are referring to sat in a meeting with you and other reviewers together with Dr Jayaram; is that correct?
McLAUGHLAN: I believe so, yes.
DE LA POER: The two of them were speaking effectively with
one voice about their concerns, weren't they?
McLAUGHLAN: In the meeting, yes.
DE LA POER: Yes. So the starting point is that bearing in mind that, do you think it is fair and accurate to suggest that this is the professional opinion of one person or do you think that in fact one person is not the correct description?
McLAUGHLAN: My understanding was that the tables, the -- the Excel spreadsheet had been done by one person and that's what I mean by that.
DE LA POER: But as we have discussed already, it's not just about that table, it's about the expertise that was brought to bear to understand how common causes were not an explanation and the fact that the deaths were unexpected, so you were dealing with a particular cohort of deaths?
McLAUGHLAN: I am, in this paragraph I am talking about that one piece of information, that one Excel spreadsheet.
DE LA POER: But you are here summarising, aren't you, your overall view of the information that you were provided with?
McLAUGHLAN: I believe I am talking about that one piece of information, which was the Excel spreadsheet.
DE LA POER: I understand that that is what you are
referring to. But are you not offering that characterisation as being the overall -- your overall assessment?
McLAUGHLAN: No, no, my -- that, that is about that -- the uncorroborated evidence I am talking about is that Excel spreadsheet.
DE LA POER: Well, let's read the whole paragraph. At paragraph 3.12 it is stated that: "The paediatric lead and all the Consultant paediatricians had become convinced by the link between Letby and the deaths but it is stated this was a subjective view with no other evidence or reports of clinical concerns about the nurse beyond this simple correlation. In section 4 it is stated there was no other evidence or history to link Nurse L to the deaths"?
McLAUGHLAN: Yes.
DE LA POER: Then you give "in my opinion", so ...
McLAUGHLAN: Yes. That is what I am referring to. That is the link to Nurse L is that spreadsheet.
DE LA POER: But --
McLAUGHLAN: That's exactly what I am referring to there.
DE LA POER: But the link to Nurse L, Letby, is in the context of the wider information that you are being provided with?
McLAUGHLAN: I am talking here about that one piece of evidence which was the Excel spreadsheet. I am very clear about that, that's what I am talking about.
DE LA POER: Well, I invite you to consider an alternative interpretation, because if we look on to what you say: "There had been no independent review or oversight of the allegations and the information provided in support of the allegations."
McLAUGHLAN: Yes, that's that one piece of evidence which was the Excel spreadsheet.
DE LA POER: It was -- I'm sorry, I don't want to stop you saying something you want to say.
McLAUGHLAN: Nobody else had looked at that spreadsheet. We were just given the spreadsheet with the analysis undertaken. We didn't even get to see the underpinning rosters and rotas on which that was based. That's what I am talking about there.
DE LA POER: So --
McLAUGHLAN: That's what --
DE LA POER: The spreadsheet that Dr Brearey created was attached as appendix 1 to the thematic review, that was a meeting at which a number of people visited. It was based on the work of the nursing manager of the unit, Eirian Powell, who had created that spreadsheet earlier. It was reviewed by the Executives and nobody ever
suggested that its content was wrong. The dispute was about its interpretation?
McLAUGHLAN: I am not aware of the thematic review that you are talking about other than in -- in the broadest terms. I was presented with the Excel spreadsheet in isolation.
DE LA POER: So the thematic review was a document that was provided to all reviewers beforehand and it was the document that the lead reviewer commented upon in that email which you say you didn't see?
McLAUGHLAN: Yes.
DE LA POER: So that is --
McLAUGHLAN: Yes.
DE LA POER: So that is Dr Brearey's work in February that you were told about and the document that you received?
McLAUGHLAN: I only remember seeing the Excel spreadsheet. That's what I am talking about there, I am not talking about the thematic review.
DE LA POER: Well, did you think that there was in fact any dispute of fact over whether or not Letby had been correctly identified at nine out of the ten deaths?
McLAUGHLAN: The -- sorry, can you say that again?
DE LA POER: Yes, of course. Did you think that there was any dispute of fact about the contention that Letby was present at nine out of the ten deaths, or associated
with them?
McLAUGHLAN: Not later. But at that time, which is what I am talking about here, that's all I was aware of --
DE LA POER: So --
McLAUGHLAN: -- was that Excel spreadsheet.
DE LA POER: The Executives told you that a nurse had been identified by a Consultant, that is what they told you?
McLAUGHLAN: Yes, a nurse had been identified by a Consultant.
DE LA POER: Yes, yes. And they also told you in that first meeting that they had conducted their own investigation, Ian Harvey is noted as recalling "it's all been investigated". We can look at that note if you would like to?
McLAUGHLAN: I would like to, please, yes, just to remind myself.
DE LA POER: Yes, of course.
McLAUGHLAN: Thank you.
DE LA POER: Of course. INQ0014604. We will look at the first page. Just four lines up you see against Ian Harvey's name: "Been through all the evidence." And he then starts talking about another aspect of the evidence. It's just the first part that's the important bit;
that, do you agree, Ms McLaughlan, that at no time did the Executives suggest to you that the analysis which suggested an association was wrong?
McLAUGHLAN: I don't know that he's referring to the Excel spreadsheet or --
DE LA POER: I will just ask my question again. Do you agree that at no time the Executives suggested to you that the analysis indicating that Letby was associated with nine out of ten deaths was wrong?
McLAUGHLAN: No.
DE LA POER: They are here saying that they had been through all the evidence, that's what the note records. So do you agree it would be quite a surprising state of affairs if there was actually any dispute about something which could be so readily checked if you hadn't been told about it?
McLAUGHLAN: Sorry, say that again, please?
DE LA POER: Of course. It would be quite a surprising state of affairs, given how easy it would be to check that, if the Executives had checked it, found that it was wrong, and then didn't tell you?
McLAUGHLAN: That's right. But we hadn't seen it for ourselves.
DE LA POER: But --
McLAUGHLAN: That's what I am talking about in that -- in that paragraph 108; that it was at that point it was uncorroborated, it's that simple.
DE LA POER: But uncorroborated by whom?
McLAUGHLAN: Anybody.
DE LA POER: Well, it had been corroborated by the Executives.
McLAUGHLAN: But I don't know that that's what he's referring to four lines up on that page.
DE LA POER: Well, if you were uncertain about whether that underlying very simple analysis was correct or not, did you ever ask?
McLAUGHLAN: We didn't get that at that point.
DE LA POER: Well, you --
McLAUGHLAN: We didn't have it at that point.
DE LA POER: You had received the thematic review which said the same thing?
McLAUGHLAN: I don't recall seeing that Excel spreadsheet before we received it -- I believe I received it on that first day of the review.
DE LA POER: When the Executives told you that the doctors had or the doctor had identified this association, did you say to them, "Have you checked to see whether that's right?"
McLAUGHLAN: I don't recall.
DE LA POER: Well, is there any record of you having said
so?
McLAUGHLAN: No.
DE LA POER: Do you have any recollection of having said so?
McLAUGHLAN: I just said I don't recall.
DE LA POER: Well, I think -- so you don't have a recollection of saying so?
McLAUGHLAN: No.
DE LA POER: So does it seem likely that you didn't say that?
McLAUGHLAN: I didn't ask.
DE LA POER: Could the explanation for that be because everybody at all of the meetings that you had were proceeding on the basis that underlying facts were correct, that it was a dispute about the interpretation of those facts that represented the difference between the different sides?
McLAUGHLAN: Yes.
DE LA POER: So if that is the basis on which the entire review was conducted, just help us with why in your reflection in May of 2024 you are talking about that particular chart as not being based on fact and being uncorroborated?
McLAUGHLAN: Because we hadn't seen -- I hadn't seen the evidence on which it was based. It was that moment in
time when we were given that document -- that I was given that document to see that that's all we had.
DE LA POER: On what basis could you assert that it wasn't based on fact?
McLAUGHLAN: So the -- the doctor that I understand completed that was one person who may, who could have and -- manipulated the data without seeing the underlying rotas. We had seen the doctors' rotas, I understand, but not the nursing rotas.
DE LA POER: I'm afraid I am going to have to ask you to look at your assertion: you weren't saying maybe it wasn't based on fact, you have asserted in terms it was not based on fact. How were you in a position to hold that view in circumstances, particularly as this is a doctor who's done the analysis, and that analysis has been available for everybody to check at the hospital and nobody in the 48 hours you conducted this inspection suggested it was wrong, so how is it that you come to be asserting it was not based on fact?
McLAUGHLAN: I was wrong to do that.
DE LA POER: Well, just taking a step back. Do you think until this moment, in this hearing, you had rather underestimated the significance of the information you were provided with by the doctors?
McLAUGHLAN: That --
DE LA POER: The overall significance of it, do you think that at the time you ascribed too little significance to it?
McLAUGHLAN: Yes.
DE LA POER: Why do you think it has taken until now for you to see that?
McLAUGHLAN: I can't answer that specifically. I -- I can't -- I -- I don't know.
DE LA POER: Well, what additional factors were you, incorrectly as it must be, weighing in the balance to -- to cause you to think less of that information at the time?
McLAUGHLAN: The circumstances in which I was given that information were that there was a lot of assertions at the time that Ms Letby was being scapegoated.
DE LA POER: Do you think that you placed too great an emphasis upon that?
McLAUGHLAN: In retrospect, yes.
DE LA POER: Did you have enough information at the time to make the balanced judgment that you are now making?
McLAUGHLAN: No.
DE LA POER: Why not?
McLAUGHLAN: Because a lot has happened since then.
DE LA POER: But on the one hand of course you are mindful of the individual employee and the possibility of being scapegoated. On the other hand you have got two doctors, as we will come to in a moment, sitting in front of you telling you that they are, having exercised their professional expertise, dealing with an unusual cohort of patients and they cannot see any other explanation and they are worried. Why is that not enough to weigh in the balance and say; well, obviously it's not for me to determine which is right, but we need to act on the basis that the frankly more serious of those risks is right?
McLAUGHLAN: In the context we were at the time we also had had -- we had knowledge that the cases had been through a Coroner's investigations who had, they had been through network reviews. So I don't think we were in a place at that time to think the unthinkable.
DE LA POER: Well, you presumably -- and in fact you tell us in your witness statement, you are aware of the case of Beverley Allitt?
McLAUGHLAN: But not -- we weren't in that context at the time.
DE LA POER: Well, the context is that somebody was saying a nurse may be killing babies.
McLAUGHLAN: That wasn't until afterwards, I think.
DE LA POER: Wasn't that exactly what Dr Brearey and Dr Jayaram were saying that that was their worry;
somebody may be killing babies?
McLAUGHLAN: Yes. But I think that -- I can't speak for everybody else but I think at that time we thought that had been excluded because of all of the other work that had gone on around before the College was involved.
DE LA POER: What did you think that had been done to exclude that possibility?
McLAUGHLAN: That there had been no red flags raised by the organisations I had already talked about, so the Coroners had been involved and the CDOP and the network review had all looked at those babies' deaths.
DE LA POER: The network review had concluded that they couldn't identify a common theme, that was in the thematic review --
McLAUGHLAN: (Nods)
DE LA POER: -- that was sent to you. But what organisation is capable of determining whether or not murder has been committed?
McLAUGHLAN: So the -- well, of course that would be the police.
DE LA POER: You knew the police hadn't been involved?
McLAUGHLAN: Yes.
DE LA POER: Although the doctors wanted the police to be involved?
McLAUGHLAN: Yes.
DE LA POER: Well, look, let's have a look at some of what you were told in more detail. We can deal with the preparation fairly briefly. You saw both sets of Terms of Reference but I think that not knowing the information that Ian Harvey provided to Sue Eardley you didn't perceive a difference between the two of them?
McLAUGHLAN: There was a slight difference in one of the Terms of Reference about the common themes I think, but --
DE LA POER: You also tell us that you didn't see the lead reviewer's email in which he identified the commonality of Letby?
McLAUGHLAN: Yes.
DE LA POER: I mean, if we just pause to think about that. The lead reviewer on the information that you had all been sent had identified that for himself?
McLAUGHLAN: I'm not sure that that was in ...
DE LA POER: He saw the thematic review --
McLAUGHLAN: Okay.
DE LA POER: -- which identified Letby as being present at nine out of the ten deaths which is?
McLAUGHLAN: I don't recall seeing that.
DE LA POER: Was it your practice to read every document that you were sent?
McLAUGHLAN: Not every single document, no.
DE LA POER: If a document was identified as thematic review, would that be the sort of document that you would think may be important?
McLAUGHLAN: I am surprised that I didn't look at it, yes.
DE LA POER: Are you able to take it from me because I know that you read Ms Eardley's evidence from Thursday or we can look at the references, that in her email circulating it to you all access to the material, she specifically drew attention to the thematic review as being one the documents that should be considered?
McLAUGHLAN: Could I see that, please?
DE LA POER: Yes, of course. INQ0012846. This is 12 August and what she says here, it is the third paragraph: "Key things to look at but probably the Mortality Reviews. There are some concerns coming out of Transport Service. Please keep the Terms of Reference in mind."
McLAUGHLAN: That is, is that I -- I thought you said it was entitled "Thematic Review"?
DE LA POER: "Of Neonatal Mortality" is the full title of the document?
McLAUGHLAN: Okay. Okay. I -- I don't remember seeing the email. I obviously received it. I don't recall.
DE LA POER: Well, let's move forward to day one and it's in your first meeting with Ian Harvey and Alison Kelly that you are told about the doctors' concerns.
McLAUGHLAN: Yes.
DE LA POER: What was your overall impression of Mr Harvey's attitude towards the seriousness of the allegations and the calling of the police?
McLAUGHLAN: I don't recall the conversation specifically and the detail of the conversation. I think the feeling that I got was that he didn't want to do that.
DE LA POER: Are you able to give us any more detail about where that feeling might have come from? Is that just an impression of the overall conversation?
McLAUGHLAN: Yes.
DE LA POER: And so far as Alison Kelly was concerned, the other person present at that first meeting, what was your overall impression of her attitude towards the seriousness of the allegations and calling the police?
McLAUGHLAN: I don't recall. I recall her being supportive of Ms Letby.
DE LA POER: Now, one of the notes, and we will bring it up on screen, we are not going to look at all of it, INQ0014604, this is a note by Ms Eardley who was acting as notetaker, and this is really just to prompt your collection, I hope. We can see halfway down the text, so it's about
two-thirds of the way down: "Director of Corporate Affairs was DCI before he" and then "huge nettle to grasp, need to unpick things around", then "rely on him". So these are handwritten notes transcribed so they are not always easy to interpret. But do you have a recollection of being told that the Director of Corporate Affairs was a former Detective Chief Inspector?
McLAUGHLAN: I don't recall that. However, could it -- is it possible to see the handwritten note because I looked at this again last night and I think the -- this transcript is not quite accurate?
DE LA POER: If you just bear with me a moment.
McLAUGHLAN: Thank you, sorry.
DE LA POER: Not at all. INQ0010124. So you will just have to help us to navigate where it was that you --
McLAUGHLAN: It's down further down the notes where there is an indent.
DE LA POER: So if we go to the next page.
McLAUGHLAN: And further down, sorry. And further down again. Oh, where was it? Sorry. Further down. No, it must be --
DE LA POER: I think we are going to need to go back because we are moving off that meeting?
McLAUGHLAN: Yes, go back to the top.
DE LA POER: Go back to the first page, I have got up in front of me --
McLAUGHLAN: It must be.
DE LA POER: -- the transcription.
McLAUGHLAN: Yes. Sorry, it's halfway down on that first page.
DE LA POER: Yes.
McLAUGHLAN: So it says £the Director of Corporate Affairs was DCI before" and then there is the bit that is redacted.
LADY JUSTICE THIRLWALL: Before he retired.
MR DE LA POER: He retired.
McLAUGHLAN: Yes, and then the arrow down below that is "rely on him reference police" I think that says, rather than "not police". So it would appear to me that they took advice from the Director of Corporate Affairs about going to the police.
DE LA POER: At that time what did you understand Ian Harvey and Alison Kelly's attitude towards going to the police was?
McLAUGHLAN: Not to do that because they had taken advice from the DCI. But this is my -- the previous DCI. This was my interpretation now as I don't recall that from the time.
DE LA POER: Thank you. I wonder if we can go back to the typed notes, INQ0014604. We are going to need to go to page 2. This is something that your colleague Ms Mancini says. In the middle of the page, "Alex", do you see that that reference, "Can we see PM reports?"
McLAUGHLAN: Yes.
DE LA POER: Now, would it be normal for an Invited Service Review to be reviewing the postmortem reports for individual patients?
McLAUGHLAN: I don't know. I don't think so but I don't know.
DE LA POER: Well, just -- I appreciate this is what the nursing member of the panel is saying, but you have an understanding of what the purpose of such reviews is for?
McLAUGHLAN: (Nods)
DE LA POER: Do you think that was an opportunity for you to say: I just think we all need to take stock here?
McLAUGHLAN: Yes.
DE LA POER: That we are not here to look at the postmortem reports for individual children, we are here to do a service review?
McLAUGHLAN: I think we were all a bit shocked about what we had heard. Yes, it was a missed opportunity.
DE LA POER: So that's a wrong turn, isn't it, for the whole review process?
McLAUGHLAN: Okay.
DE LA POER: If we go to page 3, just above "CM's process" which I think we will come to in a moment, which is a reference to you, we see what it says is: "Need details of nurses who looked after the babies at the time." Again this appears to be the reviewer's, and it is not ascribed to any particular individual, asking for the details of individual nurses who were looking after the babies?
McLAUGHLAN: (Nods)
DE LA POER: Again is that something that you would expect at an Invited Service Review?
McLAUGHLAN: Given the information -- it goes back to what I said before about not having had the information until this point. It's getting a bit muddied.
DE LA POER: Well, it rather looks like you are suggesting to the Executives that you will carry out some kind of investigation of which nurses were on duty or associated with the deaths and when I say "you", I mean you collectively, not you personally?
McLAUGHLAN: Yes, yes.
DE LA POER: So again would you say that is another wrong turn that the review is taking in that first meeting?
McLAUGHLAN: It could be seen like that, yes.
DE LA POER: Well, do you see it that way?
McLAUGHLAN: Yes.
DE LA POER: We then see "CM's process", and was this you with your background and experience trying to understand for yourself what had been done so far as the nurse who you had been told about was the subject of suspicion?
McLAUGHLAN: Yes. I believe I was asking about what process had been undertaken.
DE LA POER: Yes. And if we go over to page 4, we can see again it is not attributed to anybody but what seems to be said is: "Just taken out of duties. How to get her back in again."
McLAUGHLAN: Yes.
DE LA POER: That seems perhaps more likely that that's the Executives speaking --
McLAUGHLAN: Yes.
DE LA POER: -- rather than the reviewer. But on the basis of that note, what seems to be being said to you, the reviewers, on 1 September by the Executives is that they have taken her out of the duties, but what they are looking to do is get her back?
McLAUGHLAN: Yes.
DE LA POER: Is that what they were telling you at that time?
McLAUGHLAN: I think that was the impression we got which gave us the impression that they hadn't given any credence to the allegations.
DE LA POER: Page 5. We can see right at the bottom: "CMC parents complaints", which appears to be you asking whether the parents had complained, and then what appears to be an answer from the Executives: "Contacted as many parents as possible before it went to the paper. No extra complaints." Then over the page: "Accepted we are doing the right thing. Nobody had raised concerns." And no -- and there is a triangle signalling no draining, presumably, before that in terms of complaints or no warning." Did you think that the views of the parents were important to your review?
McLAUGHLAN: Sorry, could we go back down to the previous page?
DE LA POER: Yes, of course.
McLAUGHLAN: Because I think this was about the unit being downgraded.
DE LA POER: I think the preceding topic is discussion about Occupational Health as recorded in these notes.
McLAUGHLAN: I don't -- I don't know, I can't recall the context that I would have asked about that.
DE LA POER: Bearing in mind that Ms Mancini appears to have asked to see the postmortem results in relation to those babies, what was the ethical position so far as the RCPCH were concerned and consent? Would you have regarded yourself as needing to get the parents' consent before you could see a postmortem on their baby or would you have regarded that as something, I mean, I saw your expression there and quizzical perhaps is the right way of describing it?
McLAUGHLAN: Yes.
DE LA POER: I mean, you were there representing the interests of patients and parents --
McLAUGHLAN: Yes.
DE LA POER: -- and so on, so invading their privacy is something that you would have an eye on presumably as part of that function to make sure that their confidentiality was respected. What did you understand the position about whether they needed to consent to postmortem reports about their babies being given to the reviewers?
McLAUGHLAN: I can't say I gave it thought at the time.
DE LA POER: Do you think that's something you should have been thinking about?
McLAUGHLAN: I should have done.
DE LA POER: Do you think that there's a possibility at least that you were for whatever reason perhaps not putting the parents of those babies at the centre of your thinking as you were conducting this review?
McLAUGHLAN: I can't, I can't, I can't say. Perhaps they weren't at the centre.
DE LA POER: Is it fair to say that of all the people who were there, and everybody should have that in mind, but it was your role to be the check and balance on that and ensure that that happened?
McLAUGHLAN: But -- yes.
DE LA POER: The next discussion -- thank you, we can take that down and again I am certainly not trying to rush you, but we have been over some of this already in terms of what you were told. You had a discussion with Dr Brearey and Dr Jayaram and in summary, they told you that things had been fine until June 2015 when they had had three deaths?
McLAUGHLAN: (Nods)
DE LA POER: And that at that stage, the fact that there was a common nurse was noted but not thought to be significant?
McLAUGHLAN: Yes.
DE LA POER: Dr Jayaram told you how it was the way in which the babies collapsed which was the concern to him?
McLAUGHLAN: (Nods)
DE LA POER: And they told you about the thematic review that had been conducted and said that the deaths -- increase in the mortality rate was still unexplained?
McLAUGHLAN: Yes.
DE LA POER: They told you about the fact that the nurse that they were concerned about had been on shift at all the times and that that had been something that they had told the Executives; is that right?
McLAUGHLAN: Yes.
DE LA POER: And they told you that Letby had been moved from night shifts to day shifts and that the pattern had then changed?
McLAUGHLAN: Yes.
DE LA POER: Now, Dr Stewart's note of that meeting includes this: "Paeds worried about foul play." And that is something that you looked in your statement to reflect upon. Do you recall the phrase "foul play" being used?
McLAUGHLAN: I don't think so.
DE LA POER: But they were worried about murder, weren't
they?
McLAUGHLAN: Yes.
DE LA POER: So whatever --
McLAUGHLAN: Yes, yes.
DE LA POER: Well, they also told you that they conducted research into how Letby might have killed the babies because they told you that they had looked up air embolism, didn't they?
McLAUGHLAN: Yes.
DE LA POER: And the notes record the word "chilling" against Dr Jayaram as he described the process of him conducting that research. Do you remember him using the word "chilling"?
McLAUGHLAN: No.
DE LA POER: Do you have an impression of the emotion or lack of emotion that he spoke about this with?
McLAUGHLAN: No.
DE LA POER: The note also makes it absolutely clear "injecting air into babies", that's the handwritten note of what was being said.
McLAUGHLAN: (Nods)
DE LA POER: So is it fair to say that at the end of that meeting, you had had communicated to you very clearly that they at that moment in time suspected -- no more than that, suspected -- that Letby may have murdered
babies?
McLAUGHLAN: Could you take me to that note, please?
DE LA POER: Yes, of course.
McLAUGHLAN: Sorry.
DE LA POER: INQ0014604. Which particular part of it? Is it the embolism?
McLAUGHLAN: Yes.
DE LA POER: Yes, of course. So we will go to page 10 for this. So we see at the bottom: "When thinking forensic what happens with air embolism? Looked at case studies and last [query] observation: chilling. Just like what happened. Babies [and then if we go over the page] unresponsive to any inputs." And lists them: "Odd skin discolouration, blue with eyelids of pink in the ..." And then this: "Injecting air into the babies" with "??" against it. So that is what I was suggesting the notes record?
McLAUGHLAN: Sure.
DE LA POER: My question was whether you agree that at the end of that meeting, they had communicated to you and the other reviewers that they were suspicious of whether Letby had murdered babies?
McLAUGHLAN: I'm not sure. I don't remember those words being said. So I'm not sure whether they those words were said or whether that is Ms Eardley's interpretation of what was being said.
DE LA POER: Well --
McLAUGHLAN: I'm sorry, I just don't remember that and I don't remember the word "chilling" being used.
DE LA POER: Well, there are a number of possibilities that arise, if you don't remember. One of them is that it wasn't said, although we do know what Ms Eardley has recorded?
McLAUGHLAN: Yes.
DE LA POER: Another is that you didn't really in light of what the Executives had told you, perhaps, think that what they were saying was important or significant?
McLAUGHLAN: I don't recall it. That's the problem.
DE LA POER: But if somebody had told you that they thought somebody else was murdering babies, that's quite a memorable thing to be told, isn't it?
McLAUGHLAN: It is, which is --
DE LA POER: So can you help us at all?
McLAUGHLAN: I am trying to help. I don't recall.
DE LA POER: We know that the meeting -- thank you, we can take that down -- which followed was with the other
Consultants and they were all concerned, weren't they, between them, about the deaths, that was the impression they were giving, and did they appear to you to be supportive of Dr Brearey and Dr Jayaram?
McLAUGHLAN: Yes.
DE LA POER: So now we are up to seven Consultants who appear to be crediting this possibility; do you agree?
McLAUGHLAN: Yes.
DE LA POER: Then there is a discussion at lunchtime. Do you know what the phrase "war gaming" means?
McLAUGHLAN: I -- I know what I think.
DE LA POER: Yes, well, I want to make sure we are on the same page, so an unusual phrase --
McLAUGHLAN: Would you explain it from your perspective?
DE LA POER: Yes, of course it is the notion, and it's often used in the context of military medicine because of the overlap, of where doctors -- military doctors -- come together and they come up with scenarios as to how you might treat a patient or how a particular piece of surgery might happen, they just talk about it in terms of "war gaming" that, so it is the idea that you talk about multiple scenarios in a constructive way?
McLAUGHLAN: Okay.
DE LA POER: You are familiar at least with the idea of doing that
What I suggest is that effectively what happened at lunchtime based upon the notes of what Ms Eardley told us was that the doctors war gamed how Letby may have been murdering the babies. Do you remember such a conversation?
McLAUGHLAN: No.
DE LA POER: Well, let's have a look at the note INQ0010124, page 23. This is the typed note and I am going to make a correction based upon what we know to be right and can I say that you will see that two words are redacted, we are not going to mention those words?
McLAUGHLAN: Okay.
DE LA POER: If you need to see them to remind yourself, then I will find a way for you to do that?
McLAUGHLAN: Okay, thank you.
DE LA POER: But it may very well be that we don't need to in order for you to understand the flavour of what we are talking about. So page 23, please. So right at the bottom under the line, the word is "team" that is what we understand from Ms Eardley, it actually in the typed notes says "Tom" but it is team?
McLAUGHLAN: Thank you.
DE LA POER: She told us these are her notes of the lunchtime meeting and that's where they fit in the
sequence and she told us this was the first opportunity that the team had had to sit in private and discuss everything that they had been told, much of which was new to many of them. And that there are two words that you can simply take it from me that those are chemicals.
McLAUGHLAN: Okay.
DE LA POER: Okay so two different types of chemical: "... or insulin injection or air embolism but all had different presentation." That is what her note records. This was a conversation she told us at which the team was together at lunchtime and at which the doctor members of the team were having a discussion about how it could be that there were different presentations for each of these babies if somebody was murdering them and they were war gaming how that might have occurred by making suggestions about embolism, insulin injection, and those two other matters that we are not going to publicise. Do you remember that conversation?
McLAUGHLAN: No.
DE LA POER: Do you know why you wouldn't remember that conversation, is it because that's not something that you would have paid attention to or do you think that you were not present, or what -- what explanation might that be --
McLAUGHLAN: I do not recall that at all.
DE LA POER: Because would you agree that's quite an extraordinary conversation for the Review Team to be having at lunchtime on day one of the RCPCH visit?
McLAUGHLAN: I don't recall. I -- I -- I may not have been there, I may have been doing something else but I do not recall. I was not participating in that conversation.
DE LA POER: Forgive me. My question was: do you agree that that is an extraordinary conversation?
McLAUGHLAN: Yes.
DE LA POER: Do you agree that the very fact of that conversation, whether or not you were present, the very fact of that conversation is itself the clearest indication that at that stage the reviewers should have said --
McLAUGHLAN: Yes.
DE LA POER: -- if we are getting into a conversation about how you might murder babies, we just need to walk away from this and the police need to be involved?
McLAUGHLAN: Yes.
DE LA POER: So would you say that anybody involved in that conversation ought to have been saying that?
McLAUGHLAN: Yes.
DE LA POER: We can take that down, thank you very much. After that lunchtime break, the next meeting was
with the safeguarders. Do you remember meeting some of the safeguarding team, Dr Mittal --
McLAUGHLAN: If I was there then I was.
DE LA POER: -- and Dr Isaac. So I believe this isn't one of the meetings you suggested you weren't present at. Now, one of the functions of your Invited Review was to look at how well policies and procedures were implemented and how robust things were around process. Is that right?
McLAUGHLAN: Yes.
DE LA POER: One of the policies and areas that was being investigated was what was the approach to safeguarding; is that right?
McLAUGHLAN: Yes.
DE LA POER: No doubt that explains why the safeguarders were spoken to. We will circle back to the start of my questions. What the doctors told you, the Consultants told you, do you agree fits into the definition of a safeguarding allegation?
McLAUGHLAN: Yes, it would.
DE LA POER: A meeting took place with the safeguarders and one way to test how robust procedures would be would be to say: are you aware of this concern?
McLAUGHLAN: Yes.
DE LA POER: Would that have been an appropriate question to ask?
McLAUGHLAN: Yes.
DE LA POER: Now, there is no record, you can take from me, that that question was asked. Do you think it should have been?
McLAUGHLAN: Yes.
DE LA POER: Although it's a collective responsibility, do you accept that you had some responsibility in that?
McLAUGHLAN: Of course.
DE LA POER: Now, Alison Kelly was the Executive Lead for safeguarding and we know that because that's within the material that was provided to the reviewers. Do you have any recollection of her being asked in the context of this allegation; you are the safeguarding lead, how is that being dealt with from a safeguarding perspective?
McLAUGHLAN: I don't recall that question being asked.
DE LA POER: Well, do you think that the reason for that is because it wasn't asked?
McLAUGHLAN: Yes.
DE LA POER: And do you think it should have been?
McLAUGHLAN: Yes.
DE LA POER: Letby was spoken to by you and Ms Mancini?
McLAUGHLAN: Yes.
DE LA POER: She wasn't originally scheduled to be spoken to. It has been suggested by Ms Eardley that it was your idea, that is her recollection, and she says it was to give Letby an opportunity to give her perspective, that is Ms Eardley's recollection. Do you know whose idea it was?
McLAUGHLAN: I cannot recall how the idea materialised, I don't know.
DE LA POER: Do you agree it was a wrong turn?
McLAUGHLAN: I do now.
DE LA POER: Well, did you have enough information at the time to realise that that was a wrong turn?
McLAUGHLAN: No.
DE LA POER: You didn't?
McLAUGHLAN: No.
DE LA POER: Well, you had a couple of hours earlier spoken to some Consultants who told you they thought she was a murderer, or she may be. Was that not sufficient reason to think: probably shouldn't be going to speak to her?
McLAUGHLAN: No.
DE LA POER: Why not?
McLAUGHLAN: Because of all the other information that we had that muddied the waters around her as a person.
DE LA POER: But you were conducting a service review. Why were you investigating an individual case?
McLAUGHLAN: We weren't investigating her. We were interviewing her as part of the -- the nursing cohort.
DE LA POER: Well, my question was to suggest that you were investigating her. It was her case, I was suggesting, putting it as broadly as that, whether from an HR perspective or any other perspective; you weren't there to look at individual situations, were you?
McLAUGHLAN: No, but we didn't ask her about the case, her case.
DE LA POER: Well, you were asking her about how she had been treated?
McLAUGHLAN: And relationships on the unit and those type of questions. It was much broader than that.
DE LA POER: But you had already identified all the people that you needed to speak to for that purpose, hadn't you, they were already rostered?
McLAUGHLAN: Yes.
DE LA POER: So presumably the only reason that you wanted to speak to her was because of what you had been told about her in the morning?
McLAUGHLAN: She would have been in with the other group otherwise, with the other group of nurses otherwise.
DE LA POER: So you think that Letby would have been spoken to the following day?
McLAUGHLAN: Had -- had she not been moved from the unit and she wasn't allowed to contact people on the unit.
DE LA POER: How do you know that she would have been spoken to the following day; you didn't speak to all of the neonatal nurses?
McLAUGHLAN: Well, she, she -- okay, she could have been spoken to the next day as part of the group of nurses that we spoke to.
DE LA POER: But the only reason that you would need to speak to her as opposed to whichever nurses were available to speak to you was because of what you had been told in that morning?
McLAUGHLAN: It felt like the right thing to do at the time.
DE LA POER: Well, I am not disputing that. But did you not have sufficient information to realise that you were now moving in a direction that you ought not to have been moving?
McLAUGHLAN: We didn't think that at the time.
DE LA POER: Again, but did you have enough information to realise that as a reasonable conclusion?
McLAUGHLAN: Clearly not, otherwise we wouldn't have done it.
DE LA POER: Now, in terms of the discussion we have a record of that, I don't want to ask you any questions
about that and you made notes so we can refer to those. I want to ask you about what may not have been recorded in the notes, certainly what is suggested by Letby, who we must not lose sight of the fact is a convicted murderer, but she sent contemporaneous messages to Dr U which I think you have seen and had a chance to refresh your memory from. INQ0000569 and it's page 34. Page 34. Can I just give the reference INQ0000569. Well, can we just take that down from the screen for the moment. I am going to need just to read this out to you. I know you have had a chance to, but I don't want to create any unfairness but I am not going to have that entire document up on the screen so can we take it down, please. The first message sent at 18:14. She says to Dr U: "Thank you for your help. The two members were nice." Presumably a reference to you and Ms Mancini: "They didn't ask much about the babies, it was more about the unit as a whole, et cetera." In brief it looks as though there is potential for this to go further over a long period of time. H [presumably Hayley Cooper who was her RCN representative] thinks we need to look at taking out a grievance case."
That is her first message to Dr U. About 15 minutes later she sends another one: "The report will take a minimum of six weeks with the preliminary tomorrow. They 'off the record' told me they think an investigation into the deaths will be a recommendation and I need to prepare myself that as I would play a big part in that over due to being a common factor and it could take several months." All right, so I know you have seen those messages before and you weren't in fact a party to them at the time.
McLAUGHLAN: Yes.
DE LA POER: I just want to ask about that. Was there an off-the-record conversation involving you, Ms Mancini and Letby?
McLAUGHLAN: Not that I recall, no.
DE LA POER: Did you discuss whether she should take a grievance?
McLAUGHLAN: I believe her Union representative mentioned that in our conversation.
DE LA POER: I mean, it was in your mind at the end of that day one that there would be a recommendation for an investigation, wasn't it?
McLAUGHLAN: Yes, I -- I guess, yes.
DE LA POER: And what she seems to be saying is there was some discussion about the impact upon her because she said "I need to prepare myself". So that is what she's reporting that she's being told. So that is a discussion about how she should cope with it. That is her characterisation of it?
McLAUGHLAN: Sure.
DE LA POER: Do you have any recollection at all?
McLAUGHLAN: No.
DE LA POER: Now, it appears that Letby ended up with your telephone number. Do you know how that happened?
McLAUGHLAN: No.
DE LA POER: Did you give her your telephone number?
McLAUGHLAN: No.
DE LA POER: You suggest in your witness statement: "It appears that if my number was given to them it was by the Invited Review manager." Who do you mean by the Invited Review manager?
McLAUGHLAN: Ms Eardley.
DE LA POER: Ms Eardley. What do you base that upon?
McLAUGHLAN: The way the -- the one of the notes was written the next day, I think.
DE LA POER: Well, let's have a look at that.
McLAUGHLAN: Gave -- I think it said "Gave Claire's number".
DE LA POER: INQ0014605, page 6. We will just come back to
that issue in a moment. We will take it in order that it appears. Somebody appears to say: "Not sure if the review will give you the answers you are looking for. Considered aborting and starting again but Terms of Reference to be important to get the background." Do you see that at the top?
McLAUGHLAN: Yes, sorry.
DE LA POER: Do you recollect a discussion in which the team considered aborting?
McLAUGHLAN: I think there was a discussion, yes.
DE LA POER: What -- who was in favour, who was against?
McLAUGHLAN: I -- I don't recall.
DE LA POER: What consideration, if any, was given to the possible impact upon a regulatory or police investigation if you carried on?
McLAUGHLAN: I don't recall the conversation so I couldn't say.
DE LA POER: Well, do you have any reason to think that that was mentioned by anybody?
McLAUGHLAN: I -- it would be speculation to say so.
DE LA POER: We can see that it continues: "Need independent Casenote Review of all the deaths by two independent people. Big concerns about Lucy plus need formal process to be started so she knows where she
is." So by that stage, that conclusion had been reached that there needed effectively two processes, one Casenote Review and one formal process for Letby?
McLAUGHLAN: Yes.
DE LA POER: Then if we see further down, about two-thirds of the way down: "We were worried to let her go home." That is just picking up: "Hayley to take her home, gave Claire's number to Hayley plus Lucy worried about her mental health as feels that everyone has turned their backs on her."
McLAUGHLAN: Yes.
DE LA POER: That is the reference in the notes to your number?
McLAUGHLAN: Yes.
DE LA POER: So you were present at this meeting?
McLAUGHLAN: (Nods)
DE LA POER: Did you have any concerns about the fact that your number had been given to Letby?
McLAUGHLAN: I don't -- I don't recall that, the only reason I know about this is from the note, not from giving my number. I -- I didn't give her my number.
DE LA POER: But what appears to be occurring is that at a meeting that you are present at, somebody is talking
about having given your telephone number to Letby?
McLAUGHLAN: I don't recall it being said. I only know about it from the note.
DE LA POER: Then we can see last paragraph: "Needs to be put into a process for her protection and yours. Disciplinary process to get to the bottom." This appears to be that she is going to be disciplined on the basis of the allegations of the Consultants; is that right?
McLAUGHLAN: Well a process to be put in place to --
DE LA POER: Well, a disciplinary process?
McLAUGHLAN: I don't remember saying "disciplinary process" so a process needed to be put in place because she had been moved from her place of work to another place of work, within the -- within the Trust without any process being put in place to do that. And then something needed to be done in order to investigate the allegations that were made about her.
DE LA POER: Do you agree that a disciplinary process to investigate the Consultants' allegations would be completely inappropriate?
McLAUGHLAN: But this is the type of process that needed to be put into -- in place that the Invited Guide Review I believe it is that we looked at earlier talks about for misconduct.
DE LA POER: They weren't just talking about misconduct?
McLAUGHLAN: No, no.
DE LA POER: Murder is a form of misconduct, they are talking about murder so --
McLAUGHLAN: I appreciate --
DE LA POER: I'm sorry, I don't want to talk across you but can I just ask my question: do you agree that a disciplinary process to get to the bottom of the Consultants' allegations would be inappropriate?
McLAUGHLAN: Yes. But something had to be started in order to put a formal process in place.
DE LA POER: Well, would calling the police be enough to start it?
McLAUGHLAN: Not without other things happening. So she should in my view have been put through a process that would have suspended her from practice, referred to the NMC, referred to the police, and the processes allowed to take their course.
DE LA POER: Why don't you phone the police first?
McLAUGHLAN: The order in which it happened wouldn't -- just -- it's hard to explain that this all should have been done way before the College was involved in this process. By just moving Ms Letby to another place of work without doing anything, without inform -- putting any formal process in place, left everybody at risk
including other patients in the hospital, her access to records, all sorts of things.
DE LA POER: My question was: why not call the police first?
McLAUGHLAN: I agree.
DE LA POER: So we then read on. There's reference to a grievance which you tell us you knew about. "If nothing happens good case for constructive dismissal. She knows it will be horrid." So that appears to be somebody at this meeting telling the Executives that they have, that inferentially Letby must know about the fact that there is a process to come and that it's not going to be very pleasant for her which is very much the tenor of her message to Dr U the night before about how she needed to prepare herself for it. Just seeing --
McLAUGHLAN: Yes, I can see that.
DE LA POER: Just seeing this note now, bearing in mind this is something either said by you or said by Ms Mancini because you were the only two people who could speak to Letby's state of mind, does it look in fact as if there was this off-the-record conversation in which you and Ms Mancini told Letby that there was going to be an investigation that she needed to prepare
herself for?
McLAUGHLAN: I don't know who said that. I can't answer the --
DE LA POER: Well, what other explanation can you offer for why it was said either by you or in your presence "she knows it will be horrid"?
McLAUGHLAN: But without knowing whether those were the actual words that were said, I -- I don't know.
DE LA POER: We are going to move away from the content the review, there were obviously other meetings that you had including with senior nurse, we have the notes for that. I would just like to move to the letter of 5 September. But before we do, we just need to go, while we still have this on screen, to page 34. So this is the feedback session which -- we can go up if you need to, but I hope you will be able to take from me that this is the feedback session involving Mr Chambers right at the very end of the process?
McLAUGHLAN: Thank you.
DE LA POER: We can see "Tony, were these unexpected" is right in the middle of the page there just to anchor you where we are?
McLAUGHLAN: Yes, thank you.
DE LA POER: Immediately above that "CM", so presumably you:
"... will list some areas of point to check in the detailed review what needs looking at." So ascribed to you in this note that's not your note, it is Ms Eardley's note, in the context of a more in-depth review of cases, you appear to be recorded to be saying: "Will list some areas of point to check in detailed review."
McLAUGHLAN: I don't recall. I don't know what that means.
DE LA POER: Well, let's see if we can have a look and see the recommendation. INQ0009611, this is the letter of 5 September, where the detailed Casenote Review is recommended. If we go to page 2. We can see that there are some points to check to use the language of that note. This investigation should include as a minimum the following elements ..." Then there are four listed.
McLAUGHLAN: Yes.
DE LA POER: So what we appear to have is a meeting three days earlier in which the record indicates that you said: we are going to give you some points to check for the forensic Casenote Review and then we have a letter which provides that. My question will come as no surprise. What contribution did you make to those items?
McLAUGHLAN: I don't recall making any contribution to those items.
DE LA POER: If we look at (d), for example: "Details of staff with access to the unit from four hours before the death of each infant." Are you able to recognise that that is an inappropriate recommendation for the RCPCH to be making?
McLAUGHLAN: Yes.
DE LA POER: Because that's a matter for the police, isn't it?
McLAUGHLAN: Yes.
DE LA POER: Now, you were involved in the drafting of the report in that you made some comments, but presumably you read it through thoroughly and were signed up to the finished product?
McLAUGHLAN: Yes.
DE LA POER: INQ0010131. What we are just going to have a look at now is page 6, please. Are we able to crop in towards the right-hand side? So just the centre middle, please, thank you. This is a part about the deaths in the report and you have added a comment: "I think we should mention here that some of these were actually congenital abnormalities which were
counted as unexplained and unexpected." Now, first of all, that's very much a medical issue, isn't it, that is under discussion there?
McLAUGHLAN: Yes.
DE LA POER: And your function wasn't to make a medical contribution --
McLAUGHLAN: No.
DE LA POER: -- to this report; is that right?
McLAUGHLAN: That's correct.
DE LA POER: One interpretation of what you are doing there is to diminish the potential significance of the apparently unexplained and unexpected by implying that some of them may be a result of congenital abnormalities. That is one interpretation. Do you recognise that at least --
McLAUGHLAN: Yes, yes.
DE LA POER: -- as an interpretation?
McLAUGHLAN: Yes.
DE LA POER: What you say in your witness statement is: "I thought it would be appropriate to provide some balance ..."
McLAUGHLAN: Yes.
DE LA POER: "... in connection with this." Were you seeking to diminish the significance of those factors by implying that perhaps the deaths were
as a result of congenital abnormalities?
McLAUGHLAN: No.
DE LA POER: What explanation do you offer for proposing that change, bearing in mind it's a medical issue?
McLAUGHLAN: As I explained in my witness statement, it was to provide balance.
DE LA POER: What do you mean by balance?
McLAUGHLAN: We had been told by some of the senior nurses, I think, that the cluster of babies included some of those with congenital ...
DE LA POER: Is that something the doctors had told you?
McLAUGHLAN: Abnormalities.
DE LA POER: Or that they thought were significant?
McLAUGHLAN: No.
DE LA POER: Well, let's imagine the balance that you have described. On the one hand you have got the fact that these are unexplained and unexpected. Are you suggesting that there is a countervailing factor to somehow balance out that fact?
McLAUGHLAN: Well, yes, because if some of them were as a result or some had congenital abnormalities then it would be remiss not to add that balance in.
DE LA POER: Well --
McLAUGHLAN: As I understand it, my comment was removed so it didn't happen.
DE LA POER: Well, it is about your state of mind that we are looking at, not what was ultimately in the report because an interpretation of this proposal was that you were trying to minimise the seriousness of what the doctors were suggesting --
McLAUGHLAN: No.
DE LA POER: -- by suggesting that there was a natural explanation for the increase in neonatal mortality?
McLAUGHLAN: No. I was just trying to provide some balance.
DE LA POER: The overall report did not provide an answer to the question at term of reference 4, did it?
McLAUGHLAN: No.
DE LA POER: Finally, you say in your witness statement that the fact that there were two reports was inappropriate --
McLAUGHLAN: Yes.
DE LA POER: -- or not appropriate. Why do you say that?
McLAUGHLAN: It lacks transparency.
DE LA POER: Is that something that you said at the time?
McLAUGHLAN: I think I spoke to Sue Eardley about it.
DE LA POER: Before the report was released?
McLAUGHLAN: I can't remember when. But yes, I think, yes at some point during that process.
DE LA POER: What did you say to Sue Eardley?
McLAUGHLAN: I don't recall. But I have had a conversation with her about being -- there being more than one report.
DE LA POER: Was the thrust of the conversation as you have told us that you thought that was inappropriate because it lacked transparency?
McLAUGHLAN: Yes, and it's confusing around version control and who sees what.
MR DE LA POER: Ms McLaughlan, those are my questions.
LADY JUSTICE THIRLWALL: Just wait there. Mr Sharghy, you have some questions.
MR SHARGHY: Ms McLaughlan, good afternoon, I represent one of the Families whose child was murdered by Lucy Letby and I also ask questions on behalf of six other Families as well. I am not going to go over, you will be glad to hear, a lot of the issues.
McLAUGHLAN: Sorry I am having real trouble hearing you.
SHARGHY: I am so sorry. Is that better?
McLAUGHLAN: That's much better, thank you.
SHARGHY: Thank you, I am not going to go over a lot of the issues that you have already been asked questions
about but there are a couple of matters that I do want to just press further, if I may. As lay member of the Review Team it is fair to say, isn't it, that you are not just there to make up the numbers?
McLAUGHLAN: Yes.
SHARGHY: That your role would be integral to any discussions or indeed meetings that take place either before the review starts or indeed during the review process?
McLAUGHLAN: Yes.
SHARGHY: Are you comfortable that you were involved in all discussions between the Review Team or indeed any meetings that took place?
McLAUGHLAN: I was, but I understand from looking at this information that there were discussions between the lead reviewer or email exchanges between the lead reviewer and Ms Eardley that I believe the rest of us weren't party to.
SHARGHY: The reason I am asking you this is because Mrs Mancini is going to give oral evidence just after you, but she has said in her written witness statement to the Inquiry that there was a discussion before the review actually began in relation to additional evidence that the Review Team believed would be of assistance but
the feeling amongst the team was that there was some limitations in gathering the detailed information from the Trust within the remit of the Terms of Reference. Does that ring true to your knowledge as to that discussion?
McLAUGHLAN: I don't recall a discussion like that.
SHARGHY: Do you recall any discussions at all whether with the entire Review Team, or indeed with one or two members, where the concept of additional documents was raised?
McLAUGHLAN: Not specifically, no.
SHARGHY: Did you believe when you received the information from the Trust that was placed on the Huddle system --
McLAUGHLAN: Yes.
SHARGHY: -- that it contained all of the relevant information for you and your colleagues to undertake the review?
McLAUGHLAN: I assumed it did but then again looking through the pack, the bundle that we received, afterwards there was obviously additions later on that I don't recall seeing.
SHARGHY: In relation to the process as it unfolds from the morning of 1 September, when the review begins, you say in your witness statement it became quite clear
early on in the interviews -- and I think there you are referring to those with the Consultants Dr Brearey and Dr Jayaram -- that there are these concerns raised in particular regarding a connection between increase in neonatal deaths on the unit and a particular individual on the unit; is that fair?
McLAUGHLAN: I think that was raised actually in the very first meeting with the Medical Director, but then again with the Consultants, yes.
SHARGHY: I am just going to press you a little bit further in relation to the decision thereafter made to interview Lucy Letby, knowing what you then knew, on that morning. Given that there were other nurses who you could have interviewed as a team, whether on that day or the day after, and putting aside that the service review was not going to consider any allegations against Lucy Letby, why was she so integral to the interview process that she was interviewed on that first day?
McLAUGHLAN: I think it was about availability, but I -- I don't know. I didn't arrange the -- the interview so whether it was about availability, timing, I -- I can't answer that.
SHARGHY: But specifically given what you were aware of by that stage, as a patient and public interest representative on this panel, did you not even begin to imagine that there could be a conflict here?
McLAUGHLAN: I clearly didn't.
SHARGHY: We heard from Hayley Griffiths, you may have known her as Hayley Cooper at the time, who was the RCN rep that accompanied Lucy Letby to that meeting. It was a fairly short meeting she indicated?
McLAUGHLAN: (Nods)
SHARGHY: Fairly shortly after the questioning had started Lucy Letby becomes very emotional and she leaves the room. What Mrs Griffiths said to this Inquiry is that one of the members, either yourself or Mrs Mancini said something along the lines of: does she realise the gravity or the severity of the allegations that are being made against her? Was that you who said that?
McLAUGHLAN: I don't recall that happening at all. I don't recall Ms Letby leaving the meeting.
SHARGHY: You don't recall --
McLAUGHLAN: No.
SHARGHY: -- Lucy Letby becoming very emotional, leaving the room and being followed by her representative?
McLAUGHLAN: No.
SHARGHY: And you have no recollection that one of the two interviewers had said anything along the lines of:
do you realise how severe that those allegations are?
McLAUGHLAN: No. She was very upset in the meeting which was why I was concerned for her mental health at that time. But I don't recall her leaving the meeting at all.
SHARGHY: Final question. At paragraph 81 of your witness statement, you say that although you weren't involved in this discussion you did look at the transcript of what Andrew Higgins, who was a non-executive director, had said in relation to issues about why the police were not being called and why an independent review, effectively your review, is the most appropriate concept. The words that are ascribed there is that: "He indicated that: it's important to keep the shutters down and contain the situation." Do you now understanding not just what you knew at the time, but also on reflection, appreciate that that is precisely what the review that you were part of did?
McLAUGHLAN: I wouldn't put it like that.
SHARGHY: How would you put it?
McLAUGHLAN: We were doing our best to help the Countess of Chester Hospital to discover what was going on. We were in a long line of organisations who were asked to look at those problems that they had got.
I can see why you would say that, but from the inside it didn't feel like that.
SHARGHY: On reflection, you don't believe that that is exactly what happened, the shutters were kept down and the situation was contained, ie the police weren't called?
McLAUGHLAN: That is your interpretation of that.
MR SHARGHY: Okay, my Lady, thank you those are my questions?
LADY JUSTICE THIRLWALL: Thank you, Mr Sharghy. Ms Scolding?
MS SCOLDING: I have no questions of this witness, thank you very much.
LADY JUSTICE THIRLWALL: Thank you very much indeed. Just one matter from me just in relation to the end of the meeting with Ms Letby. I just want to check my own note. Do you have any memory of speaking to Ms Cooper --
McLAUGHLAN: Not.
LADY JUSTICE THIRLWALL: She has a memory of thinking she had forgotten her coat and so went back in to the room and spoke to you without Ms Letby being there.
McLAUGHLAN: No, I have no recollection of them being separate at all.
LADY JUSTICE THIRLWALL: No, all right. One final thing. When you were talking much earlier in your evidence about the evidence of the rota which you were attributing to Dr Brearey, although we note its genesis was with Eirian Powell, you said the doctor was one person who may or could have manipulated that information. What was your basis for saying that?
McLAUGHLAN: Well, I was hesitant in saying it but I couldn't think of another word but we hadn't seen -- we had seen I think we had seen the doctors' rotas on Huddle.
LADY JUSTICE THIRLWALL: Yes, and you told us about that. I just want to know what you meant, or whether on reflection you don't want to repeat it, that he was one person who may or could have manipulated it and I was puzzled about that. What do you mean?
McLAUGHLAN: We -- because we didn't see the original data we had only got the interpretation of the data which can be, it can be manipulated is what I meant.
LADY JUSTICE THIRLWALL: So that you didn't have a basis for saying it had been manipulated?
McLAUGHLAN: No, no it wasn't a -- it was -- it, the -- it's easy to even make a mistake in putting data into an Excel spreadsheet to get that information back out again.
LADY JUSTICE THIRLWALL: So he may have made an error would have been another way to put it?
McLAUGHLAN: I wasn't suggesting that he had, but we didn't -- because we only had that Excel spreadsheet that had already been -- the data had already been entered to, we hadn't seen the source data.
LADY JUSTICE THIRLWALL: Thank you. Anything you want to ask, Mr De La Poer?
MR DE LA POER: My Lady, no, thank you very much.
LADY JUSTICE THIRLWALL: Thank you very much indeed, Ms McLaughlan. You are free to go.
McLAUGHLAN: Thank you.
MR DE LA POER: My Lady the next witness is Ms Mancini and subject to my Lady's better view we were proposing to move on with her evidence now.
LADY JUSTICE THIRLWALL: Yes.
MR DE LA POER: Albeit that I think Mr Carr will be asking for a shortened lunch break today when we get to it.
LADY JUSTICE THIRLWALL: Yes. Thank you, Mr De La Poer. So if you would like to re-organise the front bench. If you would like to come straight up to the desk.
MS ALEXANDRA MANCINI (sworn)
LADY JUSTICE THIRLWALL: Do sit down.
MANCINI: Thank you.
MR CARR: Can we start with your full name, please.
MANCINI: Alexandra Mancini.
CARR: You have prepared two statements for the purposes of this Inquiry, the first dated 26 June 2024 and that deals with your involvement in the RCPCH review?
MANCINI: Yes.
CARR: A second more recent statement dated 6 November 2024, addressing recent work you have carried out, developing a framework for BAPM?
MANCINI: Yes.
CARR: Now, in respect of your first witness statement, and that's the one that I am going to be asking you questions about, I understand there is a correction you want to make?
MANCINI: Yes.
CARR: It's at paragraph 87 of that statement. where you deal with discussions about police involvement and I think it's the last two sentences that you want to correct?
MANCINI: Yes.
CARR: So do you want to read those sentences and tell us what the correction is?
MANCINI: Yes, read them first as they are?
CARR: Read the final two sentences first and then tell us what the correction is.
MANCINI: Okay: "I wasn't actively involved in discussions with Ian Harvey about involving the police. The Review Team recommended that the Medical Director and senior management contact the police directly."
CARR: Yes, that is what it says at present. What is the correction?
MANCINI: Okay, the correction is that: "The Review Team had a discussion about recommending that the Medical Director and senior management contact the police directly. We had that discussion and we made a decision that we wouldn't recommend that in the recommendations of the report." I think that this is an absolute oversight on my part as I was preparing my witness statement, that this is one of the questions that was put to me and I haven't taken it out of the witness statement.
CARR: Subject to that correction, are the two statements true, to the best of your best knowledge and
belief?
MANCINI: Yes.
CARR: Before I start asking questions, I think there is something that you wish to say.
MANCINI: Thank you. I would like to speak directly to the parents and offer my deepest and sincerest condolences that your babies have died and this -- I can only imagine how distressing this must be for you, so I am very, very sorry for what's happened. Thank you.
CARR: By profession you are a neonatal nurse?
MANCINI: Yes.
CARR: You tell us in your statement that you qualified in New Zealand. There were two dates of qualification in your statement. Paragraph 1 suggests 1991; paragraph 2, 1990.
MANCINI: Okay. I do apologise. It should read 1990 for both.
CARR: In 1993 you started working as a paediatric nurse?
MANCINI: Yes.
CARR: Since 1998, you've worked as a neonatal nurse?
MANCINI: Yes.
CARR: You have held -- and this is set out in your witness statement -- a number of senior leadership positions?
MANCINI: Yes.
CARR: You spent around six years working as a matron on a neonatal intensive care unit?
MANCINI: Yes.
CARR: You explain at paragraph 4 of your statement that at the time of the RCPCH review, in 2016, you were the Pan London Regional Lead Nurse for national palliative care?
MANCINI: For Neonatal Palliative Care.
CARR: You weren't a member of the RCPCH, were you?
MANCINI: No.
CARR: Your Royal College was?
MANCINI: The Royal College of Nursing.
CARR: You were nominated by the RCN --
MANCINI: Yes.
CARR: -- to serve on this review and you say, it is paragraph 4 again, that was due to your nursing experience, clinical governance experience as matron and expertise as Pan London Lead Nurse for Neonatal Palliative Care?
MANCINI: Yes.
CARR: What did you understand to be the nursing perspective or the reason for a nursing perspective being required for this review?
MANCINI: I understood it to be I was part of a team, I was being asked to be part of an expert team to bring expertise and experience to a review process and so the nursing perspective will always consider the nurse staffing, the nursing culture and really ensure that there's a multi-disciplinary approach within that team.
CARR: If we can turn to safeguarding, knowledge and training, please. You say at paragraph 6 of your statement that you have not received specific safeguarding training in respect of what to do where abuse on the part or a member of staff towards babies or children in hospital is suspected. Do you recognise as a broad principle of safeguarding that concerns relating to the harm of children should be escalated?
MANCINI: Yes.
CARR: That is something that you would have appreciated at the time?
MANCINI: Yes.
CARR: Did you consider there was any reason that that broad principle wouldn't apply to staff members in hospital?
MANCINI: No.
CARR: Were you aware at the time of the review of the statutory guidance contained in Working Together to
Safeguard Children?
MANCINI: Yes.
CARR: It was a 2015 edition that would have applied at the time of the review and it was a requirement, wasn't it, of that guidance that it was read and applied by healthcare workers?
MANCINI: Yes.
CARR: If we can have up on screen, please, INQ0013235, page 54. We are going to look at a part of the statutory guidance. The guidance sets out, doesn't it, the process to be followed in respect of allegations made against people who work with children and if we look at the top of the page, page 54, the third paragraph down, that starts: "Clear policies ..." Then if you go to the final sentence of that paragraph, it reads, it has been highlighted: "An allegation may relate to a person who works with children who has ..." Then there are a number of subparagraphs: "Behave in a way that has harmed a child or may have harmed a child, possibly committed a criminal offence against or related to a child or behaved towards a child or children in a way that indicates they may
pose a risk of harm to children." In respect of those definitions, the explanation of an allegation, each of them sets a relatively low bar, doesn't it, it's "possibly", "may" ...
MANCINI: (Nods)
CARR: The requirement, and we will see this at the bottom of the page, paragraph 7, is for any allegation to be reported immediately to a senior manager?
MANCINI: (Nods)
CARR: Do you have that, where it's highlighted: "Any allegation against people who work with children should be reported immediately to senior manager within the organisation"?
MANCINI: (Nods)
CARR: Then the next sentence: "A designated officer or team of officers [going on to the next page, please] should also be informed within one working day of all allegations." The reference there to the designated officer, that is the Local Authority Designated Officer, isn't it?
MANCINI: Yes.
CARR: So taking all of that together, where there is allegation of possible criminal offending, involving somebody who works with children, it must immediately be reported within the organisation and within 24 hours escalated to the local authority?
MANCINI: (Nods)
CARR: Did you understand that process --
MANCINI: Yes.
CARR: -- at the time of this review? Turning, please, to your recruitment for the review and your experience and training. Paragraph 29 of your statement.
MANCINI: Sorry, did you say 79?
CARR: 29.
MANCINI: Sorry. Yes.
CARR: You state there: "Prior to the Countess of Chester Hospital Invited Review I had not participated as a member of a Review Team."
MANCINI: Yes.
CARR: To be clear, you are referring to not having participated in a Review Team for any College, so not simply the RCPCH, also the RCN or anybody else?
MANCINI: Yes.
CARR: So this was your very first --
MANCINI: First time.
CARR: -- Invited Review. At paragraph 33, you note that in your wider practice, you had experience of reviewing individual
deaths but not of reviewing a cohort of unexpected or unexplained deaths?
MANCINI: Yes.
CARR: Did you raise with either the RCN or the RCPCH your lack of experience in assessing or reviewing a cohort of cases?
MANCINI: Yes. From a perspective that I said this was the first time that I had participated in a review of this kind, so I said that both to Fiona Smith at the RCN and to Sue Eardley.
CARR: Reflecting on your own practice, your own experience as a neonatal nurse, how common -- if it was common -- were unexpected and unexplained deaths of neonates?
MANCINI: In my experience --
CARR: Yes.
MANCINI: -- it wasn't common.
CARR: Would you agree that it was extremely unusual for newborns to die unexpectedly and without a clear diagnosis or explanation?
MANCINI: Yes.
CARR: So would the fact that there was a cohort of unexpected and unexplained deaths by itself be a cause for concern?
MANCINI: Yes.
CARR: Had you had experience within your practice -- I know you hadn't reviewed a cohort but had you had experience within your practice of a cohort of unexpected and unexplained deaths, is that something that you had seen before?
MANCINI: Not a cohort; individual cases.
CARR: Do you consider -- you explain that you raised with both Fiona Smith and Sue Eardley your lack of experience. Do you consider that your lack of experience both in undertaking reviews and your limited experience of unexpected and unexplained deaths meant that this was an unsuitable first review for you to undertake?
MANCINI: We didn't discuss that.
CARR: Do you think it may have been beyond your competence and experience, too complex to undertake as a first review?
MANCINI: I think that the experience that I brought to the Review Team was as a senior neonatal nurse thinking about culture of the unit, thinking about staffing, about how neonatal units are run and those were the other Terms of Reference. But I agree that I didn't have the experience of reviewing a cohort of babies with unexplained or unexpected deaths.
However, within the team we all bring different experiences and expertise to it and there were two very experienced paediatricians within that team as well.
CARR: In preparing for the review, you were sent -- you deal with this in your statement -- by Sue Eardley written guidance, so a copy of the guide on Invited Reviews and you have set out a number of the provisions in there in your statement. You note at paragraph 12 that according to the guidance: "Invited Review reviewers must undertake RCPCH approved training when they are selected for role."
MANCINI: Yes.
CARR: The position is, as you explain later in your statement, you didn't receive any training, did you?
MANCINI: No.
CARR: You didn't receive any induction?
MANCINI: No.
CARR: Why didn't you undergo training or induction as required?
MANCINI: Because I was signposted to the Handbook For Reviewers, which I thought was the training, an element of training to read through what was expected of me as part of the Review Team.
CARR: So you consider that you did undergo the relevant training by reading the guidance?
MANCINI: Yes, I wasn't aware there was any other type of training.
CARR: If you look at paragraph 133 of your statement, it's there you deal with the lack of training for the role and you say: "I didn't receive [second sentence] specific training and induction for reviewers by the RCN or RCPCH I was sent the link to the Handbook For Reviewers For Invited Reviews." Indeed it's within that handbook, isn't it, that your reference from paragraph 12 comes which suggests that RCPCH approved training must be undertaken when joining a Review Team?
MANCINI: I'm sorry, could you repeat the question?
CARR: Yes. So at paragraph 133 you make the point that you didn't receive any specific training or undergo an induction for reviewers?
MANCINI: Yes.
CARR: I think when I put this point to you a few moments ago you said: Well, I was sent the handbook and I thought that amounted to undergoing training. But the handbook itself has a provision which sets out that reviewers must undergo RCPCH approved training?
MANCINI: Yes.
CARR: So it would have been clear from receiving the handbook and seeing that provision which requires reviewers to undergo training that reading the book alone didn't amount to training?
MANCINI: I have to say that when I read that I took it as the RCPCH reviewers. There is a process for applying to the RCPCH to be a recognised reviewer. I wasn't that person, I was a person that had been asked. I think there is a paragraph within the handbook or the guide that does say at times there will be the need for a nursing perspective and so the Royal College of Nursing will provide that. So I wouldn't -- I am not a recognised reviewer on the RCPCH team as such. I have been called in as needed.
CARR: So because you were a nominee --
MANCINI: Yes.
CARR: -- by the RCN you thought specific training wasn't required for you?
MANCINI: Yes.
CARR: If we can consider some of the guidance, please, it's INQ0010214 and if we can turn to page 7. I want to consider with you the paragraphs under the heading "Where Serious Concerns Are Raised". Dealing first with paragraph 6.1. It reads:
"If issues of patient safety are raised at any time the reviewers will advise the client immediately and discuss what urgent action should be taken if any." Then the final sentence of that paragraph: "For concerns about safety service beyond the scope of the review, the regulatory authority should be advised with consideration as to whether temporary suspension of a service is appropriate." So do you agree that this paragraph is setting out two levels of concern: firstly dealing with a concern which can be managed with the client, so a discussion with the client to determine what action should be taken, if action is required, but then that final sentence is addressing a more serious concern and where that more serious concern arises, on this guidance, it provides for the regulatory authority to be told of that concern?
MANCINI: (Nods)
CARR: Looking at that paragraph, do you consider that this enabled the Review Team to escalate sufficiently serious categories of safety concern?
MANCINI: (Nods)
CARR: Did you appreciate that at the time of this review?
MANCINI: I didn't.
MR CARR: I am going to deal with one more point, if I may, my Lady.
LADY JUSTICE THIRLWALL: Very well, yes.
MR CARR: Staying in the guidance before breaking, I do want to keep that up, sorry. So it's back to page -- we were at page 7, if we go to page 8, please. The section is dealing with process. At paragraph 7.5 you will see the section dealing with the circumstances in which the College would not take on cases. Now, it's right that by the time you became involved with the review, the case had already been taken on?
MANCINI: Sorry, can you repeat the question?
CARR: By the time you were recruited to the review --
MANCINI: Yes.
CARR: -- the case had already been taken on?
MANCINI: Yes.
CARR: This section however is useful in indicating the limits of a service review?
MANCINI: (Nods)
CARR: Do you agree?
MANCINI: Yes.
CARR: If we go to page 9, please. At paragraph 7.7, it sets out that: "If any of the issues raised in 7.5 [which we just looked at] come to light during an Invited Review, the review should be completed in relation to its original remit unless advised to the contrary in order to avoid prejudicing other investigations by a public authority or regulator." Now, included amongst the issues listed at paragraph 7.5 are where the expected scope includes behavioural misconduct, bullying, harassment or possible mental health concerns. Now, do you agree that allegations or concerns that a member of staff is murdering babies would be a very extreme example of that sort of conduct?
MANCINI: Yes.
CARR: At paragraph 7.5, so those cases that the College will not take on, includes cases where the police or counter fraud service are involved and that's another indication, isn't it, that matters of criminality go beyond the scope of an Invited Review?
MANCINI: Yes, but I didn't know this information at the time.
CARR: Forgive me, you were sent a copy of this?
MANCINI: I was sent a copy, yes, but I didn't know the information about the allegations.
CARR: No, I understand but just in terms of understanding the process, because you didn't undergo formal training but you have indicated that --
MANCINI: Yes.
CARR: -- reading this guidance. If we stick with 7.7 and before we break, I want to understand your interpretation of this. Did you consider this section either before the review or whilst you were at the review?
MANCINI: I read it before the review in preparation. I didn't refer to it during the review.
CARR: It contains a number of elements, doesn't it? So the first sentence which I have already read suggests that the review should be completed unless advised to the contrary. Who do you understand would be giving that advice?
MANCINI: I would see that the person that is the most senior within the review would be the lead reviewer and the invited head of reviews.
CARR: The circumstances in which the advice may be given to stop the review is in order to avoid prejudicing other investigations. So that would appear to call for an assessment, wouldn't it, of whether carrying on when such issues arise will or won't prejudice other investigations?
MANCINI: Yes.
CARR: What did you understand might be the circumstances in which other investigations may be prejudiced by continuing an investigation where the issues set out at 7.5 have arisen?
MANCINI: Are you asking what I think now or what I thought at the time?
CARR: At the time?
MANCINI: Okay.
CARR: We will come on to the issues that arose.
MANCINI: So at the time, I would have thought it would prejudice possibly an investigation into safeguarding concerns or possibly the police.
CARR: Did you understand why that is something that it was desirable to avoid?
MANCINI: Yes.
CARR: And why there needed to be an assessment if those issues arose to ensure that such prejudice would be avoided?
MANCINI: Yes.
CARR: Finally this: if the review was going to continue, then this section makes clear, doesn't it, that the reviewers firstly can't investigate those sorts of issues of concern set out at paragraph 7.5?
MANCINI: Sorry, where are you reading from?
CARR: Four lines down, "but the reviewers cannot investigator suggest solutions for any of the above"?
MANCINI: (Nods) Yes.
CARR: So the point that appears to be being made in the guidance is that if you are going to continue with an investigation, you cannot investigate those issues of concern that have arisen, first point, you cannot suggest solutions for them, and then the following sentence: "Clear scope boundaries should be agreed before further work takes place."
MANCINI: Yes.
CARR: Again that would appear to be for the purposes of ensuring that other investigations won't be prejudiced?
MANCINI: Yes.
MR CARR: My Lady, thank you, that is a convenient time.
LADY JUSTICE THIRLWALL: Thank you, Mr Carr. We will adjourn now and we will start again at a quarter to 2.
(1.05 pm) (The luncheon adjournment)
(1.45 pm)
LADY JUSTICE THIRLWALL: Mr Carr.
MR CARR: I want to turn now to the steps that you took to prepare for the review visit. Your evidence in your statement is that prior to arriving at the hospital, you were not aware of the submissions that the doctors had there about Letby; is that correct?
MANCINI: Yes, that's correct.
CARR: You were not told of those suspicions by Sue Eardley?
MANCINI: No.
CARR: You don't remember any discussion amongst the team or with any members of the team about Letby?
MANCINI: Before we met?
CARR: Before, yes?
MANCINI: No.
CARR: You have seen in the RCPCH chronology document, that is the document prepared by Sue Eardley, it contains an email from David Milligan, the lead reviewer, dated 26 August 2016 in which he identifies there are a number of questions arising from the data, including the fact that one individual appears to have been present for all but one of them. You know the email that I am referring to?
MANCINI: I know the email you are talking about, referring to.
CARR: But you say you didn't receive that --
MANCINI: I didn't receive it.
CARR: -- prior to --
MANCINI: No.
CARR: But what you do explain in your statement, it's paragraph 50, at page 10, that in your own preparation ahead of the review, you had identified yourself that Letby was present for a number of the deaths?
MANCINI: Yes.
CARR: The document that you refer to is -- and can we have it up please, INQ0001072 [not found], that's not correct. So we can take that down, the reference is INQ0010072. It's a spreadsheet, yes. There we go. It's a spreadsheet with -- we can see at the bottom a number of tabs analysing nurse staff on duty, medical staff on duty and marking whether individuals were on shift at the time of unexpected deaths and whether they were on shift before.
MANCINI: Yes.
CARR: In your statement you cite this as being the document you saw, as I understand it, prior to the review?
MANCINI: Yes.
CARR: It deals with 11 deaths in total, doesn't it, 11 deaths?
MANCINI: Yes.
CARR: It shows that Letby was on duty or on the shift before for 10 of the 11, all but one, as you say in your statement?
MANCINI: (Nods)
CARR: What view did you form about that correlation? We can take it down now, please, thank you.
MANCINI: I think this -- this is one element of all the numerous documents we were looking at. I didn't form a view at that time that there was anything particularly unusual.
CARR: Did you turn your mind as to why somebody had carried out that analysis?
MANCINI: I think there was a problem with -- we know that there was a problem with an increased number of deaths and people were trying to get to the bottom of it, so looking at various processes, looking at various information that was available and this was one element of a document that might give some information. But at that stage I was looking at it I wasn't thinking that it might be what we now know: somebody causing harm to babies.
CARR: Did you think there might be a connection between that correlation and the number of deaths, so did you consider that the fact somebody had carried out
that analysis and what it revealed there may be a connection between the individual and --
MANCINI: Okay, so what I would see as a nurse with my experience is looking at the members of staff that are on any shift and looking at skill mix. I would also take that view when you are looking at a spreadsheet of members of staff to look at might that have contributed to some of the elements of babies dying more -- more than they were used to having on their unit.
CARR: You have explained that you weren't told that the doctors had any suspicions about Letby prior to arriving at the hospital?
MANCINI: No.
CARR: Was that a possibility that occurred to you in your analysis, a possible explanation for the unexpected and unexplained deaths?
MANCINI: Do you mean by looking at this spreadsheet?
CARR: Looking either at this spreadsheet or any of the other documents --
MANCINI: No.
CARR: -- that you looked at, did you consider that one explanation for the increase in deaths might be deliberate harm?
MANCINI: No.
CARR: If we can look, please, at INQ0012846, what's about to come on screen is an email from Sue Eardley to you and the other members of the team dated 12 August 2016. Now, the third paragraph of that email, reads: "Key things to look at are probably the Mortality Reviews and there are some concerns coming out over the transport service." It's the first part of this email that I -- of that paragraph, sorry, of this email that I want to deal with. What did you understand to be key about the Mortality Reviews?
MANCINI: Well, I think the information that was included in the Mortality Reviews and if there was anything that we were having to look through this methodically, there were so many documents we had to look at, but to draw our attention to look at the Mortality Reviews and as one of the Terms of Reference was looking at any commonalities seeing if there was anything within those reviews that looked immediately obvious to us.
CARR: Did you look at the thematic review from 2016? February 2016 -- sorry, Mortality Review February 2016, it's the one that involved, Dr Subhedar from Liverpool Women's Hospital?
MANCINI: Okay, I can't remember that document exactly
without seeing it. But if it was included in these I would have looked at it in detail.
CARR: When dealing with the Mortality Reviews in your statement, it's paragraph 44, the fourth sentence?
MANCINI: Sorry.
CARR: Paragraph 44?
MANCINI: 44, thank you.
CARR: It's on page 9.
MANCINI: Yes.
CARR: Your fourth sentence reads: "I recall that it was important to consider any Mortality Reviews to ensure that appropriate processes were being followed in conducting Mortality Reviews". Can you explain what you mean by that sentence?
MANCINI: What I mean is that they followed a robust process. So when a Mortality Review is conducted, and again sometimes the terminology may be used quite loosely, but when a baby dies, there is -- there's the postmortem, there is a whole process that happens. There are multi-disciplinary meetings that we have together called Mortality and Morbidity Meetings where they would be discussed in detail within obstetrics, the maternity teams and neonatal with the postmortem results. So that's one way of looking at the reviews to do
with mortality. Then I understand again because of really not understanding why these babies were collapsing and there were these unexpected and unexplained deaths, these Mortality Reviews were taken a step further to look at in further detail and to look at them together.
CARR: So is this a fair summary: the importance of the Mortality Reviews, one, was to ensure that processes were being followed properly?
MANCINI: Yes.
CARR: Two, to consider the content of the reviews --
MANCINI: Yes.
CARR: -- and what they told you about the deaths? Finally, so far as the preparation is concerned, before we turn to the review itself, if you look at your paragraph 48, please. You describe there a meeting prior to the review visit and you describe a discussion with Sue Eardley and the final couple of sentences of that paragraph read: "I think we identified that the Review Team would be limited in gathering this detailed information within the remit and the Terms of Reference provided. I have no contemporaneous notes of this given the passage of time." You say that in the context of a discussion as to
whether or not the team did have enough information.
MANCINI: Sorry, could you repeat that last sentence, I couldn't hear very well?
CARR: Yes, I am trying to summarise your paragraph for you.
MANCINI: Thank you.
CARR: As I understand it, you are describing here a discussion amongst the team with Sue Eardley where the team is considering whether there is sufficient documentation or not?
MANCINI: Yes.
CARR: The final part of the paragraph that I'll read to you says: "I think we identified that the Review Team would be limited in gathering this detailed information within the remit and the Terms of Reference provided." Now, the suggestion appears to be that the team thought further detailed information was required but you wouldn't be able to get it?
MANCINI: So I think what I mean by that sentence, yes, is that gathering further information would be difficult within the time that we had within the remit and the Terms of Reference provided that there were significant number of elements that we had to consider within the Terms of Reference in a short space of time.
CARR: There are three different factors there, so time, remit, Terms of Reference?
MANCINI: Yes.
CARR: Firstly, before we look at those, what was the further detailed information that you and the team considered was required?
MANCINI: I think when -- when you are reviewing as, as we have already discovered this was my first review but I have experience of being a clinical adviser for the ombudsman, so when there are those situations you gather the information that you have, you read it, you check it, and then new questions will come up and then you need to have -- you will request further information on that basis. But if you are limited for time, that's very difficult to do that.
CARR: So was time the reason that the Review Team felt they couldn't request the further documentation required?
MANCINI: Yes. Well, we put in the request and it took time for the Trust to share that information.
CARR: Did you feel a sense of pressure or did you feel hurried to start the review?
MANCINI: I think the pressure was felt because this was very serious. There was -- babies were dying, this was
very, very serious and we had been in discussions since July about organising the team and the dates that we could meet in person and because of work commitments that did add to a delay of us starting on 1 and 2 September. So I don't think the pressure felt so much so that we didn't have the right information at the time that we needed it.
CARR: So you would say you were content to proceed with --
MANCINI: Yes.
CARR: -- the review, notwithstanding the missing information?
MANCINI: Yes.
CARR: Are you able to help us with the nature of the information that was missing, what was it that you felt or the team felt they didn't have?
MANCINI: I think that there was certain elements that were missing and I am -- I can't remember exactly but it was thinking about details from the Child Death Overview Panel and information about the babies that were discussed within those meetings.
CARR: We are about to turn to the review visit. I want to ask you a question about the rest of the team. You have made mention already to Sue Eardley and we have
heard evidence from her?
MANCINI: Yes.
CARR: She was the Review Team manager. There were two neonatal doctors, one of those was the lead reviewer, that's right, isn't it, David Milligan and Graham Stewart?
MANCINI: Yes.
CARR: Then the final member of the team in addition to yourself was Ms Claire McLaughlan?
MANCINI: Yes.
CARR: She was a lay reviewer and had you ever worked with her or met her prior to this review?
MANCINI: No.
CARR: What was your understanding of her professional background?
MANCINI: Claire's?
CARR: Yes.
MANCINI: That she had -- she had a nursing background, she was a qualified barrister and I can't remember without looking at my notes exactly the nature of her work at that time but I think that she was supporting doctors when there had been difficult situations at work, I think, so I am not 100% certain about that.
CARR: So far as her being a qualified barrister, was your understanding of that based on a discussion with
her or was it based on documentation you had seen?
MANCINI: Documentation.
CARR: Did you understand from that that she had worked as a barrister at some point?
MANCINI: No. I think, no. I -- because she hadn't written it, I am, I am talking, I am making reference to our biographies that were shared with us via email. So a qualified barrister, I didn't take that as she was currently working as a barrister or had done.
CARR: Turning to the review visit, which is made up for the most part of interviews of different members of staff--
MANCINI: Yes.
CARR: -- over the course of two days, 1 and 2 September. I am not going to go through every single interview but there are some I am going to look at --
MANCINI: Yes.
CARR: In detail -- In terms of the structure of day one, my understanding is that you had a first meeting with Ian Harvey and Alison Kelly --
MANCINI: Yes.
CARR: -- followed then by a meeting with Dr Brearey and Dr Jayaram?
MANCINI: Yes.
CARR: Then there was a morning break.
MANCINI: Yes.
CARR: It was that initial meeting -- and you deal with this in paragraph 60 of your statement -- that concerns amongst the paediatricians in relation to Letby were raised with the Review Team?
MANCINI: Yes.
CARR: Do you have that? If I understand the sequence of events as you describe them in your statement, that was the first time you became aware --
MANCINI: Yes.
CARR: -- of those concerns. There is a suggestion in the evidence that there would have been a pre-meeting amongst the Review Team the evening before --
MANCINI: Yes.
CARR: -- the review started but you don't have any recollection of the team discussing Letby or the nurse at that meeting?
MANCINI: No.
CARR: If we can look it is INQ0014604, we are going to start here, so this is the first page of Sue Eardley's handwritten notes. This is a transcript of her handwritten notes?
MANCINI: Okay.
CARR: This is the start of the review visit. And the meeting commences with DM, that appears to be a reference to David Milligan, doesn't it, lead reviewer: "... said that we may not be able to explore the detail of the deaths." So right from the start, that fourth term of reference which required the Review Team to consider factors or failings which may have caused the death and any common factors or failings, that was something that David Milligan was saying was essentially off the table, you weren't going to explore the deaths?
MANCINI: Yes.
CARR: And then after "deaths", in the transcript it says "IA", the written note looks more like "IH", Ian Harvey, what he said: "Correlation of one nurse paediatricians see as elephant in the room. Lucy Letby." You agree, don't you and you make this point in your statement, that that note by Sue Eardley reflects what you were told by --
MANCINI: Yes.
CARR: -- Ian Harvey.
MANCINI: (Nods)
CARR: The next sentence: "Pattern of babies' collapse don't seem to follow normal pattern and respond to resuscitation in normal way." Now, there are two points to make. Firstly, this report of the elephant in the room, the paediatricians' concern, it appears right at the start of the meeting, isn't it, it is what Ian Harvey is opening the discussion with?
MANCINI: Yes.
CARR: Did that primacy indicate or signal to you a level of significance or importance of that issue for the Trust?
MANCINI: Sorry, can you repeat the question, please?
CARR: Yes. So the point that I am making is that this is the first issue, first topic raised by Ian Harvey?
MANCINI: Yes.
CARR: Did the fact that you have gone to this meeting, you say you weren't aware of the concerns, did the fact that this was what Ian Harvey was opening with, did that indicate that it was a significant and important point?
MANCINI: Yes.
CARR: The second observation to make is that the
note refers to paediatricians in the plural, doesn't it?
MANCINI: Yes.
CARR: It does not suggest that it is just a single doctor who has that view?
MANCINI: Yes, I agree.
CARR: In fact the reference appears to be to the paediatricians as a body, doesn't it, it seems to be referring to the collection of paediatricians?
MANCINI: Yes.
CARR: If we can go to page 2, please, and about two-thirds of the way down the section underlined, we see it is recorded: "Clinicians threatened to go to the police."
MANCINI: (Nods)
CARR: Now, what did that indicate to you as to the degree of seriousness with which the paediatricians held their concerns?
MANCINI: Very serious.
CARR: If we can go forward, please, to page 4 and we are still within the interview with Ian Harvey and Alison Kelly. Third line down: "IH [that is Ian Harvey] had to intervene with the neonatal lead as junior doctors had been referring to her as "Nurse Death". Ripples through the team and trying to function. Can't see how it is concluded without calling the police. Unless there is something to satisfy the medical staff, they can call the police." Now, what I want to ask is, what did you understand by that final reference: "Unless there is something to satisfy the medical staff ..."
MANCINI: I would -- thinking about this now, I would think that suggests that unless there is another cause for this increased number of deaths, then the medical staff may follow their concerns in contacting the police.
CARR: Was the suggestion that unless you as a Review Team came up with something, the police would be called?
MANCINI: No. I didn't -- from what I understand from your question is that unless we found something and we were being urged to find something, then the medical staff would call the police. I -- I don't agree with that. I --
CARR: Forgive me, sorry.
MANCINI: No. I think that may be interpreted in that way but I didn't feel that at the time. We would find what we found.
CARR: Yes.
MANCINI: Which was the truth.
CARR: Put aside the suggestion then of being urged
to find something. But did you or did the team understand that whether or not the police were to be called depended on whether or not you as a team deliver something to satisfy the medical staff?
MANCINI: So if I can repeat back to understand it. Do you mean that unless -- it was dependent on what we found in the report, and what we wrote in the report was dependent on whether they went to the police or not?
CARR: What I am trying to understand is what you, what impression you had and what you understood from the suggestion that unless there is something to satisfy the medical staff, they can call the police, what is the something as you understood it, that would satisfy the medical staff?
MANCINI: I don't know.
CARR: What was your impression of the attitude of Ian Harvey and Alison Kelly to the doctors' concerns and their suspicions?
MANCINI: I think his attitude was disbelieving.
CARR: You said "his attitude", is that a reference to Ian Harvey?
MANCINI: Also I believe that Alison Kelly felt that as well.
CARR: So you got the impression that they didn't believe the allegations?
MANCINI: (Nods)
CARR: Did you get the impression that they were treating the allegations seriously and recognised the seriousness?
MANCINI: No.
CARR: The next meeting, and I think it followed immediately afterwards, was with Dr Brearey and Dr Jayaram. We are staying in the same document but going forward to page 7, please. The entry roughly in the middle of the page, next to the name "Steve", that is a reference to Dr Brearey. You see there that he reports: "Things okay until last June, were comparable to other units et cetera" and "didn't feel they were much of an outlier. "Three neonatal deaths in June. Reviewed in detail. Met Alison and SI Panel to discuss them. "Learning from every case but no overarching deficiency in practice. Identified one nurse present at all collapses." Just pausing there, you knew at this stage that that nurse was Letby?
MANCINI: Yes.
CARR: "Didn't think it was significant. Agreed to keep an eye on things. As the year progressed each
subsequent mortality not a huge concern but by end of 2015 numbers stacked up a little." So what Dr Brearey is describing there is a realisation as mortality increased of the connection, correlation between Letby and that increase in mortality?
MANCINI: Yes.
CARR: Now, that is something that you had already identified in your own preparation?
MANCINI: (Nods)
CARR: If you go forward, please, to page 9, and the first entry by the name "Steve" and the final couple of lines: "Even after PM [postmortem] unexplained." So do you have that?
MANCINI: Yes.
CARR: It's a little bit further down, so it's that entry that has the red arrow but it but yes, the final section "even after [postmortem] unexplained". So did you understand from this that in addition to the increase in mortality, in addition to the correlation with Lucy Letby, you had Dr Brearey explaining that even after postmortem examination there was no explanation for --
MANCINI: Yes.
CARR: -- the deaths. You explained at the beginning that unexplained unexpected deaths is something that is rare in neonatal practice and to have a cluster in itself would be a concern?
MANCINI: (Nods)
CARR: Then the penultimate entry from Dr Jayaram, do you see that: "Nurse on shift at all times. Spoke to Ian and Alison." That is a reference to Ian Harvey and Alison Kelly, isn't it?
MANCINI: (Nods)
CARR: What you would have understood from that is that there were -- there was a concern which had been escalated to senior --
MANCINI: Yes.
CARR: -- managers. The next page, page 10, at the top of the page there is reference to Letby's changing of shift patterns. So if you look five lines down, the sentence that starts: "no U/E collapses", do you have that?
MANCINI: Yes.
CARR: "No [unexpected] collapses at night when she was on days but collapses happened in daytime. All
never individually realise they had thought the same thing." What the doctors were explaining to you is that the unexpected collapses had been happening during the night shift when Letby was working during nights?
MANCINI: (Nods)
CARR: She had been moved to day shifts and unexpected collapses stopped at night and started occurring at the daytime?
MANCINI: Yes.
CARR: Then in the bottom third of the page, just two lines above the redaction box that contains [Child A] it says: "Thinking about it, what could she be doing? Postmortems gave no cause. Not checked for electrolytes, levels OK beforehand." Then there's a reference to "inject". The bottom two lines: "When thinking forensic, what happens with air embolism? Looked at case studies and last observations. Chilling." Over on to page 11, please: "What had happened? Babies unresponsive to any inputs, odd skin discolouration. Blue with eyelids of pink, [query] injecting air into the babies."
So what is clear from this discussion that you had with Dr Jayaram is the level of their concern was such that they had been looking up medical literature --
MANCINI: (Nods).
CARR: -- for methods of deliberate harm to babies. And upon doing so, they had found consistency between what was reported in the medical literature and what they had being seeing on their ward?
MANCINI: Mm-hm.
CARR: The final point, it's dealt with later in the interview but you were aware, weren't you, that since Letby had been moved off the shift, no more unexpected collapses had occurred, so since she had been moved off the unit --
MANCINI: Yes.
CARR: -- no further unexpected collapses had occurred. Now, in light of your discussions with Dr Brearey and Dr Jayaram, and in light of the matters that they were raising, did you have any reason to doubt the sincerity of their views?
MANCINI: No.
CARR: Did you consider that their concerns were genuine?
MANCINI: Yes.
CARR: Did you have any reason to doubt their expertise as Consultants?
MANCINI: No.
CARR: Did you have any concern as to the factual accuracy of their analysis, whether that's to do with rotas, the correlation, their consideration of the medical literature?
MANCINI: No.
CARR: Now, there was a discussion amongst the Review Team at which consideration was given as to whether or not the review should be aborted?
MANCINI: Mm-hm.
CARR: It was at some point following this interview?
MANCINI: Yes.
CARR: I think your statement says you can't recall exactly when it was. Graham Stewart in his statement suggests that the discussion happened during the first morning break, morning coffee break, so it would have been shortly after the interview with Brearey and Jayaram?
MANCINI: Yes.
CARR: Now, I know you weren't responsible for taking any notes during the review visit, but that discussion to abort is not documented in the notes, is it?
MANCINI: No.
CARR: None of the notes that we have seen. It is something that should have been recorded in the notes?
MANCINI: Yes.
CARR: Was this a discussion involving the whole team?
MANCINI: As far as I can remember, yes.
CARR: And the conclusion was that the review should continue?
MANCINI: Yes.
CARR: The conclusion of the team and in particular, this is dealt with at paragraph 86 of your statement, you say: "I didn't think the review should be aborted and I shared this view with the others. I can't remember any other member saying we should abort the review." Now, what I want to ask you about is your view that the review should continue --
MANCINI: Yes.
CARR: -- notwithstanding the matters that you had heard in your first two interviews. Why in your view was the information that you had received which amounted to criminal activity of a serious kind, why was that an insufficient reason to stop the review?
MANCINI: Whilst we had a discussion amongst ourselves and I can remember why I thought that we should continue
because it was still a very valuable fact finding review/exercise. We were there, we had our Terms of Reference and I have to say being guided by the two most senior people which was the head of the Invited Reviews and the lead reviewer, that it was the right thing to continue finding further information. I do feel that if I disagreed it would not be a problem. I felt able to speak up if I disagreed with them, so I wasn't blindly guided, but I took their expertise and their experience as part of the decision-making process.
CARR: When you say the two senior members of the team, who are you referring to?
MANCINI: The lead reviewer, David Milligan and the invited head of review, Sue Eardley.
CARR: Graham Stewart, in his statement, and you will have seen this, he suggests that he raised the view that the review should be aborted. Do you remember there being discussion or anybody being of the opinion that the review ought to end?
MANCINI: I don't remember that.
CARR: Can we go through the factors that were present during this discussion? So following the interviews of Kelly and Harvey and then Brearey and Jayaram, you knew as a team there was a pattern of
unexpected and unexplained deaths. You identified in your evidence earlier that a cohort of such -- because unexplained deaths are so rare in neonatal practice, that in itself would be a concern?
MANCINI: (Nods)
CARR: You knew that there had been a correlation with Letby and that persisted when she changed shifts, it followed her when she changed shifts from night to days?
MANCINI: (Nods)
CARR: Then the unexpected deaths stopped --
MANCINI: (Nods)
CARR: -- when she was moved off the unit?
MANCINI: (Nods)
CARR: You knew that experienced doctors you described as being sincere and genuine in their views were concerned that she was responsible for murdering babies?
MANCINI: (Nods)
CARR: You had been told of threats to call the police?
MANCINI: (Nods)
CARR: You had been told that the doctors had gone so far as researching medical literature and had found
consistency with what they had seen?
MANCINI: (Nods)
CARR: In light of all those factors, didn't you think this: this really is well beyond the scope of an Invited Review, this needs the police?
MANCINI: I didn't think that at the time.
CARR: Why did you think a police investigation was not warranted in light of all of those factors?
MANCINI: It wasn't something we had considered as a team or individually at that time.
CARR: Do you agree that in light of all those factors we have just gone through, that the serious nature of the alleged offending, the fact that the views were genuinely and sincerely held by expert doctors, that the police ought to have been involved and that the review should have been aborted?
MANCINI: I think on reflection, I think on reflection the review could have been stopped at that time and aborted and further advice taken from the RCPCH, that's where I think the advice should have been taken from.
CARR: The question is: do you think it should have been stopped at that point in light of the serious nature of the concerns that had been raised?
MANCINI: I think I would still maintain that we were trying to find information and gathering information for the other Terms of Reference at that point and that's why we decided collectively that we should continue.
CARR: The notes of the team meeting at lunch on day one, it's INQ0014604 and it's page 25 -- which should be the redacted version before we put it up. The note is about to come up but, as I understand it, the discussion to abort the review occurred in the morning and then at lunchtime there was a further team discussion?
MANCINI: I genuinely don't remember that.
CARR: In the middle of this page, we see reference, it starts "Tom" underlined, but in the handwritten version of the notes that reads "team", and this appears to be a note of a team discussion: "Were RMs ..." That should be "PM". "Were [postmortems] done by perinatal pathologists?" Then the next line has two matters which have been redacted or where it says "no" that should say "insulin" "... or insulin injection or air embolism." It appears, and we have heard evidence from Sue Eardley on this point, that the team were discussing at lunchtime various different methods by which deliberate harm could be caused to babies by members of
staff. Do you recall that discussion?
MANCINI: I don't.
CARR: Were you present at --
MANCINI: I can't remember.
CARR: Do you agree that if the team had got to the position where they are discussing amongst themselves different potential methods of murdering babies, it is a clear signal that the review has to stop and it's inappropriate?
MANCINI: I agree.
LADY JUSTICE THIRLWALL: Mr Carr, I think we probably should take this page off I think there is some information on there that should have been redacted?
MR CARR: Please remove.
LADY JUSTICE THIRLWALL: So it shouldn't be reported, not the passages that you have taken us to, but that which follows, so if we can just --
MR CARR: If we can take that down, please. Towards the end of your statement in your reflections, it's your paragraph 135, you say: "I do not consider ..." Sorry, are you there, it is page 31? Do you have it?
MANCINI: Yes.
CARR: It reads:
"I do not consider an Invited Service Review to be an appropriate means of investigating an increase in unexpected, unexplained death in circumstances where clinicians suspected a nurse of criminality." That is the position that emerged on the morning of the first day of the review, isn't it?
MANCINI: Yes.
CARR: In those circumstances, the review should have been stopped, shouldn't it?
MANCINI: On reflection, yes.
CARR: The advice should have been given to the Trust to call the police, who were the appropriate agency to investigate the concerns that emerged?
MANCINI: An appropriate agency, yes.
CARR: In deciding as a team to continue, and just before the lunch break we looked at the Invited Reviews guidance, was any advice sought, did you seek any advice from the RCN, did any of your colleagues on your team seek advice from the RCPCH?
MANCINI: I didn't physically see that, no.
CARR: In your discussions as to whether or not to abort the review, was consideration given as to whether continuing might prejudice other investigations?
MANCINI: I don't remember discussing that.
CARR: When we were looking at the guidance, one of
the provisos was that if an Invited Review is to continue when serious concerns emerge, clear scope boundaries should be agreed before further work is undertaken. Were any clear scope boundaries agreed?
MANCINI: I don't remember that there was a different scope than the one that we started off with with the Terms of Reference and our plan to interview the members of staff that we did and speak with different departments.
CARR: Yes, but the fact of the guidance that we looked at which dealt with circumstances -- and I can get it back up if you would like to see it again -- circumstances in which the College would not take on a review, so it is those categories of cases listed at 7.5. Then it gives guidance on what to do if those sorts of issues arise during a review?
MANCINI: (Nods)
CARR: Okay, we will get it up. It's INQ0010214. If we go, please, to page 8. 7.5 lists those categories of cases that the College would not take on. The first subparagraph includes: "Where the expected scope includes behavioural misconduct, bullying, harassment or possible mental health concerns." At the penultimate paragraph: "The police or counter fraud service are involved." It's clear, isn't it, that an Invited Review or a request for an Invited Review looking into allegations of attempted murder would not be taken on under this terms of this guidance?
MANCINI: I agree, they wouldn't be taken on.
CARR: Then if we go to the next page, page 9, paragraph 7.7, that deals with the situation where a case has been taken on and during a review, the sort of issues we see at paragraph 7.5 emerge so this is a situation that you and the team found yourselves in?
MANCINI: Yes.
CARR: Paragraph 7.7. Now, you decide as a team to continue. What this paragraph of the guidance provides is: "The reviewers cannot investigate or suggest solutions for any of the above." Okay, so that is the issues that we looked at just at the previous paragraph.
MANCINI: Yes.
CARR: The next sentence: "Clear scope boundaries should be agreed before further work takes place in order to avoid prejudicing other investigations."
So what this paragraph seems to be envisaging is in circumstances where a serious concern emerges mid-review, firstly you need to consider whether you are going to continue at all --
MANCINI: Yes.
CARR: -- in light of the possibility of prejudicing other investigations. If you are going to continue, don't investigate or suggest solutions for the serious conduct issues that may arise and agree clear scope boundaries?
MANCINI: Yes.
CARR: Now, do you understand the reason why it's suggesting or advising clear scope boundaries?
MANCINI: Absolutely, yes.
CARR: What I am asking you is what clear scope boundaries, if any, in accordance with that paragraph did the Review Team agree?
MANCINI: When -- when we had our discussion, our focus was on continuing to fact-find and gather information that we thought would be helpful even --
CARR: Forgive me, sorry.
MANCINI: Even in light of the information that we had been given.
CARR: I am asking very specifically about clear scope boundaries.
MANCINI: We -- we didn't agree any.
CARR: If the Review Team had considered this paragraph and there had been discussion of clear scope boundaries, would one very obvious clear scope boundary be: well, we mustn't interview Letby, the person against whom these allegations are being made?
MANCINI: I agree with you.
CARR: Do you consider looking at that paragraph it was a mistake for the Review Team to decide following the interviews that morning on the first day of the review visit, it was a mistake to decide to interview Letby?
MANCINI: In relation to this paragraph, yes.
CARR: If you look, please, at your paragraph 54 in your statement.
MANCINI: 54?
CARR: Yes, 5-4. It's a long paragraph but what you set out there is that upon hearing that Letby had been removed from practice, during the morning of the first day of the review visit, you wanted to know what reasons were given for removing her from clinical practice, what HR process had been followed, what support had been given and you go on to identify in that paragraph the HR considerations that you had in mind. Why was your immediate concern in respect to
Letby's removal, HR processes and not safeguarding processes?
MANCINI: I haven't included safeguarding processes within my statement but I agree it should be safeguarding primarily.
CARR: What consideration did you give to safeguarding processes?
MANCINI: Thinking that when there are allegations and the safeguarding policy and a safeguarding process is when the allegations are made there's a very clear framework to follow in the first instance contacting your manager or designated doctor or nurse for safeguarding within the institution and then a whole process follows about fact finding and information finding. So primarily from this aspect as well, as much as the safeguarding process wasn't followed, neither was an HR process of removing somebody from clinical practice which is a very intentional move and what I was concerned about was in not having an HR process, disciplinary process or other similar, is that it might interfere with future investigations or fact-finding reviews. My experience is that following HR processes are absolutely vital to ensuring patient safety. But you have to follow those processes rigidly, so that it protects the patients and there's no room for, as I said, influencing future investigations.
CARR: Did you ask anybody at the Trust during the review whether a referral to the Local Authority Designated Officer had been made?
MANCINI: I think I did when we first -- I think I did see it when we first met when Ian Harvey told us that she had been removed from practice. I think I asked then.
CARR: What was your understanding as to whether a referral had been made?
MANCINI: None.
CARR: Did you advise that a referral should have been made?
MANCINI: No.
CARR: Why not?
MANCINI: I had just heard that information, I was processing the information about Letby and we were gathering information there as a team and it's something that I thought we would discuss at a later point.
CARR: Can we turn please to the actual interview of Letby, it was conducted by you and Ms Claire McLaughlan?
MANCINI: Is it coming up on the screen?
CARR: It will do in a moment.
MANCINI: Okay.
CARR: What I want to ask you first is in respect of your own witness statement, paragraph 70, you say: "As a Review Team we discussed topics to put to Lucy Letby and decided that they should be the same as everyone else we interviewed." Do you see that?
MANCINI: (Nods)
CARR: But you interviewed a number of different people with a number of different specialisms?
MANCINI: Yes.
CARR: So you discussed different issues with different people?
MANCINI: Yes.
CARR: So in respect of Letby, can you be more specific in explaining what it was decided that you would be discussing with her?
MANCINI: Well, along the Terms of Reference of thinking about staffing, relationships within the team, the culture of the unit, anything that they wanted to share with us and that was very much our approach with all the interviews and of course as you say there is different specialisms and people chose to share different things with us, different information with us, so that did change.
But what I mean by paragraph 70 is we didn't change -- ask anything specific or we weren't investigating.
CARR: One of the Terms of Reference required the team to consider whether there were common factors or failings contributing to the increase death rate?
MANCINI: We didn't -- we didn't ask that directly.
CARR: Did you determine before speaking to Letby that you wouldn't ask her about that?
MANCINI: No.
CARR: The document is INQ0014602. This is again a transcript of the notes made by Claire McLauglan, as I understand it, you will have seen her handwritten notes, of your interview with Lucy Letby and also we can see at the top there that in attendance was Hayley Cooper, or Hayley Griffiths as you may have known her. Now, on the basis of this note, and we will go to page 3, please, we can see there in the first paragraph that you discussed with Letby or there is a note indicating a discussion with Letby, her redeployment and the reasons for it.
MANCINI: Yes.
CARR: We can see in the second paragraph on the page a reference to her being scapegoated.
MANCINI: Yes.
CARR: Again, you have indicated that if the team had turned their mind to clear scope boundaries, Letby wouldn't have been interviewed at all. If you and Ms Claire McLaughlan had clear scope boundaries in your mind going into this interview, you would have stayed well away from --
MANCINI: Yes.
CARR: -- issues concerning her redeployment and issues connected to the increase in unexpected deaths?
MANCINI: So we didn't ask her about her redeployment. She offered that information. Because how the -- I haven't unfortunately got a list of the questions that we asked but you can see from how the interview has gone, tell us a little bit about yourself, about your nursing background, and then she offered up that she was, she exactly this on this page, about having been removed clinically for a period of 10 weeks, not knowing why. But also --
CARR: Does that -- forgive me, sorry, I thought you had finished.
MANCINI: I was going to say but Claire and I didn't explore further when she offered this information, that wasn't our purpose.
CARR: Does that perhaps underline the reason why --
MANCINI: Yes.
CARR: -- she shouldn't have been interviewed because of the danger of trespassing into areas of discussion you would or should not have been ...
MANCINI: (Nods)
CARR: Now, Hayley Griffiths, or Hayley Cooper, the RCN representative, she describes -- has described that Lucy Letby left the meeting with you in a distressed state. Do you remember Lucy Letby getting into a distressed state?
MANCINI: No.
CARR: Do you remember her leaving the meeting?
MANCINI: I can't remember her exactly leaving the meeting.
CARR: Do you recall having a discussion with Hayley Griffiths following your meeting with Letby?
MANCINI: No.
CARR: Do you remember having any discussion with Hayley Griffiths?
MANCINI: Not alone, no.
CARR: No.
MANCINI: No.
LADY JUSTICE THIRLWALL: By "alone", you mean without?
MANCINI: Without Lucy Letby.
LADY JUSTICE THIRLWALL: Yes, thank you.
MR CARR: The evidence from Hayley Griffiths is that she was told words along the lines after Letby had left the room -- she was told words along the lines of: Does she know what is going on here and what she's potentially being accused of?
MANCINI: I don't remember that at all.
CARR: Do you remember hearing Claire McLaughlan say that --
MANCINI: No.
CARR: -- to Hayley? Can we get up please, INQ0000569, it's the same document from before but it's the restricted, the one-page version, please, thank you. We might need to zoom in so that we can see that. These are text messages sent by Letby to Dr U the evening of 1 September, so shortly following your interview with her. Do you see in the first one it says: "The team members were nice. They didn't ask much about the babies. It was more about the unit as a whole, et cetera. In brief it looks as though there is a potential for this to go further over a long period of time. H thinks we need to look at taking out
a grievance case." Then the second entry further down on that page: "The report will take a minimum of six weeks with a preliminary tomorrow. They 'off the record' told me they think an investigation into the deaths will be a recommendation and I need to prepare myself that as I would play a big part in that over due to being a common factor and it could take several months." Now, just going through the substance of that. The report will take a minimum of six weeks. Did you tell --
MANCINI: No.
CARR: -- Letby that's how long it would take? Did you hear Ms McLaughlan tell her that's how long it will take?
MANCINI: No.
CARR: A turnaround time of six weeks for the report is about right, isn't it?
MANCINI: Yes. According to the Review Handbook, but I didn't say that.
CARR: So she is accurate in her understanding of how long?
MANCINI: Sorry?
CARR: She is accurate in her understanding of how long the report will take?
MANCINI: Yes.
CARR: But you say she didn't get that from you?
MANCINI: No.
CARR: And she didn't get it from Claire McLaughlan?
MANCINI: No.
CARR: As to the reference of the "off the record" discussion, did you have an off the record discussion with her?
MANCINI: No.
CARR: Did you have an off the record discussion with Hayley Griffiths?
MANCINI: No.
CARR: Did you advise her there was going to be an investigation?
MANCINI: No.
CARR: Did Claire McLaughlan advise her?
MANCINI: No.
CARR: It is correct, isn't it, and we can look at the other notes from that day, that the plan was for a recommendation for further investigation by the Review Team to the hospital?
MANCINI: Yes.
CARR: That is ultimately what was advised?
MANCINI: Sorry, what do you mean advised? To Letby?
CARR: No, to the hospital.
MANCINI: Yes.
CARR: So Letby is accurate in her description of there being an investigation into the deaths because that's what you as a team were proposing?
MANCINI: Yes, but we hadn't made that decision until the next day.
CARR: We can take the messages down. No, I understand that. Yet we have the text messages and I understand you say -- well, you didn't tell Letby that there was going to be an investigation into the deaths, but that was your plan, so she has accurately reflected?
MANCINI: She -- she has but I haven't -- I haven't told her that.
CARR: Did you tell her that she had been identified as a common factor --
MANCINI: No.
CARR: -- in the deaths? Is that an accurate description of your understanding of the evidence?
MANCINI: Sorry, what do you mean?
CARR: Did you consider that she was going to play a big part in the investigation, that the RCPCH was recommended because of the correlation that you had identified?
MANCINI: I -- I wouldn't have said that. I didn't say that.
CARR: Did Claire McLaughlan have a discussion with her as to --
MANCINI: No.
CARR: Did you advise her to prepare herself?
MANCINI: No, they are also words that I just wouldn't use.
CARR: (Pause) Forgive me, I needed to find a reference. The next document I want to take you to is INQ0014605. These are the transcripts of Sue Eardley's note for the second day of the visit and it is page 6 that I want to take you to, please. This appears to be notes from a discussion that morning with Ian Harvey and Alison Kelly. Do you recall being present at this meeting, so it is the day two meeting with Ian Harvey and Alison Kelly, it's not the feedback session at the end of the day?
MANCINI: Is that the end of the day, yes?
CARR: Sorry?
MANCINI: The end of the day?
CARR: No, it is not the feedback session at the end of the day, it is earlier in the day.
MANCINI: Okay.
CARR: So it is not the meeting with Tony Chambers,
Ian Harvey and Alison Kelly; it is a meeting earlier with Ian Harvey and Alison Kelly?
MANCINI: Okay.
CARR: There is discussion of your interview with Letby the previous day. I am looking at the bottom of the page about six lines up where it says: "Needs to be put into a process for her protection and yours. Disciplinary process to get to the bottom. Can't understand why RCN have let this go on. Suspect there will be a grievance. If nothing happens good case for constructive dismissal. She knows it will be horrid." The reference there to "she knows it will be horrid", that is a reference to Letby, isn't it?
MANCINI: I -- yes, I assume so. But I didn't say that.
CARR: No, but what did you understand or can you help us to understand what it is that Letby would know or knows is going to be horrid?
MANCINI: I don't remember having a conversation that this would have been mentioned, certainly not with Letby.
CARR: Well, looking, we have looked at the text messages and there was actually one interpretation of those text messages is that Letby has been tipped off about the fact that the RCPCH are going to recommend an
investigation into the deaths and she's going to be a part of it and the reference here to "She knows it'll be horrid"?
MANCINI: I don't know where she got that information from. But also she was under the impression and I can't remember where it's written she was under the impression that following the review, she would be reinstated.
CARR: So you don't know where she got the information from. She didn't speak to anybody else from the RCPCH Review Team, did she?
MANCINI: Not that I can remember.
CARR: So the possibilities appear to be either she was told directly by you, she was told directly by Claire McLaughlan, she was told directly by both of you, Hayley Griffiths has told her, or it's just a lucky guess?
MANCINI: I don't know the answer to that. I know that I didn't have that conversation with her.
CARR: I am going to deal more briefly now with some of the other discussions that you had over the course of the review visit. You spoke to the other Consultants, Dr V, Dr Gibbs, Dr Saladi, Dr Holt and Dr ZA on 1 September. During that meeting with those doctors, again, you were told about the unexplained nature of the deaths?
MANCINI: Yes.
CARR: It's right to say that those doctors expressed concern --
MANCINI: Yes.
CARR: -- about the situation on the unit. Dr Saladi is noted in Sue Eardley's notes to describe mottling of some of the babies?
MANCINI: Yes.
CARR: So that is further evidence of what you had been told by Dr Jayaram. The Inquiry has already heard evidence from Dr Saladi and Dr ZA. Both of those doctors describe informing your team that they had concerns with Letby, so Dr Saladi's evidence was that he and the other Consultants told you they were worried about a nurse on the unit potentially causing deliberate harm?
MANCINI: Yes.
CARR: Do you remember that?
MANCINI: Yes.
CARR: Dr ZA's evidence was: "We were very open from the beginning of our meeting that our concern was that Lucy Letby was doing something deliberate to harm babies". Do you recall Dr ZA disclosing that?
MANCINI: I can't remember that it was him or her. But
I do remember that being said.
CARR: You spoke to Dr Mittal, the designated safeguarding doctor?
MANCINI: Yes.
CARR: I can bring the notes up if necessary but I can't see in the notes of that discussion that there was any exploration with him as to whether he was aware of the concerns that the doctors on the neonatal unit had, the suspicions that they had in respect of Letby?
MANCINI: From what I can remember, without looking at documents, he wasn't aware of their concerns.
CARR: Did it ring any alarm bells for you that the safeguarding doctor was not alert to the suspicions that several doctors on the neonatal --
MANCINI: Yes.
CARR: -- unit had shared with you?
MANCINI: Yes, it did -- it did cause alarm.
CARR: Was there any discussion or advice to him as to his need to engage with the doctors on the neonatal unit as to their concerns?
MANCINI: Sorry, can you repeat that please?
CARR: Did you tell Dr Mittal that he needed to speak to the neonatal doctors about their suspicions?
MANCINI: I don't think I said that directly, more that it was assumed because we had had that discussion that
he would then contact the doctors on the unit.
CARR: Let's look at the note. It is INQ0014604 and it's page 28. This is notes from the discussion with Dr Mittal and it is a point at which he's talking about the increased deaths and can you see five lines down: "None of these deaths raised concern for Rajiv or the panel, accepted as natural death even though some had PMs but nothing found." Then further down the page there is a line that reads: "Have discussed deaths with Steve et cetera didn't find any patterns." You will have known by the time of being in this interview that that wasn't correct because there were patterns and there were patterns that were concerning the doctors on the neonatal unit?
MANCINI: Yes.
CARR: Now, given your familiarity that you described at the beginning of your evidence with Working Together to Safeguard Children, you would know that the matters that had been described to you are matters that it was mandatory to escalate within the hospital and then to the local authority?
MANCINI: Yes.
CARR: That hadn't been done?
MANCINI: No.
CARR: That is something that should have been explored with Dr Mittal?
MANCINI: Yes.
CARR: It does not appear from the notes that it was explored with him?
MANCINI: No.
CARR: The final interview in the notes that I want to go to, please, it is the interview with Andrew Higgins, it is a different document the following day, INQ0014605. It's page 22. And the second line down, the sentence that begins "Long debates ..." and Andrew Higgins, he was a member of the board, wasn't he, and he was telling you about what had gone on at board level in respect of these concerns?
MANCINI: Yes.
CARR: The note reads: "Long debates about how to deal with it for that point, eg, involvement of police after internal briefings from Exec. PAV and board needed to get an external view. View came from doctors' team itself so needed an external opinion." Something is crossed out: "I know what it was based on. Took a bit of time then about [a word that's hard to decipher] and whether to involve the police. Wanted to try and unpick this as best we could. Exec recommendation, independent review is the best way to challenge, corroborate, need to keep shutters down and contain situation." Firstly, the reference to an independent review being the best way to challenge and corroborate, was the independent review being referred to the RCPCH review that you were engaged in?
MANCINI: I'm not sure but I think so.
CARR: What was your understanding of the reference "to challenge and corroborate"?
MANCINI: I think the "corroborate" is to find proof and I make -- I am making assumptions here because I am interpreting this -- "corroborate" is to corroborate with the doctors' view that there is Letby causing harm to the babies. "Challenge" I would assume means that there's something completely different that's found, another reason why babies were dying.
CARR: Were you concerned that a member of the board saw the independent review as an alternative to police involvement?
MANCINI: I can't comment what the board's views were.
CARR: Were you concerned that a member of the board was reporting that the shutters need to be kept down and the situation contained?
MANCINI: I was concerned. I don't know what is meant by "keep the shutters down", but "contain the situation" I think is clear.
CARR: Well, again, did that ring any alarm bells for you from a safeguarding point of view?
MANCINI: Yes. But we didn't explore it further.
CARR: Now, at the end of the second day there was a feedback session with Tony Chambers, Ian Harvey and Alison Kelly and the advice given was in respect of the investigation I have asked you questions about and an HR process. I am not going to take you to the notes of that meeting. The advice is contained in the letter that followed the review visit. It's INQ0009611. It's already dated 5 September, written by Sue Eardley. You have seen this --this letter in the preparation --
MANCINI: (Nods)
CARR: -- of your evidence? It's three days after the review visit. Fourth paragraph deals with Letby being moved off the neonatal unit. The final sentence reads: "These steps appear to have been taken on the basis of an allegation made by one member of medical staff supported by his medical colleagues."
To be clear, the allegations I have asked you several questions about is that Letby is murdering babies and it's clear from the evidence that you have given that one member of staff is not an accurate description of the level of concern you received, was it?
MANCINI: I agree.
CARR: Now, it's the second page of this letter that contains the two action points, one the HR investigation, secondly a case review and the paragraph under the heading "Action by HR investigation", second sentence: "Our understanding is that an allegation has been made and therefore a process of investigation needs to be put in place which sets out nature of the allegation and the process you will follow to investigate it." Now, as somebody with experience in HR matters, did you consider an HR investigation an appropriate mechanism for investigating the allegations that had been made by the doctors?
MANCINI: No, I think in the context of this it's a safeguarding investigation.
CARR: Are you saying it should be a safeguarding investigation?
MANCINI: Yes.
CARR: Because it says "HR investigation" doesn't it?
MANCINI: But the HR investigation is specifically about her being removed and redeployed, removed from clinical practice and redeployed for 10 weeks without a process in place. But that -- that sentence, that paragraph is that specifically safeguarding, that is a safeguarding process that should be followed.
CARR: It doesn't say that, does it, in the letter?
MANCINI: It doesn't.
CARR: It ought to have --
MANCINI: Yes.
CARR: -- made recommendations to safeguarding and in light of the evidence that we have already dealt with, in fact the Review Team had heard enough to be recommending in strong terms contact the police?
MANCINI: Yes.
CARR: Can I deal with the clarification you made in your witness statement right at the beginning of your evidence. It's paragraph 87 and you have corrected your statement so it no longer states that the Review Team recommended that the Medical Director and senior management contact the police directly. As I understand it from your corrections, tell me if I am wrong, the sentence before that remains in that your evidence is there was some discussion amongst the team as to whether or not --
MANCINI: Yes.
CARR: -- to recommend the police be contacted but that recommendation wasn't made. However, you weren't involved in those discussions?
MANCINI: No, both of those are incorrect. That sentence and that starts "I wasn't actively involved ..."
CARR: Yes.
MANCINI: And "The Review Team ... " Those two sentences are incorrect.
CARR: So you were involved in the discussions and the conclusion of those discussions was not to contact the police.
MANCINI: I was, yes.
CARR: What was the justification for not contacting the police?
MANCINI: There needed to be the safeguarding process followed first and the HR process and those were the recommendations that were made.
CARR: Why was the HR process or a safeguarding process required before the police were contacted?
MANCINI: From what I can remember, the safeguarding process had been followed with those allegations was the correct first course, first point to follow. The HR
process was separate, that was because she had been removed from clinical practice and there needed to be a robust process in place.
CARR: You say it was a correct process to follow but what process are you referring to?
MANCINI: HR or the safeguarding?
CARR: Either.
MANCINI: Safeguarding is when you make a referral.
CARR: No, I understand the two processes that you are referring to. My question is about contacting the police --
MANCINI: Yes.
CARR: -- and why it wasn't done and your answer is: well, there needed to be an HR process, there needed to be a safeguarding process. I am asking you on what basis why couldn't there be?
MANCINI: The safeguarding process is the correct way to -- when there is an allegation of harm to babies or patients, other patients, is that's the first step.
CARR: Do you or did the team consider it would have been inappropriate to contact the police in light of the lack of a safeguarding process?
MANCINI: I can't speak for the rest of the team but following the discussion that we had, it was deemed appropriate to recommend the safeguarding process as the
first point because of the allegations. We had only -- as far as I was aware we had only heard those -- I had only heard those allegations that morning. And it was throughout the morning and the two days that I had found out that this had been going on for a while.
CARR: The final point I want to deal with with you is the preparation of the report and I am not going to take you to the final report, I want to take you to the comments that you made in the drafting process.
MANCINI: Sure.
CARR: There are two points. Firstly quite early in the process your recommendation was that all deaths at the hospital should be subject to further investigation, not just those which had been classified as unexpected?
MANCINI: Yes.
CARR: The reason that you give for that is you were concerned that the classification may have been wrong or inconsistent, so you wanted to cast the net quite wide?
MANCINI: Yes.
CARR: Then secondly, if we can look please at INQ0010147, and if you turn to page 7, please, we may need to zoom in, it is the comment box, the fourth one down which is slightly orange. Thank you. This comment on the right is a comment made by you, isn't it, on the report?
MANCINI: Yes.
CARR: You have added in a section of the report dealing with the allegations against Letby. "The significance of this one nurse being rostered on shift at the time of each of the deaths had not been investigated via a thorough process and is only individual senior Consultant's subjective view". Now, just on that point, individual senior Consultant's subjective view, that is not accurate, is it?
MANCINI: Not with all the other information that became evident within those two days that we were interviewing other people and a range of people. But what I mean by that, and when I say "individual senior Consultant", I do mean the -- the Consultant Dr Jayaram who was possibly more forthcoming in his views and when I say "subjective" is because again we weren't there to investigate this nurse but on the surface it very much appeared that it was from the commonality rather than from proof or evidence but that was also not our role to investigate that. So that's why I have put "subjective" and then I go on further to say ...
CARR: It's not accurate firstly because it wasn't just one individual, it wasn't an individual senior Consultant?
MANCINI: No.
CARR: Dr Brearey, Dr Jayaram, the other Consultants, all of them raise their concerns. You had been told by Ian Harvey that the paediatricians as a body had those concerns?
MANCINI: (Nods)
CARR: So it was wrong to diminish the concerns as if it was just one individual, do you agree?
MANCINI: It wasn't my intention to diminish his concerns.
CARR: It wasn't a subjective view. You considered and heard a lot of evidence over the course of the two days and although we have not gone through it, there were a number of comments made about Letby from her nursing colleagues which were quite supportive?
MANCINI: Yes.
CARR: But so far as the doctors were concerned, what they were referring to was what they had experienced, their medical expertise, the fact that the deaths were unexpected and unexplained, and consistency with medical literature. None of that was subjective, was it?
MANCINI: No, but in relation to this particular nurse there wasn't any definitive proof other than the
commonality that she was present for the majority of the collapses and deaths.
CARR: You commenced your evidence with an apology to the -- thank you that can come down -- parents for the deaths of their babies. Is there anything in respect of your own role that you would wish to say sorry for?
MANCINI: I think the -- being part of the Review Team and for the enormity of the Terms of Reference I was possibly quite naive in thinking it was possible to address all of those Terms of Reference and the significance of them within two days. And on reflection, it's thinking about having a different thought process and really listening to what people were saying.
MR CARR: My Lady, I have no further questions, thank you.
LADY JUSTICE THIRLWALL: Thank you. Mr Sharghy.
MR SHARGHY: Mrs Mancini, I ask questions on behalf of the Families of seven babies who Lucy Letby either murdered or attempted to murder. I will ask you questions on about three specific areas, if I may. You said to counsel to the Inquiry that not only had you not been provided with any induction training by
the RCPCH but you had actually not undertaken in fact any refresher process at all?
MANCINI: No.
SHARGHY: At paragraph 33 of your witness statement, you specifically say that at that time, ie in 2016, you lacked the experience of reviewing a cohort of unexpected or unexplained deaths or indeed where concerns of criminal conduct are raised; is that fair?
MANCINI: Yes.
SHARGHY: So not only had you not received any specific training from the Royal College or indeed had an opportunity of speaking to people who had previously carried out reviews, but your own professional experience meant that even on a cursory glance of the Terms of Reference you were not the right individual to be part of this Review Team; is that fair?
MANCINI: I think it's fair to say that, yes.
SHARGHY: Thank you. Can I move on now to looking at views or conclusions that you reached as part of the review process. For this can I take you to paragraph 47 of your witness statement, please. It's on page 9. In the preceding paragraph you deal with a number of documents, tables of documents that you had reviewed and in paragraph 47 you say:
"Following consideration of the documents you reached a view that although the number of deaths were higher than in previous years, I [that is you] did not identify evidence of unexpected, unexplained deaths or collapses or any common factors in increased mortality." Given what you have just accepted, that you had no experience previously in looking into a cohort or as we have referred to it --
MANCINI: Yes.
SHARGHY: -- previously as clusters in this Inquiry, how were you able to come to that view simply by reviewing documents?
MANCINI: I couldn't. But what I would say is that exploring and reviewing unexplained and unexpected deaths requires the time and the expertise to be able to do that over a period of time and that was just not possible within the Terms of Reference of the review.
SHARGHY: Yes. Mrs Mancini, isn't there a danger that if you do come to a view just based on documentation then you fall into the trap of confirmatory bias? In other words, the more you learn about a process and a review and an inquiry, the more you look for evidence that tends to support your initial view?
MANCINI: Yes, that's correct.
SHARGHY: Thank you. And matters in terms of the process, your thought process in particular, didn't just stop there because can I take you to paragraph 102 of your witness statement as well, please. This is a description of what you did having read the draft?
MANCINI: Yes.
SHARGHY: Then you provided a comment. You specifically wanted a comment put in or some form of wording that indicated that: "It was important that we as the group recognise that these allegations are only hearsay and have no substance."
MANCINI: (Nods)
SHARGHY: Did you truly believe that at the time you made this suggestion?
MANCINI: No, I think that I should have reworded it, worded it differently and what I meant was as I have previously said that we weren't given any proof that this had in fact been happening by this member of staff. That's what I meant by that comment and I haven't written it in correct language.
SHARGHY: But you can see the danger that it influences what the final report ends up suggesting --
MANCINI: I can see that.
SHARGHY: -- and the false reassurance it provides to the reader, ie in this case the Trust?
Final issue is in relation to the discussion that took place with the team and you have helpfully clarified you were part of that discussion as regards whether the police should be called based on, for some, the new information that had been discovered?
MANCINI: (Nods)
SHARGHY: Can you just take us into that room for a moment. Were all the members of the Review Team present for this discussion?
MANCINI: I think so. But I can't remember exactly.
SHARGHY: Can you assist with how and which side of the fence the various professionals fell in; other words, the nurses on one side and the doctors on the other? Or was it a mixture?
MANCINI: I think it was a mixture. I can't remember clearly, I have to say that, but I think it was a mixture. It wasn't an obvious divide as far as I can remember.
SHARGHY: How finely balanced was that divide?
MANCINI: I don't remember -- as I said earlier, I didn't remember that there was one of the doctors that had suggested we should abort the review. And I can't remember that conversation in detail, honestly. So I don't think I can give you any further information on that.
SHARGHY: The final question: when Counsel to the Inquiry asked why the team decided to continue with a review even though there was outstanding information you said: well, there were serious allegations. It was quite urgent that the work started. But in fact didn't it become even more urgent and more concerning at the end of the pre-session when you were having this discussion that rather than suggesting there should be a further review and potentially further delay, that the police needed to be called or at least the Trust told, "We have got serious concerns here you need to contact the police"?
MANCINI: I understand what you are saying but our decision was that we would advise that the safeguarding process should be the first point of call.
SHARGHY: Did you at any point think about the repercussions of that to patient safety, these very vulnerable babies who could be exposed to further harm?
MANCINI: We, we had the babies absolutely uppermost in our mind and patient safety. We knew that that member of staff had been removed from clinical practice. I know that there's lots of other elements about that not being done appropriately. But we felt that that was -- we discussed it and we thought consensus that that was right thing to do.
SHARGHY: Okay. Did you ever consider that having received your review, that the Trust might reintegrate Lucy Letby back on to the neonatal unit?
MANCINI: No, not for a minute.
MR SHARGHY: Thank you, my Lady.
LADY JUSTICE THIRLWALL: Thank you, Mr Sharghy. Ms Scolding.
MS SCOLDING: I only have one question, my Lady, to Ms Mancini. Good afternoon, Ms Mancini, I obviously ask questions on behalf of the Royal College of Paediatrics and Child Health. I just have one question in the light of everything that has been discussed today: what would you do differently if you were faced with a similar situation to the situation you were faced with in 2016?
MANCINI: I would gain advice myself about processing -- sorry, continuing with the process of the review and if that was the correct thing to do, I would get that advice directly.
SCOLDING: Who would you have got that advice from, which body or organisation?
MANCINI: The first point, I would have gone to the Royal College of Nursing and I know that they would have then directed me to the Royal College of Paediatrics and Child Health.
MS SCOLDING: Thank you very much, I have no further questions.
LADY JUSTICE THIRLWALL: Thank you, Ms Scolding. I just have one question and it is in relation to the letter that went to Mr Harvey on 5 September. I will get it up so that you can see it. It is 0009611 and then it's page 2. We have looked at it already.
MANCINI: Thank you.
LADY JUSTICE THIRLWALL: It's in relation to the first heading because I just want to make sure that I have understood your evidence correctly. It's -- this is the first action point and it's headed "HR Investigation". Now, that might be thought --
MANCINI: Yes.
LADY JUSTICE THIRLWALL: -- to connote an HR investigation but, as I understand it, your evidence is that this meant safeguarding.
MANCINI: Safeguarding plus HR investigation for the redeployment of Letby.
LADY JUSTICE THIRLWALL: Where's the clue in this paragraph that it's --
MANCINI: It's not there, I'm sorry.
LADY JUSTICE THIRLWALL: No. And in fact if we look at it, second sentence. First of all you have got to formalise the actions you are taking with the nurse?
MANCINI: Yes.
LADY JUSTICE THIRLWALL: So it's about her.
MANCINI: Yes.
LADY JUSTICE THIRLWALL: Then: "An allegation has been made and a process needs to be put in place which sets out nature of the allegation and the process you will follow to investigate it" and that is what you were saying in your evidence earlier.
MANCINI: The safeguarding.
LADY JUSTICE THIRLWALL: No, I'm sorry, no.
MANCINI: Sorry.
LADY JUSTICE THIRLWALL: The allegation made, process of investigation to be put in place which sets out nature of the allegation and the process you will follow to investigate it. So that is a different thing from investigating the nurse, is it?
MANCINI: No, that's starting the safeguarding process. That's specifically for the safeguarding process. The first sentence alludes to the HR process for her having been redeployed.
LADY JUSTICE THIRLWALL: I see. Then the next sentence: "No doubt you have your own policies for this ..." So that is not a safeguarding policy?
MANCINI: Yes.
LADY JUSTICE THIRLWALL: "... but the MHPS process used for doctors provides a helpful framework." That is not a safeguarding policy?
MANCINI: No.
LADY JUSTICE THIRLWALL: So we have this one sentence in the middle of a paragraph which the hospital were to understand was a reference to safeguarding rather than an HR investigation?
MANCINI: Yes, it's unclear.
LADY JUSTICE THIRLWALL: Well, it's either unclear or it means something different from what appears on the page, isn't it? I just wonder how you think someone would know that was safeguarding in that middle section.
MANCINI: I think it's open for interpretation but it should have a heading of "Safeguarding", we should have a process of safeguarding investigation.
LADY JUSTICE THIRLWALL: Thank you very much. Mr Carr, have you any questions arising out of my questions?
MR CARR: No, I don't, thank you.
LADY JUSTICE THIRLWALL: All right. Thank you very much indeed, Ms Mancini, you are free to go. Now, Mr Carr, is that a good time to take a short break?
MR CARR: It is, yes.
LADY JUSTICE THIRLWALL: There isn't any pressure because we can come back to evidence, but have you any idea how long the next two witnesses are likely to take?
MR CARR: They will be much shorter. I am going to try and keep to less than half an hour per witness.
LADY JUSTICE THIRLWALL: Very good, okay. In that case shall we take 15 minutes and start again at 5 to 4.
(3.41 pm) (A short break)
(3.55 pm)
LADY JUSTICE THIRLWALL: Mr Carr.
MR CARR: My Lady, may I call Dr David Shortland, please.
LADY JUSTICE THIRLWALL: Dr Shortland, would you like to come forward.
DR DAVID SHORTLAND (sworn)
LADY JUSTICE THIRLWALL: Thank you, Dr Shortland. Do sit down.
MR CARR: Can we start with your full name, please?
SHORTLAND: Dr David Shortland.
CARR: You have prepared a statement for this Inquiry dated 20 May 2024, haven't you?
SHORTLAND: Yes.
CARR: Are the contents of that statement true to your best knowledge and belief
SHORTLAND: They are, yes.
CARR: I am going to summarise your professional background, but tell me if I have got anything wrong. You qualified as a doctor in 1979, you became a Consultant in 1989?
SHORTLAND: (Nods)
CARR: And you retired from NHS practice in 2021; is that correct?
SHORTLAND: Yes.
CARR: You have held a number of leadership roles including being clinical lead of a neonatal unit for a decade and clinical director for 12 years in the course of your career?
SHORTLAND: Yes.
CARR: At the time of the RCPCH review of the Countess of Chester Hospital, you were the clinical adviser for the Invited Review Board?
SHORTLAND: (Nods)
CARR: I have also seen reference in your statement
to you being the clinical lead, those two roles are the same, aren't they?
SHORTLAND: Same, yes.
CARR: Two interchangeable terms?
SHORTLAND: Yes, they are.
CARR: That is one of several roles that you have had at the RCPCH?
SHORTLAND: (Nods)
CARR: For the purposes of your evidence today I am going to be asking you about that review. Before I do, in respect of safeguarding training you make the point that you undertook regular mandatory safeguarding training as part of your NHS practice?
SHORTLAND: Yes, it was a standard part of the mandatory training.
CARR: There was no specific safeguarding training as part of the Invited Review programme?
SHORTLAND: Yes, that's correct, yes.
CARR: Your statement states paragraph 8, you have never had safeguarding training about abuse suspected by a member of staff but is there any reason to think that different principles would apply?
SHORTLAND: No, I think if you look at the documentation I think -- excuse me, I think if there are safeguarding concerns you would follow the same principles whether it
was a member of staff or family or whoever, really.
CARR: You were very experienced in Invited Reviews, you have undertaken approximately 50 Invited Reviews each time as lead reviewer?
SHORTLAND: Yes. Yes.
CARR: But you had never done a review involving unexpected or unexplained deaths --
SHORTLAND: Yes, that's correct.
CARR: -- had you?
SHORTLAND: Yes.
CARR: Never been involved in a review where the Terms of Reference looked at mortality of individual cases?
SHORTLAND: That's correct, yes.
CARR: Is an overview of your involvement of the Countess of Chester Hospital Invited Review as follows: you had no involvement in devising or agreeing the Terms of Reference or the arrangements or preparation for the review?
SHORTLAND: Not quite correct. I think I said in my statement that a few days before the review, I had an email from Sue telling me that the review was about to take place and mentioning that one of the issues was increase in unexpected deaths in the unit. So it was on a Saturday morning and I telephoned
Sue which would be quite unusual for me to do that, so I had slight further information about the review before it took place but I wasn't -- I didn't see the formal Terms of Reference but I recognise one of the Terms of Reference, the fourth Terms of Reference which we discussed.
CARR: You are slightly getting away from my question, I was just giving an overview of your involvement?
SHORTLAND: Sorry.
CARR: The second point I was going to come to was that there was a telephone conversation with Sue Eardley a few days before the review, but the first point I was making is that you had no involvement, as I understand it, from your evidence, in devising the Terms of Reference or arrangements or preparations for the review?
SHORTLAND: Yes, that's correct, yes.
CARR: The telephone call with Sue Eardley you've alluded to. You were not approached for advice during the course of the Invited Review?
SHORTLAND: (Nods)
CARR: Following the review visit, you read the final draft of the report before it was sent to the hospital and you made a brief comment on it which we will come to?
SHORTLAND: Yes, that's correct.
CARR: That is the extent of your involvement. The first topic of questions is whether your involvement should have been greater. You have described in your statement, it's paragraph 29, you describe your role as clinical adviser for the Invited Review programme was "to Chair the programme board meeting at which, from memory, occurred every four months". So you are describing quite a limited role?
SHORTLAND: Yes.
CARR: You have seen and you will be familiar with the guide to Invited Reviews and you were sent a copy of it to prepare your evidence and I am not going to put it up on screen but you were asked questions about it. It's right, isn't it, that the guide to Invited Reviews suggests that it is for the clinical adviser to agree Terms of Reference?
SHORTLAND: (Nods)
CARR: Where there is to be a pre-visit review, that is something that would be carried out by the clinical adviser or the lead reviewer; is that right?
SHORTLAND: Yes, that's correct, yes.
CARR: So far as defining the issues and determining the methodology of a review, again the guide suggests that that should be done by either the clinical lead or the lead reviewer?
SHORTLAND: Yes, that's correct according to the guide. Yes.
CARR: So for all the important preparatory steps for an Invited Review the guidance is clear, isn't it, that there needs to be a clinical person taking those steps; it should not be left to the Invited Review manager alone?
SHORTLAND: Yes.
CARR: In circumstances where a lead reviewer hasn't been appointed, then it would fall to you to take those steps?
SHORTLAND: Yes, I think that's correct, yes.
CARR: In terms of the Countess of Chester Hospital review, the Terms of Reference were agreed and were discussed before a lead reviewer was appointed, weren't they; you would have seen that from the chronology?
SHORTLAND: Yes. So could you just repeat the question, Mr Carr, was it the Terms of Reference were agreed before the --
CARR: Lead reviewer was appointed?
SHORTLAND: I'm not sure I can answer that because I don't
know exactly when David Milligan was approached about being the lead reviewer.
CARR: The point is this: you will have seen from the documents you have considered that the Terms of Reference were discussed and agreed on behalf of the RCPCH solely by Sue Eardley weren't they?
SHORTLAND: Yes, that's correct, yes.
CARR: It's clear on the guidance that shouldn't have occurred?
SHORTLAND: Yes.
CARR: There should have been input either from the lead reviewer and until he was appointed it should have been you?
SHORTLAND: Yes, yes. Yes.
CARR: So far as your discussion with Sue Eardley in the days prior to the Invited Review visit, you have described that she told you that a nurse had been suspended and part of the reason for the Invited Review was increased deaths?
SHORTLAND: Yes, the -- the three things that I do definitely remember was the cluster of unexplained deaths. I knew that the police hadn't been involved and I knew that one of the Terms of Reference was trying to look for clinical explanations for the cluster of deaths.
I -- I think I am right in saying that I knew a nurse had been suspended. But that is from my memory and it would depend I think on when Sue Eardley knew that because obviously if she didn't know, I couldn't have known that, so it's possible that part is -- is faulty recollection.
CARR: Yes, you make the point in your statement, don't you, that you don't have a note of this telephone discussion and you are recalling it as best as you can?
SHORTLAND: Yes.
CARR: But your best recollection, it's paragraph 49 if you want to look at it, paragraph 49 in your statement.
SHORTLAND: Yes, I have got it, yes.
CARR: Four lines down you describe there your recollection that a few days before the review you received an email from the College that the review was about to take place and then over the page you describe in the rest of the paragraph the discussion you had by telephone?
SHORTLAND: Yes.
CARR: Five lines down: "A nurse had been suspended by the hospital and the primary purpose of this review was to look at other factors on the neonatal unit which would have led to an increase in mortality?"
SHORTLAND: (Nods)
CARR: And another three lines down: "It was not clear that the presence of this nurse had been linked to the increase in mortality." Did Ms Eardley tell you that there was a potential link between the suspended nurse and the increased mortality?
SHORTLAND: Sorry?
CARR: Did Ms Eardley tell you that there was a potential link between the suspended nurse and the increase in mortality?
SHORTLAND: No. I think all we knew at that time, if I am remembering this correctly is a nurse had been taken away taken off clinical duties. But we didn't know why she was taken off clinical duties.
CARR: Just specifically about what you recall that you knew. You knew that she had been moved. Did you understand that that was completely unrelated to the increase in deaths or did you understand that there was or there might be a connection?
SHORTLAND: I -- I think my recollection of this was that the -- or my assumption was that the nurse had been moved because it was linked because a conversation followed that the -- the Trust Management Team were
looking for potential clinical explanations for the change in mortality. So I don't think Sue ever said explicitly to me that the nurse had been excluded because of, you know, clearly we had no ideas of the concerns at the time and I think I have mentioned it could have been a competence issue or a training issue. But I -- I inferred from that that there was some relationship between the nurse and the -- and the events, yes.
CARR: And the possibility if there was a relationship would be either an issue with her competence, so errors in competence leading to increased deaths, something malevolent, a deliberate harm causing increased deaths or just a statistical anomaly and there being no causative link between increased correlation.
SHORTLAND: Yes.
CARR: It's right to say, isn't it, that an Invited Review was not designed to carry out investigations into those sorts of links, or to exclude --
SHORTLAND: Yes, exactly.
CARR: -- those sorts of links?
SHORTLAND: Yes.
CARR: If there were any concerns about criminality or potential criminality you are clear in your evidence, aren't you, that the answer is to contact the police?
SHORTLAND: Yes, yes.
CARR: During the review we have heard evidence from some of the reviewers and we have got written statements from others, we know that there was a discussion amongst some members of the Review Team as to whether or not the review should be aborted when details emerged on the morning of the first day of the review visit of the suspicions that the doctors had and the reasons for those suspicions. Your advice was not sought. In your view should it have been, given the complexity and unusual nature of the review and the matters that emerged?
SHORTLAND: I think it should, I think I am probably clear about that having seen the -- you know, the witness statements. In fact, Helen Crisp interviewed the reviewers and it struck me that there was a clear high level anxiety amongst reviewers even down to the, you know, professional qualifications in terms of taking on the review. So I -- I think it my view is yes, they should have escalated it. I think in mitigation, the 2016 guidance was actually put much more emphasis on to the Review Team themselves about decisions. I mean, clearly the new guidance is very different, but I do understand these are an incredibly senior Review Team and they made
a decision amongst themselves which was the normal as part of a review, we did that all the time but it was just in this particular case I think the level of anxiety probably would have been to -- or should have been to escalate it, yes.
CARR: At paragraph 61 you set out the advice that you would have been given -- sorry, you set out the advice that you would have given if the Review Team had raised concerns with you. You say four lines down: "My response would be to have explained that the allegations were so concerning that the police should be involved given that this had been the request of the paediatric team. In my professional experience it would have been very unusual for any paediatric team to make such a suggestion and so I would have taken it seriously."
SHORTLAND: (Nods)
CARR: And so if you had been contacted and if you had been told and you have seen the notes of the interviews with the paediatricians, if you had been told that the concerns that they had, then you are clear in your mind the police ought to be contacted?
SHORTLAND: Yes, I mean I think the guidance at the time was they would have continued with the non-contentious issues of the review. So I think had I been involved I think the question of should the police be involved at that point and you see from my evidence that I felt they should have been involved at probably -- well, at an earlier stage than the review took place actually. But I think that the escalation process now is very much tighter than it was at the time this review took place.
CARR: Yes, I am asking only about -- only about the policies and approach at the time the review took place. But even on the guidance that was in place at the time, and we have looked at it in the course of the evidence today, it certainly doesn't mandate a Review Team to continue, does it, it provides circumstances in which a review may continue?
SHORTLAND: Yes, exactly.
CARR: But there will be circumstances where the safety concerns are such or the risk of prejudice to further investigations are such that it shouldn't continue?
SHORTLAND: Yes, I agree with that actually. Yes. I mean, I think it's a safeguarding issue, isn't it, really, you know, what the -- the Review Team were told. So it should have been really escalated along safeguarding concerns but, I mean, there are some other factors you may ask me in due course. But I think the -- you know, this would have been pursued in
a safeguarding approach, you know, if the Review Team had severe concerns that babies were being harmed.
CARR: On a connected but more general point. At paragraph 39 earlier in your statement, when dealing with the question of the policy in place at 2016, you make two points that I am going to read out. On the third line you make the point: "We are not a criminal investigatory body and would not have wished to have interfered in any such allegations." Four further lines down: "If I had been asked about situations where there may be criminality, my advice would have been not to undertake any review where there may be criminal allegations." So there is a clear dividing line for you in terms of when to undertake reviews and when to stop any review that was in progress?
SHORTLAND: Yes, that's true, yes. Yes.
CARR: As to the decision to interview Letby during the Invited Review, you have addressed this in your statement and the position is you think it was wrong to interview her?
SHORTLAND: Yes, that's correct.
CARR: Is that for the very same reason that we have
just considered, in light of the allegations that were being raised, in light of the fact that the RCPCH is not a criminal investigatory body and the guidance that was in place at the time, do you consider that there was a risk of prejudicing any future investigation by interviewing her?
SHORTLAND: Well, I think there definitely was the risk and I think the other issue was there would have been the HR issues I would have thought involved in one of the nurses being suspended from clinical duties, I would have thought that we shouldn't be interviewing somebody in that situation because of the HR processes. So I think for both reasons I think it was probably in retrospect something that we shouldn't have done.
CARR: The final versions of the report -- I say versions, you know that there were two different versions?
SHORTLAND: Yes.
CARR: There was the full version the confidential copy and the dissemination copy?
SHORTLAND: Yes.
CARR: They were sent out under a letter in your name, weren't they --
SHORTLAND: (Nods)
CARR: -- in your role as clinical lead?
SHORTLAND: (Nods)
CARR: You have explained that before it was sent you would have received a copy, a final version of the report and you would have read it?
SHORTLAND: Mmm.
CARR: We have the comments that you made having read the report. They are contained in the RCPCH chronology. It's reference 0012748 and it's page 4, please. It's the entry in the middle of the page, 28 November. David S -- thank you -- QA of final report. Now before I read it, to be clear, you didn't conduct quality assurance of the report?
SHORTLAND: No, I didn't. It was Dr Dorling and Dr Wilson that did it, it wasn't me.
CARR: It was Dr Wilson. As for Dr Dorling, Dr Dorling was instructed to make quality assurance, did he in fact undertake quality assurance?
SHORTLAND: I think I have seen that actually, because there was some suggestion that I QA it, but I didn't --
CARR: Forgive me, carry on?
SHORTLAND: No, I was going to say I have seen somewhere in the papers that was it was Dr Wilson and Dr Dorling, I may be wrong but my memory is I -- I saw the report but I didn't QA it because I think at the -- it would have been QAd before that date, so I think my email wouldn't have been on the same date as I had seen it.
CARR: So you were looking at the final version of the report as it was about to be sent out?
SHORTLAND: Yes. I can't be clear which version I saw because I think there were two. There was the October and the November version. So I can't be sure whether I saw the redacted or the unredacted one. I am guessing I saw the unredacted one.
CARR: The confidential dissemination versions are both the same date, so they are both sent in October. There are subsequent editions dated November but the versions, as I understand it, sent under copy of your letter were the October versions, a full and a redacted. What you say or what you are noted to say in this chronology is as follows: "Quite an interesting and complex review. Good to have David M [that is a reference to David Milligan] leading that one. Almost felt a bit like the Grantham situation 30 years ago and my only question is why they didn't involve the police if they had those suspicions, otherwise looks like a good report with very clear recommendations." Now, firstly to put this into context. You have explained in your statement that you were a Senior Registrar working in Nottingham in 1988 to 89, weren't
you?
SHORTLAND: I was, yes.
CARR: You retrieved sick babies from the Grantham unit?
SHORTLAND: (Nods)
CARR: That is the unit where Beverley Allitt worked?
SHORTLAND: Yes.
CARR: Now, looking at that comment, Dr Shortland, the first point to make and you said a few moments ago you are not sure if you saw the redacted report or the full report, isn't the fact that you are referring to the Grantham situation here, doesn't that indicate it was probably the full report?
SHORTLAND: Yes, I think yes, I think --
CARR: With reference to Letby and you must have seen --
SHORTLAND: Exactly right, yes. My assumption as well.
CARR: It was the version of the report that was about to be sent to the Trust so it was the final version of the report, you hadn't seen the earlier iterations and drafts with track changes?
SHORTLAND: That's correct, yes.
CARR: So by the time you see the report, references to police involvement, threats to call the police; they are not contained in that final version are they?
SHORTLAND: They are not in the version I have as the November version. But they were in the October version.
CARR: Despite those references having been removed for the final draft, based on what you read, you saw similarities in what was being described in that report to another incident of a nurse killing and harming children?
SHORTLAND: (Nods)
CARR: You make the point when explaining this comment in your statement, it's paragraph 77, that can come down now, thank you: "In my experience as a paediatrician and neonatologist, it is extremely unusual for newborn infants to die without a clear diagnosis or evidence of a clinical deterioration and I can understand why I would have written that comment in relation to a review of unexplained neonatal deaths." The point that you are making there is it seems -- but correct me if I am wrong -- is that the cluster or the cohort of deaths in itself because they were unexpected and unexplained, that would have been a matter for concern?
SHORTLAND: Yes, yes, that's correct. Yes.
CARR: But there is the additional factor here and it is dealt with to some extent in the final full version
of the report, is the allegations against a nurse?
SHORTLAND: (Nods)
CARR: Now, in light of the concern that you would have had because of the cluster of deaths, and in light of the parallel that you draw with Beverley Allitt, why didn't you ensure that there was a positive recommendation to call the police in the report? Or going to the Trust?
SHORTLAND: Yes, yes, okay. I mean, the comment that I made actually was it was -- the email was to Sue and it was actually referenced to the conversation that I had had with her two months previously where I had made the comment because the conversation we had had is that they had thought about calling the police but had decided not to wait for the College review and I felt that was really counterintuitive at the time, that if you think about calling the police you probably should call them and that -- that reference was really directing back to the -- to conversations I had with Sue. I think the answer to your broader question is I think when you look at this review it was a really complicated one because you had the doctors, this was my view at the time, based on my recollection. You had the doctors concerned that a nurse was harming babies, you had the nursing staff really vehemently denying that. You had a management structure that wasn't probably fully engaged, you had a governance system that wasn't fully engaged and you had some issues around the clinical service which probably was a risk too in terms of the shared rotas and the lack of, you know, the concerns around escalation. So I think my thought at the time was I had this anecdotal thing in my mind from something that happened 30 years ago and actually you had had a review from five very senior reviewers who had come to a different conclusion and I think the proviso within that of course is that as far as I am aware, the paediatricians did suggest that the police were involved, I don't think they followed that through though as they perhaps could have done and they asked for another review. So I think my recollection of seeing this review was that there was still potential explanations for why the mortality was higher. But it clearly is -- and, you know, perhaps on reflection there's different ways of looking at this. But I think it was just a review that -- I had had no involvement after the conversation with Sue, so it just --
CARR: Dr Shortland, can I just stop you there. You
might be moving slightly away from my question. The first point of clarification, when explaining this email that you refer to a conversation that you had had with Ms Eardley, if I heard you correctly about police involvement, do I understand that? Was there a previous conversation?
SHORTLAND: There was a first conversation I had with Sue a few days before the review.
CARR: Before the review visit?
SHORTLAND: Yes, it was when I received the email from Sue it was I think the Saturday, the review was on a Thursday, wasn't it? So about five days before the review I had an email from Sue.
CARR: Was there a discussion as to police involvement at that stage?
SHORTLAND: I had a telephone -- I telephoned Sue which would be unusual for me at the weekend and my recollection of that was the things that I definitely knew was there was a cluster of unexplained deaths, the police weren't involved and the main purpose of the review, or one of the purposes of the review was to look at, you know, I suppose what you might call clinical explanations for the high -- the apparent increase in mortality.
CARR: Dr Shortland, just to be clear, prior to this
entry in the chronology dated 28 November, had you had a discussion with Sue Eardley or anybody else on the Review Team relating to the police being contacted about matters at the Countess of Chester Hospital?
SHORTLAND: No. What I knew was the police hadn't been contacted.
CARR: You raise your only question was why they didn't involve the police, did you receive an answer to that question?
SHORTLAND: Sorry, when you say I raised the question, do you mean in that email?
CARR: Yes, forgive me, it has been taken down but we can put it back up, it is INQ0012748. Forgive me, page 4.
SHORTLAND: Yes. Yes, I think my interpretation of my email would be that it was a complicated review; that for the reasons I have explained I think it was a very complex review to actually, you know, read and I think I just came back to the comment I had said to Sue at the initial conversation before the review took place was: basically, if you think about involving the police, you probably need to do it and I think that's what the referral is back to. So it wasn't having read the review itself I thought the police should be involved because I think
the review, a lot of it is generic and there was so many complicated factors that I don't think the review made me make that comment. It was the fact that I had made the comment relating to a conversation I had had two months previously.
CARR: Dr Shortland, thank you, but I'm not sure if there was an answer to my question in that. You say my only question was why they didn't involve the police if they had those suspicions. So it appears you are raising as a query why haven't the police been contacted?
SHORTLAND: Yes, yes.
CARR: My question is: did you receive an answer to that?
SHORTLAND: No, no --
CARR: Were you told --
SHORTLAND: Sorry, I misunderstood the question. As far as I know that email wasn't circulated and as -- I don't remember receiving a -- I think if I had probably the College would have, I am assuming, found the email.
CARR: Nobody replied? Nobody replied?
SHORTLAND: No, as far as I know, no.
CARR: The question went unanswered.
SHORTLAND: Exactly, yes.
CARR: The report was sent out without making that recommendation.
SHORTLAND: (Nods)
MR CARR: My Lady, thank you. I have nothing further for this witness.
LADY JUSTICE THIRLWALL: Thank you. Mr Sharghy?
MR SHARGHY: I know you have been sitting, Dr Shortland, in the hearing room so I will skip the introductions because you have already heard it and I just want to ask you questions in relation to two specific areas. The first is looking at your experience, and you spent I think 10, 12 years as clinical lead on a neonatal unit and at the time of this review you were working as a Consultant paediatrician at Poole Hospital, it is quite rare, isn't it, in a neonatal setting to actually catch someone who's causing a form of harm --
SHORTLAND: (Nods)
SHARGHY: -- in the act?
SHORTLAND: Oh, yes, yes. Definitely.
SHARGHY: So the only thing that as clinicians one is left with is trying to piece together information and evidence in order to create a picture; is that fair?
SHORTLAND: Mmm (Nods)
SHARGHY: And one of the ways in which one does that from a clinician's point of view is you look at common factors between them to see if there's a cluster cohort or theme --
SHORTLAND: (Nods)
SHARGHY: -- you look at idiosyncratic issues between babies, you exclude environmental factors, is that all right so far?
SHORTLAND: (Nods)
SHARGHY: And once you have done that and perhaps you can tell me any more, you start to see a trend, don't you?
SHORTLAND: Mmm.
SHARGHY: You start to see some element of commonality to explain the unexplainable and the unexpected events; is that fair?
SHORTLAND: Yes, it is fair, yes.
SHARGHY: Given what you reviewed before you actually attended the hospital on 1 September and what you learned over the period of the 1 and 2 September, isn't that precisely what these Consultants, in particular Dr Brearey as the clinical lead, had done?
SHORTLAND: Yes. Just to be clear I didn't -- I didn't do the review.
SHARGHY: I am so sorry. But you are aware of the
information and the evidence that had been gathered?
SHORTLAND: Yes, I am yes.
SHARGHY: Is that not precisely what these Consultants had done?
SHORTLAND: Yes. Yes, I mean -- I think -- yes, the problem I think is that if someone's harming babies I think it's highly likely that the medical staff that detect that because they will see idiosyncrasies within what's happening and I don't mean that disrespectfully to any other health professional, but doctors tend to approach things diagnostically. So I think if your consultants are of the view that someone is harming babies -- and I don't say that lightly -- but I think what I mean is that they have looked at other possibilities which I think your question's leading. I think, you know, maybe this is an anecdotal comment, but it is very rare as I mentioned in my witness report, for babies to die or children to die without an explanation. I mean, it is quite unusual. You know, they might become ill and they might deteriorate but the doctors usually know. So I think if your clinicians cannot find an alternative explanation, it's probably at that point that you have to take those comments very seriously.
SHARGHY: They are suspicions of crimes, aren't they,
they are not simply medical factors that need further exploration?
SHORTLAND: Yes. I mean, I think, you know, these babies are monitored massively, extensively when they are in a neonatal unit. I mean, they are going to be covered in monitors and I think to have very sudden collapses is very unusual not to be able to resuscitate a baby if they have collapsed and if they have deteriorated massively, clinically that is usually evident why they have done it. So I think this pattern is actually unusual, yes.
SHARGHY: So undertaking a service review of the type that we know was undertaken would never have actually got to answer the concerns of the Consultants would it?
SHORTLAND: No, no I think -- I think that's right. I think if your Consultants as a group have considered harm and, you know, your Consultants are respected by the, you know, the hospital and their opinions are taken seriously, it's almost difficult in my opinion to know how you can approach that other than with a forensic inquiry. Because I don't think a clinical -- I mean, the Terms of Reference of this review, as you appreciate, as I have mentioned to Mr Carr, was very much about is there a clinical explanation for this and in itself that is a sensible question. But the other question may be more important.
SHARGHY: Final question: you have carried out a large number of these reviews?
SHORTLAND: Yes.
SHARGHY: The Inquiry has heard from the other members and will hear from one more later this afternoon. What would it take to stop a review either shortly before it starts or once it's started. How significant does the concern have to be to stop a Invited Service Review?
SHORTLAND: I mean, the current guidance would put that threshold very low actually, because the --
SHARGHY: Back in 2016?
SHORTLAND: Yes, the guidance in 2016 was -- I mean, I have to be honest, I was involved in writing these documents. I don't think we ever considered this scenario. But, you know, the level I think at that point, the advice was: you carry on with the non-contentious issues but I think with something like, you know, had the Review Team considered that a criminal act was highly likely, I think the review would have stopped.
SHARGHY: So the judgement call is very much dependent on the quality and the experience of a Review Team as a whole in order to make that call to stop it back in
2016?
SHORTLAND: I think it is. I mean, when you do reviews, you probably talk to a hundred people with a hundred different views and sometimes something crystallises at that review and it might be a person or group of people that review and that changes your perspective and I think it's that that happens in a review. Because College reviews are not fact-finding reviews, they are assimilation of information that you are being given, so you are assimilating -- you are not really genuinely looking at original facts, you are hearing what people say and there is a great strength in that. But there would have to be something about I think if a Review Team from the masses of information they are receiving suddenly taking a piece of information so seriously that they actually felt that that was the crystallisation of the review. In which case, you know, the action in my opinion in this situation would have been to stop the review, yes.
SHARGHY: Would one of the reasons back in 2016 to have stopped a review have been if the team or indeed individuals within that team realised this was too complex?
SHORTLAND: Yes.
SHARGHY: Outwith their experience, would that have been
sufficient in your view to have stopped?
SHORTLAND: I mean definitely on their judgement. I mean arguably if you escalate the review, you sort of take that decision more as a College-wide decision, I guess, really. So I think it was perfectly -- you know perfectly reasonable for a Review Team to decide to stop a review. I don't think there is any question about that.
MR SHARGHY: Thank you. My Lady, thank you very much. Those are my questions.
LADY JUSTICE THIRLWALL: Thank you very much Mr Sharghy. Ms Scolding.
MS SCOLDING: My Lady, I just have two clarificatory questions arising. Good afternoon, Dr Shortland. I am Fiona Scolding, I represent the Royal College of Paediatrics and Child Health. I just have two clarificatory questions arising from the questions that have just been posed by you by Mr Sharghy. Firstly, did you see any notes of interview or any of the background information in respect of the review when you were looking at the report in November 2016?
SHORTLAND: Sorry, do you mean did I see anything as well
as the review?
SCOLDING: Yes.
SHORTLAND: No, no, I just saw the review, yes, yes.
SCOLDING: Okay. So you would not have seen the conversation that took place between Dr Brearey and Jayaram?
SHORTLAND: No.
SCOLDING: The reviewers on the morning of the 1 September?
SHORTLAND: No, no definitely not, yes.
MS SCOLDING: Those are the only questions I have, my Lady.
LADY JUSTICE THIRLWALL: Thank you very much, Ms Scolding. Dr Shortland, is it a fair summary heading of your evidence that this review could never deal with the issues that the doctors had raised?
SHORTLAND: Yes, I think that's --
LADY JUSTICE THIRLWALL: This was a service review?
SHORTLAND: Yes.
LADY JUSTICE THIRLWALL: It wasn't a fact-finding review.
SHORTLAND: (Nods)
LADY JUSTICE THIRLWALL: And it didn't produce any answers to the questions raised by the doctors?
SHORTLAND: Yes. I think that's a fair -- you know, I agree.
LADY JUSTICE THIRLWALL: Yes. Then I was just looking at the summary right at the end of the report before the recommendations at page 25, INQ0009618, page 25. We have looked at this before with other witnesses, I think Ms Eardley. But there are a number of recommendations included which are summarised there. So the first is staffing levels --
SHORTLAND: Yes.
LADY JUSTICE THIRLWALL: -- being inadequate, which was a common problem, frankly, wasn't it? That's not an explanation and, secondly, escalation of concerns to tertiary units but again that wasn't an answer to the problems and then there are two recommendations about postmortems, but again they wouldn't -- they wouldn't address the questions that had been raised in respect of what was causing the deaths of these babies?
SHORTLAND: Yes, yes, that does -- that's correct, yes.
LADY JUSTICE THIRLWALL: Yes. Thank you very much indeed, Dr Shortland. Does anybody else want to ask anything else? No. Thank you for coming. We are very grateful. It is Dr Wilson next, isn't it?
MR CARR: My Lady, may I call our final witness for today, Dr Nicholas Wilson.
DR NICHOLAS WILSON (sworn)
LADY JUSTICE THIRLWALL: Thank you. Do sit down, Dr Wilson.
WILSON: Yes.
LADY JUSTICE THIRLWALL: Mr Carr.
MR CARR: Tell us your full name, please.
WILSON: Nicholas Robert Wilson.
CARR: You have prepared a statement, haven't you, dated 29 May 2024 for this Inquiry?
WILSON: Yes.
CARR: Are the contents of that statement true to your best knowledge and belief?
WILSON: They are.
CARR: You are a Consultant paediatrician and neonatologist and have held that position since 1998, haven't you?
WILSON: This is true.
CARR: And you have also been named doctor for safeguarding children since 2003?
WILSON: Yes.
CARR: Did you, at the time that we are concerned
with, which is when you undertook quality assurance of the service review report of the Countess of Chester Hospital, were you familiar with the statutory guidance contained in Working Together to Safeguard Children in 2015?
WILSON: I was.
CARR: Did you understand when a referral to the Local Authority Designated Officer was required?
WILSON: I was.
CARR: Turning to the Invited Review. Your role was to undertake quality assurance of the report?
WILSON: Yes.
CARR: The guidance in place at the time required quality assurance to be undertaken by two people, didn't it?
WILSON: Yes.
CARR: Another doctor, a Dr Dorling was instructed to undertake quality assurance. Do you know if he did undertake that?
WILSON: I don't, no.
CARR: Is the quality assurance process independent so there is no working between two quality assurers?
WILSON: That's true. We don't contact each other.
CARR: So far as your experience at the time, in your witness statement, it's your paragraph 12, you state
that the Countess of Chester Hospital review was one of the earliest roles of this kind that you undertook?
WILSON: This is true.
CARR: And further in your statement, paragraph 14, you state you had perhaps been involved in one review as quality assurance reviewer prior to the Countess of Chester?
WILSON: This is true.
CARR: So the Countess of Chester review was either your first or second as quality assurance reviewer. Had you done other reviews before that as part of a Review Team?
WILSON: Yes, I had been a reviewer and visited other hospitals before that.
CARR: As for preparation and training for the role of quality assurance, you state in paragraph 17 of your statement, the final sentence, that you do not believe you received any specific training with regards to carrying out a quality assurance review?
WILSON: That is correct.
CARR: You have described in your statement the process for raising and escalating concerns as part of the Invited Review process?
WILSON: Yes.
CARR: And there's categorisations of concern up to immediate risk and you deal with that in your witness statement. It's right to say, isn't it, that what you are describing there is an escalation process which postdates the Countess of Chester review?
WILSON: I'm sorry, I don't fully understand the --
CARR: Forgive me. If you look at your statement.
WILSON: Yes.
CARR: Paragraph 18, final sentence. When dealing with --
WILSON: Yes.
CARR: -- escalation process, you say: "We would grade our response as a concern ..."
WILSON: Yes.
CARR: "... a serious concern or as evidence of an immediate risk."
WILSON: That's right, yes.
CARR: And what you are referring to, we can look at it, INQ0012813, I will get the section up in the guidance --
WILSON: Yes.
CARR: -- but the point is it comes from the 2023 guidance?
WILSON: Yes.
CARR: And that categorisation didn't exist in 2016?
WILSON: Yes, that's different, no, that's right.
CARR: Forgive me. We can take that down. So far as the role of quality assurance particularly where there are no -- there's no training for the role, what was your understanding of what was required of a quality assurer?
WILSON: So in a conversation, I was told that the main role was to read the report and make sure it was easy to understand, that there were not too many technical terms which might be confusing for a wider audience, because it's being looked at by managers as well as clinicians, to make sure that it met the requirements of the Terms of Reference. I think that was it: readability and making sure -- and also if there were recommendations within the report that they were justified on the evidence presented within the report. So if conclusions were arrived at that there was evidence supporting that conclusion.
CARR: Okay. So readable, coherent and substantiated?
WILSON: Yes, yes.
CARR: Two references. First INQ0010214. I am going to take you to the guidance from August 2016 on Invited Reviews, so this is the guidance that would have been in place at the time of your quality assurance. It's
page 6, please. If you look at paragraph 4.3, there is a summary of the different individuals involved in the review process and do you see the final subparagraph of 4.3 states: "There is a clear quality assurance process to challenge the report, content and conclusions." Were you familiar with that provision?
WILSON: Yes, I have seen that.
CARR: And what did you understand by "to challenge the report, content and conclusions."
WILSON: Well, again, if conclusions had been arrived at which I did not think were fitting with the statutory guidance we have from our professional organisations like the -- like BAPM, then I would suggest that it wasn't appropriate for the College to be making those recommendations.
CARR: And then looking at the letter of instruction to you, it's INQ0009631. This is the letter from Sue Eardley to you of 7 October 2016, and you will see at the bottom of the letter under the heading "Your role" a description of a quality assurance reviewer.
WILSON: (Nods)
CARR: The second sentence: "You are not expected to have visited the site or conducted interviews and the role is as an objective
external critical friend both to the reviewers and to the RCPCH Review Team." Now, that term or phrase "critical friend", what did you understand by that?
WILSON: Well, whilst one is looking at work made by a -- by a colleague who is -- we may or may not know each other, but we are all colleagues within the same field, we, we have respect for each other. So we would not want to be I think excessively critical. We would understand how our comments might affect our colleagues. Notwithstanding that, if we thought something in the report was, you know, factually inaccurate or clearly wrong then we would still bring that up. So I think as a -- it would be a critical friend, a critical colleague I guess is how I interpreted that.
CARR: And both to the reviewers and to the RCPCH Review Team. What's the difference or the distinction that's being drawn there?
WILSON: Yes, I think the -- the problem as a quality assurance person is that I wasn't sure where my -- what route my comments were actually taking. So I would make my comments, I wasn't sure who was seeing those comments. So it is here saying it's going to the College and to the team. I wasn't actually aware how that was taking place, whether my comments would go directly to the leader of the team or to somebody within the College itself. So that wasn't clear to me.
CARR: I see. So when there is a reference to being a critical friend both to the reviewers and to the RCPCH Review Team, is the distinction there that the reviewers are the people conducting the review?
WILSON: Yes.
CARR: So the Review Team for an individual review and the RCPCH Review Team are the people at the RCPCH --
WILSON: Yes.
CARR: -- who oversee the service. So far as your quality assurance, there are three sources, aren't there? There is a quality assurance form that you completed, there is a version/iteration of the draft report, which you added some comments to, and then there is an email containing some additional commentary?
WILSON: Yes.
CARR: We will consider each of those. Please can we deal first with the comments added to the draft report, the reference INQ0010145 and the page we want is page 18. If we can zoom in on the text at the bottom, which is in orange and, Dr Wilson, this is the commentary that you added to the report --
WILSON: Yes, I believe so.
CARR: -- that you reviewed? You make a number of points in that first paragraph: "All deaths should be raised as a Serious Incident." You make reference to investigations internally or externally and the decision to step down. Can you explain why you added this, why you identified this as a point that needed to be put into the report?
WILSON: From my interpretation, when I read the report I did not think that certainly early on the Trust was -- was doing this. I think the Trust was -- if they felt that a death was not -- was explicable and they did not think that there been any failure of their service they were not raising it as a possible Serious Incident. And the organisation I work within, the -- I think it's the management team really want quality assurance, want assurance about our practice. So they would expect us always to bring each death to a specific risk assessment meeting so we could go over the death and discuss it with colleagues, with management colleagues, with other professionals, so there was more openness and people could challenge our -- our practice.
CARR: And you go on to observe that unexpected
deaths must be referred to the Child Death Overview Panel.
WILSON: Yes.
CARR: And you query the role of the CCG and you think five times a year is too infrequent for lessons to be learnt and you are describing there five times a year. What's that a reference to?
WILSON: Yes.
CARR: What is it a reference to?
WILSON: Oh, I think the -- I think the panel was meeting five times a year, that's ... I'm used to it happening maybe monthly in my experience, but ...
CARR: And over the page, page 19, yes, the top of the page, in orange your final comment there: "The ODN could have an annual death meeting (if not already)."
WILSON: Yes.
CARR: So those are observations that you made so far as the systems in place particularly as they related to deaths --
WILSON: Yes.
CARR: -- at the hospital. Can I ask you within the same document, if we go back to page 7, please. There are a number of changes or added text to the document in orange. It looks like
a similar colour to the colour that you use and so my query: is are these your additions?
WILSON: I think -- I commented that I thought most of the references towards child death I had added to the report. I'm not sure if these were my comments.
CARR: But at the bottom of the --
WILSON: Yes.
CARR: -- page, we see a reference: "Circumstances in the unit were not materially different..." And then it goes over the page to the next page to say: "... from those which might be found in many other neonatal units within the UK." Now, is that a observation that you made and do you think you added this to the --
WILSON: Yes, I remember that reference. That was the -- the unit prior to its change in designation was a unit which was looking after an excessive number of very small, sick babies with staffing levels not at a safe point. That was what my reference was. I was making that reference, yes.
CARR: And the point that you were making is those lower staffing levels were not atypical --
WILSON: That's right.
CARR: -- it was something that was -- would be a feature of similar units?
WILSON: Certainly at that point, of the development of the neonatal networks, yes.
CARR: So those were the comments on the report. But it would appear, and again we go to the RCPCH chronology, that there were some additional comments made. It's INQ0012748, sorry, page 3. The entry, the penultimate entry dated 15 October.
WILSON: Yes.
CARR: And what you write is: "I hope my contribution was useful. I felt only that you might tone down your justifiable high dudgeon about how badly the Trust had dealt with the exclusion and the supine behaviour of the Union rep. Your conclusions were entirely sound. Their governance is flawed. Green for Danger, before your time of course, in neonatal medicine death is one of the few clearly definable outcome measures and should be closely monitored not just by the doctors. As has been well said if you want to drain the pond don't ask the frogs." Now, I want to ask you about different elements of that commentary. Firstly, the reference to toning down justifiable high dudgeon and how badly the Trust had dealt with the exclusion; is this a reference to the
allegations relating to Letby in the reports, the green text in the version of the report you reviewed?
WILSON: The report had sections which were redacted and I think it's a reference to parts of those redacted texts where there was a comment from the Review Team and I knew that and it was difficult to understand those sections, not having visited the unit. But, yes, it was referring to that and the Review Team were unhappy about the way the HR process had been followed within the Trust and I thought and I --
CARR: To be clear, when you say the report had redactions, you saw a version that wasn't redacted?
WILSON: Although they were -- those sections were highlighted differently.
CARR: Yes.
WILSON: And it was pointed out to me, when I took on the report, that those sections would not be necessarily clear to understand not having visited the Trust.
CARR: Was it your understanding that those comments were going to be removed altogether from the report or did you appreciate there were going to be two different versions of the report?
WILSON: My impression was there were going to be two different versions of the report.
CARR: Yes. So back to my question. This comment
refers to those green sections --
WILSON: Yes.
CARR: -- so to the Letby sections?
WILSON: Yes.
CARR: Supine behaviour of the Union rep. What do you mean by that?
WILSON: I think there was a criticism of the way that this had been dealt with by -- the individual's Union representative had not been supportive, sufficiently supportive, I think or -- or something about that Union rep had been inappropriate in terms of dealing with the process.
CARR: And justifiable high dudgeon?
WILSON: I got the impression that the Review Team -- well, there was some emotion coming across that they were unhappy about the situation they found themselves in and I think in a College report we wouldn't want that emotion to be expressed in that way. It wasn't appropriate for these emotive terms to be used in the report.
CARR: In light of what was contained in the green text, what consideration did you give, particularly in light of your safeguarding roles, to the safeguarding implications of the allegations?
WILSON: I wasn't clear that there were allegations
that any individual had wilfully done anything harmful. I thought it was more issues of competence rather than any high level of concern. There's nothing explicit in the report which made me think that that was what they were referring to.
CARR: Within the version of the report that you considered in the green text, it states, doesn't it, that this was removed from the final version but -- or it was amended in the final version: "The Consultants apparently threatened to call the police unless the nurse was removed from the unit."
WILSON: Mmm.
CARR: So that would convey a seriousness of their concern and that their concern was of criminal behaviour?
WILSON: Yes, this would.
CARR: And so I return to my question about what consideration you gave to the safeguarding implications?
WILSON: Yes. I think as the reviewer, I was looking at other people who had been there and if that hadn't been their conclusion, I didn't feel I was going to contradict their opinion. They did know more about the situation than I did. So if they had not raised their concerns, I must admit I did not feel I would do that myself.
CARR: Thinking about the letter that you received from Sue Eardley defining the role, the suggestion of being a critical friend, if you were being a critical friend then this is the sort of topic that you could be critical on?
WILSON: Yes.
CARR: You could depart from those who were visiting?
WILSON: I think it was also partly because I wasn't clear how my comment -- what direction my comments would take, this is quite true. I think it did -- we did all have opportunities to say in a way whatever we felt was important to say. So we could have said anything if we felt that was necessary.
CARR: Do you consider that as part of the quality assurance, and you only looked at the report as I understand it, you didn't look at all the notes, but from you had seen should -- in the same way you flagged issues about the Child Death Overview Panel and Serious Incident investigations, shouldn't you have flagged the need to ensure that the hospital was complying with its safeguard obligations when serious allegations of deliberate harm against children were made?
WILSON: Yes. I was aware of that process, certainly as a named doctor for safeguarding and it would have
been appropriate for me to bring that to their attention at the time -- at that time.
CARR: "Your conclusions were entirely sound. Their governance is flawed." The reference to their governance being flawed, does that arise from the text that you added to the draft report?
WILSON: Around the death process and investigating deaths.
CARR: Are there any other additional points in respect of which you considered their governance flawed?
WILSON: That was what I was most concerned about, yes.
CARR: "Green for Danger, before your time." You explain in your statement Green for Danger is a film where a patient is killed by a doctor using surreptitious means swapping an oxygen cylinder for something --
WILSON: Yes.
CARR: -- presumably noxious. We are just going to get it back up it is page, yes. Now, you explain in your statement that the reason that you refer to this film is because of what was contained in that green text and the suggestion that --
WILSON: Yes.
CARR: -- a member of staff was responsible for the
deaths. And on reading, on reading the draft report, did it create a parallel in your mind with this film?
WILSON: So reading the redacted sections it -- I got the impression that something unusual, unexplained, inexplicable was going on in this hospital; this is true. And the film is more about it's not clear whether anything has -- whether there's a crime been committed or not but it's -- no -- it's a situation, yes, where a member of staff is suspicious, is suspected of having harmed a patient. So, yes, I thought that from the redacted text that was -- that was, to some extent that conclusion was mentioned within the -- within those sections, yes. That was a worry.
CARR: And in light of safeguarding practice and safeguarding principles in place at the time, the fact that there is a low bar to -- there's a low bar before there needs to be escalation and referral where there are those suspicions, there needs to be onward escalation?
WILSON: Yes, if that suspicion exists then escalation should take place.
CARR: And then the final point about neonatal medicine and "... death being one of our few clearly definable outcome measures" and the reference to
draining the pond, what you explain in your statement is that you were referring here to the fact that sometimes local neonatal units can be resistant to reconfiguration because they are protective of their own interests?
WILSON: Yes.
CARR: But the situation here wasn't that the doctors were resisting reconfiguration. In fact, the reconfiguration had occurred because of the increase in deaths?
WILSON: Yes.
CARR: So what was the relevance of the draining the pond?
WILSON: Having thought about that, I think it's also a general point about people sometimes very close to a problem not necessarily being the best people to understand the problem, well, the -- what is actually going on in, in that problem. So it's true sometimes neonatal doctors want to protect their patches, but also people close to a problem aren't the ones who are able to see what what's going on most clearly. That could be the doctors, that could be other people within the unit.
CARR: Finally this, Dr Wilson, it's a form that you filled out for the purposes of quality assurance. It is INQ0009628. There's a series of questions that you have responded to?
WILSON: Yes.
CARR: And the two that I want to take you to are 2 and 8 -- sorry, 4 and 8. Number 4: "Are the elements of the Terms of Reference clearly addressed?" You have answered yes. One of the Terms of Reference, term of reference 4, asked whether or not there were identifiable factors or failings which were common and causative of the death and the report doesn't address that one way or the other, does it?
WILSON: It doesn't directly, but it makes the recommendation that a further investigation should take place, which is why I felt that was a reasonable conclusion to come to.
CARR: A connected question. Second page, number 8: "Are the recommendations achievable and realistic?" What did you understand the main recommendations to be of the report?
WILSON: Yes. That was -- my concern was around the increased activity on the unit and inadequate staffing. So the recommendations were about, you know, the redesignation of the unit, which had already taken place as you say, and also improving the management structure, making the clinicians have closer connection with their
senior managers. I think it was around those areas.
CARR: On your review and your reading of the report, did you consider that it made any recommendation to commence a safeguarding process?
WILSON: No.
MR CARR: Thank you, my Lady. I have no further questions.
MR SHARGHY: Just two questions, my Lady. Dr Wilson, I think you have also been sitting in the room as well, so you will know I will ask questions on behalf of seven Families who Lucy Letby harmed the babies of. Green for Danger. I have just done a very quick Google search; a 1946 movie. The police were called in that move, weren't they --
WILSON: They were.
SHARGHY: -- to investigate?
WILSON: Yes.
SHARGHY: And in relation to making the reference in your comments as you did, do you think you could and perhaps should have been more explicit about the police potentially being called?
WILSON: Now it seems, yes. Something about when I read the report I was concerned, yes. So clearly
I had made that reference because I was concerned and I didn't take it further and that, it may well have been some -- Well, it was something I should have taken further, yes.
MR SHARGHY: Thank you very much. My Lady, thank you.
LADY JUSTICE THIRLWALL: Thank you, Mr Sharghy. Ms Scolding.
MS SCOLDING: I have no further questions, my Lady.
LADY JUSTICE THIRLWALL: Thank you very much. You have nothing else? Thank you very much. Thank you, doctor, you are free to go.
WILSON: Thank you very much.
LADY JUSTICE THIRLWALL: Now, we've got two witnesses tomorrow, I think, Dr Hawdon and Dr McPartland?
MR CARR: Yes, my Lady.
LADY JUSTICE THIRLWALL: Yes, and we will start at 10 o'clock. Thank you, all.
(5.12 pm) (The Inquiry adjourned until 10.00 am on Tuesday, 12 November 2024)
Witnesses:
Dr Jane Hawdon: Consultant Neonatologist, Royal Free London Hospital
Dr Jo McPartland: Consultant Paediatric Pathologist, Alder Hey Hospital
LADY JUSTICE THIRLWALL: Ms Langdale.
MS LANGDALE: My Lady, may I call Dr Hawdon.
LADY JUSTICE THIRLWALL: Dr Hawdon, please come forward.
DR JANE HAWDON (sworn)
LADY JUSTICE THIRLWALL: Do sit down.
HAWDON: Thank you.
MS LANGDALE: Dr Hawdon, you have prepared a statement for the Inquiry dated 22 May 2024. Can you confirm the statement is true and accurate as far as you are concerned?
HAWDON: That's correct.
LANGDALE: Before I ask you anything about the statement, I understand you would like to say something?
HAWDON: Yes. As I am sure everybody is aware, my sincere condolences are to the Family and others affected by this -- this tragedy.
LANGDALE: You set out for us your qualifications in your statement and your various memberships. Since 2017, you've worked with the Royal Free London NHS Foundation Trust and you are the Medical Director?
HAWDON: I am one of the Medical Directors. The structure is a Chief Medical Officer and four Medical Directors reporting to the Chief Medical Officer.
LANGDALE: You are a Consultant neonatologist, although ceased acute clinical duties in January 2022?
HAWDON: That's correct.
LANGDALE: You have had various professional roles including in 2022 appointed Clinical Lead for the Royal College of Paediatrics and Child Health Invited Review service and that continues until July 2024?
HAWDON: That's ceased now, yes, that's correct.
LANGDALE: The Inquiry is aware -- indeed everyone is apparently -- you in terms of this case were involved in providing a report to the Countess of Chester. If I can take you through the chronology of communications around that and your report and its recommendations. You tell us, first of all, that you received a telephone call from Sue Eardley from the RCPCH. Can you tell us now what that telephone call was about and what she said to you back in 2016 in September?
HAWDON: It is a long time ago and it was a telephone call. As far as I recall she -- the context was that they had had the College review at the Countess of Chester and she had been asked to suggest some clinicians that could take an independent review of some
case notes and she asked if I was happy for my name to be put forward and she stressed that it was not on behalf of the Royal College of Paediatrics and Child Health that I would be doing so; it would be as an independent person.
LANGDALE: Did she say "clinicians" in the plural?
HAWDON: I don't recall, I'm sorry. I -- I --
LANGDALE: That is what you have just said now, isn't it; you said "clinicians"?
HAWDON: I don't recall. I know that she was asked to put at -- at least one name forward but I don't know what she had been asked to do.
LANGDALE: So what did you understand in that call she was suggesting you might do or be put forward to do?
HAWDON: My understanding was to review case notes.
LANGDALE: Did you get a sense of how many case notes from that conversation?
HAWDON: I did not, no.
LANGDALE: Did you get an understanding of why it was necessary?
HAWDON: I did not, no.
LANGDALE: Did you get an understanding of what they had recommended in totality?
HAWDON: No, I did not.
LANGDALE: Did you ask or did you not think it was
necessary to ask, or what?
HAWDON: My -- my view at the time was that if -- if the suggestion was taken up and I was going to be approached, that it would be the Countess of Chester that would be instructing me as to what would be required.
LANGDALE: Did you get any sense of urgency from talking to Sue Eardley about the instruction?
HAWDON: Not from that conversation, as I recall.
LANGDALE: Did you get any sense of concern from her about the situation at the Countess of Chester from that conversation?
HAWDON: Again, as I recall, I did not.
LANGDALE: Let's go to the email instructions, please. INQ0014365, page 3. We see there: "Dear Dr Hawdon, "I have been given your contact details by Sue Eardley at the RCPCH as someone who might be able to assist us in a detailed Casenote Review of a number of neonatal deaths and near misses. This is one of the earlier recommendations following a College Invited Review which was stimulated by our clinicians highlighting an increase in the number of deaths in our neonatal unit in 2015 and 2016. They also highlighted concerns about the mode of death of some of these babies in that they seemed to not respond to normal resuscitation measures as they would have anticipated. The Invited Review team have made a recommendation of detailed review and examination to be carried out together with the relevant paediatric pathologist by two independent specialists reporting separately. It is likely that the review would extend to maximum of 13 deaths and between 4 and 6 significant near misses. "I appreciate you are busy and not surprisingly there is a sufficient degree of urgency to this investigation which might make things difficult, but I would be happy to have a detailed conversation and share more information if you felt that you might be able to help." You respond at the top: "I am able to assist but first must ask about terms as I would need to do this in my own time." You say: "Do I need to attend the Trust? I do have extensive experience reporting for claims (PHSO and HM Coroner)." Looking at Mr Harvey's letter, what did you ascertain from that?
HAWDON: I ascertained that concerns had been raised to him regarding a number of deaths and regarding the mode
of deaths and near misses.
LANGDALE: Did you detect from that there was a real need for a sense of enquiry about the mode of death?
HAWDON: I -- I -- there will always be an enquiry about the mode of death and as I -- as I think we will come to, there is only so much that is available from a Casenote Review.
LANGDALE: When the request in that letter of instruction came for a detailed Casenote Review, what did you think that required?
HAWDON: The there has to be a balance between the sense of urgency and the level of detail that could go into a review. My understanding was that the sense of urgency was that it was going to be impossible to spend the 10, 12, 15 hours that would normally be required to do a full -- for example for litigation purposes, and so I chose having had a conversation with him, I think you will see about whether they had a structured review tool, I chose to use a nationally accepted structured review tool in order to go through the cases as quickly and as thoroughly as possible within the -- the sense of urgency that he described.
LANGDALE: If you go to, please, page 2 of this INQ number, we see a further email from Mr Harvey:
"Many thanks for your quick response. I absolutely recognise the workload required. This is outside normal working time and am happy to consider reasonable fees, either as a one-off or an hourly rate. Not surprisingly having reviewed in-house and had an Invited Review we have copies of most documentation. I think it would be unreasonable and inefficient to expect the review to be carried out at the Trust, with the possible exception of any particular issues or secondary review on the back of the main documentary process." If we go, please, to INQ0012066, page 1, we will see the letter of instruction. We see there, Dr Hawdon, that 5 October 2016, Mr Harvey sends you this, thanking you for accepting instructions to carry out a review of the case notes and associated records relating to 13 neonatal deaths and four near misses. Pausing there, did you know which ones and why were selected for your review?
HAWDON: I -- I did not know why they were selected other than they were the deaths and near misses that he had referred to in the first email.
LANGDALE: The next paragraph refers to the instructions following from an Invited Review by the Royal College of Paediatrics and Child Health. You had obviously spoken to Sue Eardley. Did you think at this point or at any
time subsequently about having a conversation, either with Sue Eardley or anyone else from the RCPCH, to see what they had been doing and dealing with?
HAWDON: I think that would have been completely outside my remit, it would not have been appropriate to do so.
LANGDALE: So what was appropriate from your perspective, to just take instructions from Mr Harvey on behalf of the Trust?
HAWDON: That's -- that's correct, my ...
LANGDALE: Did you think to ask him if you could see a copy of that and go directly to him for it or did you not think that was helpful or necessary or what was your thinking when you saw that?
HAWDON: I think at that stage I had been asked to carry out Casenote Reviews. Particularly having read that letter and read the other recommendations of the College, I considered at that stage I was part of a process and a defined part of the process was to carry out Casenote Reviews.
LANGDALE: He refers in that second paragraph that they recommended a detailed forensic Casenote Review. What's the difference between a Casenote Review as we see you describe it and a forensic -- detailed forensic Casenote Review?
HAWDON: So my understanding of detailed forensic is that a much broader inquiry is taken into things that may not be in the case notes. They may be in unit records, staffing records, equipment records. There are -- there is more information available than just from the case notes themselves.
LANGDALE: And in the earlier email he'd mentioned -- carrying out together with the relevant paediatric pathologist is what the recommendation was. Who did you think was going to locate or contact a paediatric pathologist if it was considered one was necessary?
HAWDON: In -- in my view the only person that could do -- the only organisation that could do so was the Trust.
LANGDALE: Would it have been helpful for you to have the instruction at the same time as you working in tandem with consultation with somebody?
HAWDON: I -- I believe it would have been. I -- either in tandem or in close sequence with discussion.
LANGDALE: When you saw that letter, did you think forensic Casenote Review, did that give you cause to pause in your understanding about what you had been asked to do about Casenote Review or did you just see it as the original task, as it were, just going through the case notes?
HAWDON: I -- I as I in my covering letter write I replied regarding the limitations of my Casenote Review and that it could not be a detailed or forensic review. Forensic can mean a criminal connotation, at that stage I did not read a criminal connotation into it. I read understandably that there had been deaths and near misses that were concerning them and therefore, a detailed review of those needed to be carried out and "forensic" in my view was another word for "detailed" including the broader context of other things around the unit.
LANGDALE: So more rigorous?
HAWDON: Yes.
LANGDALE: But not where there is a suspicion or cause for suspicion around what's happened, a criminal act or deliberate harm?
HAWDON: There was clearly concern, there was clearly concern about the number of deaths and number of near misses. The suspicion of criminal intent was certainly not raised to me and I did not read criminal intent into the detailed forensic case note expression.
LANGDALE: We see (a) to (d) and there is another one overleaf but just concentrating at the moment from (c). He repeats -- (a) to (e) are recommendations from
the RCPCH. He repeats examination with the relevant paediatric pathologist of the postmortem findings and any additional information available on their files which might identify cause of death. We know ultimately you recommended that there should be pathology and pathology investigation. Did you think to say that at the beginning, or let's have that before I do the Casenote Review, or not?
HAWDON: I think it would have been a less than necessary delay in the Casenote Review.
LANGDALE: If we go over to page 2. It stated: "We understand as part of this review you may need to consult with a neonatal pathologist." But you say that would have caused some delay. Might it have better informed you from the beginning?
HAWDON: I am used to in clinical practice the two happening either in parallel or in tandem. There are different forms of information, both need to happen. But I do think that the two needed to happen and be brought together.
LANGDALE: If we go to page 3, we see the children by reference to the indictment ciphers that you were asked to consider and if we go over or go to INQ0003328, page 1, we see when you are sent them.
It looks like they are sent on 14 October, over the page, page 2. We know of course that the recommendation or the suggestion was that you should have electronic copies and they should be paginated et cetera what state were these case notes in when you received them?
HAWDON: To my memory, they were loosely filed, they were not well ordered and I don't believe they were complete in terms of they were not full sets of records. Clearly full sets of records for some of these babies would have been quite large volumes. I -- I received -- I didn't receive large volumes and in the second box there were some loosely filed papers that didn't apply to any of the babies at all; it was -- it took a little bit of sorting out to get the individual babies in some sort of order that I could work from.
LANGDALE: In your medico-legal practice were you used to that, getting papers in that state, it is something we know you remarked upon?
HAWDON: Very unusual.
LANGDALE: Very unusual. Can we go, please, to INQ0003120 and this, Dr Hawdon, is the letter to Mr Harvey from the RCPCH, Sue Eardley's Head of Invited Reviews. You didn't see this letter or their report at the time, did you?
HAWDON: I did not.
LANGDALE: When was the first time you saw that?
HAWDON: When it was sent to me with the supporting documents regarding this Inquiry which I believe is in April this year.
LANGDALE: We see on this letter, in paragraph 4, reference to a nurse and a requirement that the nurse should move from the unit to other duties and these steps appear to have been taken on the basis of an allegation made by one member of medical staff supported by his medical colleagues. Over the page please, if we can. And a recommendation: "Action required: Trust takes immediate steps to formalise actions taken with the nurse." We also see under "Action required" the points (a) to (e) that you were instructed upon but you didn't receive this part of the first paragraph ideally using -- if we can highlight that, please, Ms Killingback, the third paragraph halfway through: "... ideally using at least two senior doctors with expertise in neonatology pathology in order to determine all the factors around the deaths. "The case notes and electronic records should ideally be paginated to facilitate reference and
triangulation." Dealing firstly with the points about the nurse being taken on to other duties and an allegation being made about her, do you think you should have known about that expressly?
HAWDON: I think it would be for the Trust to explain the rationale for not doing so. It could be that they did not want to bias or influence my review. Had I been told that there was a suspicion about a member of staff, I would have had a much more detailed conversation with Mr Harvey as to whether it was or was not appropriate for me to proceed and the basis on which I would be proceeding. But I would also have been asking what other measures were being taken on the basis of those allegations and that action that had been taken.
LANGDALE: Well, even with the information that's provided there, with your safeguarding hat on, what would you have said about what are you doing with those allegations? This refers to HR but what would you say?
HAWDON: I would have asked what safeguarding processes were being employed.
LANGDALE: Would you have expected them to be even on the information as it's given there?
HAWDON: In my own practice I would.
LANGDALE: And just to be clear. What does that mean, what would you -- what external referral would you make or what would you do with that?
HAWDON: So my experience is that Trusts have very good and able safeguarding teams, they are experts and they themselves have close working relationships with social services and the police. So my response to that sort of concern would be to involve the Head of Safeguarding if it was such a serious allegation and agree with the head of safeguarding how that would then proceed. I -- I would not as a neonatologist or as a Medical Director have proceeded without the involvement and guidance of the Head of Safeguarding.
LANGDALE: In what way -- you said earlier perhaps there was a concern that would bias or lead you to some bias approaching the case notes. But surely knowing of this concern is a full picture, isn't it, when you are looking at it?
HAWDON: That -- that's correct.
LANGDALE: When you were looking at not simply deaths, unexplained and sudden deaths, it is a crucial part of the full picture, isn't it?
HAWDON: I would agree, yes.
LANGDALE: And in fact we see to the highlighted section that is why the RCPCH are suggesting at least two senior
doctors with expertise in neonatal, neonatology and pathology and they are talking about the need to facilitate reference and triangulation. I just want to pick up on triangulation in a forensic review. What's the importance of triangulation between disciplines to understand what has happened in some circumstances?
HAWDON: Sorry, I didn't mean to interrupt. It's highly important. One person reviewing one aspect can't get a full picture and the pulling together of the information, triangulation is essential.
LANGDALE: If we go to the next page, we see they tell Mr Harvey they: ".. have identified four individuals with appropriate expertise and experience who may be able to take this on and I'll advise of these separately and continue to seek alternatives if there is an issue there." We know that of course ultimately in the police investigation there was a Consultant paediatrician, Consultant paediatric neonatologist, Consultant paediatric pathologist, Consultant paediatric radiologist, Professor Owen Arthurs, a Consultant neuroradiologist and a Consultant paediatric haematologist who was instructed across these cases. Again, dealing with the point of triangulation, what's the significance of a multi-disciplinary approach into investigations of unexplained and sudden death?
HAWDON: Because a number of people have different areas of expertise and there's also other factual information, not just clinical information, to be taken into account with the triangulation.
LANGDALE: You mention somewhere in your statement that you didn't know about the insulin administered to two of the babies, in fact you weren't asked to review those babies so wouldn't have seen those case notes and those C-peptide results?
HAWDON: (Nods)
LANGDALE: So the notes you were looking at were very much the notes provided at the time?
HAWDON: That's correct.
LANGDALE: You were relying on how full they were presumably about the nature of surprise and shock and concern from doctors and nurses at the time about various events?
HAWDON: There were very little, if -- if nothing related to doctors' and nurses' responses. As you know I asked for example perinatal review notes, et cetera, which were not forthcoming.
LANGDALE: And you didn't speak to any of the clinicians
or any of the, who you learned subsequently, paediatricians who had concerns, you didn't speak directly with any of those; that wasn't suggested?
HAWDON: I did not, my -- my communication was through Mr Harvey.
LANGDALE: Mr Harvey didn't suggest that so that you could get a handle on what their concerns were?
HAWDON: He did not. As -- as we know subsequently I did offer to take part in a telephone case conference if that was going to be in any way helpful.
LANGDALE: In paragraph 32, to go back to your statement, you say: "I was not aware, at the time of being asked to conduct Casenote Reviews, of the suspicions that a member of nursing staff was connected in some way to the sudden and unexpected deteriorations. If I had been aware, on the basis of my findings on Casenote Review, I would have made urgent personal contact with Mr Harvey urging him to follow appropriate Trust safeguarding and governance processes." You have referred to the safeguarders and how you would report to the local authority and work closely with the police. What other processes would have been engaged here?
HAWDON: That would have included review of the cases
again internally. It would have included staffing. It would have included questioning whether there had been equipment failures, contamination of nutrition solutions. They are a very, very broad level of inquiry into the circumstances of those babies.
LANGDALE: What about the Child Death Overview Panel, where would they fit into this?
HAWDON: They -- they are aligned to the safeguarding processes, yes.
LANGDALE: What's your understanding about sudden unexpected unexplained events whether they are referred to Child Death Overview Panels or not at that time?
HAWDON: I -- I can't say what the Trust was doing at the time. My recollection at the time is that -- is that all child deaths were reviewed by the local panel where I was working and it was also every infant death, every baby death would be very rigorously reviewed by the unit, by the unit's governance processes with external involvement as necessary.
LANGDALE: If we can go now to your report and your letter to Mr Harvey on 29th of the 10th 2016 INQ0003358, page 1. I will give you time and others to read this, Dr Hawdon. If we can have the first page and then the second page in a moment, Ms Killingback. (Pause)
Page 2, you respond along the lines of the (a) to (e) which we traced through the RCPCH letter, Mr Harvey's letter to you and your response. You explain that you have done a synopsis of key events rather than the level of detail required. Can you just explain why a synopsis followed rather than a full systematic chronology from each case?
HAWDON: Because that would have taken a lot of time, I did a chronology of key events as part of the synopsis and used the MBRRACE methodology.
LANGDALE: Roughly how long did you spend on all of the babies in total?
HAWDON: I believe I worked pretty solidly during the days of one, perhaps two weekends.
LANGDALE: So what's that, two days or four days I can't tell if that is?
HAWDON: I can't recall, it may have been three days of about 10 hours each time.
LANGDALE: You say you did comment to the extent that it was relevant on the second issue about whether there might have been escalation or opinion from a regional centre. In fact, the comments you made about care or sub optimal care related to matters such as delayed antibiotics, there was no red flag, was there, leading to causation of death in any of the cases that you flagged up?
HAWDON: The -- my review of the cases was that the there were varying concerns including the unexplained and unexpected. But the -- the varying concerns regarding clinical management were around antibiotics, delays in escalation, whether the baby was born in the right unit for the level of care the baby was going to require. It was a varied clinical picture.
LANGDALE: In terms of (c), examination with the relevant paediatric pathologist, was the issue, you made the point that the postmortem results had not been available and you weren't in a position to consult with the perinatal pathologist and you suggested that Mr Harvey instruct one.
HAWDON: That's correct.
LANGDALE: I think we have covered further -- earlier, rather, it wasn't something you thought to suggest before doing the Casenote Review because you saw them as separate tasks at this point?
HAWDON: That's -- that's correct.
LANGDALE: In terms of the details of all staff with access to the unit from four hours before, you state "I am not in a position to perform this". You hadn't been sent anything that would enable you to perform that even if it was your expertise or
something you would do; is that right?
HAWDON: That is correct.
LANGDALE: Have you ever been asked to look at rotas or details and try and forensically examine who was where, when and how often?
HAWDON: I -- I don't believe I have, even in my own clinical practice.
LANGDALE: Did that surprise you being even asked that? Did that make you wonder: why am I being asked that?
HAWDON: I did and it appeared that the College of Paediatrics and Child Health was putting forward many different possibilities that might explain the unexplained deaths or baby deaths. If I could come back on that, if that's all right. Looking at who's on duty and who's caring for a baby again doesn't necessarily imply criminal intent. It could be that somebody without the competences could have been caring for a baby or somebody could have been caring for more babies than was safe to do so. So a review of staffing doesn't necessarily mean that there is criminal intent.
LANGDALE: Understood. My question was more had you ever been asked to do that? You give reports on medical negligence cases, provide reports, have you ever been asked to look at who was around or is that just
a different --
HAWDON: No.
LANGDALE: -- part of the task? That is not something for you, is it?
HAWDON: No, that's correct. In clinical practice certainly we look at staffing levels and who's available to care for the babies on -- on that particular shift.
LANGDALE: If we go now, please, to the conclusions of your report, so it's page INQ0003172, page 44. We see there that you have listed a number of babies where death/collapse is unexplained. You say: "It is the investigation of cases which would potentially benefit from local forensic reviewers to circumstances, personnel et cetera." If we go to the next page, please, page 45. So same INQ, page 45. Thank you. Point 6, you say: "Subject to Coroner's postmortem reports, there should be broader forensic review of the cases described in category 2 above as after independent clinical review these deaths remain unexpected and unexplained." What did you mean by a broader forensic review?
HAWDON: Taking into account various other factors including equipment, personnel, just every detail of the circumstances that could be reviewed.
LANGDALE: There is subsequent correspondence between you
and Mr Harvey, when postmortem examinations have been sent to you. If we go, please, to INQ0003102, page 1. While we are finding that, Dr Hawdon, if you had been the recipient of your report with that list of babies requiring who you say require further forensic review, and the death collapse is unexplained, would you have recognised the significance of that grouping?
HAWDON: I think even without knowing what we know now if I had been the recipient I would have said something along the lines of: we have a problem here.
LANGDALE: If you held additional information of concern, such as about a nurse being present at these unexplained events and paediatricians raising concerns about response to resuscitation, for example, what is the level of concern your report should have triggered, do you think?
HAWDON: In my view, as the recipient of that report, and the knowledge of the other information, I have no doubt that it should have triggered safeguarding processes.
LANGDALE: What about referral to the police directly?
HAWDON: My -- I have only been involved once in a circumstance where I was worried that there might have been deliberate harm to a baby on a neonatal unit and I went through safeguarding in order to involve the police. One of the reasons for that is that the police that work with safeguarding teams are very, very sensitive to the circumstances and it doesn't -- it doesn't delay things. But it does mean that police would have a certain skillset to become involved.
LANGDALE: So they know the right police officers to go to or the right level, that's the point about --
HAWDON: That is correct.
LANGDALE: -- ongoing liaison between local authorities and the police?
HAWDON: Yes, yes.
LANGDALE: In that case you say it doesn't delay, but how quickly, if you make a referral to safeguarding in that case, did the police become involved or notified?
HAWDON: Almost immediately.
LANGDALE: Because they know who to pick the phone up to and know how to approach these matters?
HAWDON: Yes, that is correct, they have processes to follow.
LANGDALE: It is different in a hospital, isn't it, in terms of how sensitively it's managed, how it's dealt with coming into a hospital?
HAWDON: That -- that's correct. If -- if I -- if I could use the example that I was involved with, the
police came in in plain clothes and passed themselves off as estate staff who needed to take the drug cupboards off the wall in order to do an audit. Luckily there was no mal-intent, but they -- they managed it very professionally without any of the parents on the unit suspecting that there was anything amiss.
LANGDALE: Going to this document on the screen, if we may, Dr Hawdon. These are the four babies that you are sent postmortem reports for. You remain of the view that three of them remain unascertained or unexplained and [Child D] you have by now seen Dr McPartland's report, "cause of death: pneumonia", and you concur and say "delayed antibiotics may have been contributory". We will be hearing from Dr McPartland later. But she tells us that death with pneumonia as opposed to from pneumonia is context dependent. Do you agree with that?
HAWDON: I do, yes.
LANGDALE: What is important in assessing context, what do you need to know before you arrive at that distinction?
HAWDON: The clinical -- the clinical course leading up to any change in condition and -- and the sad death.
LANGDALE: You say in your case you didn't have detail from the nurses, doctors, either about any symptoms or
things that they had observed in respect of [Child D] other than the ones we have seen you summarise in your notes.
HAWDON: I have been back to obviously look at that case and what I identified was that there was a backing off of respiratory support for this baby on the day that that baby sadly deteriorated -- condition deteriorated. And so looking at the clinical details it was plausible that the change in respiratory management had contributed to the baby subsequently deteriorating again.
LANGDALE: Plausible, but not when you have the fuller picture of the surrounding evidence that became available subsequently?
HAWDON: Correct.
LANGDALE: We know that your report -- and I will ask Mr Harvey about this, I don't need to ask you -- Mr Harvey moved things around your report presumably when he got further information. For example, he moves Baby D [Child D] from the "unexplained" category above to the one that's explained. That's a matter for him, but as far as you are concerned, you didn't see any further version of your report with notes or additions or things being moved around?
HAWDON: That's correct, not until April this year.
LANGDALE: But to use that example, given what you said in this email, a change to move Baby D [Child D], it would appear to reflect what he may have thought was your view now, having seen the postmortems; is that fair?
HAWDON: That's correct.
LANGDALE: Paragraph 68 of your statement, you do say review by -- that can go down, thank you Ms Killingback: "Review by an expert in perinatal pathologist and local/broader forensic review would be separate with differing methodologies but complementary. Expert perinatal pathology review is essential for a broader forensic review of the case where postmortem information is available, and it is important for a reviewing pathologist to receive all relevant information regarding the babies who died." I just want to give you an opportunity again to say what is "all relevant information" when you are looking at this?
HAWDON: So for a pathologist it would be clinical information. I wouldn't be expecting a pathologist to be doing the broader unit based investigation, it would be a clinical pre-session.
LANGDALE: You subsequently get further emails from Mr Harvey, if we can go to INQ0099055, page 1. This is February 2017. Mr Harvey emailing you: "Apologies for emailing on a Sunday morning but I just wanted to give a heads up. The review features in an unplanned fashion in The Sunday Times. It references your review which was demanded by the College review but there are no names, nor is your name in the public domain. It is not my intention to give your name and certainly not without first confirming with you one item that features in the report and had also been highlighted by our medical team was unexplained mottling although this was only reported in the notes in three babies in your notes review. Our medical team had put great emphasis on this although disproportionately, given the incidence in the notes and my experience of medical memory is that it exaggerates numbers. I would however be interested in your comments about so-called skin mottling as a clinical feature in babies." And we see above your response: "Mottling is variable. If transient, probably not of significance, but if longer lasting reflects peripheral shut-down. Reasonable nurses and doctors spot recognise it as significant finding which if nothing else warrants close observation and additional tests if there are other concerns." There is a contrast there in his description of the
doctors and what he says they are doing and your response: "Reasonable ... significant finding which, if nothing else, warrants close observations and additional tests". What did you make of that? Did you spot that mismatch between the way he summarised it and your response: well, if they are concerned, this warrants close observation?
HAWDON: That -- that's correct. I was surprised that he asked about mottling because it is such a common finding in babies that are unwell and we were sadly talking about babies who were unwell. We know now that the allegation was of injecting air and that mottling is said to be a feature of air embolus. That is something that would not have crossed my mind at all at that stage when thinking about mottling. I would be thinking of common causes of mottling of the skin.
LANGDALE: If we go, please, to paragraph 75 of your statement. You knew -- you know now Dr McPartland was instructed but were you told at the time that she was going to be instructed?
HAWDON: I was not.
LANGDALE: Would you have expected to know or have an
input into that?
HAWDON: Well, as we've noted, I had said that perinatal pathology review was important after my Casenote Review and I assumed that that would be going ahead and were I to be required to discuss it with the pathologist, I would be called upon to -- to do so, again recognising I was part of a process.
LANGDALE: You tell us at paragraph 78 that there were there was further communication in February between yourself and Mr Harvey and indeed one of the things he sent you is a letter I am going to show you now, from the paediatricians to Mr Chambers, so that is INQ0003117, page 1. Take your time to look at this and if we could highlight please, Ms Killingback, paragraph 2 -- sorry, point 2, not paragraph 2. Go overleaf to page 2, the top: "The paediatricians said to Mr Chambers 'we do not consider that the episodes of care that she [that is you, Dr Hawdon] considered sub optimal could explain the rise in neonatal mortality and the sudden collapses in this time period'." Do you agree with that when they say that?
HAWDON: That's correct.
LANGDALE: So they were right and it was very clear, as
far as you are concerned for another medic that you were not saying wherever you describe sub optimal care that explained a sudden death and collapse in the various cases, particularly those that you had highlighted in that group?
HAWDON: That is correct.
LANGDALE: Pausing there, Dr Hawdon. We have heard from the paediatricians, and one in particular expressed her frustration that in effect both her, the Royal College review, she is a member of the Royal College, and then your report both were used to deflect suspicions and concerns about Letby and in effect to try and criticise the medical care they were providing on the unit. Do you understand now you have seen the whole picture how they must have felt frustrated by that?
HAWDON: Absolutely.
LANGDALE: Here you are wholeheartedly agreeing with them that your report didn't anyway explain these deaths or sub optimal care resulting in deaths, yet we hear this thrown around as if it did. Can I give you chance to respond to that, that it did not do that and why you say it did not do that?
HAWDON: The -- we all know that care can be improved and unfortunately sometimes if there are lapses in care, it can lead to babies becoming more poorly and sadly dying and it's very important that we take that and -- and act on it and I am quite sure they, they did. I do know from what I was told they were a busy unit and they had -- they had some very poorly babies so that -- the two have to happen in parallel. Their suspicions that there was mal-intent had to be taken seriously and any measures to improve the standard of clinical care for the babies also had to be taken seriously. But the two didn't preclude each other.
LANGDALE: So delayed antibiotics did not cause a death, something very different did, but you were looking at those features in the Casenote Review, not simply how a death was caused?
HAWDON: That -- that's correct.
LANGDALE: You couldn't explain though deaths, that is the point?
HAWDON: That -- that's correct.
LANGDALE: In terms of the near misses and deteriorations, without fully being aware of what clinicians and nurses had noted at the time, you weren't really able to do very much just looking at the records, were you, if you were missing key information?
HAWDON: That's correct.
LANGDALE: You referred to mottling; you didn't know about this rash, what it looked like, the concerns the
paediatricians were sharing about that?
HAWDON: That's correct.
LANGDALE: So it's more of an academic exercise; is that fair?
HAWDON: That's correct.
LANGDALE: What you really need in a circumstance like this is real people telling you the real events as they remembered them?
HAWDON: That -- that's correct.
LANGDALE: We see at INQ0014376, page 2, the letter that Mr Harvey sends you forwarding that letter from the paediatricians to him. Page 2 at the bottom: "Dear Jane, "I thought it was important to share this letter from ... paediatricians having shared both the College review and your review with them." He says he's had discussions with the Coroner: "... initially a briefing at the outset when all the issues were raised and again last week having shared the College review with him." When he says "all the issues were raised", what did you think that meant, if anything, if you focused on that paragraph?
HAWDON: I -- I didn't read anything into it at the time. I -- perhaps the issues that were raised by the
paediatricians.
LANGDALE: Next page, please, page 3 of the document. There is a bit of a dig at the College: "The paediatricians made allegations against one member of staff which we made the Review Team aware of, as did the paediatricians when they met the reviewers. These didn't feature in the final report but were covered in observations by the reviewers that were shared with the neonatal and paediatric leads; namely this was based on coincidence and gut feeling. We intend to now share those comments with all the paediatricians since we are unsure that the leads have." What did you make of that paragraph, if anything?
HAWDON: It's a difficult paragraph to understand but it's the first time in my recall that I knew -- that I learned that a member of staff had been suspicious or implicated.
LANGDALE: The next paragraph: "Our paediatricians repeatedly raised the issue that they still feel hasn't been resolved, ie the unexpected collapse and failure to respond to resuscitation in the way that is expected. "At one point they even went so far as to suggest that given they had observed unusual mottling, air embolism was responsible. The pathologists at Alder Hey
have assured me that a significant air embolus would be detected at PM, therefore how common is it for a neonate to collapse unexpectedly?" Was this the first time you knew directly from him there was concern about deliberate injection of air?
HAWDON: That's correct.
LANGDALE: I don't suppose you have received many letters like that in your medico-legal practice?
HAWDON: No, that's correct.
LANGDALE: Is this the only one with that allegation or suggestion put there in --
HAWDON: Accidental air embolism is not -- is not unheard of and something that is looked, for example, during exchange transfusions that are carried out three an umbilical line. So we are all -- we are all aware that air embolism is a complication. Did they -- I am trying to see whether they said injection of air?
LANGDALE: It says: "At one point they even went so far as to suggest that given they had observed unusual mottling, air embolism was responsible." Did that make you, in conjunction with the paragraph above, realise it was about a person, "gut feeling", deliberate infliction of an air embolism?
HAWDON: That's right. They are two separate suspicions that appear to go together.
LANGDALE: You respond to that email, INQ0014376, back to page 2, if we can. You answer his question about unexpected collapses, paragraph 2 of your response at the top: "Unexpected collapse in an otherwise stable baby is rare and I agree there had been more cases than would be expected especially those for whom there is no explanation and the PM cause of death is in question. The paediatricians infer more cases that I did not study." Did you begin to see that there may be more to it?
HAWDON: That -- that is correct.
LANGDALE: You comment: "... insufficient details in records and unlikely to have been possible to record in anything but real-time to determine for each whether the collapse and impossible resuscitation were [query] A and C in particular purely out of the blue and unexplained, and C the sinister cause." So you recognise the need to have accounts individually from people involved in the deaths to see what they say?
HAWDON: That is correct and that is what I assumed
would happen.
LANGDALE: There are further emails between yourself and Mr Harvey in April 2017. If we can go to INQ0003124, page 1. It starts at the bottom the page, if you can go to page 2 is the body of the email, so it is from you to Mr Harvey. Broader review. You make reference to a broader review. Actually, sorry, can we go to the email below "Good morning, Jane" first. "Just wanted to update you on progress and ask you some follow-up questions if I might. One of the sticking points we have met is your use of the phrase 'broader forensic review' with regard to the cases in category 2." In the third paragraph of the email he says: "We have instructed a QC to review our process and to give a perspective on the reviews and next steps." This is Simon Medland QC. "He has met with the board and the paediatricians and one of the challenges he has given to the latter is to set out what he's described as their best points which are those matters which they say most clearly indicate in their minds reasonable grounds for suspecting that a criminal offence has been committed. I am sure that I would know the answer because I am sure
that you would have called it out in your report but my chairman has asked the question: were there any concerns that there was anything other than natural causes in your review of the cases?" So he says he is sure he knows the answer but he wants to know whether you would have called it out. Your reply we see above: "Most deaths were explained. Some may have been prevented with different management. Completely unexplained on a neonatal unit is rare, so by definition more than one unexplained death does arouse suspicion. "Unexplained death at home is followed by a very clear process and the same should be followed with unexplained death in hospital. I think on some occasions the team was misled by the PM report and I have commented on these. With due respect, I am not a pathologist." So first of all, his question of you, you would have called out a criminal act, completely misunderstands your role and ability to do that given what you had, doesn't it?
HAWDON: That's correct.
LANGDALE: You weren't actually able to look at causation of death in any of the cases without proper accounts from the clinicians, the nurses and the concerns in the
rounder picture and working within a multi-disciplinary team; do you agree?
HAWDON: That is correct but unexplained and unexpected deaths are unlikely to be from natural causes.
LANGDALE: Yes, because the death of a neonate naturally you can understand what's happening?
HAWDON: That's correct.
LANGDALE: You might not be able to prevent it but you understand the clinical demise and the gross symptoms?
HAWDON: That's correct.
LANGDALE: But these ones you were looking at you didn't understand and as far as the deteriorations were concerned you didn't necessarily have the information to see what had happened in those unexpected deteriorations either, you didn't have the body of material, did you?
HAWDON: That is correct.
LANGDALE: The comfort in the bit that's highlighted "most deaths were explained", you mean there the natural deaths that you had viewed, the non-indictment baby deaths, do you, the ones that you could see a natural cause for?
HAWDON: Yes, on my understanding of the records and the postmortem reports, yes.
LANGDALE: On your understanding?
HAWDON: Yes.
LANGDALE: So that didn't link at all to the indictment babies or the group that you had put at the end of your first report and now would concede D should be back in the unexplained category?
HAWDON: That -- that's correct. It didn't detract from that.
LANGDALE: But at the time it appears you had some reassurance from Dr McPartland's pneumonia -- acute injury pneumonia but you reflect upon that that that's context dependent and you didn't have the context and neither did she from that?
HAWDON: That's correct.
LANGDALE: You comment in your statement on the communications with the Families about your report and you say this: "Based on my own experiences as a neonatologist ..." That can go down, thank you, Ms Killingback. "Based on my experience as a neonatologist and having held medical leadership roles, it is my personal opinion that there was insufficient covering information and explanation provided to the Families to accompany my reports. It is my opinion that it was appropriate to share the reports but with accompanying information and explanation, preferably in a face-to-face meeting,
especially at a time of grief." So what did you think about your case notes just being sent in the way that they were?
HAWDON: Again, I was not aware of that until April this year and my personal response was of shock.
LANGDALE: In terms of parental consent generally, in September 2016, had you asked whether Mr Harvey was seeking parental consent for your review?
HAWDON: I believe I did.
LANGDALE: Was that in a conversation or in emails or can you remember now?
HAWDON: I believe it was in an email. If I could just say, I don't believe I ever had an in-person conversation with Mr Harvey.
LANGDALE: Not at all?
HAWDON: I don't believe so.
LANGDALE: So all of the communication we have between you and him is by email?
HAWDON: That, that is correct.
LANGDALE: Did you ever think to phone him at any point when you had got some of the emails I have been taking you to now to say, "What is going on here"? Just to sort of get to the nub of it?
HAWDON: As you can see, I suggested that I joined a telephone case conference if the Trust was going to
find that helpful.
LANGDALE: So you were very much providing a piece of work that they had commissioned, as it were, rather than if this was happening in your own hospital where you might have gone down to have a word with someone and say, "What is going on?" Do you see the distinction?
HAWDON: That is correct and as -- as I'm sorry that I keep saying, I felt that I was part of a process and I believed that other parts of the process were happening as they should be.
LANGDALE: In terms of information that Families should have, you have seen what Mr Harvey is telling you the concerns the paediatricians had. Were you surprised, when that letter was forwarded to you, and there were seven names at the bottom, all of the paediatricians, not just one? The suggestion there was one and other support but you saw the letter to Mr Chambers with a number of names at the bottom.
HAWDON: Yes. That's -- that's not a surprise. If, if a team has concerns they will discuss those concerns and it's not unusual for them all to put their name to a letter.
LANGDALE: I will take you to the email where you do refer to parental consent. It's Q0003123. You are told at the bottom:
"Re: parental consent. We had informed parent ahead of the review that it was occurring. I had not got a particular template ..." That's to do with your template request for the review?
HAWDON: Yes.
LANGDALE: So your understanding was the parents had been informed ahead of your review, so you did ask about that. Why would that be important to you, to know whether that had been given?
HAWDON: It's -- it's vital that no -- no parent should know that the care of their baby is being reviewed by an external person without them being informed.
LANGDALE: It may seem obvious, but why?
HAWDON: The baby is their baby and all matters related to their baby are important to them.
LANGDALE: You provide reflections in your statement and conclusions from paragraph 114 onwards and you say at paragraph 115: "I do not consider that I was adequately briefed about the concerns of paediatricians at the time of my first review, or subsequently. I do not know why the Trust chose this approach." Have you reflected on that?
HAWDON: I -- it would be speculation and my speculation is that those who were instructing me or agreeing that I should be instructed did not believe that that was a likely possibility. But that is speculation only.
LANGDALE: You say: "However, this would not have changed my clinical findings on Casenote Review and my recommendation that broader forensic review should be undertaken." Just pausing there. With your own clinical findings, you might very well have asked for more direct information, the information that you were missing even on the case notes?
HAWDON: I think as we have said, I maybe wouldn't even have gone ahead without some more discussion as to what other processes were going to be more important than my Casenote Review.
LANGDALE: Because your Casenote Review could really have followed, couldn't it, more detailed pathology --
HAWDON: Yes.
LANGDALE: -- x-ray, the need here --
HAWDON: That's correct.
LANGDALE: -- for x-ray?
HAWDON: That's correct.
LANGDALE: You say at paragraph 116: "In my view it would be appropriate for
recommendations to include reinforcing the importance of recognising and exploring concerns of Families and staff, and enacting systems by which there are no barriers to Families and staff speaking up or their concerns being acted upon." Would you like to expand on that in any way?
HAWDON: It's -- it's just fundamental to -- to patient safety and staff well-being that concerns are listened to and acted upon.
LANGDALE: We know, because she gave evidence in the criminal trial, Mother E had vitally important evidence to give about her baby and that was gathered during the police investigation and after your report and Dr McPartland's report. Do you think, at any point, there should have been an invitation to parents to say how they had experienced the death and unexpected collapses of their children and what they might be able to add to the clinical picture in the circumstances?
HAWDON: Absolutely.
LANGDALE: You refer at paragraph 117 to it being a neutral act to restrict practice or to exclude a professional pending further investigation. Can you expand on that for us, please?
HAWDON: So if -- if we were to take this situation
where there is suspicion about a member of staff, the safest thing for everybody is for that member of staff not to be in clinical practice and it is supposed to be a neutral act. I know for any member of staff it doesn't feel like it, but it is also for that member of staff's protection as -- as well as the protection of in this case the babies.
LANGDALE: We describe it very fully, don't we, as a neutral act where parents are suspected of abusing children. They can come to a hospital and be told: You can't be with them on your own, we need to work out what's happened to your child. We're not saying it's you, this is a neutral act, but we're looking after your baby or child. That's a culture that people understand in a hospital, isn't it? They understand that's a neutral act or should be communicated like that to a parent?
HAWDON: That's correct, and that is a very good analogy.
LANGDALE: So really moving to the point where that's understood for members of staff, what can be done about the culture to make it the same; in other words, baby safety as the priority?
HAWDON: It's my experience that that's -- that's what we do. I can't say what was holding that back in the
Countess of Chester in -- in those -- those years. But it's -- it's just of crucial importance, if -- if there is a concern about safety.
LANGDALE: The Inquiry has heard evidence from a number of people about there were concerns about Letby's welfare, her upset, how she felt about all of this, people not being permitted to talk about it because of sensitivity to her situation and it being perceived as gossip, et cetera. How can that level of concern be taken out of an equation in terms of examining or investigating for a baby and keeping everyone calm in the investigation process?
HAWDON: That's -- that's the purpose of the processes; to follow those processes, to have the restriction of practice, to communicate as much as necessary with other professionals, to give other professionals guidance as to what is appropriate and what is not appropriate to talk about. There is a framework of professional behaviour that we need to remind our colleagues of.
MS LANGDALE: Thank you. Those are my questions, Dr Hawdon. It may be a good time to take the break, my Lady, and we are ahead of time, so perhaps I could suggest 11.30.
LADY JUSTICE THIRLWALL: Very well, I think that will be welcomed. So we will start again, Dr Hawdon, at 11.30.
(11.08 am) (A short break)
(11.32 am)
LADY JUSTICE THIRLWALL: Mr Baker.
MR BAKER: Good morning, Dr Hawdon, I ask questions on behalf of a group of the Families, two groups of the Families. Can I begin by just asking you a question about candour. It was touched upon by counsel to the Inquiry. Now, the exercise that you were carrying out or had been instructed to carry out had the capacity to identify issues in relation to the care that was provided to a number of the babies?
HAWDON: That's correct.
BAKER: Were any safeguards put in place as far as you were aware in relation to ensuring that the duty of candour was followed in circumstances where you identified issues?
HAWDON: I was not aware. I wasn't told. I made an assumption that normal processes would be followed.
BAKER: So if we look at paragraph 79 of your witness
statement. You say at paragraph 79: "On behalf of the Trust, Mr Harvey instructed me to carry out case note reviews and my report was addressed to him." You go on to say: "Based upon my own experience as a neonatologist and having had or held medical leadership roles, I would have expected Mr Harvey to share the report with the Trust Executive Team and the senior neonatal team." You go on to say: "Based on my experience ... if a report gave additional signals of concern in addition to those concerns which I am now informed were available at the time I would have expected the Executive Team to discuss the totality of the information with the Trust board." So it sets out really your expectations as to who the reports would be shared with but it doesn't include Family members within that?
HAWDON: You are correct. The -- the -- those paragraphs are in response to the questions related to release of the review to the paediatricians and questions as to what my understanding was. I -- I -- it is a serious omission that I did not say: and results should be shared with Families. But as far as I'm concerned that's a given.
BAKER: Yes, so it's -- it's really so obvious that a person in Mr Harvey's position should be following the duty of candour and keeping Families informed?
HAWDON: To -- to my mind, absolutely.
BAKER: Yes. We also touched there on the fact this was a Casenote Review. A Casenote Review, I am not here intending to denigrate the quality of the work that you carried out, but a Casenote Review by its nature is a fairly superficial exercise, isn't it?
HAWDON: That is correct. It is only based on the information that's provided.
BAKER: Yes, and if Mr Harvey had said to you that he was looking for a review to exclude homicide you would have said the Casenote Review was absolutely not the level of forensic investigation that's needed?
HAWDON: That is correct, it is part of it but absolutely not.
BAKER: Yes. So a review of the medical records is unlikely to reveal a note that says: "I saw such and such harming the patient" or indeed "I harmed the patient"?
HAWDON: That is correct.
BAKER: But in terms of the exercise that you were carrying out, it was a review of the notes and it was intended to highlight what might be termed service
issues or perhaps more colloquially errors in care?
HAWDON: I was simply asked to review them. I -- I identified what may be service issues, but I also identified the unexplained deaths as well.
BAKER: Yes. But again it would require those issues to be recorded within the notes effectively?
HAWDON: That -- that is correct.
BAKER: Now, you will know from your practice and also your medico-legal work that what's written in the medical records doesn't always tell the full story?
HAWDON: That is correct.
BAKER: Yes, and I think you also said in response to questions from Counsel to the Inquiry that it would have been helpful to be able to speak with the clinicians who were involved in care?
HAWDON: If -- if that had been the extent of what I was being asked to do. Certainly somebody needed to be in a position to pull the pieces together, not necessarily me, but somebody needed to.
BAKER: Again, it goes to the perhaps superficial nature of a Casenote Review is that it doesn't involve talking to any of the doctors or indeed parents?
HAWDON: That -- that is correct.
BAKER: That is true when it comes to identifying homicide or indeed poor medical care, doesn't it?
HAWDON: That is correct.
BAKER: Now, you were asked some questions about the input that the Family may have brought to the exercise and it's particularly relevant in relation to [Child E] as I think was said. If we go on to INQ0003172 and to page 17, please. So this is an extract from what's described in your statement as the submitted report rather than -- so it's a final version of a report that you sent and it addresses [Child E] here. So we have an outline summary of the notes. Is this a transcription of the notes or is this your analysis of what the notes contain?
HAWDON: It's not a transcription. It's my picking out what could be key points of the care.
BAKER: If we look to the bottom of page 17, we can see at 23:00: "Gastric bleed desaturation, intubation planned." Then at 23:45: "Intubated." If we go on to page 19, this is a form of setting out issues by reference to codes. We can see the key to those codes below and you have identified: "Delayed intubation, significant sub optimal care, relevant, possibly relevant."
And the reason it is possibly relevant is you say the absence of a recorded cause of death. "Further comment and relevance of care is not possible." What you are saying in short there is without knowing why [Child E] died, it's really impossible to say whether any aspects of the care were relevant or irrelevant?
HAWDON: That is correct.
BAKER: So can you assist then, if we go on to page 44, why is it that [Child E] is in the box of a group where it says: the death collapse is explained but may have been prevented with different care and learning may improve outcome for other babies, because the cause of [Child E]'s collapse and death hadn't been determined?
HAWDON: So my understanding of the case based on the information I had was that the gastric bleed was significant and was the -- was the likely cause of the collapse.
BAKER: Okay, but we don't know what caused the gastric bleed?
HAWDON: That -- that is correct.
BAKER: So in those circumstances where the cause of a gastric bleed is unknown, shouldn't [Child E] be in the second group?
HAWDON: That -- that could be argued. But gastric bleeds are sadly not unheard of in vulnerable and poorly babies.
BAKER: I think when the case was or the report was updated, did you understand it to be an upper gastric bleed?
HAWDON: I think -- I think if we go back to the case I think it was seen to be a gastric -- gastric is the upper gastrointestinal tract, the stomach is gastric. Yes.
BAKER: Yes, but there is upper and lower?
HAWDON: Yes, so the stomach is in the upper gastrointestinal tract and that was the reason they gave retrospective gene because that is a specific treatment for gastric bleeding.
BAKER: Yes, but if we go to INQ0006765, and to page 23, now this is a later version of the report so now we have had the words "Necrotising Enterocolitis" added in as a box at the top. Now, that wasn't in your original report, the one we have just seen?
HAWDON: No.
BAKER: Can you surmise as to who has added Necrotising --
HAWDON: I have no idea.
BAKER: Now, Necrotising Enterocolitis, we spoke to the doctors involved in the care provided to [Child E] and the doctor apologised for advising the Family of [Child E] not to have a postmortem and accepted that the evidence for Necrotising Enterocolitis was -- was poor. It was certainly evidence in the criminal trial, I think even the expert instructed by Ms Letby felt that Necrotising Enterocolitis didn't fit particularly well with the pattern of problems that led up to the collapse; would you agree with that?
HAWDON: I -- I would agree.
BAKER: So if it wasn't Necrotising Enterocolitis, would you not agree that based upon the notes of [Child E]'s condition leading up until the 3 August 2015, there isn't particularly strong evidence to explain why there's been a gastric bleed?
HAWDON: Gastric bleeds are rare in Necrotising Enterocolitis, as you say Necrotising Enterocolitis is a lower gut problem, but isolated gastric bleeds in stressed babies unfortunately are not uncommon.
BAKER: Yes. But the evidence that she was -- sorry, that he was stressed in the time leading up to that is again not very well made out. It was suggested I think in evidence that everybody felt that he was stable and well leading up to his collapse?
HAWDON: Yes, which is evidence that I -- I didn't have at the time. A baby who becomes hypoglycaemic is a baby that is stressed.
BAKER: But again I think had you had opportunity to speak to the doctors involved, which you didn't of course, that everybody perceived him as being stable and well up until the collapse?
HAWDON: If that is what they would have said, yes.
BAKER: Now, if you had had the opportunity to speak to [Child E]'s mother, she would have described how at about -- and if we go on to page 24, just to help orientate you here, you can see the timings which are taken from the notes. She would say that at around 9 pm she went down to see [Child E] on the ward and heard screaming which she described as an agonising scream, not like anything she had heard before. And she found Letby close by [Child E] and not doing anything and that [Child E] was bleeding from his mouth and had a significant amount of blood around his mouth and that Letby dismissed her and said there's nothing to worry about and she would call the Registrar to attend. And Mother E went back to her room on the maternity unit and telephoned her husband, [Child E]'s father, and told him what had happened and he reassured her, "Well
the doctors and nurses know what they are doing". Now, records were clear, telephone records that that happened at about 9 pm and the notes clearly record at 2210 that the gastric bleed had occurred and the doctor had been called so that would have -- that disconnect between the clear evidence from mother supported by telephone records and what was written in the notes would suggest that somebody has not been honest in what they are writing down in the notes wouldn't it?
HAWDON: That -- that is correct.
BAKER: If there was evidence that somebody had created misleading notes as to the timing of events and when doctors were called, that would have obviously raised alarm bells?
HAWDON: That is correct.
BAKER: That's the information I think Counsel to the Inquiry was alluding to when she was asking you about the opportunity to speak to Family members?
HAWDON: Certainly.
BAKER: Now, gastric bleed, idiopathic gastric bleed, or difficult to explain gastric bleed in a neonate in these circumstances would be very, very rare indeed, wouldn't it? It's plausible but rare.
HAWDON: The -- the how rare I think is difficult to
say. But it's certainly not unheard of and is something that I have experienced.
BAKER: If you had spoken to [Child E]'s mother you were aware that [Child E] had a Twin because it is referred to in the notes?
HAWDON: That's correct.
BAKER: If you, if you had had the opportunity, would you have been interested in finding out that [Child F] had also had a collapse, an unexpected sudden collapse?
HAWDON: Is [Child F] the Twin?
BAKER: He was the Twin.
HAWDON: Correct, that would have been concerning.
BAKER: Yes. And would you, if you were aware of that, had sought out [Child F]'s medical records to find out why?
HAWDON: I would have done, yes, or -- or suggested that the Trust did so.
BAKER: Of course.
HAWDON: Yes.
BAKER: I mean, you wouldn't have been able to access them yourself without the Trust providing them to you?
HAWDON: But what I mean is or suggested that the Trust look more carefully into that as well.
BAKER: Yes. Now if you had discovered that [Child F] had had an unexpected collapse due to hypoglycaemia and
that was refractive to treatment and transferred to Arrowe Park Hospital, and that [Child F] had had a blood test result which had shown a very high level of insulin with an unrecordably low C-peptide level, would that have made you concerned about exogenous insulin going given it that baby?
HAWDON: Extremely, without a doubt.
BAKER: Yes. Going back then, please, to INQ0003172, and if we can go, please, to page 5. Now, this is [Child O], one of the Triplets, two of whom died. The order in which the babies appear within a report isn't chronological. What -- what condition were the notes in that were provided to you about these babies?
HAWDON: They -- they were -- most of the notes for each baby were together but some were not and they were presented as a sort of stack of -- of sets of notes in -- in no particular order and I chose to work through all them in the order that they were presented.
BAKER: Yes, so you weren't provided with individual bundles of records; it was a pile of paper?
HAWDON: No, some were in bundles.
BAKER: Yes.
HAWDON: Some -- some were loose.
BAKER: I think one of your emails talks about somebody else's random records being included within the stack as well?
HAWDON: There was something about instructions about photocopying or something very strange.
BAKER: Yes. Now looking at [Child O], I mean, [Child O] is a healthy 33-week baby, normal weight, reasonable Apgar scores at birth who suffers on everybody's account a completely unexpected collapse on 23 June 2016 which is not capable of resolution with resuscitation which people regard as very strange as well?
HAWDON: (Nods)
BAKER: "Unexpected unexplained collapse, no response to resuscitation." Now, you list within -- if we go on to page 6: "[Query] failed resuscitation." You see under the list of potential errors at 1715: "Relevance: almost certainly relevant but quality of care?" Now, is that because it was so surprising that given [Child O]'s condition and unexpected collapse that resuscitation didn't work you were concerned that it may not have been done properly?
HAWDON: That's correct. On the evidence from the records available it wasn't possible to tell whether there was a failure of care in -- in resuscitating or
whether it was an understandable failure to resuscitate.
BAKER: So to deal with that in two parts, first of all, you would ordinarily expect a child in [Child O]'s condition to be resuscitated following this type of collapse?
HAWDON: I -- I would expect there to be attempts at resuscitation and I would expect the resuscitation attempts to be conducted properly.
BAKER: Yes. Well, to put it this way there is no direct evidence in the notes that it wasn't conducted properly because you have put question mark next to "failed resuscitation"?
HAWDON: There wasn't enough information in the notes to determine that.
BAKER: Yes. So taking two things together, one is the resuscitation doesn't achieve the outcome you would have expected it to, so a question mark was it done properly, I can't answer that question because I don't have enough information?
HAWDON: That's correct.
BAKER: Would that not be a key point to go back to the Countess of Chester on and say: well, look, can you get a better account from the doctors involved as to what exactly they did?
HAWDON: That is what I would have expected the
Countess of Chester to do.
BAKER: So this, when you put question mark next to failed resuscitation, that is the prompt to the Countess of Chester to get more information?
HAWDON: That is -- that is correct.
BAKER: Of course if you had spoken to the treating doctors, they would have said: well, forget the resuscitation, the real issue here is that we think this nurse has been harming babies or might have been?
HAWDON: (Nods)
BAKER: I mean, that would have been important information to know, isn't it?
HAWDON: That's correct. At that stage this would have been beyond my remit to deal with any further.
BAKER: Yes, because this is absolutely not the right exercise to identify homicide?
HAWDON: That's correct.
BAKER: If we go to again on to page 44, I won't take you through [Child P] because your findings are broadly the same. Page 44 is the final conclusion page. We can see that: "O and P are included within the death collapses unexplained which is the investigation of these cases which would potentially benefit from a local forensic
review as to the circumstances, personnel et cetera." So first of all what do you mean by "forensic review" and -- well, I will ask that question in isolation. First of all, what do you mean by forensic review?
HAWDON: Sufficient level of detail to take all potential factors into account.
BAKER: I mean, forensic is -- I would understand the word to mean pertaining to the court process?
HAWDON: I -- I take it in my own mind to be detailed and covering as much information as is available.
BAKER: Okay, so you wouldn't understand "forensic" to mean as in forensic pathology?
HAWDON: No, I am not using it as a legal term.
BAKER: Okay. What about personnel? What's the relevance of looking at not only the circumstances but the personnel involved?
HAWDON: It's relevant as to how that baby has been cared for, whether it be negligent acts, purposeful acts, any -- any of those things.
BAKER: So the reference to personnel could allude to the possibility that there is a person who is deliberately harming?
HAWDON: That would be one possibility.
BAKER: Okay. O [Child O] and P [Child P] are in that category presumably because the collapses are so unexplained?
HAWDON: That's correct.
BAKER: Of course there's been reference to [Child E] which we can see in the top bracket. If you had had more information about [Child E], then [Child E] would also have gone into that bracket as well?
HAWDON: Based on the information you are giving me now, yes.
BAKER: Now we see [Child D] under bracket 2. We know that in a later report, [Child D] was moved, not by you, but by Mr Harvey, into the number 1 bracket, the death or collapses explained but may have been prevented with different care. If we go back to page 22 of this document. This is a section that deals with [Child D]. I think your evidence was that you didn't direct Mr Harvey to move [Child E] into a different bracket?
HAWDON: That is correct.
BAKER: But you were later provided with details as to the postmortem that was carried out?
HAWDON: That's correct.
BAKER: If you had known or been told that the pathologist was not -- if the pathologist were to say that it was difficult to be confident that [Child D] died "from" congenital pneumonia rather than that she died
"with" congenital pneumonia, would that degree of circumspection about where [Child D] falls have gone back to how it was before?
HAWDON: Absolutely.
BAKER: Yes. Because it isn't obvious, is it, from the notes -- otherwise you wouldn't have put [Child D] in that box in the first place -- that she had sepsis before she died?
HAWDON: That's correct.
BAKER: Because the usual prodromal symptoms of sepsis, the usual course of sepsis leading to death, isn't borne out by what's written down?
HAWDON: That's correct.
BAKER: What doesn't really happen in cases of congenital pneumonia leading to sepsis leading to death is that there is an appearance of normal blood gas values, a degree of support with breathing and then a sudden collapse in the presence of normal CRP and other signs?
HAWDON: That is correct, that doesn't normally happen.
BAKER: It evolves in a fairly typical way with a progression, deterioration, organ failure and death?
HAWDON: That's correct.
BAKER: So in terms of where on reflection the children that I have been mentioning should fall, so far
E [Child E], D [Child D], O [Child O] and P [Child P] should all really on reflection be in the box marked "We don't know, it needs more investigation"?
HAWDON: Yes, based on the information you have given me, yes.
BAKER: Now, if we look at [Child C] finally and this is the same document again at page 24. So premature but not of the extremes of prematurity. A baby who was small due to intra-uterine growth restriction. Now, one of the things we can see at the bottom of that page is that you do actually have the postmortem report and there's a reference to an ischemic injury to the heart in the postmortem report and immaturity of the lungs. Now, are you accepting here that immaturity of the lungs is the cause of the collapse?
HAWDON: I believe that this is one where I -- I suggested that they reviewed it because we would not expect immaturity of the lungs at 30 weeks gestation to be a cause of death.
BAKER: No. In fact, can I assist you with what Dr Gibbs said. He was the treating -- treating doctor. He said that in terms of [Child C], he did not think -- sorry he said in his evidence that [Child C]'s oxygen requirements had reduced substantially in the days leading up to his death. He thought he was improving
from a respiratory point of view. He did not think that [Child C] would experience any significant problems at the stage, by 13 June, due to his breathing and he thought the respiratory rate was not abnormal for him. He said, and I quote: "Dr Hawdon points out he had a slightly fast respiratory rate but that wouldn't bother me knowing he was a 30-weeker prone to respiratory distress syndrome. We knew he needed support for his breathing and that was gradually reducing so that would explain the slightly raised respiratory rate." Obviously they are the observations of somebody who was there. Would you accept that analysis?
HAWDON: Yes, the -- the clinician that's there at the time is much better placed than somebody looking at case notes.
BAKER: Yes, I mean I understand that, obviously. One of the features of the -- obviously the criminal trial is that evidence was obtained from various experts in -- in that case and it was pointed out again that [Child C]'s oxygen requirement on the day of his collapse was 26%, compared to 38 to 40% on the previous day, was said by Dr Evans and Dr Bohin in the trial. What we can see from the notes that you have recorded is that there is a fast respiratory rate but normal blood gas values.
HAWDON: That's correct.
BAKER: The observation charts that are recorded I think again show that the respiratory rate on 13 June for most of the day was within the normal range, the higher end of it, but within the normal range so had again improved. I mean, would you agree that looking at the notes overall we see a pattern of improvement in terms of respiratory function as Dr Gibbs observed in the time immediately leading up to this collapse?
HAWDON: Yes, based upon what you are saying, yes.
BAKER: You would not expect, if respiratory problems, immaturity of the lungs were the cause of the collapse, for that to be happening you would expect them to be getting worse leading up to the collapse?
HAWDON: That's correct.
BAKER: So again -- and I appreciate you had very limited information by the nature of your instructions, but would you agree then based upon what I have said that also [Child C] really should be in the -- if we go back to page 44 -- death collapses unexplained?
HAWDON: I think that is perfectly reasonable.
MR BAKER: Yes, thank you. Thank you, my Lady, I have no more questions.
LADY JUSTICE THIRLWALL: Thank you very much, Mr Baker. Mr Skelton.
MR SKELTON: Dr Hawdon, I ask questions on behalf of the other Family group. I am going to focus just really on the beginning of your involvement again, if I may, and just to ask you a little about the instructions and your reflections on the information you were given. Ms Langdale took you through the ultimate instructions letter and it's fair to say, isn't it, that nowhere in that letter is it mentioned that the consultants who treated the babies that you were looking at suspected they had been murdered?
HAWDON: That is correct.
SKELTON: Or even that there was particular concerns about the quality of the care by a particular member of staff in respect of all of the children?
HAWDON: That is correct.
SKELTON: In fact, a month before -- so you were instructed formally finally on 5 October -- a month before Mr Harvey and Ms Kelly had met the Royal College reviewers on Day 1 of their review, 1 September, and during that very first meeting they had explained those
precise facts: there was a particular member of staff that they suspected was harming the children and she was a nurse.
HAWDON: (Nods)
SKELTON: Do you feel, in retrospect, that you've been/were misled by Mr Harvey when either during the emails, during your conversations or in fact during your formal instructions?
HAWDON: I now feel misled. I can't say who misled me, but I feel misled and, as I have said before, if those details had been made available to me the process I would have followed would have been very different.
SKELTON: Well, you wouldn't necessarily have conducted a Casenote Review at all, would you?
HAWDON: That's correct.
SKELTON: And likewise, in respect of the Consultants, if you had known that on their interview with the Royal College they had gone so far as to discuss the mechanism of murder with the reviewers that is clearly something that's completely outwith a standard Casenote Review of the type you were offering to do?
HAWDON: Absolutely.
SKELTON: And in your view, and I think this was accepted by Ms Eardley, would you agree that the only appropriate response if a set of Consultants suspects
murder is to call the police?
HAWDON: To either call the police or go through safeguarding processes, which would amount to the same thing in the end.
SKELTON: Because safeguarding, by definition, engaged the police?
HAWDON: Engaged the police, absolutely.
SKELTON: In the way that you've described. Looking at your letter of instructions now, do you see in retrospect that there were a few clues dropped in? The word "forensic" Mr Harvey may have been using in fact in the way which we lawyers understand it, which is to investigate crime, so forensic pathology, forensic medical examination; all of that is to exclude criminality. And, likewise, the reference to looking at staffing or particular members of staff who may have been on for the four hours before the collapses was looking to see if there was some conduct that was untoward. Do you see that now in retrospect?
HAWDON: Absolutely in retrospect, yes.
SKELTON: But that wasn't apparent to you at the time?
HAWDON: It wasn't and I'm sorry that it wasn't.
SKELTON: Can I look again at your brief recommendations in your report and it would be worth having it on the screen, please, at INQ0003172, page 45, and it's really the last paragraph: "Subject to Coroner's postmortems there should be broader forensic review of the cases described in category 2 above as after independent clinical review these deaths remain unexpected and unexplained." Would you have expected those deaths to have been the subject of coronial investigation?
HAWDON: I would have done, yes.
SKELTON: Each of them?
HAWDON: Yes.
SKELTON: And the reason was that they fell into the standard category for the Coroner being involved and that you hadn't found natural causes?
HAWDON: That is correct.
SKELTON: This paragraph doesn't say explicitly how the babies might have died. There's no explanation offered for their deaths at all.
HAWDON: No.
SKELTON: Why is that?
HAWDON: Because I had no evidence to lead me to think of any cause of death, which is why I said: unexpected and unexplained. It was for the Trust to be looking into why they might have happened.
SKELTON: Are you in fact saying here that something other than medical cause is in play and that could
include a systemic issue, there may have been a gas leak somehow that could have caused the deaths or it could include foul play; murder?
HAWDON: That is correct. There were many poss -- there are a number of possibilities which I was not placed to comment on.
SKELTON: You weren't in a place to determine which of those was correct?
HAWDON: No.
SKELTON: But those were possibilities?
HAWDON: That's -- that's correct and it was for the Trust to look into.
SKELTON: Do you see that it would have been possible for you to have been more explicit in that paragraph, or did you think that in speaking in relatively low-key implicit terms that Ian Harvey would have understood that he needed to rule out foul play?
HAWDON: In, in my view as -- as a clinician for a clinician to be told that a number of deaths are unexpected and unexplained is a message in itself.
SKELTON: It means there may be a crime?
HAWDON: It means there is something very worrying that needs to be looked into in more detail.
SKELTON: Including the possibility of a crime?
HAWDON: Yes.
SKELTON: And in your mind, you couldn't rule that out?
HAWDON: That -- that's correct on the basis of the information.
SKELTON: If it was the possibility, if there were a possibility that the babies had been murdered, wasn't this situation more urgent than your report and your correspondence made clear in that months had passed since these babies had died, it may have been a member of staff who was perpetrating the crime and you had no information before you to exclude the possibility that that member of staff could strike again. Did that occur to you?
HAWDON: It -- that -- that didn't occur to me because the -- the decision-making lay with the Trust and in my view saying that five deaths were unexpected and unexplained was a sufficient trigger for the Trust to take that seriously if they hadn't already.
SKELTON: But -- sorry to press you on this, but don't you think that if you suspect a crime having undertook a Casenote Review and you can't exclude that possibility medically that you needed to say, "Urgent action is required in this situation because it could happen again"?
HAWDON: I -- I didn't suspect a crime. Knowing what I know now, I might have suspected a crime.
I will -- I will maintain that a Medical Director to receive a report that says five deaths are unexpected and unexplained is a sufficient trigger to take the issue seriously.
SKELTON: So as far as you're concerned, are you satisfied that you said enough to ensure that patients were safe on that unit?
HAWDON: At the time, I was. Clearly we all think back to how we might have done things differently. Knowing what I know now, I could have said, "It is a crime", but that's based on what I know now.
SKELTON: There came a point where you were told of suspicions, and that was some months after you had completed your initial review, and if we could have on screen the email exchange in which it was raised with you in INQ0014376. Thank you. May I just have the bottom bit first, please. So starting with Ian Harvey's email, just so you can see it, if you can read it on the screen. I'm afraid I struggle a bit. (Pause) So here Ian Harvey I think is starting to -- can we go back up again just to the date there? It may be I think I have given you a wrong reference. But let me try and explain what Ian Harvey was telling you. He explains to you in -- when he provided the paediatric Consultants' letter that in fact the paediatric Consultants suspected a member of staff was killing the children. Do you remember that?
HAWDON: I do, yes.
SKELTON: And I just want to see your response to it. For some reason I seem to have a slightly different version than the one that's on screen. It may be that in fact we need to go further down, sorry. Start on page 3. Page 2 going into page 3. Sorry, just page 2 going into page 3 if that's possible. Thank you, that's perfect. So, sorry. He was providing you the letter, which you have talked to Ms Langdale about, but he's also explaining that there is one particular member of staff about which they are suspicious and the suspicions are obviously very serious it's clear from his correspondence.
HAWDON: (Nods)
SKELTON: Your response, if we go back up, further up page 2, doesn't demonstrate a deal of shock or surprise about that allegation. Did you already know about it or have I misread your response?
HAWDON: I didn't and I -- I based on the information that he gave me that he was then following the due process in response to those concerns.
SKELTON: But it was -- the concerns couldn't be more serious, could they; that the Consultants in a unit collectively were concerned that babies had been murdered?
HAWDON: Correct.
SKELTON: What doesn't come across from your response is the recognition of how immensely serious that is. Did you recognise the gravity of what you were being told for the first time?
HAWDON: I did, and that's why I asked if he wanted to talk on the phone and why I asked, "How will you proceed?"
SKELTON: So at this point you are told about suspicions about a crime. You don't, at this stage, mention urgency of intervention or patient safety or safeguarding or the Coroner or the police. Do you recognise that given the information you were given, given that you must have known that months and months were drifting by -- this is months after your review, let alone the Royal College and the internal Consultants' concerns -- that nothing was actually happening?
HAWDON: My assumption -- and I now know that's a wrong assumption -- was that all those things were happening locally.
SKELTON: What basis --
LADY JUSTICE THIRLWALL: Sorry, we have got some noises off -- I don't know where it's coming from.
MR SKELTON: What basis did you have for thinking that action was being taken in an appropriate and timely way?
HAWDON: Because I know what organisational responses should be to such concerns and made an assumption that that organisation was doing the same.
SKELTON: But you must have realised from your own involvement that nothing in fact happened to protect patient safety and you don't even raise it as an issue. Do you recognise that that should have been something you needed to mention?
HAWDON: I -- I didn't know what was being done and what wasn't being done. So I wasn't in a position to comment.
SKELTON: But nor did you show any curiosity about those matters, did you?
HAWDON: I did, but the remit for dealing with a worrying situation is with the organisation itself.
SKELTON: So can I put it in the bluntest of terms: told that the Consultants thought that a member of staff had murdered the children who you had reviewed, you needed to say, "Ian, have you taken immediate action to tell
the police or the Coroner or to protect patient safety?" Those things needed saying in circumstances where you had no reason to think any of them had been done?
HAWDON: My reason for thinking that they were being done was because it was the right thing to do. Knowing what I know now, that's what I would have said.
SKELTON: Did you at any point say that because you remained in correspondence with Mr Harvey for another two months at least and although you did mention CDOP at one point you didn't mention contacting the police directly, you didn't mention contacting the Coroner direct and you didn't express any concern that months were still going by -- bearing in mind this was six months that you were involved in -- in which patients could be at risk?
HAWDON: That was why I asked, "How will you proceed?" And when I didn't get a response, I assumed that they were following their own what would be confidential processes.
SKELTON: Leaving aside the point about your assumptions about the right thing to do, do you think that you were reluctant to confront the reality of what was being raised?
HAWDON: No, absolutely not. I -- I think it was entirely my naivety in assuming that other people were doing what I would have expected them to do.
SKELTON: So to be clear, you thought: he understands that children in his hospital may have been murdered, any reasonable Executive in those circumstances would be taking appropriate steps to deal with that urgently and appropriately with the appropriate authorities?
HAWDON: That -- that would be my understanding.
MR SKELTON: Thank you.
LADY JUSTICE THIRLWALL: Thank you, Mr Skelton. I have no questions for Dr Hawdon. Do you have any more questions?
MS LANGDALE: My Lady, that concludes Dr Hawdon's evidence.
LADY JUSTICE THIRLWALL: Thank you very much indeed, Dr Hawdon. You are free to go.
MS LANGDALE: May we resume at 2 pm?
LADY JUSTICE THIRLWALL: Certainly. Will that be with Dr McPartland?
MS LANGDALE: Yes. Thank you.
LADY JUSTICE THIRLWALL: So we will rise now and start again at 2 o'clock.
(12.20 pm) (The luncheon adjournment)
(2.00 pm)
LADY JUSTICE THIRLWALL: Ms Langdale.
MS LANGDALE: May I call Dr McPartland.
DR JO McPARTLAND (affirmed)
LADY JUSTICE THIRLWALL: Do sit down, Dr McPartland.
MS LANGDALE: Dr McPartland, you have provided the Inquiry with a statement dated 13 June 2024. Can you confirm if the statement is true and accurate as far as you are concerned?
McPARTLAND: Yes.
LANGDALE: As far as your qualifications are concerned, you tell us you are a Consultant paediatric pathologist at Alder Hey Children's Hospital, and your career briefly you were appointed as senior house officer in histopathology at the University Hospitals Leicester in August 2000 and subsequently a specialist Registrar in histopathology from November 2001 to February 2005. From March 2005 to June 2007, specialist Registrar in paediatric pathologist at Alder Hey. You passed the Part 2 membership examination in paediatric and perinatal pathology in November 2006 and awarded Membership of the Royal College of Pathologists and subsequently Fellowship of the Royal College of Pathologists.
You have been, as I say, appointed as Consultant paediatric pathologist at Alder Hey since July 2007 and you've worked there ever since?
McPARTLAND: Yes, that's correct.
LANGDALE: You were head of the department of histopathology for a three-year term from April 2012 to 2015?
McPARTLAND: Yes.
LANGDALE: For our purposes, what's the distinction between histopathology and pathology?
McPARTLAND: Pathology encompasses all of the different laboratory medicine disciplines, so as well as histopathology, which is the pathology of tissues, it will also include microbiology and virology, haematology and biochemistry and a number of other laboratory medicine disciplines.
LANGDALE: You tell us at paragraph 5: "[Your] NHS role at Alder Hey includes provision of paediatric surgical pathology service to the hospital and a perinatal pathology service to a number of referring obstetric units." And: "In addition to [your] NHS duties [you] perform coronial, paediatric postmortem examinations for a number of Coroners, including paediatric forensic
postmortem examinations undertaken jointly with a forensic pathologist." My question: why is it necessary to conduct paediatric postmortem examinations in combination with a forensic pathologist?
McPARTLAND: Well, if there is a suspicion that criminal activity may have led to the death or in some types of traumatic death where we might need the assistance of someone with forensic expertise then we perform the postmortem jointly and the role of the forensic pathologist is to consider matters of forensic importance and particularly those relating to injuries, and the role of the paediatric pathologist is to consider natural causes of death and look at growth and development and other medical conditions.
LANGDALE: So when you say the forensic pathologist looking for injuries, do you mean potentially deliberate infliction of injuries?
McPARTLAND: Yes.
LANGDALE: Because there is a suspicion --
McPARTLAND: Yes.
LANGDALE: -- that they may have been caused? Does that really from the off dictate who and how the pathology investigation should be being undertaken; if there is a suspicion, they go down a different route?
McPARTLAND: Yes. If, when a death is reported to the Coroner, it's clear that there -- it is a suspicious death from the outset, then the police will be involved and a forensic pathologist will be instructed as well as a paediatric pathologist.
LANGDALE: You tell us you provided four witness statements in relation to the Letby case. You did a statement relating to the postmortem of Baby D [Child D] and two addendums and also a witness statement relating to the examination of the placenta of the Mother of E and F; that's right?
McPARTLAND: Yes.
LANGDALE: You attach to your statement for the Inquiry guidance surrounding investigations of sudden and unexpected baby deaths in hospital. If we could, I would like to take you to some of the guidance that you have helpfully put together for us in thinking about this topic. The first reference, please, is INQ0101997, page 1. Dr McPartland, what will come up here is the Pan-Cheshire SUDiC documentation that you provided so this is Pan-Cheshire Sudden Unexpected Deaths in Infants Guidance April 2023. We will look at 2015 as well shortly. I would like your help if I could, please, with
page 68 of the document, the INQ reference. This -- clearly this flowchart applies to Sudden Unexpected Death in Childhood or Infancy because it refers to that at the top and it says: "Child found collapsed at hospital or anywhere other than hospital." And we see a flowchart on the right-hand side. So do you understand that where the child is found collapsed in hospital and presumably that could be with or without members of staff there, right, a child found collapsed? Or is that supposed to imply no one is in a room? What did you get from that?
McPARTLAND: Well this -- I mean, as this 2023 guideline indicates this is not usually used for neonates, which I know is what we are concerned with today. So with a SUDiC process most of the ones that I would be involved with, a child would die in the community or they are found collapsed in the community, resuscitated and brought into hospital. So a lot of them die in the emergency department. So in terms of what happens before it comes to me in -- at the mortuary I don't have much involvement with that, but this flowchart does indicate, you know, at hospital or anywhere other than hospital.
LANGDALE: So you would expect the child to be taken in
and that is why -- or collapsed -- brought in in a calculated state, potentially found collapsed and taken to hospital and then this applies "declared dead and Coroner informed" and the flowchart continues?
McPARTLAND: Yes. A lot of Sudden Unexpected Deaths in Infancy or Childhood, sometimes a child will be found deceased in the community and they are obviously deceased and no attempt at resuscitation is made. Often they are found in a collapsed state and resuscitation is attempted, paramedics will attend. Then they will take the child to hospital and it may be that the child can't be resuscitated, then they are declared deceased often in the emergency department.
LANGDALE: Understood. If we go back to page 63 of this guidance, INQ reference 63, we see at paragraph 1.11.5: "When a newborn infant suddenly collapses and dies in a neonatal unit, consideration must be given as to whether a Joint Agency Response is required. In most situations this may not be necessary." Is that because naturally sudden death of neonates, if it is a natural cause that can be recognised without the need for the SUDiC referral or what do you understand by that?
McPARTLAND: Well, the SUDiC protocol is usually used when
we are investigating if there may be something suspicious in the background. When a child -- a newborn infant dies on the neonatal unit, often they have never left the hospital and so in those circumstances, it's more often that there will be a medical cause of death and that there won't be a requirement for police involvement. So in my experience, the police wouldn't be involved unless there was a particular suspicion that a criminal act had occurred. So, for example, if a mother had been the subject of a criminal assault during pregnancy and then this had resulted in the baby being born in poor condition, that might be an example where the police could be involved. Or if there was birth trauma which might be criminally negligent, that might result in police involvement and the involvement of a forensic pathologist. But apart from rare instances like that, most newborn babies on a neonatal unit would -- would not be subject to this type of Joint Agency Response.
LANGDALE: Dr Garstang gave evidence at the beginning of the Inquiry about safeguarding protocols generally and she said this: "In practice, if an infant or child dies unexpectedly and with no explanation while an inpatient in hospital, the SUDiC process would now normally be initiated and there would be discussions between senior paediatricians and the police as to how best to investigate the death. These are, however, rare events." She went on to say that in Birmingham Solihull, when they are notified by a neonatologist of sudden and unexpected deaths, they may have an immediate discussion with the police to decide whether it's appropriate to have a Joint Agency Response, presumably to discuss what you are raising, whether there is any suspicion or surrounding circumstances that need looking at. Would that happen here or do you think the medics would make a decision about is there anything they are worried about, about family history or generally?
McPARTLAND: Yes, I think it would depend on -- on the hospital and how they conduct their SUDiC process. But from deaths I have been involved with, with deaths on the neonatal unit, I have never been aware of a senior investigating officer contacting me or being involved with me in most of those cases. But it might be that those conversations are had in the background but just that then I don't see any police paperwork received in my documentation from the Coroner.
LANGDALE: Particularly if it doesn't go forward and it's
a conversation to do a negative check, effectively, it wouldn't necessarily reach you, would it?
McPARTLAND: Yes, it might not.
LANGDALE: Next document, please, if that one can be taken down. INQ0013225, page 1. This is Pan-Cheshire guidelines for the management of Sudden Unexpected Death back in 2015. If we can go, please, to page 3. It may seem obvious to you, Dr McPartland, but if we can highlight 1.5, 1.6 and 1.7. Why is what is stated at 1.5 essential surrounding meticulous records and 1.6, the need for a thorough investigation of the highest standard?
McPARTLAND: Well, because a lot of these might involve safeguarding issues and potentially might result in a criminal process after the postmortem, then meticulous records need to be kept in the event that there might be an ongoing criminal investigation.
LANGDALE: The same flowchart appears at page 9 or similar. If we look on the right-hand side, in the first nought to four hours, Sudden Unexpected Death refers in the third box, detailed paediatric history, examination and investigations, complete Pan-Cheshire SUDiC documentation. If suspicious, joint interview of carers with police and/or children's social care. The suspicion raised in the context of this
flowchart is always about family members, isn't it, and concerns about parents?
McPARTLAND: Yes, that's why they are talking about the parents because when a child has died in the community, the parents are caring for them and so the protocol is very much aimed at detecting child abuse that hasn't been disclosed.
LANGDALE: The principle of child abuse is it's often not disclosed, whoever has committed it. So the principles here apply equally if it is a member of staff under suspicion, doesn't it, about the need for rigorous investigation and detailed note-keeping et cetera?
McPARTLAND: Yes, the principles would apply if there was a suspicion a member of staff had harmed a child.
LANGDALE: In your experience, is there much discussion within safeguarding training or generally about what to do if it is a member of staff? You are all trained obviously what to do if you are worried about a member of the community and understand a neutral act is to keep a parent or family member away from a child while you are working out what's happened and to try and keep the baby safe. Are there similar discussions ever around staff or staff members potentially harming babies?
McPARTLAND: No, I think from my recollection of all the
safeguarding training I have attended, it is very much aimed at the parents without a focus on possibility of staff harming children.
LANGDALE: There is a need presumably to trust the staff that you work with and do you think that's part of that, that those conversations are not had in safeguarding training, that it might be someone in the room that you have got to think about it?
McPARTLAND: Yes, and I suppose also that it's a rarity, but as this case shows, it's something that should have been addressed more in the past.
LANGDALE: That can come down, please, and if we can have INQ0016982, page 1. It's the Royal College of Pathologists guidance which you helpfully provided to us and the report of a working group convened by the Royal College and chaired by Baroness Kennedy. If we go to page 43, please, INQ reference 43. We can highlight, please, at the top paragraph, 7.1: "The Postmortem Examination. "The investigation should be carried out by specially trained pathologists with an emphasis on multiagency working involving close collaboration and the sharing of information between hospital and community-based clinical staff, the pathologist, the police, social services and the Coroner's service." If we move down on to the next page, 44, at 7.3: "Prior to commencing the examination, the pathologist should be fully briefed on the history and physical findings at presentation and on the findings of the death scene investigation by the lead health professional or police investigator and the postmortem examination procedure must include a full radiological skeletal survey or other appropriate imaging, reported by a radiologist with paediatric training and experience." 7.3 firstly, how important is it in forensic examinations, forensic postmortem examinations that you have a full brief of the history, physical findings, what the clinicians observed, saw, felt about what was happening?
McPARTLAND: It's very important in a -- in a forensic postmortem that the physical findings are important because they might reveal evidence of injuries before the postmortem or positioning of the body and the history is very important to determine if the child was unwell beforehand. But the social history is often very crucial in these community SUDiC cases in terms of the family environment, the home environment. That's why photographs are important of -- of the infant but also of the scene.
LANGDALE: The skeletal survey, the radiology, what is the significance of that in cases of deliberate injury?
McPARTLAND: The main thing we are looking for with radiology is fractures as part of a pattern of child abuse and those can be difficult to detect at autopsy and sometimes are very subtle and only visible on the X-ray, but they are so subtle that you would need a specially trained paediatric radiologist to detect them.
LANGDALE: There are expertly trained paediatric radiologists, aren't there, who look at child X-rays for these purposes?
McPARTLAND: Yes, because many full skeletal surveys would be performed on living children as part of safeguarding examinations, not just on deceased children.
LANGDALE: The postmortem examination procedure, if we can go to page 97, please, actually we should start on 96 with the clinical information relevant. 96, please. Thank you. So: "Prior to starting the postmortem examination the pathologist should have available a comprehensive history and report on the circumstances of the death ideally to include ..." If we see the bullet points, details of pregnancy, delivery, postnatal history antemortem history and
precise circumstances of death. Over the page at 97 reference to resuscitation procedures. What's the significance of that?
McPARTLAND: Because there might be marks of medical intervention on the body that you need to distinguish from injuries, so for example if there's been endotracheal intubation as part of manipulating the mouth you might cause some potential injury to the lips or the gums and there might be intravenous lines or lines inserted into the bones of the child.
LANGDALE: The procedure below suggests the minimum recommended level of investigation in the majority of cases but says each case should be assessed on an individual basis regarding the extent of additional investigations. We see there the bullet point: "Postmortem examinations should be performed by a specialist paediatric pathologist with training in this area." Then the second one: "If there is any suspicion of abuse contributing to the death, a joint postmortem examination with a forensic pathologist should be carried out." You highlighted that earlier but it's very clear, isn't it, within the guidance we have gone to that
that's what's required if you know there is suspicion or concern?
McPARTLAND: Yes.
LANGDALE: Thank you. That can go down. If we return to your statement, Dr McPartland, the process of neonatal postmortem examination. You indeed set out much -- as is reflected in that guidance -- that you would expect to conduct an effective postmortem examination, firstly details of the obstetric history of the mother in addition to a full medical history of events in a baby's life --
McPARTLAND: Yes.
LANGDALE: -- including any particular clinical concerns and the clinician's opinions about the events leading to death?
McPARTLAND: Yes.
LANGDALE: "In neonatal events or in neonatal deaths, events occurring in pregnancy and labour often of paramount importance including any placental abnormality, which is assessed by placental pathological examination"?
McPARTLAND: Yes.
LANGDALE: It's very important, you say, for the placenta to accompany the baby for examination?
McPARTLAND: Yes.
LANGDALE: You also set out the importance of the radiology investigations. Can I just -- so those in the room can follow the questions, no other reason -- have paragraph 25 of your statement on the screen please. It's INQ0102015, page 8, para 25. I don't know if there is a word lost in the last sentence here but I will show it to you, Dr McPartland. So it's paragraph 25. You explain: "Postmortem examination involves radiology investigations, typically a whole body X-ray and CT and MRI scan where indicated. Radiology investigations are carried out before I begin the postmortem examination and X-ray images should be available to view on the computer in the mortuary but often the reports are not available. In a forensic case with police involvement I request a report before commencing the postmortem examination which may be an interim verbal report in a case not indicated to be suspicious, such as an in-hospital neonatal death, my practice was to proceed with the postmortem examination after viewing the X-ray images." Do you mean you don't have to see them after seeing the X-ray images or?
McPARTLAND: No, I mean I would view the X-ray image before doing the postmortem examination.
LANGDALE: In every case?
McPARTLAND: Yes. Typically in a Coronial case I go into the mortuary, I ask my mortuary technician if the X-ray has been reported, but often because of difficulty with availability of the radiologist to complete the postmortem reports, often it's not available at that stage. So then we view them on the computer screen in the mortuary, have a look and then carry on with the postmortem. If it is a forensic case, because the forensic pathologist is there and the police are there with the photographers, crime scene investigators, ideally we want to know before we start a forensic case if there's any abnormality as it might affect the way that the postmortem is carried out. But sometimes it's still very difficult to get a full written report, so sometimes we are on the phone just at the beginning of the postmortem trying to chase down a radiologist to give us a verbal interim report.
LANGDALE: Do you ever chase down clinicians for a verbal interim report or do you rely on notes or summaries that are provided?
McPARTLAND: Well, typically with the postmortem we would receive written information from the Coroner so, as in
this case, I received the medical notes and a detailed letter from the Consultant. So I would always expect to have written information --
LANGDALE: Via the Coroner?
McPARTLAND: -- and generally via the Coroner's officer.
LANGDALE: Thank you, that can go down. You tell us at Alder Hey, paragraph 29: "The majority of the postmortem cases performed at Alder Hey are hospital consented postmortem examinations with a smaller proportion of Coroner's autopsies." In terms of the hospital consented ones, is it your understanding that a parent must consent for the baby's postmortem?
McPARTLAND: Yes.
LANGDALE: So if the parent didn't or in the moment was advised not to and thought "Well, I don't need to know the answer to this", "I think I know the answer to this", or whatever they are thinking in that emotion of the time, does that mean the postmortem won't go ahead in any circumstances or is that decision taken out of their hands if it's seen to be important for the safety of babies?
McPARTLAND: If it's not required by law, so if it is not a Coroner's postmortem, then the decision to have a postmortem is entirely left up to the parents and if
they don't consent, then it won't go ahead.
LANGDALE: But if it is a Coroner's postmortem, it will?
McPARTLAND: Yes, even if the family do not want the postmortem, if the Coroner requires it, it goes ahead regardless.
LANGDALE: You explain that there's -- you have two Consultant histopathologist colleagues, Dr Kokai and Dr Shukla, and whoever gets which case depends on the rota; you are not allocated cases, it is who's working that week and takes the cases?
McPARTLAND: That's right.
LANGDALE: One of the comments you make later on is that you were not aware, until your colleague Dr Shukla referred to the RCPCH review and the downgrading of the Countess of Chester, of an increased rate, if there was one, of mortality there. But you are all handling different cases presumably as they come in and nobody's handling them -- all of the same ones; is that the position?
McPARTLAND: Yes, usually we would do a week on the postmortem rota in turn covering for each other's leave, so it would be entirely random whether you received a case from a certain hospital or not.
LANGDALE: You do refer in your statement to -- and we know perinatal Morbidity and Mortality Meetings occurred at the Countess of Chester and so did neonatal mortality meeting occur. The distinction I am not entirely clear about at the moment, but it looks like you were invited, were you, pathologists in principle, to the perinatal ones, the perinatal Mortality and Morbidity Meetings?
McPARTLAND: Yes, we would be invited and we were given a list of cases to discuss that included pathology beforehand and we would travel to the Countess of Chester Hospital for the meeting.
LANGDALE: In fact, the emails around Baby D [Child D], the baby that you did the postmortem for, show that one of your colleagues attended for you, the date of that meeting didn't work, it's Dr Shukla I think who attended that meeting in September 2015. I can put that on the screen, the meeting itself, INQ0005445, page 1.
McPARTLAND: Yes, I did receive the documents sent to me last night and we weren't informed that Baby D [Child D] was on the list, it was not one of the two cases that was sent to us via email.
LANGDALE: For 10 September. It looks as though on 8 September between you and Dr Shukla there is a discussion about who can attend; do you think neither of you may have attended on 10 September?
McPARTLAND: No, Dr Kokai attended.
LANGDALE: Dr Kokai, that's right.
McPARTLAND: So there were two cases on the list given to us, one was a stillbirth that Dr Shukla had performed, one was a stillbirth that Dr Kokai had performed. Dr Kokai was going to attend because Dr Shukla and I had another meeting at Alder Hey so Dr Shukla prepared a PowerPoint of his case and Dr Kokai went to present the two cases. But on that email [Child D] was not listed so we did not know that [Child D] was going to be discussed otherwise I would have prepared a PowerPoint.
LANGDALE: So which cases do you think were discussed at that that ... two others that you think he discussed?
McPARTLAND: Yes, this is a list of neonatal cases. I have never seen minutes like this before. But the meeting always had stillbirth cases first and then there was a coffee break and then neonatal cases were discussed. So the two cases that we were sent for the list were actually stillbirth cases.
LANGDALE: Right.
McPARTLAND: I think what's happened is the neonatologist hasn't given the case details to the obstetrician that we corresponded with so we didn't know that these cases were going to be discussed.
LANGDALE: You anticipated my next question. It appears that these meetings refer to in a lot of cases antenatal care, post-delivery care, the obstetric perspective, if
you like, rather than, as was the case for Baby D [Child D], a detailed analysis of death and the circumstances of death. Would that be right in terms of your experience of other meetings, you weren't at this one but in terms of others, was the review much more about quality of care provided, antenatal care, postnatal care of the baby?
McPARTLAND: Well, it was both. So this was a joint meeting, both the obstetric team and the neonatal team attended and what would happen if a baby had died in neonatal period then typically the obstetric team would present the antenatal history and then one of the neonatal team would then come on and carry on and present the neonatal history. And then if there had been a postmortem or placenta the pathologist would then present the pathology findings and then there would be a discussion about the whole case.
LANGDALE: We know that Baby I [Child I] was similarly discussed in a meeting on 26 November. Again it's not clear to me if one of you or your colleagues were present for that one, maybe --
McPARTLAND: I checked through all of the emails that we have been sent during this period and the only baby I could find in the list that had been sent to us in terms of the cases we were shown was of Baby A [Child A], so
I suspect from this that's been sent to me last night that maybe there were other neonates discussed but that we weren't informed that they were going to be discussed because I went through the list of all the ones sent to me during that period.
LANGDALE: Is that a forum where you would expect clinicians and yourself to be able to discuss the case as a whole, so if there were factors you didn't know, for example, out of the blue, didn't expect it, a rash that looked differently that you would share those concerns or consider those issues or not?
McPARTLAND: Yes, you would expect in a clinical presentation of the case there would be full details so often at meetings such as this, things have come up in the clinical history that weren't provided to me at the time of doing a postmortem and that is why it's very useful for the pathologist to be at a meeting where cases are discussed. But I mean this meeting we are talking about is the -- what was called the perinatal meeting and this was periodically a number of times a year so I don't know if there may have been other neonatal mortality meetings that only involved clinicians which isn't part of this big day event where it's both together.
LANGDALE: No, no. You refer in your statement to these meetings because it's a chance for cross-discussion, discussion across disciplines. So there's no other meetings you would have been invited to in relation to babies at the hospital apart from these, would there?
McPARTLAND: Not at Countess of Chester, no.
LANGDALE: That can come down. What would you be invited at for other hospitals? You don't have to say what the hospitals are. Is there a better way of doing this?
McPARTLAND: Well, no, we would go to Stillbirth Review Meetings, now all of them are called Perinatal Mortality Review Team Meetings. We also attend meetings with clinical geneticists to discuss fetal abnormalities.
LANGDALE: You tell us from paragraph 36 onwards in your statement that you conducted a postmortem examination of [Child D] and you received information from the Coroner which we can find at INQ0002045, page 4. And if we go to page 7 INQ reference 7 and then 8. The information from the doctor -- sorry, it is back one page, please, Mrs Killingback, thank you. We see here this is Dr Newby's report to the Coroner that's been sent to you. We see the end of the first paragraph: "Baby well overnight. Baby weaned very well on ventilator. Extubated Sunday morning." Continues:
"Dr Newby saw the baby Sunday, though [Child D] was a little bit quiet and a little stiff thought to be clinically septic but seemed well, breathing fine. "One hour later blood gas after extubation wasn't satisfactory so put back on to CPAP. Quickly corrected and she remained in air with no real increased work in breathing." Continues then: "At 1.30 am the night Registrar was called as she had become mottled and had tracking, dark brown discolouration which had resolved after about 10 minutes." Continues further down: "Her inflammatory markers were okay and her gas was very good. She then went on to have a further episode of discolouration around 3.15 am. Doing very well at that point, had become more active. Began to be distressed with CPAP so this had been taken off. Then had episode further of discolouration, given bolus of fluid and that quickly settled, doctor called." Dr Newby concludes -- reported that: "This had been the third death in 12 days for neonatal. Also a further episode of apnoeic event and CPR for previous Twin deaths. Surviving Twin had successful CPR."
When you read that, what did you glean from that, if anything?
McPARTLAND: Just that final section?
LANGDALE: The whole all of it, really, as your role --
McPARTLAND: I don't think Dr Newby wrote this, I believe this was written by a Registrar, because Dr Newby had written a separate three-page document. I think that's why she's referred to in it as "Dr Newby". Well, it was Dr Newby's -- actually the letter that came along with this was three pages long, so that was a bit longer. Well, I gleaned that the baby had collapsed, you know, very soon after birth and it sounded like there had been -- then there was a delay before she then was admitted to neonatal unit at which point the oxygen levels were quite low, she was poorly, discoloured and so in need of medical attention and then can we go back a page? I don't know, you wanted me to summarise again everything?
LANGDALE: Yes. Yes.
McPARTLAND: And she has needed quite a lot of support and has been intubated. Then there is a bit more information in Dr Newby's report but she was extubated and then on a repeat gas after extubation, they weren't very happy about that and put her back onto CPAP. Then she seemed to do better but then overnight
collapsed suddenly and required increased oxygen and they had thought that it was septic, due to sepsis and they had added in extra antibiotics, repeated some of her investigations and another X-ray and she seemed to be okay but then collapsed again. Then if you can go on to the next page, and then got a bit more active and then collapsed again. So it seemed to me that she was at that stage quite unstable before she died and unfortunately they could not resuscitate her.
LANGDALE: If that bit highlighted in yellow had said -- reported this has been the third unexpected and unexplained death from their perspective at that time, would that have made you think differently about this death from the way it's reported there, the third death?
McPARTLAND: Yes, because they have just said it is the third death and that included obviously a pair of Twins, where both Twins have collapsed, one has survived and one hasn't died, so thinking about that I would think there is probably something in common for that pregnancy that affected both Twins. And then there has only been one other death. So just on its own, that wouldn't ring particular alarm bells for me because babies on the neonatal unit are vulnerable, in need of medical support and there could be a number of reasons why they might die. For example, prematurity or hypoxic brain damage at birth, infection. So I think for a cluster to be suspicious and not indicative of something like infection you would need it to be pointed out that those were unexpected or unexplained, otherwise I would think there is a pair of, you know, sick vulnerable Twins and one other death and it wouldn't particularly highlight there was anything to be concerned about.
LANGDALE: That can come down, thank you. We know there is a whole process around unexpected unexplained deaths for a reason and it appears in communications around this death and Sudden and Unexpected Deaths are being conflated. There is a practical consequence for that, isn't there, when you read that, you don't think: this is suspicious, this is concerning, what might this be?
McPARTLAND: Yes. I think you would have to say that they were sudden and unexpected because otherwise babies who die in the neonatal unit it might be that they are expected to die if they had a very severe congenital abnormality or very severe hypoxic brain injury. So if you want a pathologist to be alerted to something potentially suspicious you would have to highlight that
they were sudden and unexpected, unexplained and concerning, that there were concerning features?
LANGDALE: Well, is sudden and unexpected concerning enough? What we do know by the time of Baby D [Child D] and the discussion at the Perinatal Morbidity Meeting is that there had certainly been a staff association made, each doctor has given their own evidence about when they were suspicious about that and what it meant in terms of who it meant. But even the fact of there is one member of staff in common and these are sudden and unexpected without anything more, anything about that member of staff, who they were, what they were like, just that, would that be enough to raise suspicion in terms of the appropriate route to take for postmortem?
McPARTLAND: I think we would very much rely on the information from the hospital because they are in the environment, they are working with the staff and they know what's happening. So all of the information really has to come from the hospital to the Coroner, to the pathologist. So it's very difficult for us to make assessments when we are removed from the environment.
LANGDALE: Is it arguably sometimes even more difficult within the hospital because there is not the independence. Somebody says: this person seems great,
that is not possible, they are great, you know. Whereas sometimes from a distance, we know for example in the Beverley Allitt case, it was a neighbouring hospital that picked up on the number of referrals and were worried about that. So with the distance that might have helped or not?
McPARTLAND: I think I wasn't informed that the same staff member was involved.
LANGDALE: I understand that.
McPARTLAND: But I think for it to be picked up at the Coronial stage where they are doing a referral someone would have had to have said that there is an increased number of worrying deaths and we are worried that the same staff member has been involved in all of them.
LANGDALE: That would have been enough just to say it like that. Because you say in your statement at paragraph 40: "I was not under the impression that there were concerns that [Child D] was one of a group of possible murder cases." It is quite clear from the doctors thus far no one was saying at this time that the death of Baby D [Child D], this was part of a possible group of murder cases. Going to intention is a completely different thing, isn't it, and understanding what's happened before any investigation?
So would you ever expect someone to say: this is possible murder? I suppose they might in some cases.
McPARTLAND: Well, obviously it would be highly unusual in a neonatal unit setting. But for us to pick up that it was suspicious and for me to suggest to the Coroner that he would involve the police you would need to have something very concerning written down on the information provided to you and most likely if it was that concerning, the Coroner would have picked it up before even instructing me and might have made that decision himself to contact the police.
LANGDALE: If that box that we have seen, the yellow box, had said "three sudden and unexpected deaths in three weeks", do you think that would have triggered the SUDiC process or should have done?
McPARTLAND: I think if the hospital had raised a concern then probably with their own internal processes it might have triggered a SUDiC process. But I think -- I think the paediatricians who worked there would be better placed to give an opinion on that.
LANGDALE: You tell us at paragraph 42 that you conducted the postmortem examination of Baby D [Child D], you said: "The lungs were heavier than expected and I identified areas of pneumonia in the lungs on microscopic examination in addition it hyaline membranes." You said: "... and taking into account the clinical scenario of rupture of membranes before delivery it was likely that the pneumonia was present at birth and was the underlying cause of [Child D]'s initial collapse soon after birth and subsequent death". You go on to tell us later at paragraph 74 that: "A conclusion that a baby has died 'with pneumonia' and not 'of pneumonia' is very difficult to make and is inherently subjective and context dependent." Can you just expand on that for us, please? Why is it inherently subjective and context dependent?
McPARTLAND: Because when we look at the lungs under the microscope, we will see pneumonia but that might vary in extent, it might be a very small amount, or it might be a very large amount. If you have a very large amount of pneumonia in a Sudden Unexpected Death, then it will be very clear that is a very significant pneumonia and virtually all pathologists who looked at that would agree. But sometimes you might have a smaller amount of infection and it's quite difficult then to decide is that enough to be a cause of death or not and that's particularly difficult in Sudden Unexpected Deaths in Infancy in the community where they haven't even had any
symptoms before and the baby is found deceased in bed. So it depends on the context and in this case we have had clear clinical suspicion of infection and the baby has been treated as such. So as well as the findings, looking at the tissues under the microscope we also have a detailed clinical background of suspected infection in the baby.
LANGDALE: You didn't in terms of Mother D have either the obstetric notes or the placenta, did you, and you say at the beginning it's important to have those as well?
McPARTLAND: I had -- Dr Newby had given a summary of the clinical information, so I didn't have the notes but I knew details about her antenatal tests, about the mode of delivery. So the only thing I was missing that became apparent later was that the exact length of time of premature rupture of membranes which had been provided to me by Dr Newby was not correct; it was longer than she had said, so I felt I had sufficient information of the antenatal history. But the main problem is not having the placenta, that was an issue.
LANGDALE: You were told in fact it was the Coroner's notification on that report was the reference to 36 hours, but it was 60 hours before --
McPARTLAND: Yes.
LANGDALE: -- rupture of membranes, so there was a difference there. You also note at paragraph 48: "The appearance of the lungs was unusual because in addition to areas of pneumonia there were hyaline membranes in the alveoli ..."
McPARTLAND: Yes. So those are structures that we would normally see in more premature babies with Respiratory Distress Syndrome and if you see them in older babies or children or in adults, it's a feature known as Respiratory Distress Syndrome or Diffuse Alveolar Damage that indicates a greater degree of lung injury.
LANGDALE: You received follow-up communication, didn't you, from the Countess of Chester about this postmortem and if we can go, please, to INQ0101965, page 1, we see here Yvonne Williams from the Coroners' office sends to you: "Baby's mother has raised a query that I am unable to answer. Waters broke 36 hours prior to the birth, mother states it was 60 hours." You respond to that INQ0101968, page 1. You say: "The Coroner listed the 36 hours. I had copies of neonate notes but not obstetric notes. I think you need an obstetric opinion on the clinical significance of
premature rupture of membranes of 60 hours compared to 36. Copied in Dr Davies." If we go to the next email INQ0101966, page 1, she's asking you a further question: "Can I confirm: did you see evidence of infection histopathologically or was it inflammation? Is there a chance this could have been a congenital pneumonia that caused the PROM rather than the PROM causing the pneumonia?" You respond INQ0101967, page 1. You say: "I have never seen a case arising without chorioamnionitis, usually inhaled infection, amniotic fluid starts off the pneumonia. I think it's unlikely." Does this exchange demonstrate what you said before about subjective and context dependent with the queries going backwards and forwards about this?
McPARTLAND: No, what Dr Davies is asking is if the baby had a pneumonia first, could that have caused the rupture of membranes or is it that a rupture of membranes has caused the pneumonia? This is what she is asking me. This isn't so much about the amount, it is about the timing of the infection.
LANGDALE: Yes.
McPARTLAND: What often happens is you have infection in the amniotic fluid, and then that the baby then develops pneumonia after that and then is born with the pneumonia at the time of birth and it is a true congenital pneumonia. With the baby collapsing at 12 minutes of age, I thought that was most likely and if I had had the placenta and that had showed evidence of an amniotic fluid infection I would have been very happy to say it was definitely a congenital pneumonia but because I didn't have the placenta, and the baby had been ventilated during that first 36 hours of life, I felt I couldn't on pathological grounds alone rule out the fact the pneumonia might have developed afterwards during the period of artificial ventilation. I thought it most likely was congenital but I was just being cautious as --
LANGDALE: You didn't have the placenta?
McPARTLAND: -- I didn't have the placenta.
LANGDALE: Thank you, that can go down. You say at paragraph 77: "If I had been notified at that stage of a concern of the same member of staff being involved in a series of deaths, it could have prompted a discussion about possible inflicted causes of death, involvement of the police and a forensic pathologist and combined discussion of clinical features with the paediatrician, alongside X-rays taken in life and death."
We know in fact because of the problems you had with Meditech, we have seen the extensive correspondence that you and your colleagues were very frustrated, you couldn't get access to the X-rays at this time and Baby D [Child D] was in fact the first case when the Meditech system came into play; is that right?
McPARTLAND: Yes [Child D] was the first postmortem case booked into our new Meditech V6 system, which had just gone live two days previously.
LANGDALE: Who was the effect of that, that you couldn't see the X-ray at the time of doing the postmortem?
McPARTLAND: No, the effect of that was to do with me seeing the X-ray report at the time of editing and signing out the report.
LANGDALE: You would rather have seen it before?
McPARTLAND: No. I wanted to see the X-ray report at the time of editing my postmortem report but because of an incorrect set-up in the system when I came to edit my whole postmortem report, the X-ray section was not in the editing file.
LANGDALE: So you couldn't see it?
McPARTLAND: So I didn't see it at the time of editing and I commented on it because usually in my final discussion of the case I would add a line in saying: postmortem skeletal survey revealed with a comment.
When I have come back to review the case and that isn't in there I think it is because I haven't seen the X-ray report at the time of editing.
LANGDALE: When you conducted the placental examination of [Child E]'s Mother, E and F's Mother, were you told that [Child E] had died?
McPARTLAND: No.
LANGDALE: When did you find that out?
McPARTLAND: Only in the trial, I reported the placenta but I was never told the baby died.
LANGDALE: Do you think you should have been?
McPARTLAND: Well, we report a placenta after the baby is born and give our opinion there, then. The fact that the baby dies some days later probably wouldn't affect our interpretation of the placenta, so usually we would only expect to have contact with a clinician later if -- if they felt that what we have seen in the placenta was somehow relevant to the baby's death and it wasn't clear from the report and they wanted a bit more discussion about it. Or if the case then came up at a neonatal mortality meeting and we had to then show the placental findings. So I wouldn't always expect that they would tell me unless they wanted to later discuss the case.
LANGDALE: You tell us at paragraph 96 that your
colleagues Dr Kokai, Dr Shukla and yourself had undertaken postmortem examinations on [Child A], C [Child C], O [Child O] and P [Child P] and you were contacted we know by Mr Harvey in relation to conducting a review of those postmortems in combination. If we can go to INQ0101999, page 1. This will take us to an email that you say you typed out relatively closely to the telephone call that you had with Mr Harvey; is that right?
McPARTLAND: Yes, because I can see I have said "I have just taken a call from him".
LANGDALE: So you set out there what you tell your colleagues. What do you remember about that call now?
McPARTLAND: Well, I remember the call because it's the only call I have ever had from a Medical Director from another Trust and my recollection is as I have detailed there from my handwritten notes.
LANGDALE: So he suggests that he would like you to set out -- he is going to send case details and questions of a neonatologist and he would like you to review your reports and any new evidence and comment appropriately. What did you think "any new evidence" referred to?
McPARTLAND: Well, it was because the neonatologist had reviewed the cases, so we thought I think from the conversation that she had questions. So I think what I have said there: well, he said in four of the pms it might be worth a follow-up discussion with the pathologist to see if further light can be shed on the further issues. I suggested he should write to us with the case details and the questions of the neonatologists and we would be happy to review our reports and any new evidence and comment appropriately or meet with clinicians to coincide with the perinatal meeting if required. I think by "new evidence" I meant any -- any new information that they had.
LANGDALE: So we then see -- that can go down -- a letter of instruction to you, INQ0102002, page 2: "Dear Dr McPartland: "Further to our conversation I am emailing having had the approval of the Coroner to request a review of four cases." We can all see what that says. Take your time to read that and then the next page. We see: "... may be of relevance. Our clinicians have reported one clinical feature that they had noted, in some cases babies did not seem to spend to resuscitation as they would have expected." Is that all of the further information you got,
this letter?
McPARTLAND: Yes, we only received that email with just, you know, the few lines on each case.
LANGDALE: Did you ever speak to Dr Hawdon or see her report; did they send you that?
McPARTLAND: No.
LANGDALE: Did they send you the RCPCH report?
McPARTLAND: No.
LANGDALE: Did you see -- we will put it on the screen -- INQ0003120, page 1 and 2, the last paragraph on this page 1 and then page 2, if that can go on the screen, please. The "Action required: case review", can scroll up. We just need page 2 now, thanks. And we see there that: "The RCPCH recommend a detailed forensic Casenote Review of each of the deaths since July 2015 should be undertaken ideally using at least two senior doctors with expertise in neonatology/pathology in order to determine all the factors around the deaths. Case notes and electronic records should ideally be paginated to facilitate reference and triangulation." Did you see that, the RCPCH --
McPARTLAND: No.
LANGDALE: There is also -- you are going to say no, so I am not going to put it on the screen. There is
a section about the nurse and the suspicions or concerns about that, did you see that? Clearly not, if you didn't see the RCPCH report?
McPARTLAND: No.
LANGDALE: Do you think if you were being asked to do a broader forensic review of A [Child A], I [Child I], O [Child O] and P [Child P] you should have seen all that information and known what all the concerns were?
McPARTLAND: Yes.
LANGDALE: Did Mr Harvey communicate any sense of urgency to you?
McPARTLAND: No, he didn't and I didn't hear from him again for over two weeks.
LANGDALE: And we see your response to your colleagues, INQ0102002, page 1 [not found]. You say to them: "Please see message below from Countess of Chester. As I mentioned to you previously I will ask the secretaries to retrieve slides and reports refer each pathologist. Maybe we should get together and discuss them at one of our meetings in the New Year." There is other emails about you emailing to Debbie: "Due to holidays now, it will be in the New Year." There is not a sense of urgency that's been imparted to you, is there?
McPARTLAND: No.
LANGDALE: Was there any discussion about parental consent or what was involved here or --
McPARTLAND: Well, in the phone call, I indicated that he would need to ask the Coroner's permission to review the cases if they were Coroner's cases. If they were hospital cases, we would normally discuss cases at the Perinatal Mortality Review meeting and that had been mentioned in the phone call; that it might be a follow-up discussion with that. So I felt that this was all part of the normal process of clinical pathological review that would occur, so I wouldn't have expected when we were asked to give another opinion on a postmortem that we would go back to ask consent for that.
LANGDALE: If we go, please, to INQ0003135, page 3. A further email from you to Mr Harvey explaining: "Apologies for the delay. Although the slides and reports were retrieved from the file in my absence I wasn't able to distribute them to my colleagues until I returned after the New Year. Two of the cases are Dr Kokai's and one is Dr Shukla's and he's been on annual leave." You then say in another email, I don't need to pull it up: "We have discussed the cases." This is 25 January: "I need to write up my notes, share with my colleagues, I will send it to you by the end of the day. Sorry for the delay, we have been quite busy in the mortuary which has limited when the three of us could get together." Then you send INQ0003135, page 1, your report. "A summary of our conclusions." And you -- the conclusions were -- well, let's deal with this letter first. You say: "Please note this is not a full and formal medico-legal review. This would involve a second report and take about four hours of work per case with a subsequent lengthy report. If you require an ... analysis of this depth, it is probably best performed independently by someone from another centre." So pausing there. How much time had the one that you had done taken?
McPARTLAND: Well, I had passed on the reports and the slides to my colleagues for them to review the cases that they had carried out and then we had a meeting, I'm not sure how long it was, probably discussed each case perhaps for 20 minutes or so. That would be our normal practice if we were discussing cases together and then I had written it up.
So what we had done is an informal process of the type that we might normally do discussing a case for a perinatal mortality meeting and it was very much a part of routine practice. But a Royal College review is quite a formal significant process and that's why I suggested this in the letter that I felt if they had recommended more -- pathology review, that needed to be on a more formal basis than what we had been asked to do.
LANGDALE: Effectively, you all looked again at what you had already done, you were not bringing new information to the mix or changing your approach to the case, that wasn't what you had been asked to do, was it?
McPARTLAND: Well, all that had happened is that Dr Kokai and Dr Shukla had then discussed their cases in a group of three with us, which hadn't happened before.
LANGDALE: Yes.
McPARTLAND: But no, otherwise it hadn't added much to the original reports.
LANGDALE: And you say: "If you require an indepth analysis, or an analysis of this depth, it is probably best performed independently by someone from another centre." Why did you say that?
McPARTLAND: Well, that's just normal practice. If you
want to formally review someone's report, then often it would be someone independent because the three of us work very closely together, Dr Shukla and I had both been trained by Dr Kokai, so we wouldn't really be a suitable person to review that work.
LANGDALE: We see the report you attached INQ0102007, page 3 and 4. We see there for [Child A], [Child I], [Child A] agreement cause of death remains unascertained for [Child I]. You say: "Hypoxic ischemic damage of brain. Chronic lung disease and prematurity. Extreme prematurity." Over the page [Child O]: remains unexplained. You suggest for O [Child O] and P [Child P]: discuss potential of genetic causes. If you had known before you did that review or had that discussion that the paediatricians were interested to know if deliberate harm had been inflicted, what would you have said about that exercise, that it was worth doing or not?
McPARTLAND: Well, I would have said that the police needed to be immediately involved and a forensic pathologist would need to be instructed.
LANGDALE: You then receive an email from Mr Harvey, INQ0102010, the report states, this is in relation to
Baby A [Child A]: "A very small air embolism might not be detectable at autopsy, does that mean that significant embolism would be evident?" Your answer is at INQ0102011, page 1: "Yes, significant air embolism should be accompanied by forth in the vessels or lungs." This was Dr Shukla's case and you asked him about that, you say?
McPARTLAND: Yes. This was [Child A], which Dr Shukla performed so I went into his office and asked what he thought and this is what he said, and I am aware that that is a classical postmortem sign of air embolism, is froth in the vessels or the heart. And I wrote that back to Mr Harvey. I would stress that we thought the interest in air embolism was all because this child had a long line inserted just prior to the collapse and there had been concern about the line, they were going to pull it out and then the child arrested. So that's what we thought was the reasoning behind this questioning, not that there had been deliberate external administration of air.
LANGDALE: If he asked you the question: is there any evidence of deliberate external administration of air, how would you have answered that? What would you have said to that?
McPARTLAND: Well, that --
LANGDALE: Is that within your expertise or not?
McPARTLAND: That would have alerted us the fact that this was a concern of a criminal case and that this needed a much more in-depth and forensic pathology opinion. So if he had said that to us, we wouldn't have made a brief email response; it would have been apparent that that needed a very different approach.
LANGDALE: In this process, the Royal College had conducted a review, Dr Hawdon had done a report and you had been asked to do this with your colleagues and none of you had spoken to each other and seen what each other had said at any stage, but as you have seen, and Dr Hawdon did today, broader forensic review was being recommended from the off, wasn't it, because of the constellation of features that the Trust was dealing with at that point?
McPARTLAND: Well, yes, I have since been provided with all of those documents by the Inquiry and I can see that that had been recommended but hadn't been conveyed to us.
LANGDALE: Finally, from your statement reflections, paragraph 136, you set out how your current practice
with respect to the radiological investigation of neonatal deaths is different to that in 2015 and 2016. Can you tell us how it's different?
McPARTLAND: Yes. For the last several years in addition to a whole body skeletal survey, a whole body CT scan is also carried out on all of the coronial SUDI cases. Since the verdict in this case, where it became apparent that administration of intravascular air had caused death, we have now been requesting our radiology department even to do a CT scan on a hospital in neonatal postmortem cases as well as the Coronial cases, because clearly there is a potential that this could happen even when the case comes as a hospital postmortem and not just as a Coronial postmortem. But I would stress I don't think that is current practice around the country; most hospital PMs in other centres would not get a CT scan.
LANGDALE: One final matter. Mr Harvey is yet to give evidence but he says in his statement he thinks he had a discussion -- he thinks he had a discussion with you verbally that "clinicians had raised concerns over a member of staff and her presence on the ward at relevant times". Can you remember anything like that?
McPARTLAND: No, the only conversation we had was the first one that I made detailed notes in and conveyed to my
colleagues and there was no mention then of anything about a nurse.
LANGDALE: He did not get from you that there were concerns that you were raising about the deaths being suspicious in any way. Were you saying anything about the deaths being suspicious or were you not able to, given the information you had?
McPARTLAND: No, in three of the four cases we indicated that we didn't know why the babies had collapsed, but we didn't raise any suspicions from the pathologist review that we had carried out alone.
LANGDALE: When you say "we don't know why somebody died, it is unascertained/unexplained", whose responsibility is it as far as you are concerned to follow that up to get answers to that?
McPARTLAND: Well, it might be that in some cases that we find, for example, deaths in the community, that everything has been done that is possible to do if you have done a full range of investigations. I know in one of the cases we recommended that genetic opinion might be helpful because there are a large number of genetic causes that could possibly cause Sudden Unexpected Death that can be investigated by further genetic testing. But it is sudden and unexpected and it's concerning, then -- then it goes back to a SUDiC
protocol if it's come through that route.
LANGDALE: That we discussed earlier?
McPARTLAND: Yes.
MS LANGDALE: Thank you. Those are my questions, Dr McPartland. I think Mr Baker has some for you now.
MR BAKER: Dr McPartland, I ask questions on behalf of the Families of 12 children, but in particular on behalf of the Family of [Child D]. Can I begin by going to paragraph 2 of your witness statement, please, where you set out your training. You completed your degree in 1999 and obtained your registration with GMC in August 2000, having spent I think a year undergoing a general medical rotation in a hospital?
McPARTLAND: Yes, I undertook a year of house officer jobs; that is half medicine and half surgery.
BAKER: Yes, and at that point you began the route into histopathology; so your practice diverged from sort of common ordinary medical practice into a specialism of pathology?
McPARTLAND: Yes.
BAKER: Yes. So in terms of your experience with patients who are alive, if I put it that way, it is limited to this one-year period?
McPARTLAND: As well as the three years clinical training at medical school.
BAKER: Yes, yes. It's not meant as a criticism because of course your speciality is in relation to different matters, a different type of patient. But it's correct to say, isn't it, that when it comes to clinical matters, the interpretation of clinical matters, you are often heavily dependent upon information given to you by the clinicians who treat the patient?
McPARTLAND: That's correct.
BAKER: Or in different contexts from the reports of clinical experts?
McPARTLAND: Yes.
BAKER: Your speciality is interpreting the findings that you observe on postmortem and then those are applied in context alongside clinical evidence or indeed in some cases reports of other specialties?
McPARTLAND: Yes.
BAKER: Now, the forensic issue, you do carry out certain types of forensic work, I think I saw from your CV that you have a speciality in interpreting damage to eyes?
McPARTLAND: Yes.
BAKER: So in that context, you will be brought in, in
cases of homicide or suspected homicide, but for the most part if there is a suspicion of homicide then a Home Office approved forensic pathologist takes the lead as part of a multi-disciplinary approach?
McPARTLAND: That's correct, yes.
BAKER: We know from the evidence given at the criminal trial that Dr Andreas Marnerides, who leads the Forensic Children's Pathology Service at Guys and St Thomas' Trust in London provided evidence in that context and he is a well-known forensic paediatric pathologist?
McPARTLAND: Dr Marnerides is a paediatric pathologist, he is not a forensic pathologist.
BAKER: The forensic aspect then is provided by a Home Office pathologist who works alongside a paediatric pathologist?
McPARTLAND: That's correct.
BAKER: And I think your evidence to Counsel to the Inquiry is that in cases of homicide or suspected foul play essentially is there is a multi-disciplinary approach between a number of experts who interpret different aspects of the case?
McPARTLAND: Yes. So you have a forensic pathologist, a paediatric pathologist and it would depend on the nature of the case if you involved other types of
pathologists.
BAKER: So a toxicologist may be involved, a radiologist may be involved. It depends on the particular area of interest?
McPARTLAND: Yes, and in a forensic postmortem there would always be radiology and toxicology and then we would do a range of other investigations such as microbiology, biochemistry, et cetera.
BAKER: And as I understood your evidence if foul play is suspected, then it should be advertised very early so that the appropriate route can be followed in terms of gathering evidence?
McPARTLAND: Yes.
BAKER: Now if we look to paragraph 36 of your witness statement, we can see here the circumstances in which you were instructed to conduct a postmortem examination on [Child D]. It was a postmortem ordered by the Coroner.
McPARTLAND: Yes.
BAKER: And a Coroner's postmortem is a fairly routine exercise in cases of what may be unnatural death but not necessarily suspicious death?
McPARTLAND: Well, the postmortem is -- is ordered to determine the cause of death. If -- I don't see what you -- the distinction you're drawing between unnatural and suspicious?
BAKER: Well, a Coroner has jurisdiction over unnatural death, so the postmortem is carried out at an early stage in order to determine whether this is a case of natural death or unnatural death, so whether the Coroner's jurisdiction is --
McPARTLAND: Yes.
BAKER: -- activated?
McPARTLAND: Yes.
BAKER: So the exercise you would carry out is different in nature, not necessarily in quality, but different in nature to one that is carried out in the forensic context?
McPARTLAND: Yes.
BAKER: And again you will be guided quite significantly by the information in this context that is provided by the hospital and particularly their staff?
McPARTLAND: Well, and provided by the Coroner, yes.
BAKER: Sorry, I didn't quite catch that?
McPARTLAND: And provided by the Coroner.
BAKER: And provided by the Coroner. So if we go, please, to INQ0002045 and to page 7. So we can see here this is entitled "Info from Doctor." It's part of a bundle of documents that are sent to you by the Coroner?
McPARTLAND: Yes.
BAKER: And so the Coroner's officer will obtain an account from one of the treating doctors and that will be set out and provided to you?
McPARTLAND: Yes.
BAKER: If we look at this account, we have first of all the description of [Child D]'s birth. There is a reference to a full infection screen and IV antibiotics being provided shortly after baby -- [Child D] was born. That's five lines up from the end of the first paragraph, do you see that?
McPARTLAND: Yes.
BAKER: First of all, the fact that a full infection screen was performed at or about the same time as the antibiotics being provided, what would you understand a full infection screen to be?
McPARTLAND: Typically they do a blood culture. I'm not sure if they did a cerebrospinal fluid as well and probably blood tests for -- for blood count CRP.
BAKER: So --
McPARTLAND: But usually they would take the blood for culture before they have given the IV antibiotics.
BAKER: Yes. I think that's the point I'm making, is that they take the blood culture prior to giving the antibiotics because the antibiotics kill the bacteria in the blood and stop it growing?
McPARTLAND: Yes.
BAKER: And were you aware of what the outcome of that infection screen was, the microbiology?
McPARTLAND: I think in the notes I had got, they hadn't had any positive results back.
BAKER: So the blood had been cultured for a period of time, but hadn't grown any bacteria?
McPARTLAND: I would have to go back and check the report, but I think ...
BAKER: I think you can take my word for it --
McPARTLAND: Yes, yes.
BAKER: -- that that's what it was?
McPARTLAND: But that's only for bloodstream infection. So that doesn't exclude the possibility of infection in other sites such as within the lungs --
BAKER: Yes.
McPARTLAND: -- which we not involved with the bacteremia in the blood.
BAKER: So the note goes on to say: "Around 9 pm the gas [which we assume was blood gas results, so oxygenation] was improving but still not good so night Registrar intubated and ventilated 9 pm Saturday night. Baby well overnight. Baby weaned very well on ventilator and extubated Sunday morning." So again it's suggesting the pattern of improvement
leading to extubation following intubation?
McPARTLAND: Yes.
BAKER: And then a reference here to: "Dr Newby saw baby Sunday and though [Child D] was a little bit quiet and a little stiff thought to be clinically septic but seemed well. Breathing well. Intravenous antibiotics increased. Plan to repeat gases and blood soon after extubation. One hour later blood gas after extubation wasn't satisfactory so put on to CPAP." Now, CPAP is a lower level of intervention than intubation, do you know that?
McPARTLAND: Yes.
BAKER: Yes: "... which quickly corrected and she remained in air with no real increased work in breathing." So that again would suggest, after a short period of positive airway pressure support, her blood gases corrected themselves and she was able to breathe air without -- with no increased work of breathing?
McPARTLAND: Yes.
BAKER: There is a reference then to the umbilical lines and it says then at 1.30 am: "The night Registrar was called as [so during the night shift] she had become mottled and had tracking
dark brown discolouration which had resolved after about 10 minutes. During that episode she had required an increase in oxygen but by the time Dr Newby attended she was back in air." So there is a reference here to a curious episode of tracking mottling associated with a deterioration in breathing followed by a relatively quick recovery.
McPARTLAND: (Nods)
BAKER: Was it suggested to you that anybody thought that that was unusual?
McPARTLAND: Well, there's a lot more detail in Dr Newby's letter and in the clinical notes and it was noted that they thought this was -- must be something to do with infection.
BAKER: So again you would defer to the letter from the clinician having greater experience of these things clinically than you would have?
McPARTLAND: Yes, especially as I hadn't seen the rash myself.
BAKER: Yes. It then goes on to say that her inflammatory markers were okay and her gas was very good. If I pause there for a second. What are the inflammatory markers?
McPARTLAND: CRP I think they are referring to.
BAKER: So C-reactive protein?
McPARTLAND: Yes.
BAKER: Do inflammatory markers commonly alter in the presence of an infection?
McPARTLAND: It can take time for those to rise especially in young babies. So that's why neonates, even if the CRP isn't raised especially at an early stage, they will still treat as infection if clinically they are suspecting it because they are not that reliable.
BAKER: So there is commonly a lag between the onset of the symptoms and the CRP rising in a detectable way?
McPARTLAND: Yes.
BAKER: But in serious or overwhelming sepsis, one normally sees a rise in the CRP?
McPARTLAND: Yes. But it could take 24 hours, so you really need serial measurements at an interval from one another.
BAKER: And there is a reference here to her gas was very good. What do you think that refers to?
McPARTLAND: Her blood gas.
BAKER: Would it be normal for a -- again it may be a clinical matter and if so please say so -- but, would it be normal for a baby with overwhelming pneumonia to have blood gases?
McPARTLAND: Not over -- no, not if it was overwhelming.
But whether then the child can deteriorate again then with difference gases is a different matter.
BAKER: So it goes on to say: "There is a further episode of discolouration at about 3.15 am." So we are a couple of hours later now: Doing well, very well at that point: "Had become more active. Began to be distressed with CPAP so this has been taken off. Then had an episode of further discolouration. Given bolus of fluid and that quickly settled." "Doctor called. SHO was on the ward just before 4 am. She went profoundly mottled apneic lost heart rate. SHO nurse commenced CPR." I think we know what happens next. Did that strike you as being an unusual course for a child or baby to take in response to sepsis?
McPARTLAND: Well, in my experience when babies have died often they do have a fluctuating course beforehand and I have had cases before where a baby has collapsed, been resuscitated and then collapsed again and then eventually resuscitation fails. So a fluctuating course didn't seem to be that unusual to me. And then obviously she has become mottled and stopped breathing again and her heart has stopped. So
the whole picture did seem to suggest that she was unstable and very unwell.
BAKER: You see Dr Hawdon gave evidence this morning and she said that this, this pattern leading up to the collapse, was atypical for sepsis. It's not what she would expect to see?
McPARTLAND: Well, I suppose she is a neonatologist with clinical experience that I wouldn't have. As you have alluded to, I would need a specific clinical opinion to go --
BAKER: Yes.
McPARTLAND: -- into a lot of detail.
BAKER: And I appreciate in asking you to give evidence on clinical matters, I am pushing you outside of your area of expertise. But I mean, you would agree that if Dr Hawdon said that this was unusual for sepsis, that it is unusual for sepsis? You'd defer to her?
McPARTLAND: Well, I would defer to a paediatric clinical opinion on that matter, but just pointing out that I have had cases where children have had multiple attempts at resuscitation in the hours leading up to a final death.
BAKER: And I don't disagree. I mean, of course I don't have the details of those cases to understand the differences that there might be. But you would
defer to Dr Hawdon on that issue?
McPARTLAND: Yes.
BAKER: What the note goes on to say in the final paragraph: "Reported this had been third death in 12 days for neonatal. Also a further episode of apnoeic event and CPR for previous Twin death. Surviving Twin had successful CPR." Did anything strike you as unusual about the addition of that paragraph, is that something you would see normally?
McPARTLAND: Well, no, but as I discussed earlier with Ms Langdale, without knowing that any of those deaths were unexpected or unexplained or concerning in any way, a cluster in itself would not raise a suspicion of an inflicted mode of death. And especially as a pair of those are twins, and both have collapsed and one has died, I would assume that there had been something specific about that pregnancy and then there's only one other death. But as I mentioned earlier, there are a number of causes why neonates on a neonatal intensive care unit might die, so I would need to have a strong clinical steer that this was concerning for it to be flagging that this should be a case with police involvement. Because I would have thought if that was the case, then whoever wrote that would have flagged that this should be a case with police involvement right at the onset of reporting it to the Coroner.
BAKER: Thank you. If you could look please at paragraph 62 of your witness statement. So at paragraph 62 you are talking about interactions with Yvonne Williams and Dr Davies but you say: "There was no mention within these multiple interactions with Yvonne Williams or Dr Davies of any concern that [Child D]'s death was considered to be suspicious or of any increased rate of neonatal deaths and collapses at the Countess of Chester Hospital." Now, in fact, you must have known that there was an increased rate of neonatal deaths and collapses at the Countess of Chester Hospital because it's part of the "Info from Doctor" that was provided to you originally?
McPARTLAND: Well, no. They have said there are three deaths in 12 days then. But in terms of overall neonatal death rate, you know, over a period of time or per thousands I hadn't been given any specific information about that.
BAKER: Ah. So you weren't -- again this is not meant
to be a criticism -- but you weren't to know that the third death in 12 days in the neonatal unit was unusual?
McPARTLAND: Well, I don't know what their normal death rate is because we only see cases that come to postmortem. So I would require, you know, specific information to say over time they would be worried. Because usually I presume the deaths rates are plotted over, you know, quarterly or something like that, so you would need to look at those numbers to see if there had been a significant increase.
BAKER: If you had been told that this was very unusual, to have three deaths in 12 days and an unexpected collapse, your approach would have been presumably to ask why or indeed what was suspected to be the cause of it?
McPARTLAND: Well, I would expect it to be flagged from the hospital. So it's important that they report a cluster because then we might consider infections if anything turns up on the infection screen from a postmortem. But I would very much expect the hospital to report it to the Coroner if they felt they had a local cluster that was concerning because for a pathologist working at a different hospital and not in the unit it would be difficult to -- us to suspect that without being given
the specific information.
BAKER: Yes. And again because your role is to -- is to effectively interpret signs that you find on postmortem and apply those in a clinical context or apply those in a broader context, and so how you might interpret a piece of information, a sign that you obtained from postmortem, depends pretty much on the wider context in which it's found?
McPARTLAND: Yes.
BAKER: And so it is crucial for your exercise to be complete for you to be provided with all the relevant information?
McPARTLAND: Yes.
BAKER: Could we go to please page 34 of the same document. In fact, forgive me, that's an incomplete version. Can we go please to page 832. So this is the -- no, this is -- 832 is the same document, but it has -- this one has missing pages. So 830, thank you. If we go on then to page 831, so it's pdf number 833, thank you. So we have here clinical history as set out within the postmortem report and it's a much shorter document than the "Info from Doctor" that was provided. Is that because, in effect, you take from the information from documents -- from doctor those things that you see as being most relevant?
McPARTLAND: Yes, because Dr Newby had provided a three-page long letter and I also had over 40 pages of clinical notes. So I'm just putting here together a brief paragraph just to summarise the outline of the case.
BAKER: Yes. I mean, what it doesn't say here though is that there were periods of improvement or indeed that clinicians felt that at various point [Child D] was doing quite well.
McPARTLAND: Well, at the bottom of this page, it says she pinked up quickly and started regular aspirations. So that was when she had improved then after being given IPPB. You would have to go to the next page. Yes, I mean it's not a full summary, it's just a brief outline and I suppose I would be concentrating more on the deteriorations that led to death.
BAKER: So if you had been provided with information that the clinicians felt that this didn't fit with sepsis, it didn't look right for sepsis and it was explained why that was, then you would have set that out within, in effect, your factual summary at the start?
McPARTLAND: Yes. I mean, I would have to look at Dr Newby's letter. But as I recall her -- all of the information she gave, and including information that they thought the baby was septic, that they thought that unusual rash was due to sepsis, the information all seemed to imply that they were thinking that this was a baby with infection.
BAKER: Again, this goes back to what you said to Counsel to the Inquiry in response to a question about paragraph 74 of your report, that the exercise in determining whether a baby has died with pneumonia rather than from pneumonia is incredibly difficult especially if looked at outside of any context?
McPARTLAND: (Nods)
BAKER: Because pneumonia is a localised infection and sepsis is a systemic infection and it is sepsis that is far more dangerous in the shorter term than pneumonia?
McPARTLAND: Well, sepsis doesn't necessarily mean that the infection has spread everywhere. Sepsis is the systemic response to the infection --
BAKER: Yes.
McPARTLAND: So a baby can have sepsis even with the actual histological signs of infection being limited to the lung and with there not been being bacteremia in the bloodstream.
BAKER: Yes. It is a systemic inflammatory response to a localised source of infection.
McPARTLAND: Mmm.
BAKER: But on postmortem there is -- and there may
never be -- but there is no evidence of the systemic inflammatory response. There is only evidence of the localised infection in [Child E]?
McPARTLAND: Yes, the evidence of the systemic response is the -- from the baby's observations and the collapse, the collapse of the baby.
BAKER: Yes. So things like raised CRP or inflammatory markers that is part of a systemic inflammatory response?
McPARTLAND: Yes, and I believe there was neutrophilia as well with a raised white cell count, wasn't there?
BAKER: Yes, but the signs of systemic sepsis are, on postmortem, are not there to be seen because those are signs that are observed in life?
McPARTLAND: Yes.
BAKER: What you have is signs of pneumonia, which again has to be placed in context to be understood?
McPARTLAND: Yes.
BAKER: And in terms of the severity of the pneumonia, the severity of the pneumonia in this case was not so extreme that even out of context you would be able to say that that was the cause of death?
McPARTLAND: Well, unfortunately I haven't been able to review the slides because they are police exhibits and haven't been returned to me. But I can see from my
report that I specifically mentioned there were larger patches in the right lower lobe of lung and I know from some information I heard reported from the trial that the trial radiologist did agree that there were signs of pneumonia in the right lung. So I couldn't comment further on it without being able to review my slides.
BAKER: I don't think anybody in the criminal trial disagreed that there was pneumonia, and I think the issue at the criminal trial -- and it certainly was the position from Dr Marnerides, was that [Child D] died with pneumonia rather than from pneumonia, and that's because some things came in to add additional context?
McPARTLAND: Yes.
BAKER: But what I was saying to you is that it's not a case where the evidence that this was a death caused by pneumonia was so overwhelming that it could be determined simply on postmortem without any context to that?
McPARTLAND: Well, as I say, without reviewing the slides it's difficult for me to say. But there was a clear-cut pneumonia. So, for example if this was a baby who died in the community and that I didn't have all of these observations, on the balance of probabilities you would
probably still say that might be the cause of death. But I think without me reviewing the slides it's difficult for me to give any further comment in addition to the postmortem report.
BAKER: But again it is inherently difficult to make the decision about whether this pneumonia is the cause of death or it's simply a feature that was present at the time of death because in clinical practice babies have pneumonia and recover?
McPARTLAND: Yes, they -- yes, they do recover. So I think you are right. In this case, I think a lot of the extra information that came out in the criminal trial has significantly, you know, informed people's thinking about the significance of the pneumonia.
BAKER: Now, one of the things that came out of the criminal trial, if we go on to -- so the following page 832, please. It's 834, pdf number. Next one down. Thank you. We can see there a reference to the X-ray examination postmortem skeletal survey and why is there a question mark after X-ray examination, do you ...?
McPARTLAND: I'm not sure. I think that must be that the secretary has put it in and it's a typo.
BAKER: Okay, thank you. Is this a survey that has been carried out by you?
McPARTLAND: No, the -- this is a report from the Consultant radiologist and the X-rays are done by a radiographer who comes to the mortuary.
BAKER: Now, the X-rays in this case, both in life and postmortem, were reviewed as part of the criminal trial by Professor Owen Arthurs, a professor of paediatric radiology at Great Ormond Street Hospital and by a number of members of a multi-disciplinary team and it was noted that there were changes consistent with air embolism on various X-rays taken in life and following death and that there was air in the great vessels. Can you explain where the great vessels are?
McPARTLAND: Well, great vessels you would normally talk about the large vessels in the neck, so for example the large veins leading to the heart or the large vessels leading from the heart. I'm not sure if they are talking about descending aorta as well.
BAKER: Again, the observation of air in blood vessels on X-rays is something that requires the specialist input of a radiologist?
McPARTLAND: Yes.
BAKER: It isn't something that you would expect to be able to do on seeing an X-ray yourself?
McPARTLAND: No.
BAKER: No. And likewise there was evidence at the
criminal trial of air in the great vessels, but that did not result in you identifying froth in the lungs or in the heart on your examination?
McPARTLAND: No.
BAKER: Was that because, to put it bluntly, being able to find or spot such froth is a lot easier if someone tells you that there's a possibility there might be an air embolism in this case?
McPARTLAND: Well, I've got -- I took a lot of photographs of the postmortem, including 22 internal photographs, and that included photographs of the brain and the lungs and the heart and I have gone back and I can't see any froth there and also there are no air bubbles on the surface of the brain either. And so I have done a lot of reading about this and it seems to me, although in some cases in the literature there is a large amount of froth in the heart and in the lungs reported there are other cases reported where there has been a significant amount of air visible on postmortem CT, but then the pathologist couldn't identify it at all at postmortem. So I think from that, and I have had experience of another case since of a postmortem case where a large amount of air was identified on CT and with a forensic pathologist, even with filling the pericardial sac with
water and puncturing the heart we couldn't demonstrate it at postmortem. So my experience from that reading and that case I have had since then would lead me to believe that you could have a significant amount of air at postmortem and it could be completely undetectable at autopsy.
BAKER: So your statement to Ian Harvey in the email may have been quite genuine based upon your understanding at the time, but since then you have come to learn that in fact you can have a very significant air embolism without froth in the heart or lungs?
McPARTLAND: Yes, that's correct.
BAKER: Yes. And if I then can draw some of the strands together. You accept that it's difficult to determine whether pneumonia was the cause of death as opposed to something that was present at the time of [Child D]'s death. Had you been provided with key pieces of information, ie that the pattern of deterioration prior to or that [Child D]'s condition prior to her collapse was not consistent with sepsis, that there might be a suspicion of foul play involved, then you first of all would have followed an entirely different trajectory in terms of the investigations carried out. It would have been a forensic investigation rather than a hospital
postmortem?
McPARTLAND: Well, yes. If I had been informed there was a suspicion of foul play, that would definitely have been a forensic postmortem with the police involvement. If a clinician had said only, "We weren't sure it quite fitted with sepsis", that could still be a routine Coroner's postmortem.
BAKER: Yes.
McPARTLAND: But then, you know, if they really were concerned and if after issuing the postmortem report the paediatricians had come back to me and said, "We really don't think there is pneumonia", then we would have a discussion. And sometimes in these types of cases before I finalise the report, I'll ask the Coroner if I can speak to the clinician and discuss it, you know, if I'm not sure that the clinical features fit together and then I would rely very much on their opinion. So I think in this case it wouldn't only be a lack of the clinical features fitting with sepsis or pneumonia. You would have to have the strong clinical steer that it was a suspicious case to warrant insisting on police and forensic pathology involvement.
BAKER: But to look at it in a different context. If this was a hospital postmortem as it was and you have equivocal evidence as to whether pneumonia was the cause of death or simply something that was present, if you had received a steer from the clinicians that the deterioration of a child's condition prior to collapse was inconsistent with overwhelming sepsis or collapse due to sepsis, then you would have interpreted that pneumonia in a very different way, wouldn't you?
McPARTLAND: Well, there was a clear pneumonia, but not only was there pneumonia; there were hyaline membranes which indicated acute lung injury, which you don't normally see. So that did lead me to believe that there was more extensive lung injury from the pneumonia than you might expect, so that could explain then why the child didn't behave as the clinicians might have expected. But from the trial outcome in this case, I am wondering if air embolism and his survival for a couple of hours if that could explain hyaline membrane development and it's not something that's been reported in the medical literature but because it's a bit unusual, I'm wondering if that could explain that evidence of acute lung injury in this case and it would be interesting to look at all of them.
BAKER: So I mean, in short, of course the evidence that was given in the criminal trial causes you to
entirely reappraise the interpretation of what you saw at postmortem for perfectly legitimate reasons because other experts have become involved and given different opinions from the perspective of their sub specialties. That's correct, isn't it?
McPARTLAND: Well, yes, we have a child who has pneumonia but then there's been an inflicted cause of death on top of that. So obviously that would then change the opinion of whether the pneumonia led to death or not.
MR BAKER: Thank you. Thank you, my Lady, I have no more questions.
LADY JUSTICE THIRLWALL: Thank you, Mr Baker.
MS LANGDALE: That concludes the questions for Dr McPartland, my Lady.
LADY JUSTICE THIRLWALL: I have no questions. Dr McPartland, thank you very much indeed for coming to help us this afternoon. You are free to go.
McPARTLAND: Thank you.
LADY JUSTICE THIRLWALL: So we will rise now until 10 o'clock tomorrow morning.
(3.46 pm) (The Inquiry adjourned until 10.00 am, on Wednesday, 13 November 2024)
Witnesses:
Helen Cain: CQC Inspector
Dr Benjamin Odeka: CQC Inspector
Mary Potter: CQC Inspector
Elizabeth Childs: CQC Inspection Chair
LADY JUSTICE THIRLWALL: Mr De La Poer.
MR DE LA POER: My Lady, we are now moving to a phase of the oral evidence hearings focused on the Care Quality Commission. Before we begin, it is important we say something about documents. Putting it neutrally, the disclosure process of material from the CQC to the Inquiry has not run smoothly, both in terms of its timing and its content. As matters stand, we understand there are a number of documents which were created at the time which are no longer available.
My Lady, you will be hearing from a witness tomorrow, Ann Ford, a person senior within the CQC, who will give evidence as to the detail of the disclosure process, which documents are missing and why. So far as the evidence of today is concerned, you will be hearing from those who conducted the inspection in February 2016 whose evidence would have been assisted by such material and as such, it's important I identify the missing material before you hear that evidence.
As the Inquiry understands it, first, there are no records available of a number of the pre-inspection meetings. Second, there are no records available of any of the core interviews with senior managers during the inspection. Third, there is an incomplete record of the focus group with the Consultants. Fourth, there are a number of other records which might have been expected to exist for the period following the inspection which cannot be found.
As we have said, why this is so will be a matter for the evidence tomorrow, but we thought my Lady ought to know that before we get to the witnesses who would have been assisted by it.
LADY JUSTICE THIRLWALL: Thank you very much, Mr De La Poer.
MR DE LA POER: My Lady, I will turn over to Mr Carr for the first of our witnesses.
LADY JUSTICE THIRLWALL: Very well.
MR CARR: My Lady, good morning. The first witness is Helen Cain.
LADY JUSTICE THIRLWALL: Ms Cain, would you like to come forward.
MS HELEN CAIN (sworn)
LADY JUSTICE THIRLWALL: Do sit down.
MR CARR: Can we start with your full name, please?
CAIN: Helen Cain.
CARR: You have prepared a statement for this Inquiry dated 23 June 2024, haven't you?
CAIN: Yes.
CARR: Is that statement true to your best knowledge and belief?
CAIN: Yes.
CARR: So far as your background, you explain in your statement that by profession you are a children's nurse?
CAIN: Yes.
CARR: You undertook training, becoming a Registered Nurse in 1987, you worked then as a Staff Nurse before training as a Registered Sick Children's Nurse in 1990?
CAIN: Yes.
CARR: In terms of other positions, you trained as a Health Visitor in 1994?
CAIN: Yes.
CARR: In June 2015 you commenced full-time employment with the CQC as an Acute Hospitals Inspector?
CAIN: Yes.
CARR: You remained employed by the CQC until May 2018?
CAIN: Yes.
CARR: Now, the CQC inspected the Countess of Chester Hospital, undertaking visits in February and March 2016?
CAIN: Yes.
CARR: They published a report on the hospital following that inspection on 29 June 2016?
CAIN: Yes.
CARR: The way that inspections work is that different inspection sub teams inspect different services or departments within a hospital?
CAIN: Yes.
CARR: Your role for the inspection was as the Core Service Lead, so you led the team looking into services for Children and Young People's Services?
CAIN: Yes.
CARR: It was that team that inspected the neonatal unit at the Countess of Chester Hospital?
CAIN: Yes.
CARR: Following the inspection visit, it was you who wrote the section of the report on Children and Young People's Services?
CAIN: Yes.
CARR: You had on your core team two Specialist Advisers: Dr Benjamin Odeka and Mary Potter?
CAIN: Yes.
CARR: We will be hearing evidence from them later today. How was their role as Specialist Advisers different to yours as a CQC employee?
CAIN: I would -- I planned the inspection, I reviewed the evidence that was available prior to the inspection and planned where myself and the Special Professional Advisers would visit on which days. I very much approached from a regulatory perspective to inspect under the Health and Social Care Act, the Specialist Professional Advisers were there to provide clinical support, to ask if -- if I had any queries from a clinical perspective, perhaps about best practice, current guidance. I would then -- we would all individually interview members of the service. We jointly interviewed members -- members of the management team for the core service. I would then review the templates at the end of each day, the note-taking templates that we had taken to ensure that enough evidence was collected to ensure that judgments could be made when the report and -- to satisfy the subheadings of the report.
CARR: What you have advised so far is the support that they gave you during the inspection visits. So far as their involvement before the inspection visits and following the inspection visit, in the lead-up to the publication of the report, is it right that they have little to no involvement?
CAIN: Yes.
CARR: So their main function is to provide support during the visit itself?
CAIN: Yes, and their clinical expertise.
CARR: Before we turn to consider the inspection in more detail, if we take a step back to look at the context, inspections are one of the two main ways in which the CQC regulates care providers, isn't it?
CAIN: Yes.
CARR: The other being monitoring?
CAIN: Yes.
CARR: And monitoring includes things such as carrying out engagement meetings?
CAIN: Yes.
CARR: As that's where you visit a Trust and see Executives or senior managers at the Trust?
CAIN: Yes.
CARR: Management review meetings, which are internal meetings amongst CQC employees?
CAIN: Yes.
CARR: You can make decisions as to what action, if any, you need to take in respect of a regulated care provider?
CAIN: Yes.
CARR: Also receiving information and data and assessing information and data relating to Trusts quite
apart from an inspection?
CAIN: Yes, yes.
CARR: Is it right that the information gathered as part of monitoring can help to inform inspections?
CAIN: Yes.
CARR: Now, amongst the data and information that the CQC receives aside from preparation for an inspection, are those relating to notifiable safety incidents?
CAIN: Yes.
CARR: There are two systems that I want to ask you about, firstly NHS England's National Reporting and Learning System. That is a system that is used to report patient safety incidents, isn't it?
CAIN: Yes.
CARR: Where a Trust reports to the National Reporting and Learning System, that satisfies the obligation on a Trust to notify the CQC of such incidents?
CAIN: Yes.
CARR: That is because the CQC has access to reports to that system?
CAIN: Yes.
CARR: Another reporting system is the Strategic Executive Information System?
CAIN: Yes.
CARR: That's a system to which Serious Incidents or Never Events must be reported by Trusts?
CAIN: Yes.
CARR: Again is it right that the CQC has access to reports to that system?
CAIN: Yes.
CARR: Returning to the 2016 inspection. I want to look at the information gathered ahead of the inspection. Can you explain the different ways in which the CQC receives information, specifically for an inspection?
CAIN: The -- the Trusts were sent six months ahead of inspection requests through the Provider Information Report and that was a spreadsheet asking for a lot of detail about services provided, performance, anything that the Trust might hold that would be useful ahead of the inspection. There was a Provider Information Return 1 and a Provider Information Return 2. Also ahead of the inspection, CQC data analysts would review data from a number of sources and provide each inspector for each core service a data pack or an intelligence pack to -- to support the information for inspecting the Trust ahead of, ahead of the on-site visit.
CARR: If we can deal then first with Provider Information Return. So that is documents provided by the Trust ahead of an inspection?
CAIN: (Nods)
CARR: As the inspector, the CQC employee, it was your job to review the Provider Information Return?
CAIN: For the core service, yes.
CARR: For the core service?
CAIN: Yes, because it came, there was a Trust-wide section and there was a core service section and within that, there was evidence in -- for the safe, effective, caring, responsive and well-led domain so there was a number of documents that would fit in in either of those tabs.
CARR: Then once you considered the Provider Information Return, there was an ability, wasn't there, for you to seek further information through a data request?
CAIN: Not ahead of the inspection. Ahead of the inspection, you would have the Provider Information Return and the analyst pack. Data requests from a core service perspective would have been requested either while you were on site or after the inspection.
CARR: If we can consider the role of the Special Adviser, Specialist Advisers.
Now, you have explained that they are not involved prior to the inspection?
CAIN: Yes.
CARR: Is there a process that you undertake, having looked at the Provider Information Return, to determine what documents, if any, you need to share with the Specialist Advisers?
CAIN: I think it, at the -- on the first morning of the inspection you would meet with the Specialist Professional Advisers, I would -- I shared the inspection plan and would, and discussed what evidence we had, what information we had and if there were any areas that we specifically or I specifically felt needed further attention.
CARR: Would you share documents received from the Trust, whether through a Provider Information Return or a subsequent data request, would you share that documentation with Specialist Advisers?
CAIN: Yes. I -- I have done. I can't remember on the Countess of Chester whether there was a specific, any specific documents, but certainly -- or if there was anything in the documents that came that I was unsure about, any clinical questions I had, anything that I needed clarification on from a clinical perspective.
CARR: So it sounds like -- correct me if I am
wrong -- the process is you consider the Provider Information Returns as part of your role and if there are documents which cause you concern, then you will share those with the Specialist Advisers for specialist advice?
CAIN: Yes. And my understanding was that the -- the intelligence report or the data pack that we had that they were also provided to the Specialist Advisers.
CARR: I am going to come to that in a few moments. Dealing first, please, with the adequacy of the documents received as part of the Provider Information Return, paragraph 19 of your statement, you say the following: "As noted at paragraph 8 above in preparing a statement I have only had access to the documents provided to me by CQC. I am confident that there were -- there was more information provided by the Trust as part of the PIR and in response to data requests which I have not been shown. I understand that CQC is working to locate these documents." What you are describing there is although you had been given some documents for the purposes of providing this statement --
CAIN: Yes.
CARR: -- you think there were more documents
obtained by the Trust for the purposes of this inspection?
CAIN: Yes. And the second cohort of documents that I received a couple of weeks ago, a lot of those I was referring to there have now -- were provided to me in the second collection of evidence.
CARR: Can you explain the nature of the documents that weren't provided to you initially that have more recently been provided that would have made up the Provider Information Return?
CAIN: I am trying to think what else came through. I -- to be honest I can't think of a -- a specific document that would have made up the Provider Information Return.
CARR: Again, dealing with this information or data and looking at paragraph 47 of your statement, please, there you state: "I do not recall having any concerns about the sufficiency of the information provided by the Trust in the PIR. However, it is difficult to comment on this without access to all the documentation." I want to cross-reference that with your paragraph 18 and there you describe that to the best of your recollection you requested additional documentation from the Trust ahead of the inspection?
CAIN: Not ahead of the inspection. The -- the requested documentation as data requests were as part of the on-site inspection or following the on-site inspection. The PIR, or the Provider Information Return, you have prior to the inspection while you are on inspection and afterwards for the purposes of writing the report further data requests are made, and that is what I am referring to there. By the time you get to inspection because of the six months lead-in time, a lot of the data is old data for want of a better -- and actually while you are on site, you want current data to inform the report.
CARR: If we can have on screen, please, INQ0103249, if we turn, please, to page 3 of that document. The email in the bottom half of that page dated 15 February 2016 from John Cunningham to Ruth Millward at the Trust. John Cunningham, he's a CQC employee, isn't he?
CAIN: I don't -- I don't know, if I honest, I couldn't remember.
CARR: This email -- and dated 15 February 2016, so that's a day before the inspection started.
CAIN: I would not have made any requests. The -- it looks like the core service, the accident and emergency and surgical care, but my practice, I didn't -- as far
as I remember and I don't think I ever did for any inspection -- make any requests prior to the inspection.
CARR: If we turn to page 4, please. This sets out a list of requests for documents and we can see the second half?
CAIN: Yes.
CARR: The bottom half of that page is made up of requests for documents concerning Children and Young People's Services. Is it your position that these requests were not made by you?
CAIN: No, they would have been made by me. Can we go back to the date of the --
LADY JUSTICE THIRLWALL: Sorry did you say "No, they would have been"?
CAIN: They would have been made by me, yes, these would have been my requests but my -- the inspection period -- it tended to be the inspection period I would have counted as that week. I mean, to be honest, I can't remember whether the Monday was -- but I would have made it in this inspection period. Maybe I am not making myself clear. The -- that week was the inspection period. The period of the on-site inspection.
MR CARR: So you asked to see the date, it is on page 3. It is 15 February 2016, so it is a day before
the first visit.
CAIN: So it must -- the, that was the period of the inspection week. So it would have been that -- that I would -- I would take as the week of the inspection.
CARR: Back to page 4. So these requests for additional documents in this service area, these have come from you?
CAIN: Yes, and as part of the inspection as part of the on-site inspection.
LADY JUSTICE THIRLWALL: Do you know why you would have said "pre-inspection requests"?
CAIN: I think no, I don't. If I am honest, my understanding is that that was the inspection week so although we hadn't arrived on site, that was the week of the inspection.
LADY JUSTICE THIRLWALL: So I suppose from the perspective of the hospital, these were requests made before the inspection? Because it was before you were in the hospital.
CAIN: Yes, from the Trust's perspective. But I think it would have -- from my CQC perspective this was part of the on-site inspection. Making the distinction between these and the Provider Information Report that would have been sent evidence through up to six months before the inspection.
LADY JUSTICE THIRLWALL: Yes. But so we are clear, you did ask for them before you got to the hospital?
CAIN: Before we were actually on site.
LADY JUSTICE THIRLWALL: Yes, yes, thank you.
MR CARR: Thank you. And you described a few moments ago that one of the reasons for a data request might be that by the time you arrive at a hospital the information obtained under a Provider Information Return might be a bit out of date?
CAIN: Yes.
CARR: So if we look at some of the entries here, fourth from the bottom: Paediatric speciality meeting minutes for the last two months, while they wouldn't have been included in a Provider Information Return that came six months previously?
CAIN: They couldn't have been because I wouldn't have asked for them if they had.
CARR: Yes. The penultimate entry you have asked for minutes from the Paediatric Mortality and Morbidity Meeting from 10 December 2015. Why were you asking for that?
CAIN: Because it's -- it's part of the inspection process, part -- for the subheading of incidents in the safe domain to ensure that, for the -- to see how the Trust assure themselves that they are reviewing deaths and learning from them. Every Trust should have a mortality and morbidity process. Part of the inspection process is to identify how the Trust assure themselves they are learning from that, they are following the process and learning from deaths and subsequently assure the CQC that the process is in place and it's being followed.
CARR: Page 5 of this document, please. The first entry. "Incidents relating to neonates and paediatrics, last 12 months"?
CAIN: Yes.
CARR: So you are asking there for incidents leading right up to the time of the inspection?
CAIN: Yes.
CARR: Again that is presumably because you want the most up-to-date information as to what's going on in the hospital?
CAIN: Yes.
CARR: Did you receive all of the documents that you requested?
CAIN: No.
CARR: Which documents did you not receive?
CAIN: The only one that I can remember specifically is the Mortality and Morbidity Meeting minutes from
10 December.
CARR: When did you receive the documents that you had requested?
CAIN: It could -- it was -- it could be immediately, it could be during the period of the inspection. It could be subsequently following the on-site visit.
CARR: Do you know which of those applied here?
CAIN: I'm sorry?
CARR: Do you know which of those timeframes applied on this inspection, did you --
CAIN: It was that -- it would -- it could be any time. The Trust -- during the inspection the Trust were questioning, we were -- the CQC requested a lot of documents from the Trust and it was quite an undertaking for the Trust to provide all the documents for all the core services as they were required.
LADY JUSTICE THIRLWALL: Sorry, just so that I understand this, so you made the request for all the documents that we are looking at now before you got there but then did you make more requests for more documents while you were there?
CAIN: It is possible.
LADY JUSTICE THIRLWALL: Well, can you help a little bit more than that?
CAIN: Sorry, yes, yes, I would have done. Normal
practice, I -- I would take although the day before the on-site inspection it is part of the inspection period which is I think where my confusion has come between making them months before or weeks before and the day before. If it was the week of the on-site inspection that I would -- my interpretation is that that is part of the inspection week. Those documents that we had asked for would come through in tranches, either myself or any of the other core services leads, it could be the next day, it could be with -- on the inspection time, we were on site, it could be subsequent to the site visit.
MR CARR: What was the nature of the further documents that you requested after 15 February?
CAIN: I am sure -- I would have to have a look to see what I have requested.
CARR: The other page is page 4.
CAIN: There would definitely be staffing information because during the on-site inspection, nurse staffing on both the paediatric unit and the neonatal unit was identified as a cause of concern.
CARR: In circumstances where a data request is not made until the day before the inspection visit starts, and may not be responded to until after the inspection visit occurs, any documents received afterwards can't be
discussed with the people you are interviewing?
CAIN: Usually the request for a document has come as a result of an observation or a discussion on site.
CARR: Well, this request is dated 15 February, so it can't have come as a result of an observation or a discussion?
CAIN: I'm sorry, I think -- there were -- you would -- there would be a normal number of documents that you would request as a matter of course to support the judgment making. And this -- you would -- these are part of those requests.
CARR: Wouldn't you want to see up-to-date information and to receive it prior to conducting interviews?
CAIN: It -- it would depend on the information. Some of it is information that you require to -- to support the judgment. Some of it is to provide assurance of what, of the service that's been provided. So not every piece of evidence requested would require a conversation. You wouldn't need to ask about every piece of evidence.
CARR: Yes, but you wouldn't know what you need to ask questions about or not until you have received it and assessed it?
CAIN: Not necessarily. Because some of the information you would ask -- you would request would -- you would request for every inspection. Not all of it would be focused from a conversation.
CARR: We can take that document down now, thank you. Can we consider information relating to deaths and mortality, please. If we turn to paragraph 20 of your statement, you say there: "I would expect to receive information relating to neonatal deaths prior to an inspection."
CAIN: Yes.
CARR: At paragraph 22, you say: "I would hope to receive information regarding an increase in neonatal deaths before or during an inspection." Would you not expect also to see information about an increase in neonatal deaths rather than hope?
CAIN: The -- I think the distinction is the information would be about neonates, about -- it would be expected -- that's what I would expect to see. If there was an increase I would, I would hope that that would have been highlighted in the evidence.
CARR: Why would you not expect an increase in neonates to be part of the evidence that you see?
CAIN: Can you repeat the question again, please?
CARR: Why would you not expect an increase in neonatal deaths to be part of the evidence that you would see?
CAIN: Well, I would hope it would be provided but not -- not every Trust would, would highlight if there was an increase. Often mortality is -- is one of the things that we would always look at, always -- or the CQC would always look at as part of the inspection process. If there was anything out of the ordinary, that's what I would hope that the Trust would highlight that.
CARR: The query is why isn't there an expectation, is an increase in mortality not something that you would expect to see as a matter of course for an inspection and if not, why not?
CAIN: Well, I would expect it but I wouldn't -- I am not, I wouldn't think not every Trust would -- would provide it.
CARR: Not every Trust would meet your expectation --
CAIN: Possibly.
CARR: -- is your concern but your expectation is if there is an increase --
CAIN: That.
CARR: -- you would want to see it?
CAIN: Absolutely.
CARR: At paragraph 24 you state: "At the time of this inspection, I would not have known how many neonatal deaths would be usual for the neonatal unit and how many would constitute an increase. At that time, I would be reliant on either the Child and Young People's Services Special Advisers or the Trust itself to highlight any such increase in deaths to me. This did not occur in relation to this inspection." How would you expect the Trust to highlight neonatal deaths and how many would be usual for the unit?
CAIN: When we discussed in a discussion because mortality and morbidity was discussed as part of the interview with the -- at the core service level with the core service, the leadership team for the specialty.
CARR: So your expectation is that that is information that would emerge at interview?
CAIN: Yes.
CARR: But why wouldn't you expect it to be provided in advance?
CAIN: Because my experience was that some Trusts you would have to ask for the information rather than it being automatically provided.
CARR: When you describe being reliant on Children and Young People's Specialist Advisers, as to what is
a usual number of deaths for a neonatal unit or what constitutes an increase, how would the Specialist Advisers be able to advise you on that if they aren't given the data contained in Provider Returns?
CAIN: Because it's not always -- not all of it is in the Provider Return. And I think it would be in the -- because they were in the interviews with us, with me when I interviewed the service leaders and we talked about neonatal mortality and morbidity. I think if there was anything out of the ordinary that's where I would hope the Special Professional Advisers would be able to provide that clinical expertise and that knowledge of perhaps what would be normal for a unit of this size.
CARR: At any point did you raise with either the Trust or the Specialist Advisers or the CQC that you were missing information as to the usual death rate or what would constitute an increase in neonatal mortality?
CAIN: No.
CARR: At paragraph 25 of your statement, when addressing unexpected or unexplained deaths, you say and it's the final sentence of that paragraph: "I would expect unexpected or unexplained deaths to have formed part of the documentation provided to the CQC." Now we are about to look at some of the documentation. But from who and how would you expect that information to be provided?
CAIN: Through the Provider Information Return.
CARR: When you considered the Provider Information Return did you find anywhere in there clear documentation setting out details regarding unexpected or unexplained deaths at the neonatal unit?
CAIN: Not that I remember.
CARR: Again, did you raise with the Trust or the CQC the absence of that information?
CAIN: No.
CARR: I asked you earlier about the two NHS England reporting systems: the National Reporting and Learning System and the Strategic Executive Information System, so the systems for reporting serious incidents and patient harm incidents?
CAIN: Yes.
CARR: You explained that the CQC tracks those systems as part of its monitoring. For the purposes of preparing your evidence, you have been provided the spreadsheets, haven't you, showing entries on those two systems --
CAIN: Yes.
CARR: -- containing reporting made by the Trust.
Now, I am not going to put that document on screen because it contains sensitive third party information but you will have seen from those spreadsheets that on 3 July 2015, the Trust reported to the Strategic Executive Information System for Serious Incidents and Never Events the inspected potentially avoidable death of Child D?
CAIN: Yes.
CARR: It was reported as a Serious Incident, due to what was reported as a delay recognising sepsis. Were you made aware of that report in the course of your preparations for the inspection?
CAIN: Not that I can remember.
CARR: The deaths of Child A, Child C, Child D, Child E and Child I were reported to the National Reporting and Learning System in the months prior to your inspection. Were you aware of the reports made to the National Reporting and Learning System?
CAIN: No, not that I remember.
CARR: Given the CQC has access to that information and tracks those systems, should it have been provided to you?
CAIN: My -- my understanding is that the intelligence report provided by the CQC data analysts reviews Serious Incidents Never Events and provides that
information for the core service ahead of the inspection. I don't remember from the intelligence pack those being highlighted.
CARR: We will look at some of the documents relevant to the inspection in a few moments. But they don't identify, do they, the report of the Serious Incident of Child D?
CAIN: No.
CARR: And they don't make any mention at all, do they, of the entries that I have described, to the National Reporting and Learning System, in respect of Child A, Child C, Child D, Child E and Child I?
CAIN: No.
CARR: Had you been given access to this information would it have changed your approach in preparing for or conducting the inspection?
CAIN: Yes.
CARR: How so?
CAIN: Because it would have been more of a focus of the inspection. There would have been more direct questions asked about mortality and morbidity.
CARR: And something that you would have investigated?
CAIN: Absolutely.
CARR: A document that you did receive, and again I am not going to put it on screen because of the sensitive third party information it contains, is one that I understand was prepared by the Trust, it is a spreadsheet titled "NNU Paediatric Incidents 1 December 2015 to 31 January 2016".
CAIN: Yes.
CARR: You know the spreadsheet that I am referring to?
CAIN: Yes.
CARR: It contains in total some 377 entries?
CAIN: Yes.
CARR: It's arranged over six columns with a column for an ID number?
CAIN: Yes.
CARR: A column for the date of the incident?
CAIN: Yes.
CARR: A column for the location of the incident?
CAIN: Yes.
CARR: And then there is a column which is colour coded for actual harm with green for none, yellow for low, so low harm, orange for moderate harm and red for severe harm?
CAIN: Yes.
CARR: Then there is a description of the incident in question?
CAIN: Yes.
CARR: What was your understanding as to the basis for that document, how it had been prepared?
CAIN: It was a list, with detail, of all the incidents that had been reported in the Children and Young People's Service within that timeframe.
CARR: The presentation of that document, is that a standard document that you would see for most inspections?
CAIN: Yes.
CARR: It's quite a substantial document, isn't it?
CAIN: Yes.
CARR: It runs to some 25 pages with as I said what appears to be 377 entries. Are you confident that you would have read each and every entry or is it likely that you would focus only on those coloured red for severe or orange for moderate?
CAIN: I would have looked at every incident.
CARR: Eight entries in that table include in the description death, don't they?
CAIN: Yes.
CARR: Now the first query. Would you expect all neonatal deaths on a unit to be included in a table such as that?
CAIN: Yes.
CARR: And those eight entries, they are all marked green for none, aren't they, in the "Actual harm" column?
CAIN: Yes.
CARR: Can you explain your understanding of the "no harm" categorisation? It's paragraph 58 if you want to see what you said in your statement.
CAIN: My understanding was the clinician completing the incident form made the assessment that no harm had occurred as a result -- direct result of the clinical care provided. So not that the death in itself wasn't harmful but in their opinion when they were completing the incident form, that no harm had occurred as a result of the treatment or care.
CARR: Did it strike you as odd that cases involving death were marked "no harm"?
CAIN: No, for the reasons I have just mentioned.
CARR: Did you share or discuss this table or the entries in the table with the Specialist Advisers?
CAIN: I can't remember.
CARR: Do you think this is a document that you should have shared or discussed with the Specialist Advisers?
CAIN: I think incidents would have been discussed. I can't remember exactly the detail of, of the conversation.
CARR: Dr Odeka, one of the Specialist Advisories and we are going to be hearing evidence from him later today, but in his statement when looking at this table he reviewed it for the purposes of his statement. He says that the categorisation struck him as inaccurate and he wondered if the data was being inputted into the Datix system incorrectly. Now, if you had had a discussion with him about this table, at the inspection, and he told you that he considered the categorisations to be inaccurate, how would that have affected your conduct of the inspection?
CAIN: It would have been one of the questions asked with the service leads.
CARR: If you can turn to your paragraph 57, please. It's the first sentence. When dealing with this table you say: "Overall, nothing from the table of incidents appeared immediately concerning when I reviewed it in advance of the inspection." That would suggest, then, when looking at the table, reading all of the entries, you weren't concerned as to whether the categorisation, particularly of events
involving child death, was or might be incorrect?
CAIN: No.
CARR: Going back in your statement to paragraph 51, and again this is a reference to one of the entries in that table, it's one concerning Child A and it's entry 188 in the table, the spreadsheet. You describe the entry there, what the entry in the table says is: "Sudden and unexpected deterioration and death of a patient on the neonatal unit after full resuscitation. Requiring postmortem." So within the description in the table you have a reference, don't you, to a Sudden and Unexpected Death?
CAIN: Yes.
CARR: There is a suggestion -- well, it's clear, not a suggestion -- that the cause of death is yet to be ascertained?
CAIN: Yes.
CARR: It is awaiting postmortem. Now whilst this has been marked "no harm" in the table, there's nothing in the description that explains or seeks to justify why it's been marked "no harm"?
CAIN: But there was no evidence, there was no -- nothing in the description to suggest that there was any harm caused.
CARR: Well, it may be that you are making the same point. The description identifies a sudden and unexpected deterioration and death. There is no cause of death. There is nothing on the face of that description which would justify a no harm or any other categorisation, there is an absence of an explanation for how to categorise it?
CAIN: Yes.
CARR: Now, in light of that, wouldn't you want to explore at the inspection, for instance, why the death was unexpected and whether an explanation had been obtained?
CAIN: The role of the inspection is not to look at specific -- specific incidents. It's to ensure that there is from a regulatory perspective, there is a process in place to ensure incidents like this are identified, reported, identified, investigated and lessons learnt. So individual examples of incidents would not be pursued. But, however as part of the inspection, evidence would be requested to ensure that that mortality and morbidity process was being followed. So as part of the inspection and certainly in my inspection report I do mention that I reviewed three incident
reviews to ensure the process was taking place so that how -- to identify how the Trust assured themselves that they were investigating incidents and learning lessons and how that information was disseminated.
CARR: Part of the regulatory function and considering, for instance, whether incidents are properly reported and lessons learnt would involve, wouldn't it, considering whether incidents are properly categorised?
CAIN: Yes.
CARR: If on reading a table you saw an entry involving an unexpected death without an explanation, that would be a very pertinent -- that would be marked "no harm", that would be a pertinent example to test the processes in place for reporting and learning lessons?
CAIN: Yes. But like I said, I -- my report states that I looked at three incident reviews, I can't say which incidents they were but that to ensure that the process was being followed.
CARR: Well, paragraph 49 of your statement deals with the entry in the table concerning Child E and although not set out in your statement, the entry in the table, it's line 200, also lists the death as an unexpected one, albeit marked green for "no harm". Again a similar question: wouldn't that warrant
discussion and exploration to test the system of reporting, to test the system of categorisation?
CAIN: And the process was tested, like I say, I did -- we talked about incidents with numerous members of staff about incident reporting, about what would be reported, how it would be reported, how things were investigated, how lessons were learnt. And as part of that process, I reviewed three incident reports. I can't tell you which ones they were because that's part of the information that I have not been privy to. But so it was tested, the process was tested. I just can't tell you which specific incidents it was.
CARR: You say the process was tested. How was it tested?
CAIN: I would, I requested the reviews so I would look -- looked at the review reports to ensure that the mortality and morbidity process was being followed, that the appropriate information was included in the report, if there were any lessons learnt, what the actions were, and how they were disseminated to staff, where they would be discussed, whether that be at governance meetings as well as Mortality and Morbidity Meetings and what -- what the progress was with the actions as a result.
CARR: How did you test the categorisation of incidents within Children and Young People's Services?
CAIN: Through discussion with staff so I would ask, I asked staff as a matter of course in an inspection: what would you report? How would you report it? What type of incidents would you report? Where would you find the policy? Do you know what the policy says? Could you access it? Often I would ask individual members of staff what was the last incident you did report, did you have feedback, were there any lessons learnt? How are lessons learnt shared? And where are they discussed?
CARR: Please can we have up on screen INQ0017411. The section of your statement dealing with this is at paragraphs 59 to 62. What we have on screen is an email from Alison Kelly at the Countess of Chester Hospital to Ann Ford. Ann Ford is another CQC inspector, isn't she?
CAIN: No, she's actually -- she was actually the head of hospital inspection at the time of this inspection.
CARR: Forgive me, she's a CQC employee rather than a specialist adviser?
CAIN: Yes.
CARR: And this is an email that you address in your statement. If we look under the heading "Context", you will see that what Alison Kelly writes is: "The Trust has identified an increase in the number of deaths of newborn babies differing levels of prematurity on our neonatal unit in 2015 to 16 and now in 2016 to 17 compared to previous years. "An in-depth thematic medical review of the individual cases was undertaken internally followed by a subsequent peer review by a Consultant from Liverpool Women's Trust. However the reviews have failed to identify any cause or common theme for this increase. These reviews were submitted as part of our recent CQC inspection data pack." Now, the first point to make is in terms of the date of that email it is 30 June, so that is the day after the CQC inspection report had been published?
CAIN: Yes.
CARR: The final line of the paragraph I read, that is in parentheses, that suggests that two reviews were shared with the CQC and you have been given access to those reviews for the purposes of preparing your statement, haven't you?
CAIN: Could you clarify which reviews you mean?
CARR: Yes, it is the Dr Brigham report from 2015?
CAIN: Yes.
CARR: November 2015, forgive me. And the Thematic
Reviews involving Dr Subhedar from February 2016 and then another version dated March 2016?
CAIN: Yes.
CARR: Now, in your statement you explain you do not recall seeing any of those reviews?
CAIN: At the time of the inspection?
CARR: Yes.
CAIN: No.
CARR: At paragraph 62 of your statement you say: "I do not think I requested this review from the Trust. If it was requested by anyone else at CQC it may have been one of the senior members of the CQC team." In respect of the comment "I do not think I requested the review from the Trust", were you aware, before seeing for the purposes of preparing your statement, that those reviews had been undertaken?
CAIN: No.
CARR: Was there any discussion of those reviews during your inspection?
CAIN: No.
CARR: Now we can, I can put -- we can take that down now please, thank you. I can put the reviews up if necessary but you have looked at both of them, the November 15 review starts by stating:
"In response to a perceived increase in number of stillbirths and neonatal deaths at the Countess of Chester Hospital in 2015 it was decided to set up a panel to independently review all of these cases again." The February 2016 Thematic Review starts by saying: "There was a higher than expected mortality rate on the neonatal unit in 2015." Now, if you had become aware of the existence of those reviews, during your inspection, would you have requested them?
CAIN: Absolutely.
CARR: Had you received and considered those reviews and for the moment I am talking just about those two, so the November 2015 review and the first version of the Thematic Review dated February 2016, how would that have affected your preparation for or conduct of the inspection?
CAIN: Rather than just review the mortality and morbidity process and how it was being followed and how the Trust were assuring themselves in more general terms, there would have been specific questions asked about what action is being taken following identification of either a perceived or an increased rate in neonatal mortality.
CARR: Paragraph 67 of your statement, the second sentence, you state: "I would have hoped to have been provided with the information in these reviews." Again I am going to ask you about the use of the term "hope". Would you not expect to receive the reports or at least the information contained in them?
CAIN: If -- if a review of this nature had taken place, I would have expected it. However, not all Trusts are as open and transparent as you would hope that they would be in the inspection process.
CARR: Would the fact that two internal reviews had been carried out -- well, sorry, two reviews, one internal one, involving a Consultant from another hospital, what would that tell you about the level of concern about the neonatal mortality?
CAIN: It would tell me that they had identified that there was an increase in mortality, that it had been recognised and that clinicians were looking into why that was. It's -- for want of a better expression, spikes in mortality happen within healthcare. It's about identifying it and trying to explain or find the reasons for it. So that would suggest to me that they had identified it and were investigating further. Having reviewed each case individually, they were also looking at neonatal mortality in a wider context to see if they could identify anything, any common cause, anything that could be acted on.
CARR: The second version of the Thematic Review and we will get it up, it's INQ0003251, please. Now, although on the first page there it has the date, 8 February, 2016, which refers to a meeting, this version of the document is actually dated 2 March and so that is after the planned visits at the hospital in February, it's a day before the unplanned visit because you went back in March, didn't you?
CAIN: Yes, I did.
CARR: 4 March. It is some four months prior to the CQC report being published --
CAIN: Yes.
CARR: -- isn't it? If we look at page 7 of this document, please, and it's at number 1 on that page, under the heading "Themes identified during discussion of all cases", and this is one change from the previous version of the report in that you can see there: "One sudden deterioration. Some of the babies suddenly and unexpectedly deteriorated, but there was no
clear cause for the deterioration/death identified at postmortem." So clearly identifying there unexpected and unexplained deaths. Now, three questions, please: firstly, if the first report had been provided to you, that is the 8 February version of this report, had been provided to you prior to or at the inspection, would you expect an update of that same report also to be provided?
CAIN: Yes.
CARR: Even if that first report had not been provided to you at the inspection, would you expect this updated version of the report, particularly in light of what is highlighted on the screen in front of you at number 1, would you expect a reporting containing that to be provided to you prior to the finalisation of the report?
CAIN: Yes.
CARR: If you had received this document, post the planned visit, but just before you returned for the unplanned visit, what would you have done with it? Would you have been able to conduct further investigations as a result?
CAIN: It would -- there would have been further enquiries made, it would have been one of the -- one of
the focus, a focus of the unplanned visit. It would have given an opportunity for questions to be asked.
CARR: So a point that you have made in respect to a number of these entries that we have looked at and in a number of documents that we had gone to is that, well, if you had seen that information, it would have given you an opportunity or you would have asked more questions, you would have focused on the issues arising. Is the position that when you went to the inspection you didn't focus on issues concerning neonatal mortality, you didn't ask direct questions in those areas, because you were unaware of the concerns that we now know there were?
CAIN: Yes.
CARR: Now, on a related point, if we can -- we can take that down, please -- go to another document, INQ0103620, and it is page 7 of that document, please. Now, this is titled "Self Assessment from PIR", it is Provider Information Return. So this appears to be a form filled out by the hospital ahead of inspection where they assess themselves and identify what they think their ranking should be?
CAIN: Yes.
CARR: For services for children and young people,
which was the sector that you were dealing with, we can see it is a very positive self assessment, isn't it?
CAIN: Yes.
CARR: It's the most positive -- well, equally with maternity and gynaecology -- of all the services?
CAIN: Yes.
CARR: Three good, two outstanding. What impact would a positive self-assessment like this have on your preparation for an inspection?
CAIN: It wouldn't have any impact.
CARR: Well, you have commented that if you had known about some of the concerns that we have been looking at, then you would have asked more direct questions about those concerns. Does the converse apply? So where you have a service which is representing itself as "good" and "outstanding", does that give a level of reassurance or mean that you don't have to focus questions so much on any troubled areas?
CAIN: No, because the -- the inspection and the core service frameworks which we followed and the key lines of enquiry, you would look at every area equally and follow the evidence. So prior to inspection, if there was anything that you particularly wanted to look at you would identify it, but as part of the inspection process, all areas would be looked at. If a Trust thought that they were outstanding in caring, that wouldn't mean that you wouldn't look at caring. You would look at it equally regardless of how they rated themselves.
CARR: We can take that down. If we look please now at document INQ0101422. This is a document created by the CQC. It is labelled "Pre-inspection document". What is the purpose of this document?
CAIN: It's to bring together evidence that -- by the CQC analysts evidence that is available to support the inspection.
CARR: So I have seen references in the evidence to a data pack. Is this the data pack?
CAIN: This and the intelligence document, the subsequent intelligence document that was used in the presentation.
CARR: Is this a document which would be provided to the Specialist Advisers?
CAIN: To my recollection, yes.
CARR: And if we look, please, at page 5 of this document we have here a summary of analysis. So this will be based on the Provider Information Returns and the other documents available to the CQC?
CAIN: Available to the CQC analysts, yes.
CARR: Whilst there are other versions in the documents provided by the CQC of this, it doesn't appear that this analysis was ever updated. Have you seen another version of this document with this information --
CAIN: The inspection plan has actually got a differing date for the no Never Events and Serious Incidents -- sorry, the intelligence pack.
CARR: Because we see there the first entry "No Never Events or Serious Incidents have been reported by the Trust between November 14 and October 15." Well, you know from looking at that entry on the STEIS report that that's not correct, is it?
CAIN: Now -- now, yes.
CARR: There's nothing in this document about reports to the National Reporting and Learning System, is there?
CAIN: No.
CARR: We will look at one more document before the break, please. We can take that down now. It is INQ-- sorry, ready? -- INQ0106785. And if we go, please, to page 7. This is titled "Inspection framework". We didn't need to zoom in on that, we don't need to zoom in. It's page 7. This is titled "Inspection Framework
NHS Acute Hospitals". Are you familiar with this document?
CAIN: Yes.
CARR: And it appears to act as a guide for the issues to be considered for the purposes of a Children and Young People's Services inspection?
CAIN: Yes.
CARR: In particular for preparing the report?
CAIN: Yes.
CARR: If we look, please, at page 10, in the second half of the page, the box titled "Safe". To clarify, "safe" is one of the categories against which you would be inspecting a hospital and grading it?
CAIN: Yes.
CARR: In the first box under the heading it describes what safe means: "By 'safe' we mean people be protected from abuse and avoidable harm." The box underneath that requires further investigation: "Never Events involving children and young people Serious Incidents involving children and young people reports to NRLS re: moderate and above incidents."
CAIN: Yes.
CARR: And so that is identifying all the categories
that you need to look at in order to make a determination, an assessment of the safety of a service?
CAIN: Yes.
CARR: And if we look at page 11, please, the next page, under the heading "Incidents", and relevant to S2, "What is the track record on safety?" The first bullet point: "What is the safety performance over time based on internal and external information?" So looking at safety performance, you would want to look at outcomes and you would want to look at outcomes over a period of time to see how a service is performing?
CAIN: Yes.
CARR: Bullet point 2: "How does safety performance compare to other similar services?" So you would want to carry out a comparison with like services?
CAIN: Yes.
CARR: 3: "Do staff understand their responsibilities to raise concerns, to record safety incidents, concerns and near misses and to report them internally and externally?" Now, the reference to reporting externally safety incidents, that would be reporting externally to whom?
CAIN: NRLS, STEIS. At the time the Clinical Commissioning Group; those sorts of people.
CARR: Now, in respect of those first two entries: "Safety performance over time, how does safety performance compare?" Did you obtain evidence as to the safety performance over time or the comparison with like units?
CAIN: That was the intelligence that the CQC analysts provided.
CARR: At page 19 of this document, please, under the heading "Effective": "Requires further investigation ..." Sorry, two boxes down, in bullet points "NRLS incident" and that is not restricted, is it, it doesn't say "only moderate"? That has an NRLS incident and then secondly STEIS -- Serious Incident, STEIS, Never Events. So in order to assess in the "effective" category this document is suggesting that you look at the entries on those reporting systems or you obtain evidence of the entries?
CAIN: But all those incidents that would be going to NRLS and STEIS would be part of the multiple incidents
that were reviewed as part of the spreadsheet. So they would be on the incident spreadsheet, they would then be reported -- those that required reporting would then be reported up to NRLS or STEIS. So they should have already been part of the incident spreadsheet.
CARR: Yes, you reviewed the incident spreadsheet. It doesn't identify does it whether any of the entries were reported to NRLS or STEIS?
CAIN: Not that I am aware of,, that I can remember.
CARR: When I was asking you earlier about the STEIS report in respect of Child D, your recollection was that you were unaware that there had been a report to STEIS in respect of Child D?
CAIN: Yes.
CARR: You were unaware of the reports in respect of several children to NRLS?
CAIN: Yes.
MR CARR: My Lady, that would be a convenient moment for a break, if it pleases you?
LADY JUSTICE THIRLWALL: Thank you very much indeed. So we will take a break now and we will come back in at 20 to.
(11.21 am) (A short break)
(11.40 am)
LADY JUSTICE THIRLWALL: Mr Carr.
MR CARR: Thank you. I asked you about the document dated December 2015, the pre-inspection document and I took you to what you said about Never Events being reported and you mentioned that there had been an update from the December document to the intelligence briefing. I just want to get that intelligence briefing back up, it's INQ0103620. So that we can understand the purpose of this document, it appears to be a PowerPoint presentation for, a presentation on 16 February, the first day of the inspection visit?
CAIN: Yes.
CARR: It would be a presentation to who?
CAIN: To all the inspection teams.
CARR: And so the Specialist Advisers would see this?
CAIN: Yes.
CARR: Would they be given a copy of it as well or would it just be on the screen?
CAIN: I don't know, to be honest.
CARR: If we go to the section dealing with Children and Young People's Services the summary of intelligence is takes up only two pages. Page 27. We see the first bullet point there:
"No Never Events or Serious Incidents reported up to January 2016." So although it is right to say that the December 2015 document was updated to January 2016 --
CAIN: Yes.
CARR: -- it still has the same omission, doesn't it?
CAIN: Yes.
CARR: The summary of intelligence doesn't include, does it, any entries from the National Reporting and Learning System?
CAIN: No.
CARR: Thank you. We can take that document down. There is a pre-inspection briefing pack which presumably was provided to you and Specialist Advisers which set out the key lines of inquiry to explore?
CAIN: Yes.
CARR: I am not going to take you to that, I am going to move forward, please, to the inspection itself. Now, ahead of the inspection, a week before, there was a listening event for patients on 9 February 2016, but as I understand it you didn't attend that?
CAIN: No.
CARR: Did you receive any feedback of any issues raised at that meeting?
CAIN: Not that I remember.
CARR: There was a briefing inspection -- sorry, an inspection briefing session on 10 February but again I don't think you attended that?
CAIN: I can't remember, to be honest.
CARR: As to interactions with the Special Advisers, did you meet or have any discussions with the Special Advisers before turning up at the hospital for the inspection?
CAIN: I can't remember but my usual practice was to telephone the Special Advisers just to introduce myself. That was my usual practice. I can't say for sure whether this happened at the Countess of Chester.
CARR: Now, the visit, the planned visit occurred over three days: 16, 17, 18 February?
CAIN: Yes, and if I am correct, possibly on the Friday, the -- possibly the 19th as well if -- I am trying to think. That inspection week tended to be three and a half days for the CQC staff, that's generally what happened, you would have three days with the SPAs and then I am sure the CQC staff were around until the Friday lunchtime.
CARR: 16 February you did a walk through the neonatal unit with Yvonne Farmer?
CAIN: Yes.
CARR: You also did a walk through the paediatric
unit, so the 16th was walk around the units and getting familiar with the hospital?
CAIN: And collecting evidence as we went, so any observational evidence, perhaps cleaning checklists, anything -- anything that was obvious from an observational perspective.
CARR: On 17th and 18th you conducted a number of interviews. Now you have described those in your statement at paragraphs 88 to 108: I count 16 interviews in total and some interviews with were multiple members of staff?
CAIN: Yes.
CARR: Now, at paragraph 113 of your statement, please, you state: "I did not discuss concerns about an increase in neonatal deaths with any of the interviewees." Paragraph 114: "I did not discuss concerns about unexplained or unexpected deaths with any of the interviewees." Is the position that you didn't discuss unexplained or unexpected deaths at all?
CAIN: We discussed mortality and morbidity in the process, not specifically unexplained or unexpected deaths.
CARR: So there's no discussion of neonatal
mortality?
CAIN: Yes, discussions on neonatal mortality, absolutely. In the lead, in the service leads' interviews we discussed neonatal mortality.
CARR: I am going to take you to those notes in a few moments, but that was a discussion of Mortality and Morbidity Meetings, there was no discussion, was there, of mortality rates, the experience of mortality at the hospital?
CAIN: Nothing, no, nothing like that.
CARR: No discussion of incidents of unexplained and unexpected deaths at all, so not simply there was no discussion of concerns; the topic of unexpected and unexplained deaths was not discussed?
CAIN: No.
CARR: None of the entries in the table of paediatric incidents that I have taken you to concerning death, none of those were discussed?
CAIN: Not specifically.
CARR: And nothing on the NRLS or STEIS concerning deaths was discussed because you weren't aware of those entries?
CAIN: No, because all the entries -- any entries to NRLS and STEIS would have come from the incident table. So --
LADY JUSTICE THIRLWALL: Sorry, would you mind just saying that again because there was noise.
CAIN: Certainly. The NRLS and STEIS reports would have come from the incident table. So all the incidents in the table, those that were required would have then gone to NRLS or STEIS.
MR CARR: Turning to the discussion of -- forgive me, my Lady.
LADY JUSTICE THIRLWALL: Yes, sorry do go ahead.
MR CARR: Thank you. Turning to the discussion of Mortality and Morbidity Meetings that you have described. Can we have on screen please, INQ0017339. Page 206. These are your notes of a meeting, aren't they?
CAIN: Yes.
CARR: And this was a large meeting as we can see in that there were a number of attendees, we can see in the middle of the page the box for attendees, we have Dr Brearey, Dr Jayaram, Anne Murphy, Sarah Jackson, Gill Mort, Karen Townsend, Karen Rees and Eirian Powell?
CAIN: Yes.
CARR: This was a meeting I think you described it as a team leads meeting?
CAIN: A service leads meeting, a core service leads meeting.
CARR: All three of the -- or rather you as the inspector and the two Specialist Advisers all attended this meeting?
CAIN: Yes.
CARR: The discussion that you have referred to, which was of Mortality and Morbidity Meetings rather than neonatal mortality, we see your notes of it at page 207. It is the bottom third of the page, I know you have translated this in your witness statement, it's difficult to read. Can you help us with that section?
CAIN: Certainly. So Mortality Morbidity Meetings we discussed, there was five from the neonatal unit last year, four this year, with obstetricians and midwives. Neonatal mortality, two last year depending on the cases to be discussed. Two paediatric mortality meetings numbers were fairly small. Majority were teenage suicides for the last meeting. Awaiting an action plan from a serious case review, cases were reviewed by the Cheshire and Merseyside Neonatal Network and peer review and monthly governance meetings, paediatric, neonates, obstetricians, gynaecology and governance board.
CARR: If we can zoom out, there is a note on the right in the margin of that box to the bottom right
text. Yes. Can you tell us what that says?
CAIN: The leads told us that the neonatal meetings hadn't happened as frequently as they would have liked but they were back -- back on track now.
CARR: Thank you. If we can go back to the main box then and zoom in and just try to understand this. We can zoom in. The "times 5 from NNU last year, time 4 this year", so that's referring to Mortality and Morbidity Meetings?
CAIN: For the Perinatal Mortality Meetings so with the obstetricians and the gynaecologists -- obstetricians and the midwives, I beg your pardon. Then neonatal mortality was separate and they were two from last year.
CARR: So your understanding was that there had been two meetings last year and the numbers of meetings were fairly small?
CAIN: For the neonatal unit.
CARR: Did you enquire as to how many cases were being discussed at these meetings?
CAIN: No.
CARR: Did you ask any questions as to the themes emerging from these meetings?
CAIN: No, I don't think we did here.
CARR: You make the point and we can take that down you make the point -- thank you -- at your statement paragraph 93, that when describing that section of the notes I just took you to you say: "I would like to be clear again here that there was no mention of an increase in deaths. If such an increase had been raised this would have been recorded in my notes and further enquiries would have been raised." The point you are making is when looking at those notes, the discussion is about meetings rather than about mortality rates?
CAIN: Yes. I'm sorry, can you tell me what paragraph you are referring to again?
CARR: Forgive me, it is paragraph 93 of your statement, which is at page 16. If you look at paragraph 93 and go four lines down.
CAIN: Yes. So it wasn't specifically deaths, it was about the process of reviewing mortality and morbidity.
CARR: Yes, the point emerges here and it emerges in other parts of your statement that I have already taken you to is that at no point during your visit were you told about any increase in neonatal mortality; that is your recollection, isn't it?
CAIN: Yes, that is right.
CARR: You weren't told about any concerns about an increase in neonatal mortality?
CAIN: No.
CARR: You weren't told about any concerns about incidents of unexpected and unexplained deaths?
CAIN: No.
CARR: You weren't told about any concerns as to a correlation between those incidents and a member of staff?
CAIN: No.
CARR: Concerns about potential deliberate harm by a member of staff?
CAIN: No.
CARR: Did you ask any of the interviewees questions directly related to neonatal mortality?
CAIN: Only insofar as neonatal mortality and morbidity in the process, as far as I can remember.
CARR: So is the answer to the question no?
CAIN: No.
CARR: Was -- particularly we have looked at the guidance to key lines of inquiry, to report writing, the focus on safety performance. Wasn't discussion about an outcome like mortality, wasn't that important to discuss in order to assess the safety of the unit?
CAIN: I think by discussing the process and how the Trust assured themselves that they were assured was part of that, about that safety process. How they investigated, reported, investigated, reviewed and assured themselves that mortality and neonatal morbidity was being reviewed, investigated as appropriate.
CARR: We know that there were concerns on the unit about the increase in mortality. I have already asked you questions about the Thematic Review and the internal review. Did you or your team ask any questions that you consider should have elicited that information?
CAIN: I think discussing neonatal mortality and morbidity would -- should have elicited some information about if there were any concerns or any increase. That would have been the opportunity for that to be raised.
CARR: If I understand your answer correctly I think what you are saying is: well, we were having a discussion about neonatal mortality within the context of meetings and so the Thematic Reviews being relevant to that, it should have been volunteered at that stage?
CAIN: It wasn't just about meetings, though; it was about the whole mortality morbidity process. So it was about how, how they approached neonatal mortality morbidity. So although meetings were mentioned and the number of meetings, that would have been the opportunity
to -- to advise that there was -- there were concerns, there had been an increase, that there was a Thematic Review had taken place. But that was the opportunity.
CARR: Yes, that was an opportunity for it to be volunteered, but my question is slightly different. My question is: did you or your team put questions to the interviewees to which you think the answer ought to have been or should have been: we have these concerns, there's been this Thematic Review?
CAIN: Not -- not direct questions as far as I -- I -- from that meeting, from the statements I have read and the notes I'm not sure if one of the Special Advisers actually spoke about mortality but that's from reviewing the evidence.
CARR: My question wasn't restricted only to that interview with the team leads. My question was in respect of your entire -- your entire period during the inspection, so in any of the interviews.
CAIN: My understanding is that one of the Special Advisers discussed mortality.
CARR: Do you, or did you, once you worked at the CQC, find that there could be a reticence or a reluctance amongst staff who were being inspected to volunteer difficulties or concerns that they were having of their own volition?
CAIN: On some occasions.
CARR: You have made the point in respect of documents you would expect to see and I asked you earlier about information relating to increases in neonatal mortality and unexpected and unexplained deaths. In your statement you said you had hoped to see it and when I asked you questions about it, I think to summarise your evidence, the position was: well, you would expect to see it, but some hospitals don't send it?
CAIN: (Nods)
CARR: In those circumstances, and given the reluctance that can sometimes occur, wouldn't you ask, for instance, open questions to interviewees that might give them an opportunity or encourage them to volunteer information such as: is there anything causing you concern at the moment?
CAIN: Yes.
CARR: Did you ask that question?
CAIN: I think in, in -- from my -- from my recollection in the interviews I -- I used to conduct with staff, I would very much, I would ask: is there anything you're particularly proud of, is there anything you could do better? Is there any -- and I always used to finish the interviews with: is there anything else
you think we should know, anything you would like to tell us? And that --but that wouldn't specifically be about neonatal mortality. It would be about --it could be about anything. And I think that's where a lot of the concerns regarding staffing were raised and if I remember rightly, one of the interviews from the paediatric department, the information that came that occupancy -- bed occupancy rates weren't always accurate as they could be because of how they were -- how they were checked -- the time of day that occupancy rates were -- were assessed. So certainly at the end of every interview, it very much there was an opportunity for whoever we were speaking to or I was speaking to for them to -- to -- and like I say it wouldn't necessarily be about safety. It could be about -- about staffing, it could be anything. It could be about facilities, it could be about equipment, it could be about training. There was an opportunity at the end of the interviews for whoever we were -- I was interviewing to tell us anything that they wanted us to know.
CARR: Yes, so that catch-all question gave an opportunity for interviewees to raise concerns?
CAIN: Yes, and that was -- I -- that was a standard way to -- to sort of finish an interview.
CARR: Would you ask a more pointed catch-all question such as, rather than "is there anything you want us to know?", "is there anything that concerns you? Is there anything you are investigating at the moment?"
CAIN: I certainly wouldn't have said "investigating". I may have said "concerns". But I would have also said "or anything you are particularly proud of?" Because the inspection process isn't just about finding things that perhaps aren't as they should be but also it's to give a complete and accurate picture of a Trust's performance, whether that be positive or a negative. So it's an overall picture.
CARR: If we can on screen, please, INQ0017339. Now, at paragraph 99 of your statement, you describe your interview with Eirian Powell and we will need to go forward, please, to page 200 of this document. Subparagraph (i) of paragraph 99, you say that: "One of the points discussed was a positive relationship with doctors." Are you able to expand on nature of that discussion? And you may want to do so by looking at these notes, they are difficult to read, I think the
relevant part might be the second half of the page.
CAIN: Yes. And it was -- the feedback was that there was a positive relationship between the nursing staff and the Consultants, that it was a positive working relationship. And actually they also -- she also said that working -- there was a positive working relationship with maternity and obstetrics and gynaecology. Because while maternity and children and young people were different services, actually the maternity service sort of provided the patients for the neonatal unit so -- so it was -- although they were different core services, it was important that they worked well together.
CARR: Thank you. We can take that down. There is evidence that we will be hearing in due course about a focus group of the Consultants and I know that you weren't present at that focus group. There is some evidence to suggest that at the focus group issues were raised as to a bullying culture and an oppressive air at leadership level. In the course of your interviews and your inspection, did you hear any concerns of that nature?
CAIN: No.
CARR: At the end of the inspection visit, how do the
Specialist Advisers, if they do, how do they give you their specialist advice or their views, is there a debrief?
CAIN: At the end of every day on site, the whole -- the whole team came together for corroboration and each core service would feed back any sort of high level findings that they had. But prior to that, the core service lead on the Special Advisers would get together to discuss what -- what their findings were because not all interviews were conducted with all three members of staff. We would all go and visit speak to different people and come back and feed back and then at the end of every day, the core service lead would collect their note-taking templates to go through that evening.
CARR: Is it predominantly a verbal feedback session or do they provide written analysis or --
CAIN: No.
CARR: -- written documents --
CAIN: No, it was verbal, to support what was already in the note-taking templates.
CARR: Now, in the course of the preparation of the report and prior to the publication of it, there was a meeting on 26 May 2016, an NQAG meeting which you attended?
CAIN: Yes.
CARR: There was some discussion of a possible inadequate rating --
CAIN: Yes.
CARR: -- in safety for Children and Young People's Services. But ultimately we can get the report up, it wasn't an inadequate rating. Can you address the concern that there was in the debate as to whether there should be an inadequate rating or not?
CAIN: Could I have a look at the meeting minutes?
CARR: It's INQ0017295, at page 10. The fifth column "High level ratings indicators". We see "panel" --
CAIN: Yes, yes. And that was about whether there had been an inadequate rating considered due to the concerns found. So staffing was -- was a major consideration and the lack of advanced paediatric life support staff at night on the paediatric unit. So that was the reason for this meeting is to challenge the evidence, to speak with the inspector to find if, how -- how they had got to their determination even though they had read the report and it's, we discussed about whether it should be "requires improvement" or "inadequate" and my position, having been on site was that there were significant issues, particularly with staffing in both the neonatal unit and the children's and paediatric services. However, risks were mitigated, managers were aware of the risks, and were actively -- had actively described scenarios and experiences that they had moved to to mitigate that risk. They could describe actions that were being taken. So my view at that point was that managers we had spoken to were aware of the situation, and were actively trying to address and mitigate any risk.
CARR: So the decision was made and it's reflected in the final report, which we can now look at, that "safe" would be graded "requires improvement"?
CAIN: Yes.
CARR: The INQ reference 0017433 at page 106, please, so this is the section that you drafted, isn't it?
CAIN: Yes.
CARR: From page 106, Services for Children and Young People. "Safe" "requires improvement" but everything else ranked good?
CAIN: I'm, sorry say that again?
CARR: "Safe" has been graded "requires improvement"?
CAIN: Yes.
CARR: Everything else has been graded "good"?
CAIN: Yes.
CARR: The overall grading as well is "good"?
CAIN: Yes.
CARR: If we go forward to page 107, we can see in the text on the right of the page, when addressing safety under "requires improvement" a number of bullet points explaining why there was a "requires improvement" grading. Again it's mainly staffing issues, isn't it?
CAIN: Yes.
CARR: Do you want to summarise the basis for the finding "requires improvement" as set out there?
CAIN: The paediatric staffing, the staffing on the paediatric unit didn't reflect our Royal College of Nursing guidance and the neonatal unit didn't follow British Association for Perinatal Medicine guidance for staffing on a number of occasions. It was a risk on the Risk Register and staff had told us throughout that staffing was a concern for them.
CARR: If we can look, please, at page 108, left-hand side, under the -- this is the second bullet point on the left under the term "however" there is a section there about: "... incidents being reported appropriately with the majority being 'low' or 'no harm'." I have asked you many questions on that, that
table. Your evidence, as I understand it, is that that categorisation was tested by you looking at three particular examples --
CAIN: Yes.
CARR: -- and determining that their categorisations were correct?
CAIN: Yes, but not just the categorisation, it was actually the fact that the reviews were conducted and investigated appropriately. So it was about incident reviews.
CARR: Under the heading "Incidents" on that page on the left-hand side, second bullet point?
CAIN: Yes.
CARR: "No Never Events or Serious Incidents reported" -- well, you have seen the entry on the first STEIS, so that remains, doesn't it, carries over from the other CQC documents that we have seen, that remains an error?
CAIN: That is the information that was provided in the intelligence briefing and the previous draft of the -- the data pack.
CARR: There is no discussion in this report, is there, of mortality -- of neonatal mortality at the unit?
CAIN: Not specifically. There's obviously
a neonatal mortality process, but not rates of neonatal mortality, I don't think.
CARR: We can take that document down. Now, moving away from the inspection and perhaps a short point. You were subsequently involved with the Trust in 2017 in the monitoring rather than the inspection side --
CAIN: Yes.
CARR: -- of CQC regulation, you became for a brief period the regulation owner?
CAIN: Relationship owner.
CARR: Relationship owner, sorry, forgive me.
CAIN: Yes.
CARR: You attended an engagement meeting and that was in December 2017 and a management review meeting in November 2017?
CAIN: Yes.
CARR: Now at that point, the CQC were aware that a police investigation was under way --
CAIN: Yes.
CARR: -- and that had been communicated by the Trust? Were you aware that the police investigation was into or arose out of concerns and suspicions relating to a member of staff and deliberate harm by that member of staff as at November 2017?
CAIN: I think possibly then, yes, I think.
CARR: Dealing finally, then, with some reflections. Dealing finally with some reflections, looking back particularly on the inspection. The CQC inspection did not detect the concerns that we know existed at the neonatal unit. What is your explanation for the failure to detect those concerns?
CAIN: I think some of it is the -- the data, the -- the there is always a lag with data and sources of data so I think that is -- is an issue is a consideration. And I think very much the on-site inspection you can ask a lot of open questions, a lot of general questions but you are very much reliant on -- on people's responses.
MR CARR: Thank you, my Lady, I have no further questions for this witness.
LADY JUSTICE THIRLWALL: Thank you. Mr Deakin, do you have any questions? No, thank you. Ms Cain, just one or two from me.
LADY JUSTICE THIRLWALL: You have mentioned a number of times the intelligence and that comes to you from the data analysts?
CAIN: Yes.
LADY JUSTICE THIRLWALL: Just so I have understood
this: it's they who should have picked up the reports to the NRLS?
CAIN: My understanding is that they, they review, yes, and they bring that data together ahead of an inspection to provide to the core service leads.
LADY JUSTICE THIRLWALL: And so the purpose of the data analysts really is to save the team the effort of looking for that information, I don't mean that in a disparaging way.
CAIN: No.
LADY JUSTICE THIRLWALL: But that is their role?
CAIN: Yes.
LADY JUSTICE THIRLWALL: Then they then present it to you?
CAIN: Yes.
LADY JUSTICE THIRLWALL: But they are still part of the CQC process?
CAIN: Yes.
LADY JUSTICE THIRLWALL: What explanation is there for the fact that there was no reference to the NRLS in the intelligence pack?
CAIN: I'm sorry, I don't know, I can't answer, I don't know what the explanation would be.
LADY JUSTICE THIRLWALL: What's the process for quality assuring the data analysts, do you know?
CAIN: Again, I'm sorry, I can't answer, I don't know.
LADY JUSTICE THIRLWALL: Do you know anything about their background, what actually their qualifications are, what their instructions are.
CAIN: No, I'm sorry, I don't. I'm sorry.
LADY JUSTICE THIRLWALL: So you are just -- I don't mean "just", but you are the passive recipient of what they tell you?
CAIN: Yes, of the data they provide, yes.
LADY JUSTICE THIRLWALL: Thank you. On a second related point, we looked at a slide with colours of the Countess of Chester's own self-assessment of how they were doing and I know earlier in the evidence I think from someone working in risk in the hospital, we saw a form that had been filled in in some detail, a sort of self-assessment. This is obviously a different thing. I want to know whether you know that whether the document with all the colours on came from the Countess or again was something that was produced by the data analysts having analysed the data from the Countess?
CAIN: The self-assessment?
LADY JUSTICE THIRLWALL: Yes, the one with all the colours on, yes.
CAIN: That would have come from the Countess of Chester.
LADY JUSTICE THIRLWALL: In the colours?
CAIN: That was their self-assessment as part of the Provider Information Return, as far as I am aware.
LADY JUSTICE THIRLWALL: That is what you would have assumed it was?
CAIN: That was their self-assessment, yes.
LADY JUSTICE THIRLWALL: Yes, certainly, I just wanted to make sure that it wasn't a sort of a restatement of it in a slightly different form by a data analyst?
CAIN: No, my understanding is each Trust prior to inspection rated themselves, assessed themselves against the domains.
LADY JUSTICE THIRLWALL: I see, thank you, that is helpful. Mr Carr asked you a number of times about the difference between what you would expect and what you would hope. Can I just check that my understanding is correct? So your professional expectation would be that the information that you were then being asked about would be and should be provided?
CAIN: Yes.
LADY JUSTICE THIRLWALL: And the reason you expressed it, sometimes as hope, is because experience has shown you that people do not always provide the information that you would expect as a matter of professionalism?
CAIN: Yes.
LADY JUSTICE THIRLWALL: Why do you think they do that? Why do they hold back?
CAIN: Pardon?
LADY JUSTICE THIRLWALL: Why do you think they hold back?
CAIN: I think some Trusts would rather you find out -- find it for yourself. I think some, as with perhaps the self-assessment here, they want to show themselves in the best light possible. And some Trusts are better than others at acknowledging their risks and challenges. My experience was certainly as a relationship owner for other Trusts you would have one Trust who every time there was something significant rather than waiting to -- for me to detect it on NRLS or STEIS, they would phone up and say: we are declaring a Serious Incident, this is what's happened, this is what we are doing about it immediately, as soon as we have our Serious Incident report, we will pass it to you. Others --
LADY JUSTICE THIRLWALL: Would that be between inspections?
CAIN: Yes, and that would be the relationship owner.
LADY JUSTICE THIRLWALL: I see.
CAIN: So if I was a relationship owner for a Trust, I actually had one Trust who would pick up the phone, very transparent, this has happened, this is what we are doing about it immediately, the rapid review or the SBAR, the investigation report, and these are the measures we have put in place immediately. Other Trusts you would wait, it would wait and you would find it on NRLS or STEIS. So two very different approaches in the relationship with the Care Quality Commission.
LADY JUSTICE THIRLWALL: Just to go back to my earlier question, would the relationship owner as a matter of course be checking NRLS in respect of the hospital with whom they had the relationship?
CAIN: Yes.
LADY JUSTICE THIRLWALL: Thank you. Those are my questions. Mr Carr, do you have anything else?
MR CARR: No I don't, thank you very much.
LADY JUSTICE THIRLWALL: Thank you very much, you are free to go.
CAIN: Thank you.
MR CARR: My Lady, the next witness is Dr Odeka, may I call him.
LADY JUSTICE THIRLWALL: Sorry, Dr Odeka, I didn't see that you had arrived. Do come forward.
DR BENJAMIN ODEKA (sworn)
LADY JUSTICE THIRLWALL: Do sit down.
MR CARR: Can you provide your full name, please?
ODEKA: Dr Benjamin Odeka.
CARR: You have prepared a witness statement for this Inquiry, haven't you, and it's signed and it is dated 10 June 2024?
ODEKA: Yes, yes.
CARR: The contents of that witness statement, are they true to the best of your knowledge and belief?
ODEKA: Yes.
CARR: You give evidence in that statement, don't you, of your professional background, you have been a Consultant in paediatrics and gastroenterology since 1994?
ODEKA: That's correct, yes.
CARR: You describe at your paragraphs 3 and 4 a variety of academic posts and positions of responsibility?
ODEKA: Yes.
CARR: That includes being a tutor at the University of Manchester from 1994 to 1996, a Clinical Director of paediatrics for eight years, a clinical area lead for paediatrics for two years, a Divisional Medical Director and Associate Medical Director for Women's and Children 2006 to 2009?
ODEKA: Yes.
CARR: And you have particular experience in safeguarding, having chaired the Safeguarding Group for the Child Health Division?
ODEKA: Yes.
CARR: So far as your role with the CQC you explain at paragraph 5 of your statement that you have assisted with CQC inspections since June 2014?
ODEKA: Yes.
CARR: The 2016 inspection at the Countess of Chester Hospital with which we are concerned, you think was your fourth such inspection?
ODEKA: Yes.
CARR: You were a Specialist Adviser --
ODEKA: Yes.
CARR: -- on that inspection and that's distinct from a CQC inspector, isn't it?
ODEKA: Yes.
CARR: Do you want to explain the difference in the roles, as you understood it?
ODEKA: As a professional adviser, we or for myself were meant to give a professional slant and support to the CQC interpreting medical issues that they might encounter during inspections and to make the inspections more clearer in terms of interpreting medical issues they encounter during inspections. So in short it's just to advise them on medical issues picked up at inspection using their templates of inspection but to put a medical angle to it.
CARR: The role isn't simply advisory, is it, you are an active participant, you partake in interviews during the inspection?
ODEKA: Yes.
CARR: There were some interviews, judging from the notes, that you undertook alone, so without the other two?
ODEKA: Yes.
CARR: Specialist Adviser and CQC Inspector?
ODEKA: Yes.
CARR: And the division appears to have been you focused more on interviewing doctors, whereas the other Specialist Adviser, who was a nurse, she did more of the interviews with nurses?
ODEKA: Yes, that's correct.
CARR: Was there any training that you received from the CQC or elsewhere for the Specialist Adviser role or was it unnecessary?
ODEKA: There was a brief training. It's -- it wasn't a detailed training as such but you had introductory training of induction and explained to us what the role was and I think what they did was they looked at our background to match what they expected from us to the role and that formed the basis of the short training that they gave us.
CARR: I wanted to turn now to the documentation that you receive ahead of and for the purposes of an inspection visit and you explain in your statement the information you receive is quite limited, isn't it?
ODEKA: That's correct. Yes.
CARR: You don't receive the Provider Information Return?
ODEKA: No.
CARR: Or the documents submitted as part of a Provider Information Return and you don't receive the response to data requests --
ODEKA: No.
CARR: -- from a Trust?
ODEKA: No.
CARR: And what you say at paragraph 10 of your
statement is: "As a Specialist Adviser I would ordinarily expect to receive the following information in advance of an inspection: information regarding the venue, the reason for the inspection, the focus of the inspection from CQC, any particular areas of concern or red flags to be aware of."
ODEKA: That's correct.
CARR: You are aware that the CQC will gather a lot of documentation for the purposes of an inspection?
ODEKA: Yes.
CARR: Also as part of their ongoing monitoring?
ODEKA: Yes.
CARR: But that doesn't get provided to you as a Specialist Adviser?
ODEKA: No.
CARR: At paragraph 13 you say: "Provider Information Returns and data requests were matters for the CQC Inspectors. I would only receive information which CQC and in particular the CYP inspection lead ..." And that is Children and Young Person's Services inspection lead --
ODEKA: Correct.
CARR: -- Helen Cain "consider to be relevant."
So you did understand there to be a process that if there were particular documents which were a cause of concern or which called for specialist advice then you would see those?
ODEKA: I would -- I would be informed of such and subsequently I will be provided with such information if they deemed relevant and necessary.
CARR: Can I try to understand, please, what it was that you were sent. So paragraph 42 of your statement, you describe, if you find it, receiving the information pack in advance of the inspection. You say it was received by email and you understand searches are ongoing within CQC to locate this email and its attachments. Now, I want to see if we can identify that document. Have you subsequently seen a copy of the pack that you think you were sent?
ODEKA: I think I have seen a copy of it.
CARR: Is it the intelligence briefing pack?
ODEKA: Yes.
CARR: If we can get that document up, it is INQ0103620. So this is the document?
ODEKA: Yes.
CARR: As I understand it, it was a PowerPoint presentation. Are you saying you would have been sent it by email as well?
ODEKA: Sorry, this is not the -- this is not the one that is sent which is which contains the -- for the Women and Children's Division. It's not this one. This was -- this was a presentation at the -- on the day of the inspection itself, this was the intelligence presentation on the day.
CARR: Okay, we can take that down. INQ0101422. Now we have this document. It's labelled "Draft Pre-Inspection Document, 22 December 2015", the document that you are describing, is it --
ODEKA: This, yes.
CARR: It's like this?
ODEKA: Yes.
CARR: If we go forward, please, to page 5, we have a summary of analysis on this page into the next page -- I will go to the next page in a moment -- against the five domains of regulation: "Safe", "effective", "care" and "responsive" and "well led". Now, this version of the document is dated December 2015. Do you believe that you received an updated version of this document or was this the one that you received for the inspection?
ODEKA: I can't -- I can't be very specific here, but it looked familiar but I am not, I am not very clear
about it. It's a long time now.
CARR: And is it -- would it be typical for you as a Specialist Adviser for the information that you receive to be limited to this kind of document?
ODEKA: Yes.
CARR: Would the extent of the information contained in such a document be similar in its scope to what's contained in this version?
ODEKA: Yes, maybe not as detailed but similar, yes.
CARR: If, for instance, we take the "safe" section. Nothing in positive analysis, nothing in negative analysis. Then neutral analysis it says: "No Never Events or Serious Incidents have been reported." And we will come back to that. There's another bullet point dealing with pressure ulcers and falls. Bullet point 3 deals with questions in the children's survey. Now, the children's survey, is that a survey that goes out to patients?
ODEKA: Yes.
CARR: Then bullet point 4, a comment on the staff skill mix. It seems quite light in terms of evidence that's been given to you as a Specialist Adviser ahead of going into inspecting a hospital to assess its
performance?
ODEKA: Yes. Can I -- okay, I think the answer is yes, but when we look at our inspection templates we are looking at -- looking at governance issues. So even if the information given not as robust as it should be, we have the -- I do have --we do have a template where we look at the overall picture using the key lines of inquiries to try and expand on that because we have the scope that we need to examine. So even with limited information like this, we still have to go through the whole gamut of it.
CARR: I have seen the inspection briefing pack -- and you can take this down now -- we can go to it if we need to, but that is a document which sets out the areas for the inspectors to probe at inspection, doesn't it?
ODEKA: Yes.
CARR: It doesn't contain information about the actual Trust?
ODEKA: No.
CARR: So for you as a Specialist Adviser you are not given access to the wealth of information that the CQC has and you are going into a hospital, you are given the analysis at the level which I have just taken you to, so a summary of four bullet points, one of which is a survey, one of which is staff skill mix.
There doesn't seem to be much that you can provide specialist advice on in terms of data prior to the inspection?
ODEKA: Correct, yes. It's not -- not detailed, not robust enough for inspection, yes.
CARR: Now, you weren't given ahead of the inspection, were you, any information relating to neonatal mortality at this unit?
ODEKA: No.
CARR: At paragraph 14 of your statement, you say: "In my role as a Specialist Adviser I would not necessarily expect to receive information concerning neonatal deaths directly in advance of an inspection but would have such information if this was available to the CQC inspector." And just so that I can make sure I am understanding that, is the point that you are making there: well, if the information has gone to the inspector then you would expect it to be shared to you but if the inspector doesn't have it, so if Helen Cain doesn't have that information, then she can't share it with you?
ODEKA: No.
CARR: Is that the point you are making?
ODEKA: The point I am making is they might receive the details of neonatal deaths. That may not be given to me directly, but mentioned as part of our inspection plan, if it's an area that needs to be looked at closer, then in that context, they also want to ask if the deaths have actually been reviewed appropriately and adequately and that's where I come in, to now advise on that, to see if the -- if the different enquiries have been made as to the reasons for deaths or the reasons for the issues raised in the mortality reports, so I think that is where I come in.
CARR: Do you know who it is who makes the decision as to whether or not you as a Specialist Adviser doctor, with the experience that you described, should consider for instance data or evidence on neonatal mortality?
ODEKA: Sorry, I didn't quite -- can you just repeat the question again, please?
CARR: I said who is it -- as you understand it, who is it that makes the decision about whether you should consider the data. So what you have described is the information comes in, the CQC will decide whether or not you need to see it, I am trying to work out who at the CQC makes that decision as to whether specialist advice is needed on data?
ODEKA: I think -- I think the lead inspector will be the person to do that because she will be the direct communicator with myself. If she had concerns or she
has data that she needed to be advised on, she would actually share it directly with me. So if I don't have access to the data and the lead inspector has access to the data then she would actually ask me if she has any issues to raise.
CARR: You comment again paragraph 14 it is the last sentence, that your expectation is that that information would essentially be filtered down to you if there was a concern which you have addressed or if it was a red flag issue and there's a number of ways in which there can be concerns or red flags about neonatal mortality, aren't there?
ODEKA: Yes.
CARR: One issue might be: well, if the unit or the hospital was an outlier?
ODEKA: Yes.
CARR: Another might be if there was a significant increase in mortality beyond what is usual for that particular hospital?
ODEKA: Yes.
CARR: If the doctors themselves had concerns about the increase?
ODEKA: Yes, that is useful information.
CARR: If there were incidents of unexpected and unexplained neonatal deaths?
ODEKA: Yes.
CARR: If there were concerns about the correlation between a member of staff and those unexpected and unexplained deaths and suspicions of potential deliberate harm?
ODEKA: I'm not sure -- I am not -- it might be mentioned but I'm not sure if that's -- that will be something that will be discussed in such meetings.
CARR: Well, I am asking you about the circumstances in which you would expect details about neonatal mortality to be communicated to you as a red flag and I am suggesting those factors that I just went through would all be red flags where you would expect it to be communicated to you?
ODEKA: Yes.
CARR: At paragraph 17, you say: "In respect of unexpected and unexplained deaths I would expect CQC to be informed about unexpected or unexplained neonatal deaths that these would be identified at local level, ie within a particular hospital. Unexpected or unexplained neonatal death could still be a red flag even if the hospital's overall statistics remained within the regional or national trends. If an unexpected or unexplained neonatal death was identified as a red flag I would expect this
information then to be filtered down to me through the Children and Young People's Inspection Lead." Now, is the point that you are making there is that even if the statistics on death might not constitute an outlier, if you suddenly have, particularly within a neonatal unit, incidents of unexpected and unexplained deaths, that in itself is a red flag?
ODEKA: Yes, it will be, yes.
CARR: You have seen for the purposes of preparing your evidence for this Inquiry the Thematic Review carried out in February 2016?
ODEKA: Yes, please.
CARR: The review by Dr Brigham in November 2015. Both of them identify an increase in neonatal mortality at the unit. In light of that and the concerns we know that there were, that is information that -- or do you think that is information that the Care Quality Commission and your team should have been provided with?
ODEKA: Yes.
CARR: At paragraphs 46 to 48 of your statement, you address the spreadsheet of neonatal incidents that was provided to the Care Quality Commission by the Trust as part of the data for the inspection. Now, because of the sensitive third party information in that document, I am not going to put it on screen. But you are familiar, aren't you, with the document that I am referring to?
ODEKA: Yes.
CARR: It is a table with some entries marked and colour coded by the degree of harm?
ODEKA: Yes.
CARR: Green for no harm. Yellow for low harm?
ODEKA: Yes.
CARR: That is a document that you did not see prior to preparing the evidence here?
ODEKA: Yes.
CARR: It wasn't shown to you by the CQC or by Helen Cain?
ODEKA: No, it wasn't shown.
CARR: There was no discussion with you by anybody at the CQC about that table?
ODEKA: No, no discussion.
CARR: Or the contents of it?
ODEKA: No.
CARR: You have reviewed it to prepare your statement. Now the first question is this: would you expect all neonatal deaths at the unit to be included on a table like that?
ODEKA: Yes.
CARR: Now, there are on my calculation eight entries in the table involving death, all of which are marked green -- coloured green and marked "none" in the "Actual harm" column. This is something that you were asked to address in your statement and you say at paragraph 46: "On the face of the document the categorisation of incidents involving neonatal deaths as 'none' in the 'Actual harm' column immediately strikes me as inaccurate; clearly a neonatal death is a significant event. It appears that this may be due to the data being input into the Datix system incorrectly. However, I would need to see the key which was used to inform the recording of incidents in order to comment more categorically on whether the non-categorisation for actual harm was incorrect." So immediately striking that those entries are marked green for "no harm". If this document had been shared with you, or if you had been asked questions about it, what would you have done?
ODEKA: I would have checked the entry itself and enquired about the decision or the reason behind the decision. But having looked at that particular entry, I think I have some idea as to why they have categorised
it in that fashion.
CARR: So had you received the table it's something that you would want to investigate and test the categorisation of?
ODEKA: Yes, yes.
CARR: Is that something that you would explore at the interviews?
ODEKA: The interviews was -- excuse me, was to confirm that the entries --
CARR: Yes.
ODEKA: -- and also to speak to the -- the managers -- when I mean the managers, those who actually lead in governance, produce that document. Then I would explore what they have done about it and to see if the actions they have taken, if it's in line with good practice and if it also addresses the issue and if there are any lessons to be learnt from those. So it's the process I would be interested in looking at and that would be something that CQC would be interested in in terms of making a decision.
CARR: But the point is because it strikes you as inaccurate, that would be something that you would want to look into to --
ODEKA: Yes.
CARR: -- find out what's happened --
ODEKA: Yes.
CARR: -- and assess whether it is appropriately categorised or not and investigated. Is that correct?
ODEKA: Yes, that is correct, yes, sir.
CARR: Your paragraph 47C, just to take one example, if we may, you address there the entry on that table concerning Child A and that's entry 188 in the table. Now in the table, the details of the incident are given as: sudden and unexpected deterioration and death of a patient on the neonatal unit after full resuscitation requiring postmortem. Now, if you had seen that in advance and seen that it had been entered as a "no harm" or green for a no harm entry, is that a particular incident that you would want to explore as part of your inspection?
ODEKA: Yes.
CARR: There are a number of features here. One the fact that it is a Sudden and Unexpected Death, so is that something that would ring alarm bells?
ODEKA: Yes.
CARR: You have connected to that, don't you, that at the time of the entry, you have a cause of death that is unclear, it is awaiting postmortem?
ODEKA: That's right.
CARR: So would you want to explore at the inspection what the postmortem said and whether a cause of death had been established?
ODEKA: Yes, I would and obviously most of the deaths would have been referred to the Child's Death Inquiries so I would want to know the outcome of such inquiries.
CARR: What would you explore based on that description? For instance, whether the SUDIC guidelines were complied with, would that be appropriate to your regulatory investigations?
ODEKA: Yes.
CARR: But in the event of course you didn't see this table?
ODEKA: No.
CARR: And there was no discussion of those events at inspection?
ODEKA: No.
CARR: Now, there are two reporting systems which the Care Quality Commission track. So there's the National Reporting and Learning System to which patient harm events are reported and there is the Strategic Executive Information System for Serious Incidents and the CQC has access to reports to those systems, doesn't it?
ODEKA: I can't answer to that because I don't know.
CARR: You have seen, again as part of your
preparation for giving evidence to this Inquiry, you have seen spreadsheets showing reports by the Trust to those two systems, haven't you --
ODEKA: Yes.
CARR: -- in the period --
ODEKA: Yes.
CARR: -- covering that prior to your inspection? Were you, for the purposes of the inspection or during the inspection, informed by the CQC of the reports in those table concerning children?
ODEKA: No.
CARR: Do you think you should have been?
ODEKA: Yes.
CARR: Were you aware, did it come up during the inspection that the death of Child D had been reported to the Strategic Information System for Serious Incidents and other events as an unexpected potentially avoidable death and as a Serious Incident due to a delay recognising sepsis?
ODEKA: No.
CARR: Turning to the visit itself. You were involved in a number of interviews, weren't you?
ODEKA: Yes.
CARR: As you have explained already, your focus was mainly on interviewing the doctors. You interviewed, on
my reading of the notes, you interviewed Dr Brearey?
ODEKA: Yes.
CARR: Dr V, Dr Lowe, Dr Gibbs, Dr Cooke?
ODEKA: Yes.
CARR: Sorry. You also took part in the large interview with the team leads with both of the other members of your inspection team?
ODEKA: Yes.
CARR: When I said you interviewed Dr Brearey, that was an additional interview to the interview as part of the team. So you would have seen him as part of the large interview, but you also had a separate interview with him?
ODEKA: Yes, that's correct.
CARR: Turning to your statement, paragraphs 87 and 88 please. Paragraph 87, are you there? "I do not recall discussing concerns about an increase in neonatal deaths with any of the interviewees. If this had been discussed I would expect it to be recorded in the notes." Paragraph 88: "I do not recall discussing concerns about unexplained or unexpected deaths. Again I would expect any discussion of this nature to have been recorded."
Just looking at both of those sentences. It's correct, isn't it, that it's not only that concerns about an increase in deaths or concerns about unexplained or unexpected deaths was not discussed. Those topics weren't discussed at all?
ODEKA: Not at all.
CARR: We have already seen there was a discussion in the team leads' interview as to Morbidity and Mortality Meetings but not a discussion as to neonatal rates on the unit.
ODEKA: No.
CARR: Sorry, neonatal mortality rates on the unit. Wouldn't discussion of outcomes at the neonatal unit, including for instance mortality rates, instances of unexpected or unexplained deaths, wouldn't that be an important topic to explore for the purposes of assessing safety of the unit?
ODEKA: Yes.
CARR: Why wasn't it explored?
ODEKA: I -- the -- the incidents reports is what triggers such discussions because we will get the reports of incidents, you look at -- we look at the way it's been investigated, the outcome and the processes involved in that. But since those information were not available to myself, it wasn't -- so all we will do it in that instance would be to look at processes. So that discussion did not take place and that's the reason for that. That wasn't --
CARR: So in the interviews that you attended --
ODEKA: Yes.
CARR: -- were any of the interviewees asked questions about neonatal mortality?
ODEKA: No, it didn't come up in a discussion. Can I just explain a bit there? Can I?
LADY JUSTICE THIRLWALL: Yes.
ODEKA: Right. The questions to the doctors, the trainees and also parents reflects around incidents reporting, that comes up in our discussion. Are incidents reported in the unit? And are they discussed? Are they properly done? And do you get feedback? So that's the prompt that triggers situations where they can come up with things. So it's not that we go in and ask for specific cases. You look at the processes and the processes actually brings up things that we explored in detail and I think that that's the way the inspection format goes.
CARR: You have suggested that having the information that you weren't provided with would have caused you to ask direct questions --
ODEKA: Yes.
CARR: -- as to issues of neonatal mortality?
ODEKA: Yes.
CARR: Because you didn't have that information, that's the reason you didn't ask direct questions?
ODEKA: Correct, yes.
CARR: It wasn't volunteered by the interviewees in your interview sessions?
ODEKA: None of them.
CARR: As an inspector and from your experience in healthcare more broadly, can there be a reticence amongst staff subject to an inspection to volunteer difficulties or concerns that they have without being asked?
ODEKA: They do. They do. Some, some do. Because even when you don't ask direct questions and if we go through the incidents reporting system and we say, "Do you report incidents and are they investigated and do you get feedback from the incidents reported?" it actually gets them to tell us things that they didn't volunteer initially. So, yes, some of them do.
CARR: Well, that's asking questions about reporting systems. What I am asking questions about more specifically is concerns about increases in neonatal mortality, instances of unexpected, unexplained death at
the unit. Now, you weren't aware of that.
ODEKA: No.
CARR: We know that there were concerns about that at the hospital. Did you ask any questions which, in your view, should have elicited that information?
ODEKA: The questions we -- that I asked generically should have brought that up.
CARR: Such as?
ODEKA: Do you report incidents? Do you have a process of reporting incidents in the unit? And are the incidents, are they investigated? And do you get feedback from ...? That's the standard process questions that we ask on incidents.
CARR: Forgive me. That will tell you there is a process, but it wouldn't -- that question is not or might not elicit concerns about increased neonatal mortality. Do you ask in an open sense: Is there anything in the unit which is causing you concern, anything that you are having to investigate at the moment?
ODEKA: I can't recall if I asked in that -- questions in that line.
MR CARR: My Lady, I am conscious of the time. I probably only have a short amount more, but I am happy to break now if that's more convenient.
LADY JUSTICE THIRLWALL: It's probably a bit more convenient for the witness if we continue and finish. How much longer do you think?
MR CARR: About five to 10 minutes. Is that all right if we continue?
ODEKA: Yes, yes.
LADY JUSTICE THIRLWALL: Yes, let's do that, Mr Carr.
MR CARR: Thank you. We have seen and you have been shown notes regarding the Consultants' focus group as part of the inspection. You weren't at the Consultants focus group, but one of the themes that emerged from that group was a bullying culture. In the course of your discussions with interviewees, were any concerns raised with you about a bullying culture?
ODEKA: No.
CARR: Were any concerns raised with you at all by any of the Consultants that you spoke to, any of the doctors you spoke to?
ODEKA: Not that I can recall. Anything different from the report I have already -- is in my statement.
CARR: Paragraph 100 of your statement deals with feedback that you provided to the Children and Young People's Inspection Lead, so that's Helen Cain, based on your findings at the inspection. Now, does your role come to an end at the end of inspection week?
ODEKA: That's right, yes.
CARR: And so what you are describing here is the feedback that you give to Helen Cain, who will then go on to prepare the section of the report?
ODEKA: That's right, yes.
CARR: When you say you provided a narrative, was that in writing or was that verbal?
ODEKA: We do have a verbal discussion. Then we will give, we provide our written notes, all the recorded interview notes, we hand everything over at that time in addition to the --
CARR: Do you recall what your feedback was?
ODEKA: Sorry, can you repeat that again?
CARR: Do you recall what your feedback was? You said, you say in your statement you provided a narrative based on your findings at the inspection. What were the issues that you raised with her?
ODEKA: The -- sorry, I couldn't quite hear that.
CARR: It's paragraph 100.
ODEKA: Yes. Please.
CARR: "I provided a narrative to the CYP inspection lead based on my findings at the inspection."
ODEKA: Yes.
CARR: I am asking if you can help us to understand what that narrative was. What did you tell her?
ODEKA: Just the findings.
CARR: Which were?
ODEKA: Which were the things written in my notes, all the things.
CARR: The interview notes that we have?
ODEKA: Correct. Because I would have told her the key findings. And in the front of the notes there is usually a summary. I usually summarise the key points, so the key points would have been discussed with her.
MR CARR: My Lady, thank you. I have no further questions for Dr Odeka.
LADY JUSTICE THIRLWALL: Thank you. Mr Deakin.
MR DEAKIN: My Lady, if I may.
LADY JUSTICE THIRLWALL: Yes, of course.
MR DEAKIN: Thank you. Dr Odeka, I just have a few questions, please.
ODEKA: Okay.
DEAKIN: Is it your understanding that it's the role of
the CQC to investigate individual incidents of concern or processes?
ODEKA: Not individual concerns, but processes.
DEAKIN: Thank you. The role of a Specialist Adviser, can you just explain what your role as a Specialist Adviser is again, please, very briefly?
ODEKA: The role is to support the CQC from its professional standpoint, giving advice on medical-related issues, to help with the inspection and also to support and interpret processes as they relate to medical investigations. Just basically to advise them on different medical aspects of the inspection.
DEAKIN: Thank you. In advance of the inspection, you were provided with information and you were taken through some of that?
ODEKA: Yes.
DEAKIN: I don't propose to take you through it again. At the time, do you consider that you were provided with enough information to fulfil your role as a Specialist Adviser in this process?
ODEKA: Yes. And can I just qualify that, please?
DEAKIN: Please.
ODEKA: Right. The answer is yes, but the proviso is that I would, I would have assumed that the CQC had all the information and that the information they now
provide to me is assumed to be the filtered one that are relevant to the inspection. So in that regard I have said yes. So it's a qualified yes.
DEAKIN: Thank you. Finally, and following on from that, would it be right to say that there could be all sorts of different issues in a hospital. Would you be expected to be informed about all potential issues of concern even if they were not in fact of concern? I can ask that slightly convoluted question another, another way?
ODEKA: Please.
DEAKIN: You have been asked a lot of questions about whether or not you should have been informed about neonatal mortality rates. I want to step back from that. Neonatal mortality is one issue among a host of potential issues in a hospital, is that fair?
ODEKA: Yes.
DEAKIN: If an issue is not of concern, the CQC has no reason to think that an issue is of concern, would you expect to be informed about a range of issues as a matter of course or would you only expect to be informed of issues in advance of the inspection that stood out for some reason?
ODEKA: I think the information that's for reasons we would be expected to be informed.
MR DEAKIN: Thank you very much. Thank you very much, my Lady.
LADY JUSTICE THIRLWALL: Thank you very much, Mr Deakin. Have you got anything arising out of that, Mr Carr?
MR CARR: No, I don't. Thank you very much.
LADY JUSTICE THIRLWALL: Thank you very much indeed, Dr Odeka.
ODEKA: Thank you.
LADY JUSTICE THIRLWALL: We will rise now until 10 past 2.
(1.08 pm) (The luncheon adjournment)
(2.10 pm)
LADY JUSTICE THIRLWALL: Mr Carr.
MR CARR: May I call Mary Potter, please.
LADY JUSTICE THIRLWALL: Ms Potter, would you like to come forward.
MS MARY POTTER (sworn)
LADY JUSTICE THIRLWALL: Thank you very much, do sit down.
MR CARR: Can we start with your full name, please.
POTTER: Mary Potter.
CARR: You have prepared a witness statement for this Inquiry dated 21 June 2024, haven't you?
POTTER: Yes.
CARR: Are the contents of that statement true to the best of your knowledge and belief?
POTTER: Sorry?
CARR: Are the contents of the witness statement true to your best knowledge and belief?
POTTER: Yes.
CARR: So far as your professional background, you are a nurse, aren't you, you qualified in 1973 and you've worked as a Registered Sick Children's Nurse in the past?
POTTER: Yes.
CARR: In 2004 you trained to become a RCN representative, a Royal College of Nursing representative?
POTTER: (Nods)
CARR: You became a Specialist Adviser in Children's Services for the CQC in July 2014?
POTTER: I think it was 2012, but it might have been 2014.
CARR: At paragraph 6 of your statement, you state your recollection to be that you completed three or four inspections, the last of which was the inspection for
the Countess of Chester in February 2016?
POTTER: Yes.
CARR: That's the inspection that I will be asking you questions about. Your recollection was that it was the only inspection you undertook involving an inspection of a neonatal unit?
POTTER: Yes.
CARR: So far as the role of a Specialist Adviser, can you describe your understanding of that role and how it differed to, for instance, a CQC Inspector?
POTTER: Yes, as a Specialist Adviser on the -- for the duration of the inspection, we go in on a daily basis and we observe what is happening in the clinical areas on that day and make comments about what we are actually seeing.
CARR: So the visit itself occurred over three days of announced visits and then there were two other days of unannounced visits, only one of which involved Children and Young People's Services. So you would have been present for the three day's worth of announced visits?
POTTER: Yes.
CARR: Outside of your presence during those three days, what was the extent of your involvement in the inspection process?
POTTER: Sorry, could you expand on that?
CARR: So you visited for three days?
POTTER: Yes.
CARR: Three days' worth of inspection, and we are going to come on to that in a few moments. But putting that to one side, what was the role of a Specialist Advisor either running up to the actual visit or in the period following the visit?
POTTER: As a Specialist Adviser I wasn't involved in anything prior to the actual inspection of the clinical areas.
CARR: So --
POTTER: Sorry.
CARR: Forgive me.
POTTER: Post the inspection, we may have been called to do an unexpected visit, but on this occasion I never was, so my only involvement was the actual three days of the inspection.
CARR: Did you ever receive any training for the role of Specialist Adviser?
POTTER: Yes.
CARR: Where was the training, who provided the training?
POTTER: The CQC provided the training and it was to my recollection because this is eight years ago, so longer than that since I did any training, I think it was all done remotely.
LADY JUSTICE THIRLWALL: Eight years ago, it was done remotely?
POTTER: Sorry?
LADY JUSTICE THIRLWALL: All done remotely eight years ago, did you say?
POTTER: Probably -- now that you have questioned that, no, probably not. But it was a long time ago and I don't remember what was involved in my actual training. But I had some training about the role of the Specialist Adviser.
LADY JUSTICE THIRLWALL: But you can't remember what, what it was?
POTTER: No, it -- it was around how we would be expected, what we would be expected to look for.
MR CARR: You were a Specialist Adviser with a nursing background?
POTTER: Yes.
CARR: We have heard evidence from the other Specialist Adviser who was a doctor. So between the two of you, Specialist Adviser doctor, Specialist Adviser in nursing, were there different issues that you would provide specialist advice on?
POTTER: Yes.
CARR: How was the division of work or advice arranged between the two of you?
POTTER: As a Specialist Adviser from a nursing background my main role was to look at the clinical areas and observe the service provision of, from that area.
CARR: When it came to interviews looking at the notes, it appears that you focused on interviewing nurses, most of the nurses and Dr Odeka did more of the doctors?
POTTER: Yes, I don't recall interviewing anybody other than nurses or care providers, healthcare assistants.
CARR: If I can turn to documentation provided to you ahead of the inspection. For the purposes of you preparing your statement to this Inquiry, you have seen, haven't you, the Provider Information Returns, and the responses to data requests that the hospital sent to the CQC?
POTTER: This was sent to me in preparation for making -- preparing my statement.
CARR: Yes. About at the time of the inspection the point that you make in your evidence is you wouldn't have seen those documents?
POTTER: No.
CARR: What you describe is receiving an information
pack which was given to you on the first day of the inspection?
POTTER: On the inspection, yes.
CARR: So prior to arriving at the hospital, you received no document containing any detail about the service at all?
POTTER: No.
CARR: So you arrive on day one and you receive an information pack. Now, there's a few different documents and I want to see if we can work out quite what the data pack was. If we can look, please, at INQ0101422, does this look like the data pack that you are describing?
POTTER: Yes, to my recollection.
CARR: Now, this version has draft marked on it, it's titled "Pre-inspection document 22 December 2015".
POTTER: I don't recall seeing a pre-inspection document.
CARR: That was the point of my question. So the draft pack that you described receiving on the first day --
POTTER: The draft pack on -- on the day would have included the service provision of the Trust or organisation we were inspecting. What provisions they, they had, what services they provided I do not recall
seeing anything prior to that, that included a pre-inspection document.
CARR: So this document was not part of the information pack and is not the information pack?
POTTER: Not that I recall.
CARR: If we can look at INQ0017286, this is the inspection team briefing pack. Now, is this the document that you say you received on day one?
POTTER: From my recollection this would have been the document.
CARR: Now, what this document does is, there is a few introductory pages, we can look at page 11, please. Now, part of this pack there is an agenda for an inspection briefing section, 10 February at 2. Did you attend that briefing section?
POTTER: Not to my knowledge or recollection.
CARR: Your recollection is that in fact you didn't receive this document until day one --
POTTER: Yes.
CARR: -- of the inspection which was on the 16th. Now, I have skipped over a few introductory pages that have individual's contact details. If we go to page 14, a section dealing with the services to be inspected, we can see the penultimate heading "Services for Children and Young People" and that's the service that you were inspecting?
POTTER: Yes.
CARR: But there is nothing in there which is specific to the Countess of Chester, is there? This is generic information about services for children and young people?
POTTER: (Nods)
CARR: Then if we go forward, please, to page 16, this is a section of the document that deals with the key lines of inquiry, which contains the prompts for you to use when conducting interviews?
POTTER: Yes.
CARR: It's aimed at obtaining evidence for the purposes of the inspection report?
POTTER: (Nods)
CARR: Now, again this runs over several pages, it's split into the different domains that you were inspecting "safe", "effective", "responsive", "well led". But there's nothing in these key lines of inquiry which is specific to the Countess of Chester, is there?
POTTER: No, this is a general, a general document for how we -- we would -- the things we would look for during an inspection.
CARR: So in fact these are the same key lines of
inquiry that you would see on other inspections?
POTTER: Yes.
CARR: Then there are some concluding pages, page 32, which has procedures for the visit. And finally within this document, page 35, which deals with escalation procedures "Where an issue of concern arises". This is the bit in bold in the middle of the page "Where an issue of concern arise during an inspection", but again that is all generic, isn't it, nothing specific?
POTTER: Yes, it's a generic one.
CARR: So going into the inspection, you receive this document which tells you nothing about the service you are about to inspect. Did you receive anything else which did contain information about the Countess of Chester?
POTTER: Not to my recollection.
CARR: Was that usual for a CQC inspection that you as a Specialist Adviser turn up on day one --
POTTER: Yes.
CARR: -- and you don't know anything about -- you don't have any advance information about what you are inspecting?
POTTER: No.
CARR: That was usual or --
POTTER: Sorry, yes, this was usual that we wouldn't
receive anything specific.
CARR: The next document please, INQ0103620. Now, this appears to be a PowerPoint presentation, slides from a PowerPoint presentation. You see there "Intelligence presentation 16 February 2016". Do you recall if you went to this presentation?
POTTER: I think this was, yes, yes, to that. This would have been the first discussion we had on the morning of the first day of the inspection.
CARR: If we go to page 7 of this document, please. So when you are going through these slides, the first few slides deal with Trust-wide issues and once you got to slide 7, there is information as to Children and Young People's Services', which of course you are most directly concerned with?
POTTER: Yes.
CARR: So the first thing that you -- the first bit of data that is specifically relevant to Children and Young People's Services that you would have seen would have been this slide?
POTTER: I believe so.
CARR: We can see the title, can we not, "Self-assessment from PIR" so it's Provider Information Return. So it's clear this is how the Trust is assessing their own performance?
POTTER: (Nods)
CARR: But for Services for Children and Young People we can see it is a positive assessment, isn't it, three "goods" and two "outstandings"?
POTTER: Yes.
CARR: When you see an assessment like that, "good" for safe "good" for effective, "outstanding" for caring, "outstanding" for responsive and "good" for well-led, how does that shape your approach to the inspection in the upcoming days?
POTTER: Seeing this document wouldn't have shaped my approach to an inspection. My approach would be that I go in and comment on what I personally am seeing of the service provision during the inspection.
CARR: So your approach would be the same even if it was "requires improvement across the board"?
POTTER: Sorry.
CARR: Your approach to the inspection would have been the same even if the self-assessment was "requires improvement"?
POTTER: Yes.
CARR: If we go forward, please, to page 27 and here we have what is described as a summary of intelligence findings. So this is the first real data that you would have seen about the service that you were about to inspect?
POTTER: (Nods)
CARR: "No Never Events or Serious Incidents reported up to January 2016." What conclusion would you draw from seeing that entry?
POTTER: Again, I would try not to allow any of this to influence how I approached the inspection and I would be asking to look at their data recording myself.
CARR: Looking at this page, the data contained on this page, and thinking particularly about the domains of safety and effectiveness, are there any other entries on that page which are relevant to the assessment of safety or of effectiveness?
POTTER: Sorry, can you expand on that? I am not really sure what you are asking.
CARR: Yes. The inspection is according to the key lines of inquiry?
POTTER: Yes, yes.
CARR: The key lines of inquiry are in five different domains?
POTTER: Yes.
CARR: One of those domains is safety?
POTTER: Yes.
CARR: We looked at the document briefly before, but
within those key lines of inquiry there are prompts for safety, so the evidence that you are looking for or looking at in determining safety. Another is "effective", one of the prompts looking at effective. So what I am asking is when you look at these bullet points this is the first bit of information you have about the Trust, are there entries on that slide which are relevant to either of those two domains?
POTTER: No. Again I'm not sure what you are actually asking me.
LADY JUSTICE THIRLWALL: Perhaps we will move on, Mr Carr.
MR CARR: We can take that document down.
LADY JUSTICE THIRLWALL: Actually, just before you do that, could I just ask a question.
MR CARR: Yes, of course.
LADY JUSTICE THIRLWALL: The second last bullet says paediatrics is -- and then it's something WTE.
POTTER: Sorry, it's gone off my screen.
LADY JUSTICE THIRLWALL: I know, it's coming back.
POTTER: Sorry.
LADY JUSTICE THIRLWALL: Can you just -- I'm sorry Mr Carr, could you remind us of the page?
MR CARR: Yes -- no.
LADY JUSTICE THIRLWALL: Here it is.
MR CARR: Up a page, I think.
LADY JUSTICE THIRLWALL: The next.
MR CARR: It is page 27.
LADY JUSTICE THIRLWALL: Thank you. Do you see the second last bullet paediatrics is "2.19 WTE over establishment". What does that mean?
POTTER: The over establishment so "WTE" is whole time equivalent, so they are saying that they have more staff than their establishment calls for.
LADY JUSTICE THIRLWALL: So that is more staff than they would expect to have?
POTTER: Than they would expect to have.
LADY JUSTICE THIRLWALL: Thank you. Is that something that you would have explored?
POTTER: I would have explored it with the nursing establishment in general with the staff on the ward and the manager of the ward.
LADY JUSTICE THIRLWALL: Which ward?
POTTER: Sorry?
LADY JUSTICE THIRLWALL: Which ward?
POTTER: The areas -- the clinical areas I was inspecting, so the neonatal unit and the children's wards.
LADY JUSTICE THIRLWALL: Thank you. Sorry, Mr Carr.
MR CARR: Thank you. One of the documents that was provided to the CQC by the hospital was a spreadsheet titled "NNU paediatric incidents 1 January 2015 to 31" -- sorry, forgive me, 1 February 2015 to 31 January 2016. It is a document that you wouldn't have seen at the time of the inspection but you have seen it for the purposes of providing your statement for this Inquiry, haven't you?
POTTER: (Nods)
CARR: It is a table that has the coloured column to the left marking incidents or categorising incidents according to harm, with the majority of them being in green. Now, having looked at that document, what you say in your statement, and I am considering your paragraph 34, you say: "Unless specific concerns relating to this document were identified by the lead inspector, I would not have expected to receive this document in my role as Specialist Adviser." Is the process then that you are describing: lead inspector looks at this document and would only come to you if the lead inspector identified concerns that she wanted your input on?
POTTER: Yes.
CARR: On a document such as this, and in particular issues as to categorisation of incidents, would that be something that you would give specialist advice on or would you expect Dr Odeka to be the appropriate person to give specialist advice or would it be both of you?
POTTER: We -- we would both have given some input on that. But obviously our perspectives in it would be slightly different and I would be doing it from the perspective of the nurses on the ward or clinical area.
CARR: You say at paragraph 35 of your statement: "Having not had access to this document at the time of the inspection, I am unable to comment on why these incidents have been categorised as they have been." Well, of course categorisation was done by the hospital. The question for you is: if you had received this table at or during the inspection, and considered it, what impact it would have had, if any, on your approach to the inspection?
POTTER: It's very difficult to say what -- what approach, if any, it would have had on my -- sorry, influence on my approach to the inspection. Had -- had I seen causes for concern, I would have explored that further and I would have spoken with the inspector asking: is there further information that we can see? Or: is there anything you want us to be
specifically asking for information around, from the people I was seeing on the ward?
CARR: So if you identified something which caused you concern you would investigate further?
POTTER: Certainly.
CARR: I understand that. Having looked at the table, the query is whether it contains matters which would have caused you concern. There are eight entries in a table in which the description of the incident includes death. Each of those entries is marked green for none in the "Actual harm" column. Would that categorisation have been something that would have caused you concern leading to you to investigate further had you seen it?
POTTER: Now I would say yes, you know, if incidents -- if concerns were raised with me or I seen a document that was raising concerns I would have asked for further information or for it to be looked into further.
CARR: The question is whether you would be concerned by an entry which is marked green, "no harm", in circumstances where it involves neonatal mortality, not that the description itself states concern?
POTTER: I -- I believe that I would want more information about how they got to the "no harm" category.
CARR: National Reporting and Learning System, Strategic Executive Information System. Those are both reporting tools operated by NHS England that NHS Trusts report patient incidents to?
POTTER: (Nods)
CARR: The Strategic Executive Information System, that's for Serious Incidents, patient harm incidents must be reported to the National Reporting and Learning System. You have again, for the purposes of the preparation of your evidence for this inquest (sic), you have been provided with spreadsheets showing reports from the Trust to those two systems, haven't you?
POTTER: Yes, for the preparation of my statement, yes.
CARR: Yes, you didn't see them at the time?
POTTER: No.
CARR: I took you to that PowerPoint presentation where the first entry said "no Serious Incidents reported"?
POTTER: (Nods)
CARR: Now, having seen the reports by the Trust, you have seen that in fact there was a Serious Incident report, wasn't there, in respect of the death of Child D?
POTTER: I don't recall it.
CARR: Had you been provided with entries from the National Reporting and Learning System and the Strategic Executive Information System relating to neonates at the Countess of Chester ahead of the inspection, how would that have impacted your approach to the inspection?
POTTER: As I say, it's -- it's eight years ago and information would have allowed me or prompted me to ask different questions to what I was asking during the inspection. But I can't now say how that would have been because at that point I didn't have that information.
CARR: What different questions do you think you would have asked?
POTTER: I say again it's difficult now to say in hindsight what I would have done differently. But I think I would have wanted more information about the Serious Incident.
CARR: At the inspection you were involved in a number of interviews. You in particular attended an interview with the two other -- the two other members of your team and the team leaders within the neonatal unit. If we can go, please, to INQ0017339, page 164. Now, we have looked earlier today at notes made by Helen Cain of this same meeting, but this is your handwriting, isn't it?
POTTER: This is my handwriting, yes.
CARR: So this is your note of the same meeting. The third line down: "Mortality and Morbidity Meetings equals five last year. Planned four this year -- CS." What does CS refer to?
POTTER: Sorry, I didn't hear that question.
CARR: The CS that is highlighted on the screen, what, what is that a reference to? Or is it C-5 caring 5, is it one of the prompts?
POTTER: I think it's C-5 but as I say, this was eight years ago and I can't fully recall.
CARR: The next sentence: "Neonatal depend on number of cases to be discussed." What's your recollection as to what was said at this meeting as to Neonatal Mortality and Morbidity Meetings?
POTTER: My recollection is that all the cases would have been discussed. It's very difficult, as I said, eight years on, to really recall what that sentence means.
CARR: Now, you have considered your notes of the interviews that you conducted, you have also seen the
notes of others. Based on those notes and based on your recollection, did you discuss -- we can take this down, did you discuss directly with any of the interviewees neonatal mortality?
POTTER: No.
CARR: You didn't discuss therefore concerns about neonatal mortality?
POTTER: No.
CARR: Instances of unexpected and unexplained deaths?
POTTER: No, because we weren't given information around that on, during the inspection.
CARR: When you say you weren't given information, did you directly ask any -- did you directly ask anybody that you interviewed about neonatal mortality?
POTTER: No.
CARR: You didn't ask and it wasn't volunteered by anybody who you interviewed?
POTTER: It wasn't.
CARR: Did you ask any question that you think should have elicited an answer describing concerns about neonatal mortality given that there were concerns on the unit?
POTTER: To my recollection, I didn't ask any specific questions.
CARR: Yes, I am thinking less about specific questions, but whether you asked any general questions any open questions that could have encouraged an interviewer to share with you concerns they had, such as do you have any concerns on this unit? Is there anything unusual? Is there anything that's worrying you? An open question?
POTTER: No, I didn't ask any of those questions. I did ask how staff felt about when an incident had occurred how they were supported and what feedback they got and what learning, if anything, came from those incidents.
CARR: Were you not keen to understand, particularly for the purposes of the assessment of safety and the assessment of effectiveness, what the performance was so far as outcomes, neonatal mortality was?
POTTER: We -- we dealt with what we saw during the inspection.
CARR: In paragraph 71 of your statement, and here you are making reference to the Thematic Review from February 2016 which references increased mortality and also the November 2015 Dr Brigham report, and again you didn't see those at the time of the inspection?
POTTER: No.
CARR: You saw them subsequently. But at
paragraph 71, you say: "I had been asked to provide a view on the relevant significance of these matters referred to above and whether they should have been raised by interviewees. I think these matters were relevant and significant to the inspection and my expectation would be that they would be raised by interviewees such as Band 6 nurses and above where they were aware of these." You go on to say: "I appreciate that it can sometimes be difficult to provide these kinds of disclosure in the presence of colleagues or managers and we offered the opportunity for one-to-one fact-focused interviews during the inspection to accommodate for this." Were you taken up on that offer of --
POTTER: No.
CARR: If you look, please, at paragraph 40 of your witness statement?
POTTER: Sorry, which?
CARR: Paragraph 40.
POTTER: 14?
CARR: 4-0. Do you have it?
POTTER: Yes.
CARR: This is another paragraph dealing with those reviews, the Thematic Review and the Dr Brigham review. You say in the first sentence that: "The provision of the Thematic Review or peer review ahead of an inspection would not have changed my approach to the inspection insofar as there was a CQC process for inspections and for inspectors and Specialist Advisers to follow." But you go on, don't you, in the rest of that paragraph to explain how receiving that information would have shaped your approach to the inspection and would have changed the areas of focus and the areas of questioning?
POTTER: (Nods) I believe that it would have done had I had that information prior to my inspecting the clinical areas and interviewing staff. I may have asked different questions but I was -- I did not have that information.
CARR: During interviews when you are asking staff about safeguarding policies, safeguarding practice and safeguarding knowledge, how do you go about testing the safeguarding knowledge of the people you are interviewing?
POTTER: I wouldn't say that we tested the knowledge. I would have a conversation with them just to see if they were aware of the safeguarding processes within the Trust.
CARR: In the course of that conversation would you -- would you ask them, for instance, what the safeguarding processes were?
POTTER: Yes.
CARR: Rather than just saying: have you had safeguarding training, and they say yes, would you seek evidence that demonstrates the person before you did actually and could articulate what safeguarding processes were?
POTTER: Yes.
CARR: You were not at the Consultants' focus group; that was conducted by another member of staff. As you will be aware as part of your -- part of the preparation of your evidence for this Inquiry, there were some concerns or concerns noted at the Consultants' group of a culture of bullying. In the course of your interviews with staff members predominantly nurses did you hear any evidence were you told of any culture or bullying at the hospital?
POTTER: No, I asked a number of staff how they felt they were supported in their clinical areas and by their senior staff and I -- nobody said to me they had concerns about how they were supported. Nobody voiced any concerns about bullying with me.
CARR: And beyond the concerns about staff numbers
which is described at paragraph 85, you say: "To the best of my recollection some staff expressed concerns during interviews that staffing was not adequate and there were times when the ward unit was short-staffed". Aside from that, were there any concerns that emerged during your participation in this inspection?
POTTER: Not that I can recall now.
CARR: In terms of providing feedback because you were not involved at all, were you, in the writing of the report?
POTTER: No.
CARR: You have explained you were there for three days and that's it and then the report is written by Helen Cain. At the end of the three-day inspection, did you provide feedback to Helen Cain?
POTTER: At the end of each day of the inspection, we provided feedback on that day's inspection.
MR CARR: Thank you, my Lady, subject to any questions Mr Deakin may have, those are my questions.
LADY JUSTICE THIRLWALL: Thank you, Mr Carr. Mr Deakin? Thank you very much indeed, Mrs Potter, you are free to go.
POTTER: Thank you.
LADY JUSTICE THIRLWALL: Would you take the oath please.
LADY JUSTICE THIRLWALL: Do sit down.
CHILDS: Thank you.
LADY JUSTICE THIRLWALL: Yes, Mr De La Poer.
MR DE LA POER: Please could you state your full name?
CHILDS: Elizabeth Childs.
DE LA POER: Ms Childs, is it correct that on 22 June of this year you provided the Inquiry with a witness statement?
CHILDS: Yes.
DE LA POER: Is the content of that witness statement true, to the best of your knowledge and belief?
CHILDS: Yes.
DE LA POER: We will begin briefly with your background. Did you qualify as a nurse in 1977?
CHILDS: Yes.
DE LA POER: Did you subsequently work in a management role within Women and Children's Services?
CHILDS: Yes.
DE LA POER: Did you obtain a Master's in Healthcare Management in 1999?
CHILDS: Yes.
DE LA POER: In 2000, did you become the Executive Director of Nursing at an NHS Foundation Trust?
CHILDS: Yes.
DE LA POER: And was the role of Deputy Chief Executive added to your portfolio in 2009 for the same Trust?
CHILDS: Yes, yes, it was.
DE LA POER: In 2011, did you qualify as an Executive coach?
CHILDS: I did.
DE LA POER: Did you subsequently become a Non-Executive Director at a different NHS Trust, in 2013?
CHILDS: Yes.
DE LA POER: I think you retired from that Non-Executive role in 2019?
CHILDS: Yes, I did.
DE LA POER: If we deal with your experience of the CQC. In 2014, did you start acting as a Specialist Adviser on an ad hoc basis for CQC inspections?
CHILDS: Yes.
DE LA POER: And did you undertake that special advisory role during the period 2014 to 2016?
CHILDS: Yes, I did.
DE LA POER: You estimate in your witness statement, is this correct, that you did between five and six
inspections in that role?
CHILDS: Yes, that is an estimation, yes.
DE LA POER: And of those five or six, you say that you were the chair for two of them?
CHILDS: Yes, that's right.
DE LA POER: Of course as we know you were the Chair for the inspection of the Countess of Chester in February 2016?
CHILDS: That's right.
DE LA POER: Can you help us. Do you think that was the first time you acted as chair or the second time?
CHILDS: I think it was the second time I acted as chair.
DE LA POER: And was the Countess of Chester the final inspection you were involved in or did you have subsequent inspections in 2016?
CHILDS: I think that was the final inspection that I was involved in.
DE LA POER: So in this sense, you were the most experienced that you ever became of acting as an inspector and chair --
CHILDS: Yes.
DE LA POER: -- at that inspection?
CHILDS: Yes.
DE LA POER: Can you tell us please in your own words what
the role of chair of a CQC inspection involves?
CHILDS: It involves supporting the head of hospital inspection who's a CQC employee, it involves making sure that the team that you have in front of you particularly the specialist professional advisers are used to the best advantage. It involves ensuring that you have a thorough but a fair and respectful inspection because you are working through a hospital that's engaged in its duties. You help to lead or you lead with the head of hospital inspection the -- the briefing sessions and the corroboration sessions when people come together and you listen to the evidence that's been provided and if there are issues, any issues that are raised, you deal with those areas of concern which we probably discussed with the head of hospital inspection. And my experience is that as a chair you would usually be involved in the interviews of senior people in the organisation, such as the chairperson, the Chief Executive, the Director of Nursing.
DE LA POER: In that list of responsibilities, you identify that the role of the chair was to ensure a thorough investigation?
CHILDS: Yes.
DE LA POER: Does it follow from that that if it transpires
that the investigation -- or the inspection, rather -- was not thorough, that the person who bears responsibility for that overall would be the Chair?
CHILDS: I think that would -- let me think. Alongside the head of hospital inspection because as a chair you only have responsibility for those days you are actually in the on-site inspection, not prior to the inspection or following the inspection. I suspect you would have some responsibility for ensuring it was thorough. But you would hope that also the head of hospital inspection who does this full time actually would work closely with you to ensure that that was the case.
DE LA POER: One of the things I am sure you will appreciate is that an important principle is accountability?
CHILDS: Yes.
DE LA POER: And if I have understood your last answer, that if it is objectively determined that a particular inspection was insufficiently thorough, the person who would be accountable for that would be the Chair and also the head of hospital at the CQC.
CHILDS: I think that's --
DE LA POER: Is that a fair way of characterising it?
CHILDS: I think that is probably a fair assessment, yes.
DE LA POER: At least that was your view at the time?
CHILDS: Yes. I only hesitate because the role of the chair is quite a minimal role in just those few days that you are on site in the organisation.
DE LA POER: That being the case, just to explore this with you further, is it a surprising statement you have made then that you are on the one hand accountable for the thoroughness of the investigation but on the other have only a very limited role within it? Just help us to understand that apparent tension?
CHILDS: In gathering the statement, putting the statement together for this Inquiry, and you can look at information that you may not have had sight of, that was prepared ahead or seen ahead of the inspection and how the detail following the inspection, it allows you to realise that your role is actually quite limited. It's not exactly as a chairperson would normally carry a role where you may have a clear overview from start to finish of a process.
DE LA POER: So the idea that you may be one of the two people accountable is that simply your interpretation or is that something that was part of any training or information given to you by the CQC when telling you: you are the Chair, you are ultimately responsible for
making sure that this is thorough?
CHILDS: No. There would be no communication from the CQC about that aspect of the Chair's role.
DE LA POER: So that has come from your own reflection?
CHILDS: It is just my own interpretation to your question.
DE LA POER: Now, I mean this with the greatest of respect, but you hadn't in fact done very many inspections --
CHILDS: No.
DE LA POER: -- prior to becoming a chair? Just looking back on it, if it's right that you are accountable for the thoroughness of an investigation, does it surprise you that you were appointed to the role of chair and considered suitable for that when you had relatively limited experience of even being involved in inspections?
CHILDS: It does surprise me now. I am sure at the time it probably didn't surprise me that much. I don't recall having any training at all as being a chair. It was more to do with the seniority of the role you had outside of the CQC.
DE LA POER: Well, plainly it was important that any person who sat down with the leadership team of any Trust was able to speak to them on an equivalent level of seniority?
CHILDS: I think that's exactly right, yes.
DE LA POER: And so part of your function was to do exactly that?
CHILDS: Yes. Yes.
DE LA POER: But I think you have described your understanding of the remit as being broader than just being an appropriately senior person for those interviews because you have talked about liaising with the head of hospitals and ensuring that the whole process worked?
CHILDS: Well, yes, you didn't just interview the senior people in the organisation. You actually were, I suppose, overseeing the Specialist Advisers who were there. I was a Specialist Adviser, they were Specialist Advisers making sure that actually they were supported if they needed support and they were used to the best of their advantage along with the head of hospital inspection, who of course is much more used to inspections than I was.
DE LA POER: That person, so we are all clear, is a person called Ann Ford at the time?
CHILDS: That's right yes.
DE LA POER: We will be hearing from Ms Ford tomorrow.
CHILDS: Yes.
DE LA POER: At the time, did you think that the culture of
inspectors should be one of curiosity?
CHILDS: The culture of inspectors?
DE LA POER: Yes, should -- should the inspectors be curious?
CHILDS: Yes.
DE LA POER: Was it part of your role to encourage that curiosity?
CHILDS: Yes, it would have been part of the role although it was quite a strict format that people followed. But you would expect that people would ask questions and if that might lead to further questions and they would look for evidence to support what they were asking the questions about.
DE LA POER: You have talked about a role as in a way managing the Special Advisers and how they operated, was there an opportunity for you to say: Right, well this is the inspection that I am the chair of, this is what I am hoping we are all going to achieve? Did you have that short of leadership role where you spoke to the team and told them how you wanted it all to run or how you thought it should run?
CHILDS: There was a format at the pre-inspection briefing that you would just welcome everybody -- that was a Zoom call. You would welcome everybody and say that, you know, the culture is that we are polite, we are respectful, so you just go through those headings. There was no further -- I don't recall there being a further sort of opportunity to really engage fully with people. At the start of the inspection, you would again reiterate the behaviours you expected of people.
DE LA POER: And was one of those behaviours, being curious?
CHILDS: I don't remember using the word "curious".
DE LA POER: So let's just consider the inspection in February 2016 and please bear with me here, I am going to provide quite a lot of information in quite direct terms about what we know now --
CHILDS: Okay.
DE LA POER: -- as at the morning of 16 February --
CHILDS: Yes.
DE LA POER: -- and the position at the Countess. We know now that in the nine months prior to that first morning, Letby murdered five babies and attempted to murder four more. We know that now. We know that during the inspection she attempted to murder another baby. Her murders had caused an unexpected increase in the neonatal mortality rate for the neonatal unit in that nine-month period previously. We know now that staff at the hospital had identified that unexpected
increase in mortality?
CHILDS: (Nods)
DE LA POER: All of the seven Consultants were aware of it, including the Lead Clinician for children's services, and the neonatal lead. The lead nurse for children's services and the neonatal unit manager was aware of it and the recent deaths had caused considerable distress, we know, amongst junior doctors and nurses. We also know that the risk and patient safety department was aware of the unexpected increase and the obstetrics department was aware of the unexpected increase and that the Medical Director and the Director of Nursing were aware of it and that the local neonatal network was aware of it, or at least one of its members was. We know now that numerous investigations had been undertaken including a Thematic Review trying to understand that unexpected increase and that despite all of the investigations that were undertaken, no non-sinister explanation for that unexpected increase had been identified. In the week before your inspection, we know that there was a Thematic Review meeting which brought together all of the deaths and said that there was no common theme for the unexpected increase and that that
draft report was sent to the Medical Director and the Director of Nursing the day before you attended and I am just going to bring up an email that you won't have seen before --
CHILDS: No.
DE LA POER: -- INQ0003140. If we go to the bottom email there, this comes from Ian Harvey the day before you arrived. "Dear Steve", and if we just scroll down: "Am I correct in thinking that you commissioned an external review of recently neonatal deaths? If so, is there any early feedback ahead of this week's visit?" That is a reference to your visit. If we go up, we can see that Dr Brearey, who is one of the people your team interviewed, explains a little bit about what occurred and we know that he attached to that email the draft minutes of the meeting which had taken place just seven days before this email exchange. Finally at the top we can see that Dr Brearey's email was then forwarded by Mr Harvey to the Director of Nursing, Alison Kelly, with some comments about the interpretation of it.
CHILDS: Yes.
DE LA POER: The final thing we know -- and I promise that there is a question coming at the end of this -- that over and above all of that, over the nine months prior
to your inspection, four Consultants at least, two nursing managers, and one Risk and Safety Lead had identified or were otherwise told that Letby was associated with the unexplained spike. And that in the case of the four Consultants they had varying degrees of concern that that association may suggest causation. Now, I am sure you will agree with this, the CQC did not identify any of that in the inspection; is that right?
CHILDS: That's right.
DE LA POER: In fact the CQC published a report which said that particular part of the hospital was "good"?
CHILDS: The safe element was "requires improvement" but overall --
DE LA POER: Overall "good"?
CHILDS: -- it was "good".
DE LA POER: So members of the public may find that a surprising state of affairs?
CHILDS: (Nods)
DE LA POER: Now, plainly one explanation is that it was deliberately hidden from the CQC and you can't comment upon that directly. But there is no documentary evidence that any direct lie was told. What I am hoping you might be able to assist us with, reflecting on all of that information, much of which I daresay you knew already --
CHILDS: No.
DE LA POER: Well, reflecting upon that information, was there anything about the CQC inspection that you think failed to draw that out in some way?
CHILDS: I was able to look through the transcripts of the interviews that had been held with the paediatricians and the nurses and the unit managers of the Children's and Young People's Services and the neonatal service. I wasn't involved in those interviews, but I did have a chance to look through them and make a comment and I -- nowhere could I find a comment or the words "Concern", "unexplained", "unexpected" in those notes. The Mortality Morbidity Meetings were mentioned in three of those notes, briefly in a couple, but no transcripts that would say that actually this was raised with a level of concern. That's all I can say, I wasn't in those interviews but I did look through those records and that's, I could not find evidence of that being written down.
DE LA POER: So it wasn't volunteered, you can't see evidence of it being volunteered?
CHILDS: I don't -- I would have to say I could not see evidence that it was volunteered.
DE LA POER: If inspectors are operating and the Special Advisers are operating curiously, would you expect them to be asking questions that might draw that out?
CHILDS: Well, you would expect that they would be discussing them, mortality and morbidity meetings, and you would depend on the answer in a sense to lead you to where the next question is. If there's a discussion that we have Morbidity and Mortality Meetings and we know that we look at the actions taken and the learning from that and we haven't yet found any common themes but there hasn't been a mention of a rise in deaths, then actually you would see that as good practice; that each neonate that dies has a review of the care that's undertaken with junior staff engaged in that, actions are identified, lessons are learnt. There was evidence from those notes that actually action from incidents was passed through staff on safety briefings, et cetera. So you would be following that lead. I think without somebody giving you information that it's an unexpected number or a rise in our number, using those terms, it may be difficult to think that you would pick that up.
DE LA POER: Well, one way to pick it up is to say as part
of a standard meeting, "Is there anything that you think I should be aware of or anything that you are concerned about that we haven't talked about yet?"
CHILDS: And quite often at the end of a session, you would finish with, "Is there anything else you want to tell me that we haven't discussed?" And also you would probably say, you know, we'd hope that people would say, "There's opportunity if you wish to raise something individually to a CQC member of staff" and it would be anonymised. And throughout the organisation there was opportunities, you know, posters that would allow staff to use what they might see as the whistleblowing policy but to come forward if they had a concern that they didn't wish to discuss in a -- in a forum where other people were with them.
DE LA POER: Now, you didn't yourself, because it wasn't your role, speak to anybody in the children services area?
CHILDS: No.
DE LA POER: But you did speak to Ian Harvey and to Alison Kelly?
CHILDS: Yes.
DE LA POER: And you have seen the email that --
CHILDS: Yes.
DE LA POER: -- chain the day before. Did you ask either of them, "We have talked about all of that. Is there anything else that you think I should be aware of or that I need to know or that you are worried about?" Did you ask that question to either of them?
CHILDS: I can only say I may have asked. I can't absolutely remember, but I would have asked, "What are the serious concerns or risks you have around patient safety?" That's usually one of the questions I would ask. "Tell me what those serious risks are. Where are you most concerned? What are you doing to mitigate against that?" So that would be one of the regular sort of questions that I would ask around the safety and quality of patient care generally. You know, not asking about a particular -- neonates because I wouldn't have considered that to be something to ask but generally, "What are the serious risks? Are there any concerns you have about care? What are you doing about those concerns? What are you doing to mitigate those concerns." That would be a question that I would ask.
DE LA POER: Drawing on your experience as a Executive Director of Nursing and as a non-executive director, if you had an unexpected increase in a mortality rate in any department, and that there was a Thematic Review done of those cases and that review came back and said, "We cannot identify a common theme that explains this", is that something that a Director of Nursing or a non-executive director should regard as an area of concern?
CHILDS: I think it is. It's also an area of good practice in that sense that actually you've investigated to that point, you have investigated, you have had a concern, there's a raised number, you have looked at that. You have had a Thematic Review. You haven't as yet found any common thread.
DE LA POER: So --
CHILDS: But you have taken it seriously to the point that you have looked at it through a Thematic Review.
DE LA POER: Good practice you haven't ignored it. But the fact that it remains potentially unanswered, is that something that you would regard as being sufficient to arise in a meeting with somebody like you coming to inspect?
CHILDS: What you would probably want to do is follow on with that. So, you know, "Okay, there's no common threads. Where do we go from here? Where are you going to go next? What are you going to do?"
And then, you know, if -- part of CQC's role because they have a consistent monitoring would be to say, "Keep us informed. We need to know what the next steps are that you are going to take."
DE LA POER: So just to absolutely tie you down. Does it cross the threshold, as I have described it to you, for being something that should be brought up at a meeting with the Chair of a CQC inspection or is it sufficiently well under control not to reach that level?
CHILDS: Sorry, could you say that -- ask that question again?
DE LA POER: Of course.
CHILDS: I'm not sure --
DE LA POER: I am just inviting you to put yourself in the position of Director of Nursing --
CHILDS: Okay.
DE LA POER: -- or Medical Director?
CHILDS: Yes.
DE LA POER: They've got lots of things to talk to you about as an inspector. We know that they received a report which said: Here is the increase in deaths, no common theme has been identified. There's some further detail behind it. I'm just trying to understand whether your view is: Well, if that's sort of information coming in just
before the inspection, I really ought to raise it with the inspector, or the special adviser or do you think: Well, it might not need to be raised?
CHILDS: I think it's -- it was common practice to feel that you should always raise things early if there was a concern rather than wait until it was too late. So with CQC, what we would tend to do is let them know ahead, "We've got a bit of a concern here, this is what we are doing about it", and then it's on their agenda. If nothing comes of it then actually that's all well and good, but if there's further work on that that raises something else then they have already been made aware of it.
DE LA POER: Now, the Inquiry has received some evidence to the effect that if you tell the CQC about your problems there's going to be an adverse consequence for you or potentially because they are going to give you a bad rating. Is that -- whether it's correct or not or whether that's the right way of thinking about it -- is that an attitude that you are aware of existing within the National Health Service?
CHILDS: No, no.
DE LA POER: You have never heard anybody say, "Don't tell the CQC" or "We don't need to quite let them know yet,
this may turn out to be nothing. We don't want them worrying about this or putting it on our rating."
CHILDS: I don't feel that that was something that was commonly thought through the NHS, no.
DE LA POER: Turning to the detail of your particular involvement in this inspection. You hadn't had any previous involvement with the Countess of Chester before this?
CHILDS: No.
DE LA POER: And your first involvement with the inspection was, I think you tell us, a pre-inspection briefing call?
CHILDS: Yes.
DE LA POER: And did you also receive a pre-inspection briefing pack?
CHILDS: Yes.
DE LA POER: And was that -- it sounds like you got it before 16 February?
CHILDS: Yes.
DE LA POER: You are satisfied you did?
CHILDS: Yes.
DE LA POER: You weren't involved in any of the information gathering that produced that pack, is that right?
CHILDS: That's right.
DE LA POER: One part of -- well, let's have a look at a document. It's the children's pack, INQ0101422. That's termed a pre-inspection document, it's dated 22 December 2015. Do you recall whether this was within your pre-inspection pack?
CHILDS: Yes, this was. Yes, this was part of the pre-inspection pack.
DE LA POER: Now, you had a background in children's services as a clinician, didn't you?
CHILDS: Yes.
DE LA POER: But that wasn't your function at this particular inspection. Is this something that you will have read before you went to the inspection?
CHILDS: Yes. This would have come out prior to the pre-inspection briefing, which was held on the 10th February. So there would have been an expectation that anybody who was attending the pre-inspection briefing would have looked at the -- the pre-inspection pack.
DE LA POER: Now, just one query as to whether you noticed it at the time and if so whether it was in any way a problem. If we look at page 6, we can see there is a summary of analysis presumably provided by people at the CQC based on information that they were --
CHILDS: I have got page 5 up on my screen.
DE LA POER: It's page 6, it's document page 6.
CHILDS: Sorry. Okay, yes.
DE LA POER: No trouble at all. But this, this appears to be information gathered by the CQC and prepared for the inspectors?
CHILDS: Yes.
DE LA POER: Now, "Well-led" is blank.
CHILDS: Yes.
DE LA POER: Is that something that was common, that there would be a blank field about an important area that you were looking at?
CHILDS: I can't remember if it would be common in the pre-inspection briefing pack or not to be quite honest.
DE LA POER: And if you were reading that, would you be sufficiently concerned about that absence to say, "We need to know that before we come along", or would you just say, "Well, I am sure we will find that out when we get there." I mean, how important is this?
CHILDS: I think I would assume that that would be found out when you get there, when you start talking to staff and asking them about their role, the way they work within the organisation, et cetera.
DE LA POER: Thank you. We can take that down. The next document I want to ask you about is a table of neonatal incidents. I think you have had a chance to have a look
before you have come in today to give your evidence. I'm not proposing to put it on screen.
CHILDS: Okay.
DE LA POER: You say in your statement that you don't recall having seen that?
CHILDS: No.
DE LA POER: If you had seen it, do you think it would have made a difference to your approach, is it something that you would have looked at and thought I need to ask about this?
CHILDS: That's the table with the 200 -- or a long list of the incidents in the unit?
DE LA POER: Yes, exactly so.
CHILDS: Quite possibly if you were in the Children and Young People's team, you would look at those, some of those in more detail and want to ask, pick one or two out for example to ask the questions of them. I think from memory there were a couple where there was very little detail around the neonatal deaths. So those in particular you may want to say, "Can you explore, can we explore this a little bit further?"
DE LA POER: Sitting there now, the fact that you don't have a memory of having seen that table, does that suggest that it's likely that you weren't sent it in advance or as part of your inspection?
CHILDS: No, no, I had not seen that table.
DE LA POER: You had not seen --
CHILDS: I had not seen that table until I had it sent to me in readiness to put the statement together.
DE LA POER: And the third and final pre-inspection document, INQ0103620. This is the intelligence presentation?
CHILDS: Yes.
DE LA POER: Was this something that you will have seen before the inspection or on the day of the inspection?
CHILDS: This is on the day of the inspection.
DE LA POER: And was this a presentation to the Trust or was it just within the inspectors that this presentation was --
CHILDS: I think it was just to the inspectors in the presentation -- in the inspection team.
DE LA POER: So it's a way of preparing you for what you were about --
CHILDS: It is a way of preparing everybody for the inspection which was about to -- which had started that day.
DE LA POER: Others have been asked about this. We can go to page 7 and see the self-assessment where we can see for services for children and young people that the hospital has rated itself as "good", "good", "outstanding", "outstanding" and "good" across the five domains?
CHILDS: Yes.
DE LA POER: How important was the fact that the hospital thought that it was doing well in particular areas to you in formulating what you were going to explore or examine?
CHILDS: I don't know that it would have had such an impact on you. Your job was to look at evidence in front of you that you had gathered from that. It -- it may have related to that but I don't think that, you know, that influenced. So if you saw "outstanding", I don't think you were thinking, right, this is going to be outstanding. It was your job to actually look at the evidence against the key lines of inquiry and standardise the approach to the inspection.
DE LA POER: Your answer, if I may say, is broadly similar to the three previous witnesses that we have had about this.
CHILDS: Phew.
DE LA POER: Well, it is important to get your perspective. But if it wasn't going to make any difference, why do you think you are being told this on the morning of your inspection? What's the value of that information
if all you are going to do is say, "Well, that's what they think. I am now going to get on with what I think I need to do"?
CHILDS: It would be worrying if actually a Trust felt it was outstanding in very many areas and you found that it required improvement. That would indicate to you that maybe this is a Trust that isn't really understanding, you know, its services. So in that respect you might think, well, you know, we are seeing something very different from this organisation. So that would make you sort of question things, wouldn't it?
DE LA POER: But that's only a comparison that's valuable once you have conducted your own independent assessment.
CHILDS: Yes, it is. Yes, it is.
DE LA POER: But I am trying to understand why before you go in you thought you were being told what they thought about themselves when you were effectively just going to ignore that?
CHILDS: I can't say what value it had then.
DE LA POER: Page 34, please, within this document. This is the recap key messages. The fourth bullet is: "Data quality and reporting issues in some areas of the Trust." Do you recall whether that was something that you
actively investigated or tried to get to the bottom of with the interviews that you conducted?
CHILDS: I honestly can't recall. The -- the interviews that I conducted, I have very little memory of those, I'm afraid. Unfortunately, I haven't been able to see any of the records of those either.
DE LA POER: No. Well, that is because they cannot be found.
CHILDS: Yes.
DE LA POER: When I say that, you shouldn't think that I am implying criticism of you.
CHILDS: No, no, I don't.
DE LA POER: So we can take that down and just deal with some other areas of information. Did you know anything about healthcare episodes statistics or HES?
CHILDS: Vaguely.
DE LA POER: What did you understand that was?
CHILDS: It was a way of comparison between different organisations in terms of their performance and patient incidents and deaths.
DE LA POER: And did you expect to see the output of that as part of your preparation so that you would be told in advance what the big data picture was?
CHILDS: I'm not sure that I expected to see that.
DE LA POER: Is it fair to characterise your reaction that
from the fact you only knew it vaguely that this wasn't a big part of what you understood was going to be important for the inspection process?
CHILDS: I think had it been something that was off-kilter, we would have been informed about it prior to the inspection.
DE LA POER: So it would only come to you if it was identified in advance that that data had suggested a problem?
CHILDS: Yes.
DE LA POER: Before you attended, did you have any reason to think that there had been an increase in the mortality rate on the neonatal unit?
CHILDS: Before I ... ?
DE LA POER: Attended the inspection?
CHILDS: No.
DE LA POER: Before you attended the inspection, did you know anything about suspicions which may have existed about a particular member of staff being connected with that mortality rate?
CHILDS: No.
DE LA POER: The Thematic Review document, which you have seen referred to in those emails --
CHILDS: Yes.
DE LA POER: -- do you have any recollection of having seen a Thematic Review of neonatal mortality?
CHILDS: I did not see a Thematic Review, no.
DE LA POER: I have characterised that document to you now. It's about 10 pages long or so and it goes through each of the deaths, looks at different factors --
CHILDS: Yes, yes.
DE LA POER: -- identifies some areas for improvement but says ultimately no common theme. Is that a document that should have been provided to you and the inspection team beforehand, do you think? Is it a document that would have been valuable to your inspection?
CHILDS: I think it would have been, as we said earlier, giving CQC a heads up that there had been a concern raised and this is the work that had been undertaken to try and identify a little bit more about that concern.
DE LA POER: So does it all come to this: that your position is that you should have been told about whatever concerns existed certainly about the increase in mortality rate?
CHILDS: Yes.
DE LA POER: And that that should have come before you started?
CHILDS: Or as we started discussing with the paediatric team or the Medical Director or the Director
of Nursing.
DE LA POER: We will just identify the people that you interviewed. I can bring a document up but I'm sure you can take it from me you interviewed the non-executive Director for Quality and Safety, Mr Higgins?
CHILDS: Yes.
DE LA POER: The Chair, Sir Duncan Nichol?
CHILDS: Yes.
DE LA POER: The Director of Nursing, Alison Kelly?
CHILDS: Yes.
DE LA POER: The Senior Information and Risk Owner, also Alison Kelly?
CHILDS: Yes.
DE LA POER: The chief operating officer, Lorraine Burnett?
CHILDS: Yes.
DE LA POER: That was all on the 17th. And then on the 18th, the Senior Lead for HR Sue Hodkinson, the Chief Executive Tony Chambers and the Medical Director Ian Harvey?
CHILDS: Yes.
DE LA POER: As you have told us you have got no notes available to you to refresh your memory from that?
CHILDS: No, I haven't.
DE LA POER: Were notes kept of those meetings?
CHILDS: Oh, absolutely.
DE LA POER: Who kept those notes, who was the scribe or was everybody writing their own notes?
CHILDS: Well, you could write yourself and there would be a second person with you, a CQC person, who would also be transcribing. All of the records would be handed in at the end of any inspection. It was really important that every record you had was handed in to CQC, which obviously became part of the process of taking the report writing forward.
DE LA POER: Was it your practice to make notes?
CHILDS: It was my practice to make notes, yes.
DE LA POER: So do you think for each of these interviews there existed, at one time, your record of what was said?
CHILDS: Yes. And there was a, you know, a table that you would use from CQC that you could write them down on, yes.
DE LA POER: Now, you have told us your recollection is extremely limited.
CHILDS: Yes, I'm afraid so.
DE LA POER: You do have a recollection of Alison Kelly becoming distressed in your meeting with her?
CHILDS: Yes.
DE LA POER: And just tell us what you recall she became
distressed about.
CHILDS: Well, we visited in February, as you know, and it was the middle of winter, winter pressures, what we call in the NHS winter pressures, and the hospital was under a great deal of strain with patients who were ready for discharge, but couldn't be discharged. So really things had come to pretty much a standstill in terms of, you know, putting people through A&E, emergency admissions, trying to get elective surgery in, trying to move people out that didn't require the acute hospital beds any more, and extra beds had been opened, surgery had been cancelled. And I recall this specifically because I have been in that situation many a time myself and I -- I knew how dreadful that situation is because as much as you try there's very little you can do to sort of alleviate it. And so you worry about the quality of care that's being given to people, you worry about the staff that are working extremely hard, and maybe having to do overtime et cetera. So it's a real concern.
DE LA POER: I think in fact you subsequently spoke to Ann Ford to effectively make the observation, "I wonder if we'd had a different picture if we'd come at a different time of year."
CHILDS: Yes, yes.
DE LA POER: In terms of other things that you have recorded in your witness statement that were or weren't said, you say that you can't recall discussing a situation of any unexpected or unexplained increase in neonatal deaths and that you can say, with absolute certainty, that there was no mention of any suspicion or correlation with a member of staff and neonatal deaths?
CHILDS: Yes.
DE LA POER: And had that, had either of those things been raised, would they have provoked a reaction from you?
CHILDS: Yes, I would have discussed those with -- well, you might have asked more questions in the actual interview itself. But I think I would have discussed those with the Head of Hospital Inspection, that concerns had been raised that maybe we hadn't been made aware of before the inspection, particularly correlations between staff members and, you know, patient deaths. That's a serious issue.
DE LA POER: You record in your statement that staff were generally positive about the culture of the organisation?
CHILDS: Yes.
DE LA POER: And that they spoke positively about the visibility of the CEO and Director of Nursing?
CHILDS: That wasn't necessarily just the Children's
Unit. I think that was when I was asked to give an account of the interviews that had taken place with other staff groups, yes.
DE LA POER: Yes. So this is you giving your overview as Chair effectively?
CHILDS: Yes. I wasn't involved in any of those but I looked through all of the transcripts and I was trying to get an overview for the purposes of the statement and the Rule 9.
DE LA POER: You say your review caused you to find that generally interviewees gave positive accounts of the care they delivered to children and young people?
CHILDS: Yes.
DE LA POER: That in two interviews the issue of the Children's Unit not having a voice at board level was raised?
CHILDS: Yes.
DE LA POER: However, you say the neonatal unit department manager gave a slightly different impression?
CHILDS: Yes.
DE LA POER: That person is Eirian Powell. I think you say that she described the board as being visible and supportive?
CHILDS: Yes.
DE LA POER: You say that staff shortages were most
frequently mentioned?
CHILDS: Yes.
DE LA POER: And that there was real concern about that?
CHILDS: Yes.
DE LA POER: But that the nursing shortages in particular were long-standing?
CHILDS: Yes.
DE LA POER: Your involvement as you have told us was effectively for three days?
CHILDS: Yes.
DE LA POER: That's the 16th, 17th and 18th. The inspection continued on the 19th?
CHILDS: Yes.
DE LA POER: But even though you were Chair, that wasn't your function to be present for that?
CHILDS: No. That was I think a CQC wrap-up meeting. I'm not quite sure how that was addressed. But no, we stayed for the three days that we were conducting the inspection in the hospital itself.
DE LA POER: And it would appear there was some sort of connected visit in very early March, but I don't think --
CHILDS: An unexpected -- an unexpected?
DE LA POER: I'm not sure I would go that far but it appears to be connected with -- the follow-up is
connected with the February visit. For my purpose, what's important is you didn't go back in March?
CHILDS: No. No, I didn't, I didn't go back.
DE LA POER: And you say in your witness statement you don't believe you went to any post-inspection meetings?
CHILDS: No, that was the quality summit and my name was on the template and I wasn't present at the quality summit.
DE LA POER: And you weren't involved in the drafting of the report?
CHILDS: No, no, I wasn't.
DE LA POER: Or provided with the email sent by Alison Kelly on 30 June?
CHILDS: No, no.
DE LA POER: So I would just like to invite you to reflect and you have had a little bit of processing time, although I have been asking you questions about it; if it is thought that something's gone wrong with this inspection --
CHILDS: Yes.
DE LA POER: -- the process overall and everybody involved in it, where do you think improvements might be made to try and prevent that in the future? And when I say something gone wrong, an important piece of information does not appear to have made it to the CQC and as a result the CQC has given a report that suggests that effectively there isn't a big problem when there is?
CHILDS: I think if some of the raw data that was seen in the Provider Information Returns was seen by the people who were going to inspect the service, the specialist professional advisers, not just the CQC Inspectors, then actually they potentially would actually use that to base further questions on. So I think that would have been helpful rather than just a summary of. I think it's made me think about the role of the Chair undoubtedly because, you know, an expectation really, when you use that terminology, is that somebody's there at the start and right through to the finish and in a sense signs something off. So whether that's the right terminology for somebody who's called in for three days just to provide some sort of sense of leadership alongside the Head of Hospital Inspections is maybe not the right terminology. Or if you do want somebody to do that role who's external to the CQC, it needs to be thought through differently so they can give more time to it and they are not somebody who's, you know, already working and just doing this as another issue.
Yes, can you say the question again because I have sort of forgotten where we are with that?
DE LA POER: No, not at all. I mean, one possibility is you say it was your practice to ask quite a general open question?
CHILDS: Yes.
DE LA POER: But it seems that that was something that you decided to come up with rather than something you were trained to do or it's something that you were told in every meeting, "You need to make sure that you're asking this" in case people aren't being forthcoming on the basis that people may not want to volunteer information but they may be less likely just to lie. Do you think that that's the sort of thing that inspectors need to be doing, not just focusing on process but just asking people to step back and say, look --
CHILDS: Yes, I do.
DE LA POER: Sorry.
CHILDS: I do. But I can't say with any certainty that that wasn't already in place, that maybe it was suggested that at the end of every interview or focus group one of the final things should be, "Anything else you need to say? Anything else that anybody wants to say that we haven't yet covered?"
I can't recall that that was something, but it may well have been something that was actually explored with all the Specialist Advisers and CQC Inspectors that that's how you would finish off every interview or every focus group.
DE LA POER: And --
CHILDS: It's certainly important I think that that would be stated. It was obviously very important that you allowed people to know that they could come and see you independently if they had a concern and that that would be confidential.
DE LA POER: You frame that question in terms of "Anything you want to say?" Isn't there a slightly tighter question which is, "Is there anything that you think you should tell us?", not that you necessarily want to, but that you --
CHILDS: Yes.
DE LA POER: You know --
CHILDS: Yes, I think that's probably a better word to use. "Is there anything that you think you should tell us that we haven't already covered?" Yes, I think that's a better word.
MR DE LA POER: Yes, thank you very much indeed. Those are my questions, my Lady.
LADY JUSTICE THIRLWALL: Any questions, Mr Deakin?
MR DEAKIN: No questions.
LADY JUSTICE THIRLWALL: Thank you. I have no questions either, Mrs Childs, so thank you very much, you are free to go.
CHILDS: Thank you.
MR DE LA POER: My Lady, that concludes the evidence for today. As my Lady knows there are two further witnesses from the Care Quality Commission tomorrow morning.
LADY JUSTICE THIRLWALL: Very good. Thank you very much, Mr De La Poer. So we will rise now until 10 o'clock tomorrow morning.
(3.44 pm) (The Inquiry adjourned until 10.00 am, on Friday, 15 November 2024)
Witnesses:
Ann Ford: CQC Inspector
Julie Hughes: CQC Inspector
LADY JUSTICE THIRLWALL: Mr De La Poer.
MR DE LA POER: My Lady, the first witness today is Ms Ann Ford and I wonder if she might come forward to the witness box, please.
MS ANN FORD (sworn)
LADY JUSTICE THIRLWALL: Thank you, do sit down.
FORD: Thank you, my Lady.
MR DE LA POER: Please could you give us your full name?
FORD: Before we do that, my Lady, is it okay if I say something, please?
LADY JUSTICE THIRLWALL: Of course, you might want to give your name first.
FORD: I'm sorry, my name is Ann Ford.
LADY JUSTICE THIRLWALL: Yes.
FORD: I would just like to offer my sincere condolences and sympathies to the families affected by these awful events, both on behalf of myself and the CQC. I do feel very sorry for their pain and suffering. Thank you.
MR DE LA POER: Ms Ford, you have provided the
Inquiry with three witness statements; we are just going to identify each of those now. Is it correct that the first is dated 24 June of this year?
FORD: Yes.
DE LA POER: The second, 8 August of this year?
FORD: Yes.
DE LA POER: The third, the 18 October of this year?
FORD: Yes.
DE LA POER: Is the content of those witness statements true to the best of your knowledge and belief?
FORD: It is.
DE LA POER: If we just review, in summary form, what each of those statements deals with. The first deals with disclosure by the CQC; is that right?
FORD: Correct.
DE LA POER: When we say "disclosure", we are talking about documents held by the CQC disclosed to the Inquiry?
FORD: Indeed.
DE LA POER: And that that statement was provided in response to a request from the Inquiry formally under Rule 9 of the Inquiry rules; is that correct?
FORD: Yes. Yes.
DE LA POER: Your second statement, also provided in response to a Rule 9 request, provided further detail about the disclosure process; is that correct?
FORD: It is.
DE LA POER: It also provided some information about the inspection in February 2016?
FORD: Correct.
DE LA POER: The third statement, the one dated just a few weeks ago, provides further detail about the inspection; is that right?
FORD: Yes, it is.
DE LA POER: That statement was effectively volunteered on the basis that you, and no doubt others at the CQC, took the view that you had additional information that you could provide the Inquiry with?
FORD: It was, yes.
DE LA POER: We will come back to the sequence of those witness statements in just a moment, but let's first introduce you. You are currently the Director of Operations for network north within the CQC; is that right?
FORD: It is, yes.
DE LA POER: Does that give you overall responsibility for that area of the country so far as the CQC is concerned?
FORD: It is, yes, I am responsible for the regulation of health and social care in that area.
DE LA POER: That will include inspections; is that right?
FORD: Yes.
DE LA POER: But also other aspects of the CQC's regulatory responsibility?
FORD: Yes, it is.
DE LA POER: When did you take up that position?
FORD: I think it was about 2020. Thereabouts.
DE LA POER: Now, at the time that we are going to be focused upon when we come to look at the inspection, you had a different role, didn't you?
FORD: I did.
DE LA POER: You were the Head of Hospital Inspection?
FORD: I was for the North West, yes.
DE LA POER: You began in that role a couple of years before the inspection took place?
FORD: I did, about 2014, yes.
DE LA POER: Beginning in that role of head of hospitals 2014, how long did you hold that role for?
FORD: About three years, I moved into another role about 2017.
DE LA POER: You had been acting in the role for well over a year, if not a full two years at the time of the inspection. Did you regard yourself as having a good control over what was required from a hospital inspection?
FORD: Yes, I believe I had a good understanding of the methodology, yes.
DE LA POER: Just help us a little bit in terms of your background. We don't need an entire CV, but do you have a clinical background or other background prior to that role that equipped you for the role of head of hospitals?
FORD: I am a Registered General Nurse and I have got 30, 30 years' experience as in a management role, and I have been in regulation since about the year 2000. So I have got 24 years' experience of regulation of health and social care.
DE LA POER: Just fleshing that out a little bit, when you say "a management role" was that a management role in any particular NHS hospital, or was it outside of the NHS?
FORD: No, it was, it was both. I was a ward sister, I was a nurse tutor, I worked at the health authority in a commissioning role, I have worked in the independent sector as a manager, and I came into regulation into Liverpool Health Authority in about 2000.
DE LA POER: Did you have any particular knowledge or experience of children's services within the NHS?
FORD: Children's service is not my experience, no, it's not my background.
DE LA POER: On the one hand, taking us to 2016, head of hospitals, but also did you attend the inspection
yourself effectively as an inspector?
FORD: No. I -- I didn't attend the inspection, but I was inspecting the well led component of the -- of the inspection. I had a team to inspect each of the core services.
DE LA POER: I may have just misunderstood your answer slightly. You have said you were inspecting the well led, does that make you an inspector?
FORD: Yes, I was part of the well led team, yes, I see what you mean.
DE LA POER: You were one of the inspectors?
FORD: Yes.
DE LA POER: No, I am sure it was my question. So you effectively had a dual role, oversight over the whole process, but also a boots-on-the-ground role interviewing people, trying to understand what was going on in that hospital during that inspection?
FORD: Yes.
DE LA POER: The second part of my questioning will be looking at that inspection. The first part is going to focus upon the CQC and disclosure. Now, you provided your first statement [INQ0102609] in June of this year in response to the Inquiry seeking to understand what the CQC was doing with the disclosure process; is that right?
FORD: Yes.
DE LA POER: At the beginning of your statement, you identify yourself as the appropriate person to make the statement; is that right?
FORD: Yes.
DE LA POER: Because although you don't work in the inquiries part of the CQC or necessarily the disclosure part, you have oversight and understanding in all of that and responsibility for the whole area; is that right?
FORD: I have a responsibility for the regulation of the whole area and the Countess of Chester was in my patch, so I had oversight of the Trust, yes, I did.
DE LA POER: You tell us in your statement that you have spoken to a significant number of people within CQC to try and understand what was going on so that you could provide the Inquiry with an accurate update?
FORD: Yes, we met weekly.
DE LA POER: Now, if we take a couple of steps back from the time at which you gave that statement, in the early part of this year, Mr Trenholm gave two statements on behalf of the CQC effectively setting out what he understood at that time the CQC's corporate understanding was of the inspection and the Countess of Chester; is that right?
FORD: Yes, I think he did, yes.
DE LA POER: Is it fair to say that after he gave those statements a very significant number of documents came to light that Mr Trenholm will not have known about when he was seeking to assist the Inquiry with the CQC's corporate position?
FORD: I'm not sure I understand your question.
DE LA POER: Well, perhaps I will ask that at the end?
FORD: Yes, please.
DE LA POER: What the Inquiry was told in May, just before you provided your statement, is that in the search for documentation the CQC had realised that the Inquiry required a broader scope of information?
FORD: Yes.
DE LA POER: Were you aware of that?
FORD: I was, yes.
DE LA POER: In effect, the CQC had interpreted the Inquiry's request too narrowly?
FORD: Yes, I was aware.
DE LA POER: At the time that Mr Trenholm was drawing together information and trying to understand what had gone on, the CQC's understanding about what the Inquiry needed was too narrow?
FORD: I believe so, yes.
DE LA POER: What happened next was that in May of this year, the CQC employed a system called e-Discovery; is that right?
FORD: Yes, we did.
DE LA POER: Let's just try and understand what that means. But before that, is it correct that the CQC had assumed that all relevant material would be held in particular places upon its filing system?
FORD: I think most of the records would have been held on our customer records, CRM customer records management system, and also on people's personal drives, but we did have a huge amount of paper records as well that were stored in the Newcastle office. I think we knew that we had records both electronically and physical paper records as well.
DE LA POER: When was it realised that there were those additional records?
FORD: I can't remember the date exactly, I took advice from the Inquiry's team regarding that.
DE LA POER: But it was late in the process?
FORD: I believe so, yes.
DE LA POER: It may be thought that it was quite an obvious thing for the CQC at an early stage to think "I wonder if there are any paper records relating to this because our process at the time was for everybody to create paper records"?
FORD: Mm-hm.
DE LA POER: Would you agree, taking responsibility on behalf of the CQC, that that was quite a significant oversight on the CQC's part at an early stage?
FORD: Yes. I would, I would admit that. I think our disclosure wasn't timely and it wasn't complete, and I apologise for that.
DE LA POER: Well, we will just complete our review to understand what you mean by "wasn't timely". You provided the statement on behalf of the CQC in June of 2024 and the Inquiry was informed at about that stage of the scale of the further documents the CQC had discovered?
FORD: Yes.
DE LA POER: It was over 4,000, wasn't it?
FORD: It was.
DE LA POER: We just need to reflect upon the CQC's starting assumption which was, in your words, most of the documents would be stored in those Y drive and on the customer or the client file?
FORD: Yes.
DE LA POER: In fact, that was quite a gross underestimation of where the weight of the records would be, wasn't it?
FORD: I think it was an underestimation.
DE LA POER: Well, a very significant underestimation?
FORD: I believe so, yes.
DE LA POER: The upshot was that over 4,000 documents were sent to the Inquiry identified as being relevant in July of this year?
FORD: Yes, that's correct.
DE LA POER: Can you, on behalf of the CQC, recognise that providing over 4,000 documents to a public Inquiry, a matter of weeks before the oral evidence hearings are about to begin, and over the summer period, was unacceptable?
FORD: I think I would have to accept that the way we managed the disclosure was not good enough and I think there are profound lessons to be learnt and improvements to be made.
DE LA POER: Well, I am going to invite you to consider two specific words to see -- you have said "not good enough" was it inadequate?
FORD: I'm not sure that I would agree that it was inadequate, but it certainly could have been improved upon.
DE LA POER: Was it unacceptable?
FORD: I think the delay was, yes.
DE LA POER: That's the timing issue. We are going to turn to the second part of it which is the content issue. Again, you have provided us a lot of information, but
I am going to try and distil this down. Do you agree that the starting point is that in 2015, the CQC was notified by the independent investigation -- Independent Inquiry into Child Sexual Abuse -- that it should retain all material save for a few identified categories?
FORD: Mm-hm.
DE LA POER: From that moment, the CQC should have adopted a rigorous filing system to ensure that every single record, save for that narrow exception, was carefully retained in case it was needed?
FORD: Yes.
DE LA POER: We can deal with the exception point, we are going to come to what class of material cannot now be found, but that material all should have been retained under the IICSA requirement, shouldn't it?
FORD: It should have, yes.
DE LA POER: Now, if we now reflect upon a separate reason why the CQC might have thought to rigorously file its material, in May 2017, the CQC was told that a police investigation had been opened into events at the Countess of Chester?
FORD: Yes.
DE LA POER: And that that investigation was in relation to the increase in neonatal mortality?
FORD: Yes.
DE LA POER: Eleven months earlier, the CQC was told by Alison Kelly that there had been an increase in neonatal deaths which applied to the period of the inspection?
FORD: Yes.
DE LA POER: Putting those two pieces of fairly simple information together, is it fair that in May 2017 the CQC was on notice that the police was investigating a period which included the inspection conducted by the CQC?
FORD: I think that's reasonable, yes.
DE LA POER: At that point, is there any record within the CQC that the CQC said, "we may hold information relevant to that investigation, we need to be careful and file it all"?
FORD: Not that I am aware of, no.
DE LA POER: On behalf of the CQC, do you accept that that thought process should have been had in May 2017?
FORD: I think that would have been a sensible thing to do.
DE LA POER: Now, we heard yesterday that Ms Cain said that she believed that by the end of 2017 that she was aware that the police were identifying a specific member of staff. At that stage, it is not just an investigation which might be corporate manslaughter or gross
negligence manslaughter necessarily, but here focus on a member of staff which gives rise to the possibility of a murder investigation; do you agree?
FORD: I do.
DE LA POER: Was that another opportunity for the CQC to say, "we may hold material which is relevant to a murder investigation"?
FORD: I think it was, yes.
DE LA POER: We know that there was an incident co-ordination meeting on 4 June 2018, forgive me, the first of its type, chaired by NHS England, where there was express discussion of what was going on with the police investigation. Do you agree that that was another opportunity for the CQC to pause and say, "we need to get our house in order no case this is relevant to a police investigation"?
FORD: I don't believe that I was part of that group.
DE LA POER: I am not suggesting you were, I am asking corporately --
FORD: Corporately.
DE LA POER: -- for the CQC?
FORD: Yes, I believe yes, it was, yes.
DE LA POER: You will forgive me, but you are the witness who the CQC has identified and you have acknowledged --
FORD: Yes.
DE LA POER: -- that you are appropriate to speak to these issues.
FORD: Yes.
DE LA POER: It is very important that there is accountability where there has been errors, do you make that concession on behalf of the CQC?
FORD: I think there were a number of missed opportunities and you have highlighted some of those.
DE LA POER: Let's continue. We know that a month later, an arrest occurred, another missed opportunity, do you agree, for the CQC to get its house in order?
FORD: I do.
DE LA POER: 12 November 2020, charge of Lucy Letby. Another missed opportunity for the CQC to get its house in order; do you agree?
FORD: I do, but I think -- I think if you look at what we know now and what we knew then -- and our systems have significantly improved since that 2016 inspection -- so I think we would have been better placed in 2020 to provide information than we were because we were not at that point as heavily reliant on paper records, and I think the electronic records about our dealings with the Trust would have been more available.
DE LA POER: Well, let's just think about that answer for a moment. The core interviews and indeed some of the records of the Consultant focus group were paper, weren't they?
FORD: They were.
DE LA POER: What needed to happen with those was that somebody or a team of people identified at the earliest possible stage where they were, ensured that they were scanned and retained electronically or otherwise filed in a way that was robust and accessible?
FORD: Yes.
DE LA POER: Do you agree?
FORD: I think that was a missed opportunity, yes.
DE LA POER: We start from the proposition that the closer to the time that happens, the easier --
FORD: Yes --
DE LA POER: -- and more complete it's going to be. As time passes, the challenge is going to increase?
FORD: I agree.
DE LA POER: We have just marked a number of clear, as you have conceded, missed opportunities. We, of course, had the trial in October 2022, very widely publicised; another opportunity, would you agree, for the CQC to get its house in order?
FORD: Of course.
DE LA POER: It would appear that, in fact, it was not until September 2023, on the very eve of the Inquiry being announced, that a missive went round telling the CQC that records need to be pulled together?
FORD: That's correct.
DE LA POER: That is, would you agree, far, far too late?
FORD: Yes, I think it was too late.
DE LA POER: What explanation is there that the CQC can offer for why all of those opportunities were missed?
FORD: I don't have an explanation. I think I would have to -- for why those opportunities were missed. I think at the time, we were very, very focused on the Trust itself, rather than our input into any subsequent investigation. I think with hindsight that was a real shortfall in our record-keeping and in our records and documents management.
DE LA POER: Now, let's just reflect upon what the consequences of those missed opportunities are. We deal with this in your statement. You can take it from me or I can take you to the paragraph, but I will try without taking you to your statement. If we start with meetings before the inspection, what you say is: "Although the CQC considers that the following meetings could have taken place, its searches and
inquiries so far have not revealed any corroborative evidence of the fact that they did or anything that was discussed at (1) a pre-inspection meeting with the Countess of Chester Trust during February 2016; (2) a meeting between the CQC and the Countess of Chester NHS Trust during February 2016; (3) a quality summit meeting dated 29 February 2016; (4) a quality surveillance group meeting dated 28 July 2016."
FORD: Mm-hm.
DE LA POER: Is that correct, that is the position as at today; those documents haven't been found?
FORD: No, they have not been located.
DE LA POER: You also say that no notes from a listening event on 9 February 2016 have been found.
FORD: No, they have not been located.
DE LA POER: In terms of the substance of the inspection itself, what you tell us is: unfortunately the CQC is unable to locate the notes from meetings with Sir Duncan Nichol, that is the Chair, Ruth Millward, that is to say the head of risk and safety, the meeting with the Staff-Side representative, the safeguarding lead, the non-executive director for quality and safety, Alison Kelly, that is to say the Director of Nursing, Lorraine Burnett, Ian Harvey, that is to say the Medical Director or the complaints lead?
FORD: Mm-hm.
DE LA POER: Now, those were a number of those meetings that you yourself attended?
FORD: Yes.
DE LA POER: In your own words, what is the extent of the disadvantage to you, as a potentially important witness, about the fact that the CQC cannot find those notes?
FORD: Well, I am reliant on the power of recall and I am also reliant on the inspection report and I am also reliant on some of the information stored by others. So the Quality Surveillance Group, for instance, is led and managed by another stakeholder, so I would have to refer to them for that. But I think what possibly may have happened is that at the time of that inspection our records management policy was that within six months of the inspection, and six months of publication of the report, the records of the inspection could be destroyed. And I don't think or I believe that the excerpt directive wasn't particularly well understood, and I think some of those records may have been destroyed in accordance with that previous policy. That may be a possible explanation for why we can't locate them. We looked extensively in every reasonable place
that we thought we would find the records. I put together quite a big resource team to do that in advance of the Inquiry and, as I said earlier, I do accept that the response was not timely or comprehensive enough and for that I apologise.
DE LA POER: My question was about the disadvantage --
FORD: Sorry.
DE LA POER: -- to you. You say you have to rely on recall?
FORD: Yes.
DE LA POER: It is now 2024, that was 2016. Would you agree that that is a substantial disadvantage to you as a witness?
FORD: I think I would have been a lot more confident had I had the records, but I do believe that I can recall the range, nature and substance of that inspection.
DE LA POER: Well, we can test that right now. Do you recall whether in any of the meetings that you attended, whether you or anybody else conducting the interview on behalf of the CQC said to any of the people you were questioning, "Are there any concerns that you think the CQC should be aware of?"
FORD: I can say with confidence that I believe we did because most of -- at the end of each interview it was standard practice for the interviewers to say to the interviewee: "Is there anything else that you would like to tell us? Is there anything that we have missed? Is there anything you want to share with us?" And that was quite common practice. So I believe we will have said that.
DE LA POER: If I was to take a particular interview and ask you specifically about that person, and say, "Was that question asked in that interview?" Would you be able to tell us with certainty whether it was?
FORD: Not with absolute certainty, no. But the probability would be that we asked that question. I think we did that at most focus groups, we did that at most interviews and we also had the prompts and the key lines of inquiry that we used and part of that is asking about challenges, risks and issues for escalation. So I think there is a strong possibility that we asked that question in those interviews.
DE LA POER: Can you recognise nonetheless that it is unsatisfactory that there is no contemporaneous record one way or the other on that point?
FORD: I think that's unfortunate, yes.
DE LA POER: In relation to the Consultants' focus group, you say: "The CQC understood that the inspection team would
have generated paper rather than electronic notes as this was the practice at the time. Any such notes like other 2016 inspection notes discovered as part of the disclosure process were expected to be held within the paper record archives."
FORD: Yes.
DE LA POER: You haven't found any such paper notes?
FORD: No.
DE LA POER: But I think that it's right to say that there are some other records that have been found which at least give a partial picture of those meetings?
FORD: I believe there are, yes. A colleague at the time kept her own notes separately to the paper notes.
DE LA POER: Then in relation to other documents -- and we will just need to understand in a moment what you are saying about this -- what you say is: "We have also continued to make further enquiries in relation to any additional documents that we would have expected to have been generated by the inspection process but which we have not encountered. We are not able to say that such documents definitely existed but there remains a possibility that some items were created but because of some human factors ..." And you give some examples: "... such as the documents not being stored in CRM
..." That's the client record management, isn't it?
FORD: Yes.
DE LA POER: "... or the Y drive as suspected or because original papers were not kept or were destroyed that any information contained with them is no longer within the CQC's possession." There are documents which you don't even know whether they were generated; is that right?
FORD: I believe so, yes.
DE LA POER: If they were, they have been lost?
FORD: It would appear so, yes.
DE LA POER: If we look at a practical consequence for a public Inquiry, this public Inquiry, one of the ways, is this correct, that the CQC have sought to help the Inquiry as best it can with the documents it has is to scrape diary entries to try and identify who was at which meeting because you don't have any notes of the meeting to confirm that fact; is that right?
FORD: Well, I think we tried to look everywhere where we thought -- records could be reasonably stored and I think I gave a full list of those searches in my statement, and we searched using keywords like Countess of Chester, Countess, Chester. We searched people's personal drives, the Y drives, SharePoint, the customer
records management system. As I said, we went through about 500 plus boxes of paper records stored in Newcastle. We looked everywhere that we felt we would reasonably have records stored. We did have some technical difficulties because a couple of our ex-employees, a couple of ex-colleagues, had moved on and when we changed IT provider, we couldn't get into their accounts because the accounts with the old provider had been deleted and they had not transferred into the new provider. So there were some technical difficulties. I can't give you a full response to that because obviously that was allocated to people who understand the tech systems much more comprehensively than I do, but that is my understanding of the searches we carried out. I think the paper project in 2017, because at that point -- and I remember myself -- after an inspection, you would have a large amount of paper in your possession in your office at home and we, the CQC, ran a paper project where we asked colleagues to return any records they held to their local office for storage and for scanning by the person we were -- the people we were contracted with Iron Mountain. So we were reliant then on inspectors to pack the records appropriately, to tag and label them and to submit them into our local offices. I remember I took mine to the Preston office, people took theirs to their local office. Then they went round to Iron Mountain for scanning. But again, we were reliant on people following that process correctly.
DE LA POER: Doesn't this only illustrate to understand the impact of the failure to seize earlier opportunities that the closer to the time this had been done, the easier it would have been, if documents had not been treated as they should have been, to go back to those individuals and say, "well, you did this inspection not that long ago, we can't find your records, let's have a conversation while everyone still has a memory of it as to where those records might be"?
FORD: Yes, I think that would have been the right thing to do.
DE LA POER: Has the data protection officer at the CQC been notified of the problems that have been identified with finding material?
FORD: I am -- I -- my honest answer is I can't recall.
DE LA POER: Well, given your position of responsibility and your oversight over this and all the conversations
that you have had with everybody about it, would you have expected somebody to have told you if that had happened?
FORD: Yes.
DE LA POER: And nobody has told you that?
FORD: Not that I can recall.
DE LA POER: Do you think, from the position of knowledge you have, that the data protection officer at the CQC should be aware that the CQC cannot find a significant quantity of its records?
FORD: Yes, and obviously they haven't.
DE LA POER: Do you think that there should be a very careful and thoughtful discussion about whether or not the Information Commissioner's office should be notified of this?
FORD: I think we should have that discussion, yes.
DE LA POER: Knowing what you know now, not predetermining the outcome of that discussion, but can you see that there may be good reasons to make that formal notification?
FORD: I think -- I can't say, I can't say from the present vantage point, but we will certainly have the discussion.
DE LA POER: Now, if we look at the CQC's regulatory function, one of the things that CQC does is to go into
hospitals and care homes and scrutinise a document's approach to record-keeping?
FORD: Yes.
DE LA POER: Is that fair?
FORD: That's right.
DE LA POER: It's one of the things that you do?
FORD: Yes.
DE LA POER: And one of --
FORD: And one of the things we rely on.
DE LA POER: Yes. And you hold organisations to account and are critical of them in the event they do not manage their records properly; is that right?
FORD: Yes.
DE LA POER: And yet we seem to be in a position here, do you agree, that the CQC has fallen significantly short in a domain, an area where it is charged with the responsibility of holding others to account; do you agree?
FORD: I do agree in that we would hold a provider to account for poor record-keeping and we would expect that provider to acknowledge the shortfall and to address it. And I think CQC has to model that same behaviour and I think this Inquiry has highlighted that we have got some significant work to do around that.
DE LA POER: I am going to move in just a moment to the
inspection, but as we have been through all of these stages and reached the end of my line of questioning about it, I just want to give you one further opportunity on behalf of the CQC to provide us with a reflection and, if you consider it appropriate, an apology. Is there anything further you wish to say to what you have said already?
FORD: No. I think I have said that our response to the Inquiry was not timely or good enough. And for that I do apologise. And you have an undertaking from me and my colleagues that we will look into why that happened and what we need to do to prevent it happening again.
DE LA POER: Let us turn to look at the inspection in 2016. Some of these issues have been explored with the witnesses yesterday, so I should just ask, are you aware of what the witnesses, the CQC witnesses and the Special Advisers, said yesterday to the Inquiry?
FORD: No, only, No, I am not -- I have not seen their statements, so...
DE LA POER: Did you hear their evidence or read the transcript?
FORD: Yes, I heard their evidence.
DE LA POER: Right. That is the important thing because it may allow us to short-circuit some matters without needing to go to some documents.
FORD: Okay.
DE LA POER: We start from the position that in the intelligence briefing that the CQC provided it was suggested that there were no Serious Incidents reported to NHS England when, in fact, we know that there was a Serious Incident during the period the inspection was focused upon, the death of [Child D] was reported on STEIS?
FORD: Mm-hm.
DE LA POER: Firstly, do you acknowledge that that was a way in which the intelligence document was inaccurate?
FORD: At the point on which the data pack is prepared -- obviously there is an ongoing process with the reporting of incidents and sometimes an incident can take a while to get on to the system. So at the point at which we shared the data pack, that may be inaccurate the following week because there will be other incidents applied. So I think what we -- we based -- so I think that incident may well have been reported but not yet included in the data, if that makes sense.
DE LA POER: Well, let's just have a look at the adequacy of the overall system if that be right, because what period was the CQC inspecting?
FORD: The inspection we usually look at retrospect is 12 months.
DE LA POER: 12 months?
FORD: Yes.
DE LA POER: So starting in mid February 2015?
FORD: So we might start 21 February to 21 February.
DE LA POER: I understand. Now, [Child D] died in June of 2015.
FORD: (Nods)
DE LA POER: On 2 July, there was a Serious Incident Panel meeting within the Countess when it was resolved to report [Child D]'s death on STEIS?
FORD: Mm-hm.
DE LA POER: That is the start of the process?
FORD: Yes.
DE LA POER: Your intelligence pack was created. I think it's dated December 2015; is that right?
FORD: Correct.
DE LA POER: It would be a very unsatisfactory state of affairs if a hospital decided to report a death at the beginning of July if that was not --
FORD: No, that should have been -- that should have been included.
DE LA POER: Well --
FORD: Yes.
DE LA POER: -- precisely my point?
FORD: Yes, it should have been included.
DE LA POER: The evidence yesterday was to the effect that the inspectors and in particular the Special Advisers were misled because they didn't know that there was an incident, and they say that if they had known about it, they would have asked about it.
FORD: I think that's -- I think I wouldn't say misled. We gave the information available. I don't think we intentionally misled anybody. We based our inspection on the intelligence that we had and the data collection and the analysis of that data by the analysts. So we gave that information in good faith.
DE LA POER: Well, nothing about my question was suggesting that it was a deliberate act. My question was to the effect that the inspectors were misled. In other words, they did not understand correctly the true state of affairs because they believed that on the one hand no Serious Incidents had occurred.
FORD: Yes.
DE LA POER: Whereas on the other hand the truth --
FORD: In the children --
DE LA POER: -- was that one had occurred.
FORD: In the children's and young people's services.
DE LA POER: Exactly.
FORD: Yes.
DE LA POER: So they were misled?
FORD: Yes.
DE LA POER: As a result, they did not ask potentially important questions that they would have wanted to ask, and that's a serious consequence from being misled; do you agree?
FORD: I think when we look at incident management on an inspection, what we do is we look at the range and nature of the incidents reported. We look at the volume of the incident reporting and what you are looking for is a good level of reporting with a low incidence of harm, that there is a good process for the investigation of those incidents, that there is learning and any learning is applied and monitored. So we wouldn't necessarily look at every single incident. We couldn't, we don't have the capacity to do that. We wouldn't necessarily look at every single incident in every single service because over the -- overall, it can be many hundreds, so we tend to random sample incidents. Now, I accept had we known there was a Serious Incident we could have sampled that, but again it would have been how it was investigated, what the findings were, and how those -- any learning was applied.
DE LA POER: A number of points fall out of that. The first is that it would be a random sample taken from a population of one, because if they were to ask themselves "I wonder whether there's a particular worked example that we can explore", there is, in fact, only one Serious Incident?
FORD: One.
DE LA POER: It does seem quite likely, do you agree --
FORD: We would have looked at that.
DE LA POER: -- that that one would have been --
FORD: Yes, we would.
DE LA POER: Quite so, and that is consistent with the evidence we received from the people who would have made that decision --
FORD: Mm-hm.
DE LA POER: -- making. If we follow that up, [Child D] formed part, [Child D]'s death formed part of, as I am sure you understand now, the increase in neonatal mortality?
FORD: Yes.
DE LA POER: Whilst nobody can know how that conversation would have developed, do you recognise it presented an opportunity for what CQC witnesses have consistently told us did not emerge to have emerged?
FORD: I think in relation to that child, yes, we
could have looked at that incident and it may have lead onto other questions about the mortality in the service.
DE LA POER: Just so that we understand the potential significance of that piece of information not being in the hands of the inspector. It was capable, do you agree, of uncovering for the CQC the problem which existed, or at least part of it, which could have led to important follow-up questions?
FORD: I think it certainly would have warranted an exploration of that incident which may have then led on to a broader conversation, yes.
DE LA POER: Can you just help us. The intelligence report is pulled together by data analysts; is that right?
FORD: It is.
DE LA POER: What qualification does one need to become a data analyst at the CQC performing this kind of role?
FORD: I don't know.
DE LA POER: Is there any kind of quality assurance process over the drawing together of that information?
FORD: Yes, I think there is. You'd -- data and insight team are highly technical and I am not really involved in the management or the running of that team. But I do know our data is quality assured and validated. So -- but I can't say any more than that, really.
DE LA POER: Sitting there now, on behalf of the CQC, do
you understand the mechanics of how that Serious Incident was not communicated to those conducting the inspection?
FORD: Yes, I do. I think I --
DE LA POER: Do you want to just explain how, with the death that occurred in June with the information being pulled together in December, did it state something which was in fact untrue?
FORD: If that incident was reported as a Serious Incident on STEIS, it should have formed part of the data analysis had it been reported at that time. The information we had in the data pack for Children and Young Peoples Services, as I recall, said there had been no Serious Incidents, there had been no Never Events, and the incident reporting generally was of -- within expectations as I recall. And I think you can see that from the pack itself.
DE LA POER: In terms of exactly what went wrong here, is it a question of that data not being visible to your data analysts, or is it a question of the data analysts having overlooked it?
FORD: I couldn't honestly say. As I say, it's well out of my area of expertise.
DE LA POER: Is that something that you can organise to be found out?
FORD: I think we could, yes.
DE LA POER: Well, that is helpful to know. Another aspect of the pre-inspection preparation is something called HES monitoring. HES stands for Healthcare Episodes Statistics?
FORD: Yes.
DE LA POER: We are just going to take this slowly. Can I ask you please to turn up your second statement [INQ0107911], and in particular go to paragraph 3.9 because we just need to untangle some of what is said here and try and understand this process.
FORD: My second statement, did you say?
DE LA POER: Your second statement, please, yes.
FORD: Thank you.
DE LA POER: Do you have 3.9?
FORD: Yes, I do.
DE LA POER: We will just read it along together so that everybody knows what we are talking about: "Analysis of Healthcare Episodes Statistics (HES) by CQC during the course of the inspection did not flag the Trust as an outlier for higher than expected rates of perinatal or late neonatal mortality for the period April 2015 to December 2016."
FORD: Yes.
DE LA POER: Next paragraph: "I should explain that HES provides data to monitor a range of maternity indicators which include perinatal mortality and late neonatal mortality rates. Statistical outliers are identified using cumulative (CUSUM methodology) and CUSUM [you tell us] involves analysis of the cumulative sum of differences between data points in order to identify trends in data over time." Two more paragraphs: "For the period April 2015 to December 2016, the Countess of Chester did not register as an outlier for higher than expected rates of perinatal or late neonatal mortality. "The number of perinatal deaths during the 2015/2016, quarters 2 and 4, [which you give as eight and seven deaths respectively] were higher than most other quarters which were less than 6, but to register as a statistical outlier over this period, the data would have had to include at least three standard deviations from observed and expected indicator values. Applied to the data for this period, the Trust was not flagged as an outlier and the data was not examined further at this time." That is what you told us in your second witness statement.
FORD: I do, yes.
DE LA POER: Now, let's just have a look at one paragraph of your third witness statement [INQ0108375], please. Paragraph 4.2. Again, so that everybody can follow what we are saying, I will just read it out to you and you can perhaps follow along: "The briefing pack..." you tell us -- I'm sorry, have you found it?
FORD: Yes.
DE LA POER: "... was a comparative analysis of a trust's performance using a standard set of indicators. This included available metrics on mortality and 'outliers' and other contextual data about the service. During the preparation of the inspection of [the Countess of Chester] in 2016, the Statistical analysis of Healthcare Episodes Statistics ... by CQC as part of the 'outliers' programme did not flag [Countess of Chester] as an outlier for higher-than-expected rates of perinatal or late neonatal mortality for the period April 2015 to December 2015. This means that the data did not show a statistically significant difference between the actual number of deaths and expected number of deaths over this period. This is because the data for neonatal mortality was and still is published retrospectively and the data of the 2015-16 was not available at the time of the inspection."
FORD: That is my understanding, yes.
DE LA POER: Do you agree that, in your second statement [INQ0107911], you say that the Countess was not identified as an outlier by this statistical modelling, and the reason you give is because the number of deaths did not meet the at least three standard deviations; that seems to be the reason that you give in your second statement.
FORD: There are two sets of data that -- well, a number of datasets that we will use around mortality. I think the one that we rely on most for neonatal mortality is the MBRRACE data. The HES data. So what we tend to do is -- well the analysts tend to do is bring together all the data from a variety of sources and determine whether or not that the Trust is an outlier and my understanding and the understanding I shared with the inspection team that the Trust was not an outlier for mortality. And when we carried out the inspection on that understanding.
DE LA POER: Yes. What you say in your second statement, just to come back to it, is the reason, according to your second statement --
FORD: Yes.
DE LA POER: -- that it was not an outlier -- and I am looking here at 3.12, where you give us the actual
number of deaths, and you say: "But to register as a statistical outlier over this period the data would have had to include at least three standard deviations from observed and inspected indicator values." What you appear to be saying there is that the data was analysed, it did not meet the three standard deviation threshold, therefore the Trust wasn't an outlier?
FORD: Wasn't an outlier.
DE LA POER: That is what the plain English means; do you agree?
FORD: Yes.
DE LA POER: But by the time we get to your third witness statement [INQ0108375] -- and again it may be that I am just misunderstanding this -- you say in the last two paragraphs that the data didn't show a statistically significant difference, in other words it didn't meet that criteria, but then you add this: "This is because the data for the neonatal mortality was and is still published retrospectively and there was no data available at the time of the inspection."
FORD: I think, I think that's true. That some of the data was not available. I think I have made -- I think I have made a mistake and I have confused the HES with the MBRRACE.
DE LA POER: We just need to be absolutely clear about this.
FORD: Yes, I need to think -- can I just take a moment to think?
LADY JUSTICE THIRLWALL: Yes, absolutely.
MR DE LA POER: Of course. You must do so, this is important for us to understand and if you want the references again, I can give you them.
FORD: No, I have it here. Thank you. (Pause) Thank you. I think it's both. On reflection, I think it's both. I think the data is not in real-time and the deviation wasn't met.
DE LA POER: But the significance of the deviation not being met is close to zero if the data set is incomplete, isn't it?
FORD: Yes.
DE LA POER: Because, in fact, it's potentially even worse than that, isn't it, because it may cause you to think, as inspectors, the outlier threshold has not been triggered when, in fact, the explanation for that is simply that the data hadn't all come in?
FORD: Mm-hm.
DE LA POER: And --
FORD: That is -- that is correct, that is the process, yes.
DE LA POER: Just think about this. You went along to the Countess of Chester presumably thinking to yourself the outlier threshold for mortality has not been met?
FORD: That's correct, we did, yes.
DE LA POER: But --
FORD: Because had it been, we would have pursued a line of Inquiry.
DE LA POER: But the significance of that was close to zero and, in fact, was misleading; do you agree? Because you may have thought it wasn't an outlier when in fact it was and the only reason you hadn't been told was because the data hadn't come in?
FORD: Yes, that's right.
DE LA POER: Can you see the very significant problem there is with that?
FORD: I think there is always a problem when data is not in real-time.
DE LA POER: But what is the point of outlier data if the data set is not going to be complete?
FORD: I see. I take your point.
DE LA POER: Does it follow that you went into that inspection, as everybody else, thinking, "This is not an outlier for mortality" in circumstances where you didn't
realise that not all the data for that was in?
FORD: Mm-hm.
DE LA POER: Is that --
FORD: I think we relied on our analyst colleagues to bring together data, to give us an overview of what the data indicated. The -- the data is really very important. But it's the start of the conversation, not necessarily the end of the conversation. And we would also expect a Trust to be monitoring its own themes and trends and be honest and open with us about any issues that they'd identified because they would know as well the time lapse in the data because they submit some of their -- they submit the information. And I think, at this point, we did not know that they were a statistical outlier. We did not know that there was a problem on the neonatal unit and we were -- we were not alerted to the fact that it was.
DE LA POER: I grant all that and in fact we need to be fair about this. Once all that data came in, because it didn't meet that three standard deviations, it wouldn't have triggered it anyway, but this is just going to the process --
FORD: I understand.
DE LA POER: -- that was being adopted. Do you think you
understood in 2016 that you were relying upon what was effectively a warning system that was based on incomplete data? Do you think you understood that so far as --
FORD: I think we understood that the information we had was the -- right at the time. We knew that there was an ongoing process and we didn't only just inspect. We had an ongoing, we had process of ongoing monitoring and engagement with the Trust. And we expect -- and we certainly try to be open and transparent in our dealings with the Trust, and we would expect the Trust to be the same with us. So when we meet with them, when the data is -- or they identify a problem, we expect that open dialogue where we can look at the issue and manage it and where we feel the Trust is not managing it, regulate accordingly.
DE LA POER: Now, the Inquiry has received a statement from Professor Sir David Spiegelhalter who spoke in quite general terms, he didn't use the name of the tool --
FORD: Yes.
DE LA POER: About a CUSUM tool that he had developed for the --
FORD: Yes.
DE LA POER: -- CQC in 2007. Just to try and close the loop, is it your understanding that what Professor Sir David Spiegelhalter is talking about is your HES tool or is there a different tool, or do you not know what he is talking about?
FORD: I didn't know what he was talking about. It is a bit technical from a data point of view for me. It is not my field of expertise, data analysts, you know, we rely on the analysts for that. So I couldn't honestly say whether we used it or not, and I'd not -- I'd not heard the term before the Inquiry gave it me.
DE LA POER: Now, whether or not it would have met the three standard deviations, which presumably was a threshold set by whoever was creating the tool --
FORD: Yes.
DE LA POER: -- do you know whether or not it was capable this outlier signal, of distinguishing between deaths which were unexpected and unexplained and just the crude mortality figure?
FORD: No, I don't. I don't know enough about the tool to be able to tell you that. No.
DE LA POER: Because one of the things that we have heard consistently from the paediatricians, I am sure you can recognise the force of --
FORD: Mm-hm.
DE LA POER: -- is that it isn't just the fact that the
death rate is higher than expected, it's the fact that it's babies who weren't expected to die --
FORD: Absolutely.
DE LA POER: -- who were dying?
FORD: Trusts don't have to report every death, but we do expect them to focus on unexpected and avoidable deaths. And we do expect there to be a robust process around that mortality and morbidity reviews, you know, child death oversight panels and so forth. And the investigation into those deaths lies with the provider who should then identify what went wrong, be open and honest about it and put it right.
DE LA POER: Now, one of the data requests that were made of the Trust, you tell us in your witness statement, was made on 15 February, so the day before the inspection; that was a Monday --
FORD: (Nods)
DE LA POER: -- the inspection began on the Tuesday, which included paediatric incidents?
FORD: Yes.
DE LA POER: I am sure you have had a chance to remind yourself of this --
FORD: I have.
DE LA POER: -- and it was a table that was spoken about yesterday a number of times. It is a table that
includes 378 lines of incidents.
FORD: Mm-hm.
DE LA POER: Our Special Advisers all say that that was not a table that they saw.
FORD: (Nods)
DE LA POER: Do you agree that the interpretation of the potential significance of paediatric incidents is very much a matter for the Special Advisers rather than the CQC staff?
FORD: I think the -- the incidence is very much a matter for the Trust and for CQC because when we -- on an inspection like this, we look at how the Trust -- the Trust is charged with the responsibility of investigating those incidents and, as I say, that commitment to continuous improvement and learning. So when we look at incidents, we look at them in terms of the process and how they are discharging those responsibilities. If we feel they are not, then that would be a cause for us to do something different.
DE LA POER: The evidence we had from the Special Advisers is that they, having looked at that now, identify incidents which may have prompted further discussion because they were inadequately described or they couldn't understand, using their expertise, what it was that was being talked about. That suggested, to use
that word, a process problem because it's not recorded properly, but underlying that may be a genuine inadequacy in healthcare provision. So they say -- and they told us this -- that they would have wanted to explore some of those incidents with the clinicians and the people that they were dealing with during the inspection. That is what they say about it?
FORD: (Nods)
DE LA POER: Now, the first question really is this: requesting that information the day before the inspection has this consequence: your inspectors can't read it in advance of turning up, can they?
FORD: No, not for the inspection starting the next day, but it's something that they can do over the course of the inspection and after the inspection and in the report-writing period.
DE LA POER: They say they never saw those documents.
FORD: The inspection team leader would have, would have seen it.
DE LA POER: And who was the inspection team leader?
FORD: Helen Cain was leading the inspection there. I think she would have had access to it. I can't say for certain whether she saw it, but she would have had access to it.
DE LA POER: How about the people with the clinical expertise to interpret that and to ask meaningful questions about it. I mean, aren't they the ones who need to see it?
FORD: I think it would have been helpful to share it with them, yes, if it wasn't.
DE LA POER: Do you agree that is another missed opportunity to uncover what was actually going on here?
FORD: I think potentially, yes.
DE LA POER: Why was it not until the day before that the CQC was asking for material that would be relevant to the people who were conducting the inspection?
FORD: It was an ongoing process. So we look at the data pack, we plan the inspection, Helen Cain, I was confident, was -- and Benjamin and the Specialist Adviser, I was confident that they had an idea of what they needed to do while they were there. I think we often made data requests pre, during and after the inspection, to add to our intelligence, to add to our thinking and to underpin our judgments. So it's not uncommon for people to be asking for information before, during and after the inspection.
DE LA POER: Is there any good reason why it wasn't asked for before?
FORD: I don't think it was part of the data pack
unless, so I think, I think it's important that we had -- we did have information around the incidents, around the incident reporting. The service specific I think it might be worth for future asking with the data pack. I think that would be a good thing to do.
DE LA POER: Well, it is just the sort of document, 378 lines is not something that you can glance at and digest.
FORD: I think we -- looking at -- you know, hindsight is a wonderful thing, and I think when we look back now we followed the process of the inspection accordingly. Could it be improved? Yes, I think it could and have we improved it? Yes, I think we did. So I -- if you are expecting an organisation to continuous learning and improve, as I mentioned earlier, we have to model that behaviour ourselves. So where there is opportunities for learning we have to take them and we have to be honest about the learning and we have to apply it.
DE LA POER: Please don't think for a moment I am suggesting that there shouldn't be learning from this, but you have used the word "hindsight". Do you need hindsight to recognise, at the time, that asking for a document which is dense with information about individual patients, asking for that the day before and
not ensuring that it is put under the nose of the people who can interpret it and ask questions in good time is a problem? Do you need hindsight to recognise that problem, or is that something that should have been recognised at the time?
FORD: Yes. I think it would have been a good thing to do.
DE LA POER: Now, Dr Brigham did a review that was badge neonatal, but in fact had an obstetric lens, as it's been termed by others, towards the end of 2015. Was that a document that was provided to the CQC before the inspection?
FORD: Not to my knowledge.
DE LA POER: Now, as we understand it, the CQC has disclosed a copy of that report to the Inquiry from the client relationship management folder, and the inevitable inference from that is that at some point the CQC has come into possession of that document?
FORD: I -- I don't recall seeing it in 2015. I don't.
DE LA POER: Well, it would be quite an important document to consider, wouldn't it?
FORD: I think it would -- if I can explain how information was managed at that time. Each Trust had
a relationship owner and an assigned inspector and the relationship owner managed, if you like, the business as usual, engagement and monitoring, with the -- with the inspector and the inspection manager. I necessarily would only be included if there was deemed to be a particular risk or -- so I -- the day-to-day oversight of the Trust was not, was managed by me but not carried out by me. So I may not have seen it, although the inspector may have done.
DE LA POER: Well, it was something that the inspector should have seen if the CQC had it?
FORD: Yes.
DE LA POER: Because it does, in fact, specifically refer to the increase in neonatal mortality. Now, that document was referred to in the minutes of a QSPEC meeting at the Trust in December and in the minutes of the women and children's care governance board meeting in December. I will just tell you the terms that it's referred to. In QSPEC, it is recognised as being an increase in neonatal and stillbirths during the period January to November, so that information is in those minutes. In the Women & Children's Care Governance Board meeting, a panel has been set up to review each case individually and there are 18 cases is said about that increase. So on the face of it, for a relatively modest sized hospital, quite a significant number of cases?
FORD: Mm-hm.
DE LA POER: But do you know whether the minutes of the meeting for QSPEC and the Women's & Children's Care Governance Board in December 2015 were provided before the inspection?
FORD: No, I don't.
DE LA POER: If they were provided, do you agree the process -- well, do you agree the process should be that they should be provided to the CQC, those minutes, as part of the governance assessment is to look at the minutes of the meetings?
FORD: Not always. Not always. But I think where there was an issue it should have been provided, yes.
DE LA POER: That would be up to the Trust to decide whether or not the CQC --
FORD: To disclose that.
DE LA POER: -- needed to know that? If it was provided as being potentially relevant in the minds of the Trust, the process should then be that it's given to the --
FORD: Relationship owner to look at and assess.
DE LA POER: -- relationship owner and from there it's going to need to go to those with the clinical expertise
on the inspection so that they can see it and engage with it?
FORD: If -- if issues are identified, yes.
DE LA POER: Yes, and there doesn't appear to be any evidence that that, in fact, occurred, that total process. Would you agree that something, at some point in the process, appears to have gone wrong?
FORD: In terms of the information sharing? CQC or with --
DE LA POER: Yes, whether that lies with the Countess for not providing it or whether it falls to the CQC for not ensuring it ended up in the hands of the people who needed it.
FORD: I think -- I think once there was a hint or an indication that there was a problem with mortality on that unit, my expectation would have been that the Trust alerted ourselves, NHS England, and any other party that there was a problem and they were looking into it. And I think, as part of that, any documentation, any audits, any reviews, any work they have undertaken should have been shared transparently and openly. That is my view.
DE LA POER: Included within that view, no doubt, is the Thematic Review of neonatal mortality conducted by Dr Brearey and others --
FORD: That's right.
DE LA POER: -- a week before the inspection?
FORD: (Nods)
DE LA POER: Was that February version to your knowledge provided to the CQC?
FORD: Not to my knowledge.
DE LA POER: Now, it was described as a draft at that stage --
FORD: Mm-hm.
DE LA POER: -- and it was provided to the Medical Director and the Director of Nursing the day before the inspection, the 15th --
FORD: Yes.
DE LA POER: -- upon request by the Medical Director, specifically by reference to the CQC inspection.
FORD: Mm-hm.
DE LA POER: What is your expectation of a Medical Director and Director of Nursing in receipt of such information at their interviews with the CQC in the following 48 hours?
FORD: I think they should have shared that with us. I think they should have made us aware of that.
DE LA POER: Now, the Thematic Review was finalised on 2 March, so after the --
FORD: We were off-site.
DE LA POER: -- the notified inspection, but before the inspection which took place on 4 March, which I think was an unannounced aspect of the overall inspection.
FORD: Mm-hm.
DE LA POER: Once finalised, bearing in mind it related to the period of the CQC review, should it have been provided to the CQC?
FORD: That would have been my expectation, yes.
DE LA POER: What was the CQC's stated policy on the generation or the provision of documents which are generated after the inspection but which related to the period that had been inspected?
FORD: In terms of what was reported --
DE LA POER: Well, did --
FORD: -- or the actions taken?
DE LA POER: I will put it bluntly. Did the CQC say in writing to the Countess of Chester, "If a document is generated after the inspection which relates to the inspection period, you need to give it to us"?
FORD: Yes, I think we did in -- I don't think we were explicit about after the inspection, no. But I think it was understood that our expectation was this was different, you know, this just wasn't information, this was about an emerging serious concern and I think they should -- and it would have been our expectation. This is not just things that can help you make a judgment in your inspection. This was really, really significant issue and I think they should have made us aware of that immediately.
DE LA POER: Do I understand you are saying that outside of the inspection regime, this is something the CQC should have been notified about?
FORD: Absolutely.
DE LA POER: It wouldn't have mattered whether you were inspecting them in February or not, that should have been brought to the CQC's attention?
FORD: Absolutely.
DE LA POER: In the situation where at least some of the people involved on the ground didn't regard it as an emergency -- and there is some evidence to suggest that in some people's minds it was not an emergency -- nevertheless, it was relevant, wasn't it, to the CQC inspection period?
FORD: It was, yes.
DE LA POER: Setting aside the emergency notify anyway, I am just trying to understand how a Trust would know that they were under an expectation to provide documents which are finalised after an inspection to send it to you. How would they know that if you haven't told them expressly that that's what you require?
FORD: As part of the ongoing relationship management model -- so if we take the inspection to one side and a risky emerges, the Trust -- the expectation is, in that spirit of openness and transparency -- and they are the principles on which we have -- hold our relationships with providers, that they will be open and transparent with the regulator and the regulator with them. That when an issue like that emerges, it is important that they alert us to it at the earliest opportunity. Now whether that is pre, during or post an inspection, the Trust, my expectation was that they would alert us to the concerns that were emerging on that unit.
MR DE LA POER: My Lady, I have a little more for the witness, but I wonder, given the balance of work this morning, that it would be appropriate for us to take our break at our normal time now and I will then be able to conclude relatively swiftly after that break and we can then move to our final witness.
LADY JUSTICE THIRLWALL: Yes, certainly. We will take a break now and we will start again at 11.35.
FORD: Thank you.
(11.17 am) (A short break)
(11.35 am)
LADY JUSTICE THIRLWALL: Yes.
MR DE LA POER: Ms Ford, one final aspect of the pre-inspection documentation. We have asked each of the CQC witnesses about the self-assessment form and each of them told a variation on this; that they looked at it and then decided to make their own independent judgment about each of those domains.
FORD: (Nods)
DE LA POER: What is the point of the self-assessment?
FORD: The point of the self-assessment is to sort of test out the Trust's view of its own services and its perception of where it might be in terms of quality, safety and performance. And we use it as a piece of information, but we are never really influenced by it in terms of our own judgments which we do based on the evidence we find during the inspection. So it's an opportunity for the Trust to showcase some of the things it does well, to be clear about some of its challenges and what it's doing about that, and to talk about how it is performing in terms of its -- the quality of service delivery to patients.
DE LA POER: Is it a document that the inspectors actually need to see before they carry out the inspection, if they are simply going to ignore it?
FORD: Well, I don't -- I don't suppose they ignore it. Well, I'd like to think they didn't because I certainly don't, because I do like to see how the Trust perceives itself and compare that to the findings because it does tell you something about the way the Trust operates. So there was some outstanding self assessments there, particularly around the caring domain, which we didn't agree with.
DE LA POER: I wasn't suggesting it did influence, but it just seemed to me that -- and I am not suggesting it isn't relevant at some point -- it's just why is it being provided at the start as opposed to "now we have conducted our independent inspection we can test that against how the Trust thought it was at the start of the process". It is just trying to understand; do you see?
FORD: Yes, I understand what you are saying, yes.
DE LA POER: I am not saying it is irrelevant, it is just why do the inspectors need to see it as part of the documents they get.
FORD: Because I think it gives them some insight into how the Trust perceives itself.
DE LA POER: Turning to the inspection itself, you participated -- and if you need to be reminded I can bring up a document, but I am sure you can recall -- in core interviews with Sir Duncan Nichol, Hayley Cooper, Sue Hodkinson and Tony Chambers.
FORD: Yes.
DE LA POER: Sitting there now, do you have a recollection of each of those meetings and the faces of those people and the conversations you had with them?
FORD: Yes, I -- I do, I would recognise the people again if I saw them and I have others. There is no record, as you quite rightly said. The prompts and the key lines of inquiry, I have a reasonable idea of what we would have discussed in those meetings.
DE LA POER: What was Sir Duncan Nichol telling you about how the Trust was?
FORD: Well, he felt that the -- as I recall, he talked about the vision and future of the Trust in terms of the model hospital and the work they were doing around that. He talked about his confidence in the Executive team and he talked about the challenge in scrutiny of the board, as I recall, because they are the topic areas we tend to speak with, speak to the chair about.
DE LA POER: Mr Chambers, the Chief Executive, what did he tell you?
FORD: I can't recall verbatim, but again, he told us
about when we -- when we worked through the -- when we worked through the -- the prompts. Sorry, I couldn't remember the word "the prompts", the interview prompts, where he is asked what the plans were for the Trust, what the current risks and challenges were, what the -- what the Trust was particularly proud of. What support, you know, so if there was an issue around perhaps delayed transfers of care, I am not saying we did, it is just by way of an example, we would ask what the system support was like around that because it impacts on the flow of the hospital. So some of it would be bespoke and some of it would be more general.
DE LA POER: You have just listed the questions he was asked; what did he say in response?
FORD: Well, I think they were quite committed as -- they were quite committed as an Executive team to engagement. They were quite committed to improving services, as I recall, and they were quite committed to the model hospital and taking the service to the next level. They are the broad issues, as I recall.
DE LA POER: There was also a focus group with Consultants; did you attend that?
FORD: No.
DE LA POER: Do you recall being told about any of the things that dropped out of that focus group?
FORD: Yes, I do. At the end of -- at the end of each of the inspection days, we hold what we called a corroboration session. So all of the core team leaders would come together and meet with their teams and they would discuss the findings of the day, who they had met, what they found, what they'd heard, what they'd read, what they saw, what they'd been told. And at the end of the day, the Chair and I would sort of be at the front of the room and we'd go through each core service over the five domains and they would give the headline feedback of what would happen -- what happened.
DE LA POER: That is the process. What were you told came out of the Consultant focus group?
FORD: When we talked about the focus group, I was told that the Consultants -- because more generally we had feedback and I think I did a focus group with the nurses who were quite positive about the culture in the Trust, that the Consultants had raised that -- no, I'm sorry, I am going the long way around things here, but we don't normally take the names and the role of people, we just know they are a Consultant or a nurse because it encourages people to speak more freely, we think. So in the Consultants' focus group, I understood
that they had raised some concerns about staffing levels, they had raised some concerns about the Trust not listening to the concerns, and they had raised some issues about the Trust not responding to those concerns and at times they felt management was oppressive.
DE LA POER: You used the phrase "bullying culture" --
FORD: Yes, yes.
DE LA POER: -- in your witness statement?
FORD: Yes.
DE LA POER: Now, these Consultants, were they just Consultants from the Children's Services or are these Consultants drawn from across the hospital?
FORD: No, I think the whole idea of the focus group is that you opened it up to all Consultants. So we -- you know, there would have been a mixture of disciplines there. So I don't know how many of them were Paediatric Consultants or how many of them were surgeons, we just knew that they were Consultants at the hospital.
DE LA POER: Having been made aware that that came out of the focus group, were those concerns raised with any member of the senior management team during the inspection?
FORD: I believe they were. I believe they were raised with the Medical Director on the day.
DE LA POER: On the day of the Consultant?
FORD: I think that was fed back on the day.
DE LA POER: What is your understanding of what his reaction to that was?
FORD: That he -- he -- that more broadly they were working on culture in the Trust and that he would speak to the Consultant body and he would begin to address those concerns.
DE LA POER: Do you understand whether he acknowledged those concerns in the sense that he didn't dismiss them, but recognised that they were valid and needed addressing?
FORD: I couldn't say because I was not at the meeting. I was not at the meeting with the Medical Director post the focus group.
DE LA POER: Bearing in mind there is no record of that conversation, I am not doubting for a moment it took place, but there is no record of it. Can you see that that is a very clear worked example of the problem of not having those records to understand exactly what was communicated to him, what the Consultants were concerned about, and exactly what his reaction was? Can you see that that's a problem for this Inquiry?
FORD: I think I have acknowledged already that, you know, the record-keeping is a challenge to the Inquiry. And I -- I agree. It would have been so much more
helpful had they been there.
DE LA POER: Now, we can deal with this globally and you have already indicated that, before the visit, nobody alerted you or the CQC, you say, about the increase in neonatal mortality or the concerns that existed in the minds of some about Letby's association with that rise. During the visit, was the CQC notified of either of those matters?
FORD: Not to my knowledge. I -- and it certainly and I know it would have been. I am certain it would have been. If anybody would have raised that, it would have been escalated to me and to the Chair.
DE LA POER: Well, that, I suppose, is the question. What would you expect exactly the CQC's reaction to being told that information during an inspection to be?
FORD: Well, immediately, I would have wanted to understand what the Trust was doing about any immediate and ongoing risk to the babies in the unit. So I would have wanted to know what they are doing to mitigate that risk. How -- who else they have informed. That would have been my prime -- my first and foremost concern was the management of the immediate and ongoing risk to the babies. And then obviously, once I was assured that that was mitigated, we would look more broadly and start to look at things like when did
you know, how did you know, the staffing, that -- that sort of conversation would have taken place. But immediately I felt -- and I did, I think, focus on the immediate and ongoing -- once I knew, the immediate and ongoing risk to the patients, the babies.
DE LA POER: What was the first date of your knowledge?
FORD: I think it was 29 July, the day after we published the inspection report, I got a phone call from the Director of Nursing, Alison Walsh.
DE LA POER: 29 June, I think.
FORD: June, sorry, apologies. You have probably gathered dates ... So Alison rang me.
DE LA POER: Can I just pause you there, we are going to come to that conversation in a moment.
FORD: Yes, okay.
DE LA POER: Your evidence is that you didn't know before that. Just a couple of events to cover, one in particular. There was an unannounced visit on 4 March, we have already touched upon that, and we know that that involved inspectors going to the Children and Young Person's Services?
FORD: Mm-hm.
DE LA POER: The Thematic Review had been formally
published and disseminated to a group who were involved and needed to be sighted on it just two days earlier. Do you regard, on behalf of the CQC, that being an opportunity for the Countess to tell the CQC about that recent development?
FORD: Of course. I think the whole inspection was an opportunity.
DE LA POER: Now we come to the 29 April. I think the sequence is that you received a telephone call on that day and an email on 30th June.
FORD: (Nods)
DE LA POER: Thank you. I am now mistaking the date. Just tell us about that telephone call with Alison Kelly, please.
FORD: Alison Kelly rang me and told me that there was -- they had identified an issue in the Trust, that there had been an increase in mortality for, I think, 14/15, 15/16. I asked her what she was going to do about that. Again, the focus being the immediate and ongoing risk to anybody being cared for, the babies being cared for, in the unit. She said the Trust had made the decision to downgrade the unit, so the more poorly babies went -- the intensive care babies went to another centre. I thought that was a good thing to do and it would also help with the staffing because the closure of those cots meant that there would be a better nurse ratio for the other babies that were being cared for there as well. So that assured me that until the root cause was identified, that the immediate risk to babies was to some degree mitigated. I asked what else they were going to do. She said there had been an independent review that had supported the -- supported the assertion around the mortality, that they were going to do a deep dive, they were going to invite the Royal College in, which again I thought was a good thing to do because they are specialists in the field and they would be able to identify any failings that their own reviews had been unable to do so. I thought that was a good thing. They were then looking at staffing and competency which seemed appropriate. So my immediate thinking about the response she shared with me, I was reassured that they were -- they were taking action. That was then confirmed in the email and at that point, I was still unaware of any concerns around Lucy Letby.
DE LA POER: Well, that was to be my next question. We know that the Consultant body met on 27 June and it was
then resolved to contact the Medical Director which occurred and we know that another meeting took place involving senior nursing staff and the Medical Director on the 27th, and that there were then some subsequent meetings later in the week.
FORD: Mm-hm.
DE LA POER: And that the substantial part of those meetings were spent talking about Letby. Do you think that's something that the CQC should have been alerted to at that stage?
FORD: I think we should have been alerted to the fact that there were concerns about a practitioner on the unit, and I think they should have told us how they were managing that. So whether they, you know -- at that time, we didn't know what the range and nature of the allegations were about Lucy Letby. So I would have expected them to say "we've got concerns about a member of staff. We've removed them from the unit. We've put them under..." -- you know, I would have expected them to let us know that they were carrying out an investigation and in the interim, while they were concerned, she was taken away. So again, part of the mitigation of immediate and ongoing risk. So I would have expected them to share that. If not the intimate detail because of the employer/employee
relationship, I would have certainly wanted to know that that had happened.
DE LA POER: Now, as to the timing of that call and the publication of the report, were the Trust on notice that the report was going to be published that day?
FORD: Yes, yes, we usually agreed the publication date with the report. The two comms teams work together around the publication of the report.
DE LA POER: Had the report been formally published before you received that call?
FORD: Yes. Yes, it was the day before, I think. Or a day or so before.
DE LA POER: You think it had been published not on the 29th, but on the 28th?
FORD: I think it was the same day.
DE LA POER: That is what I am trying --
FORD: Yes, it was the same day. Sorry.
DE LA POER: My understanding was it was published on the 29th, I am trying to get the chronology right.
FORD: You are quite right. The phone call was the same day, the email was the day after.
DE LA POER: Yes.
FORD: Yes.
DE LA POER: At the time of the phone call, had the report been published?
FORD: Yes.
DE LA POER: Just in terms of this, obviously even when the terms are given to you, a highly significant piece of information which applied to the period that the report was talking about, what thought, if any, did you give to thinking: "well, I am now worried that that report isn't giving the full picture, we need to withdraw it or take it down from the website". Was there any consideration of that given at the time that this phone call came in, did you attach that significance to it?
FORD: At the time of the phone call, no, there wasn't because what I was most focused on was the immediate management of the ongoing risk to patients. That was my focus. You know, what are they doing? If there is a mortality issue here, what are they doing to mitigate that risk? And that was my first thought, I have to be honest. I didn't even think about the report at that point.
DE LA POER: Just reflecting upon it now -- and we appreciate that the report is a snapshot in time and you have emphasised repeatedly that this is an ongoing relationship and information comes to light --
FORD: Mm-hm.
DE LA POER: -- members of the public accessing that report would see what you say about the unit and nowhere in the report is an indication that there is a pretty substantial issue that is being -- that has arisen during the inspection period. I mean, would it have been appropriate to take the report down, or is that not appropriate in your view, bearing in mind you have just had that information when it was hot off the press --
FORD: Yes.
DE LA POER: -- which directly related to the period that the report was commenting upon?
FORD: I think that is a very fair question.
DE LA POER: And is it --
FORD: I didn't -- I didn't on the day, I didn't, you know, I have to be honest. Was it something we could have considered later? And maybe we should. I suppose there's a balance to be had -- and I am only thinking this through now -- there is a balance to be had, isn't there, you know, because a lot of what we said about the Trust was accurate based on the information we had at the time. We would have published the report. The caveat -- we -- we would have published a report with information that there was a mortality outlier on the neonatal unit that was under investigation, which would have been accurate. So I think we could have considered -- we could
have considered amending the report. But I think it was accurate at the point of publication.
DE LA POER: Just building on that answer, I am not for a moment suggesting other than it might be appropriate to reflect upon whether or not an addendum or caveat could be added --
FORD: Yes.
DE LA POER: -- you will be aware that members of the public might look at that and say: "well look, the CQC has been in right in the middle of this and they have said they have not identified any problem, we can rely on the CQC to tell us whether there is a problem or not," you can see how members of the public rely upon you as a regulator in that way?
FORD: That is a possibility, yes.
DE LA POER: That, presumably, would inform the thinking about whether or not some kind of an addendum --
FORD: Caveats.
DE LA POER: -- needs to be added?
FORD: Mm-hm.
DE LA POER: Now, after your telephone call, we know an email was sent the following day. Let's just bring that up on screen. INQ0017411. Now, you have seen this before, so we don't need to look at all of the detail. Help us. Does this reflect the content of your
call? Is this as good and accurate a record as we are going to get of what you were told the day before? Is there any more information in here? Is there any less information in terms of just understanding what you were told the day before?
FORD: I think that's a fair reflection.
DE LA POER: As you have told us in relation to the day before, in this email, would it have been your expectation that there would have been some mention that there was a member of staff had been identified and that steps were being taken to better understand that concern?
FORD: And the risk had been mitigated, yes, there would.
DE LA POER: Yes, we know that, as at the 29th of your call, Letby it would appear, was still operating on the neonatal unit. So if you had been told that, so let's just hypothesise here, you are told on the 29th there is also a concern raised about a member of staff that we are looking into, what would your reaction have been?
FORD: What are you doing about that? How are you mitigating that risk? And certainly I would have either relocated her or suspended pending investigation.
DE LA POER: That would have been advice given as a regulator as to what you need to do to reassure us?
FORD: Yes. We can't -- we can't tell an employer what to do with an employee, but we could certainly make -- we could certainly say: "my advice would be to ..." And then it's up to the Trust to take it, but I think we would expect them to take that sort of advice.
DE LA POER: Knowing yourself, as you do, is that the sort of advice that you would have given if you had been told this?
FORD: I think so, yes. I know so.
DE LA POER: Thank you. We can take that down. Now, subsequent to the report, there are a series of engagement meetings and I think they were conducted by the relationship manager --
FORD: Yes.
DE LA POER: -- who you have already mentioned. Is that person for the period that we are concerned with somebody called Debs Lindley?
FORD: Yes, Deborah Lindley, yes.
DE LA POER: Just to take a couple of examples, no doubt you have a general understanding of this although you weren't participating directly, we know, for example, that there was a meeting on 22 December 2016 with Ms Lindley. We know that the RCPCH report was mentioned, but there was no mention about the nurse.
FORD: Mm-hm.
DE LA POER: We know on 17 February of the following year, which is at a time when the Consultants were pressing hard for further action from the Trust, there was reference to the RCPCH report, but no discussion recorded about neonatal mortality. I am sure you have said this to us already, but to your mind, were those opportunities for the CQC to be informed about the concern about the nurse?
FORD: Yes. I believe so.
DE LA POER: We know that dropping out of the RCPCH report Dr Hawdon, Consultant Neonatologist, was instructed. Were the CQC ever notified of that, do you know?
FORD: We were told that the Trust were commissioning the Royal College to carry out the review.
DE LA POER: Yes.
FORD: And they were agreeing the Terms of Reference which would have been what we expected to happen.
DE LA POER: But the RCPCH recommended that Dr Hawdon should be instructed. Did you know about that additional forensic case note investigation?
FORD: No. No.
DE LA POER: Is that, bearing in mind the RCPCH said: "further work needs to be done in this area, this isn't the end of it" --
FORD: Mm-hm.
DE LA POER: -- should the CQC have been told about that further work?
FORD: I believe so, yes.
DE LA POER: Similarly, the day Paediatric Pathologist Dr McPartland was also instructed to look at some cases, is that another step that the CQC should have been told about?
FORD: I believe so, yes.
DE LA POER: Now, in terms of the police -- and you might just want to turn this up, it's the penultimate thing that I am going to ask you about, which is in your third statement [INQ0108375] at 9.2 --
FORD: Excuse me.
DE LA POER: No, take your time, please.
FORD: Yes.
DE LA POER: This is the statement that was volunteered once the Inquiry came underway --
FORD: Yes.
DE LA POER: -- and it contains a reflection. What you say is: "I am of the view that once the police investigation was launched, CQC was deferential to the police. We understood that the police investigation was extraordinarily complex and we did not wish to muddy the
waters or interfere with this important investigation. In addition, the CQC consideration of the level of risk was reduced by the fact that there was a police investigation and that Letby had been removed. However, I consider that this is an area where the CQC could potentially have been more professionally curious." I just wanted you to expand on that and what is it that you are saying there?
FORD: When we heard that there was a police investigation, we have powers for criminal prosecution under specific incident guidance, and normally we would look at that in terms of whether we should have done an investigation into the Trust. I think the police had primacy, obviously, because this was a criminal investigation. I think we should have considered earlier whether or not we could have done something in tandem with the police rather than -- because we are bound by the statute of limitations and because -- I think what we could have done is considered that earlier in case there was an opportunity for us to carry out our own investigation under -- under that regulation.
DE LA POER: Let's just reflect upon your limitation point.
FORD: Yes.
DE LA POER: The offences that the CQC is many empowered to
prosecute --
FORD: That's right.
DE LA POER: -- are strictly limited by time?
FORD: Yes, they are.
DE LA POER: I think there are two timescales running which relate to the date of knowledge --
FORD: Yes.
DE LA POER: -- and an absolute cut-off. The sort of things that the CQC can investigate are important things, such as whether the duty of candour was observed --
FORD: Mm-hm.
DE LA POER: -- and of course whether or not patients were effectively exposed to a risk of harm by a failure to provide care adequately?
FORD: (Nods)
DE LA POER: These are important tools in the CQC's regulatory armoury?
FORD: Yes, they are.
DE LA POER: But they are time-barred?
FORD: Yes.
DE LA POER: Is what you are saying here that there should have been some thought that, "look, an absolute statutory time limit is running here, we need to make sure that we have thought about this before that runs out"?
FORD: Yes, I think we could have been more curious at that point to see whether the -- rather than thinking we don't want to offend or upset or muddy or contaminate anything that the police might be doing because we knew it was such a complex investigation, I think we could have been more curious around whether there was anything for us to do at that point and that's what I mean about professionally curious.
DE LA POER: And --
FORD: Because historically we waited for the -- we have waited for the police to conclude their investigation. But more recently, as relationships and understanding matured, we have been able to do something in tandem.
DE LA POER: Typically -- and we have seen this, it is in the public domain at Grenfell -- that the Health and Safety Executive and the Metropolitan Police have a memorandum of understanding at an early stage so that everybody knows what everybody is doing --
FORD: Doing, yes.
DE LA POER: -- from an enforcement point of view. Is that something the CQC now thinks about in the event --
FORD: Yes.
DE LA POER: -- that it's aware of police investigations which have an overlap with the CQC's jurisdiction?
FORD: Yes, I think it does. And we also use the emerging concerns protocol, which is a number of agencies can come together, when a risk or a theme or a trendy emerges, and you can sit together and decide who's doing what and formally record that, and who has primacy and who can take it forward, the investigation, and under what powers. So the emerging concerns protocol is -- is quite helpful in that regard.
DE LA POER: That's a reflection that you volunteered --
FORD: Yes.
DE LA POER: -- as part of the preparation once the Inquiry was undertaken. I would just like to conclude by giving you an opportunity to reflect from your perspective. We have talked about many things, but do you think it's fair to say that something has gone wrong here with the CQC's involvement, not ascribing responsibility within that, but something has gone wrong, do you think? The CQC didn't uncover, weren't told something that they should have known over a protracted period of time? Do you agree?
FORD: Can I just take a moment to think about that?
DE LA POER: Of course you can.
FORD: Thank you. (Pause) I think, on reflection, you can always do things better. I think we applied the methodology as it stood at the time. I think there are opportunities or there were opportunities for us to learn and do things better. I think your point about the sharing of the incidents, the data quality, all of that were, were reasonable questions for you to ask and I think we have strengthened our approach in that regard over time. So I think as professionals and as regulators, we have to be open to continuous and ongoing improvement. So I think we do have to understand and acknowledge that with hindsight, could -- there were things we might have improved upon; I accept that. What I am finding it very difficult to accept is the lack of transparency in not alerting us to those concerns because I think we would have acted very differently.
DE LA POER: Just explain to us why do you use the phrase "I am having difficulty accepting that"; what do you mean by that?
FORD: Well, I really do think the Trust had a professional obligation and an obligation to patients to be open and transparent with us. And I would have liked to have known about those concerns much earlier
and then maybe -- well, I know we would have responded.
MR DE LA POER: Ms Ford, thank you very much for answering my questions. Those are all the questions I have for you.
FORD: Thank you.
Questioned By LADY JUSTICE THIRLWALL
LADY JUSTICE THIRLWALL: I have just got one or two, if I may.
FORD: Yes.
LADY JUSTICE THIRLWALL: Just going back briefly to the documents, they have not been located; either they are lost or they have been destroyed?
FORD: I believe so, my Lady.
LADY JUSTICE THIRLWALL: On the destruction -- and forgive me, I meant to go and check the transcript -- I think you said that six months after an inspection must have been reported, that there was a direction that documents could then be destroyed.
FORD: That's correct, my Lady, six months after the publication of the report.
LADY JUSTICE THIRLWALL: Of the report. Thank you.
FORD: If there was no challenge, we could destroy the paper records.
LADY JUSTICE THIRLWALL: Yes. Why do you think -- because we do have some of the records here --
FORD: Yes.
LADY JUSTICE THIRLWALL: I am wondering when that six-month rule was introduced or got rid of?
FORD: I think then when the IICSA directive came --
LADY JUSTICE THIRLWALL: Yes, in 2015.
FORD: -- I think that was better understood by some than others; colleagues. When we did the paper project to bring the papers back into the paper records, back into CQC, because people still had them in their own homes --
LADY JUSTICE THIRLWALL: Yes.
FORD: -- we were reliant on that safe return and the tagging.
LADY JUSTICE THIRLWALL: Yes, and you have explained that.
FORD: Yes, so I think -- I think some -- I can't be certain, but I think it's a possibility that some were destroyed.
LADY JUSTICE THIRLWALL: Yes. And you may have said this already, but when was it that you went through that paper retrieval process?
FORD: 2017.
LADY JUSTICE THIRLWALL: 2017. Thank you. What is the current policy?
FORD: The current policy is that we retain the
records for at least seven years. There are exceptions to that. The policy has been revised many times since then and now currently reflects best records document practice.
LADY JUSTICE THIRLWALL: Thank you. You mentioned the emerging concern protocol and just really a pick-up for me: how does that link with Safeguarding Processes and Working Together?
FORD: Well, again, most of the agencies have a responsibility, when there is a risk emerging --
LADY JUSTICE THIRLWALL: Yes.
FORD: -- will meet and sometimes, if there is a safeguarding issue, that we become the alerter. Each, each of the regulators around the table, will have their obligations under the Working Together to alert the relevant local authority in respect of safeguarding matters.
LADY JUSTICE THIRLWALL: Thank you. Then one last question, if I may. You helpfully set out for us what some of the Consultants were saying at that focus group. They were saying that the Trust -- they were raising concerns about staffing levels, one of the things, and then the Trust was not listening to their concerns and at times they felt that management was oppressive or bullying, both words were used.
FORD: Mm-hm.
LADY JUSTICE THIRLWALL: The follow-up, I think was by Ms Cain, was it, because you were in charge of the well-led part of it?
FORD: Yes, yes.
LADY JUSTICE THIRLWALL: But you didn't go back?
FORD: When we were -- went back to follow up with the Medical Director, do you mean, my Lady?
LADY JUSTICE THIRLWALL: Yes, the only follow-up was with the Medical Director, wasn't it, I think?
FORD: Yes, we spoke with the Medical Director and then the engagement with the Consultants, as I understand it, and how they were managing those concerns.
LADY JUSTICE THIRLWALL: Sorry, so did you actually speak to the Medical Director?
FORD: No, not that I recall.
LADY JUSTICE THIRLWALL: You said "we", you meant "she".
FORD: Yes.
LADY JUSTICE THIRLWALL: She raised it with the Medical Director on the day and he said "we are working on culture in the Trust".
FORD: Yes.
LADY JUSTICE THIRLWALL: The nurses said they had
not had any problems with culture, I think, from what said. Nurses were positive about the culture --
FORD: Yes, they felt well supported. It was that group of Consultants.
LADY JUSTICE THIRLWALL: A group of Consultants who were raising concerns who didn't feel management were listening and were?
FORD: Quite oppressive and bullying in their approach.
LADY JUSTICE THIRLWALL: That is quite a -- that is quite a thing to raise, isn't it?
FORD: It is.
LADY JUSTICE THIRLWALL: Also, it was in a sort of partly anonymous session in that none of them was identified, and you said that that's done deliberately. Was that not something that warranted a bit more than going straight to the Medical Director and saying what --
FORD: No, you are quite right because we followed that up after the inspection around the Freedom to Speak Up --
LADY JUSTICE THIRLWALL: Yes.
FORD: -- and medical engagement and how the Trust was managing those tensions, but we were doing that in the context of not knowing --
LADY JUSTICE THIRLWALL: No, I understand that.
FORD: -- what the concerns were.
LADY JUSTICE THIRLWALL: I think I am just looking to see what happens when someone did at least say something, although not at all what --
FORD: Yes, I think --
LADY JUSTICE THIRLWALL: -- should have said. I understand that. So what was the follow-up?
FORD: Well, the follow-up would be: "What have you done? How are you engaging your medical workforce? What response have you made to them?" And that would be done as part of the ongoing engagement.
LADY JUSTICE THIRLWALL: By?
FORD: By the Relationship Manager.
LADY JUSTICE THIRLWALL: This would be Debbie --
FORD: Debs Lindley and Bridget, yes. I think the other thing, my Lady, if I may say, is that the Consultants I wish would ... We did create some opportunities for them to speak with us on site.
LADY JUSTICE THIRLWALL: Yes, we have heard about that --
FORD: I do wish they had taken that opportunity.
LADY JUSTICE THIRLWALL: Yes, I think that point has been made. I just wanted to know about what had happened about what they had said. Mr De La Poer.
MR DE LA POER: If I may just pick up on that, my Lady.
LADY JUSTICE THIRLWALL: Yes, of course.
MR DE LA POER: Ms Ford, the decision was taken to go and raise these matters with the Medical Director. Why not with Sir Duncan Nichol or Tony Chambers, who sat at the very top of the organisation?
FORD: The Medical Director is usually responsible for the medical workforce, so -- and as peer-to-peer, we usually, in the first instance, will raise a concern with the Medical Director who is directly responsible for the engagement, the development and the support to the medical workforce.
DE LA POER: But by the sound of it, one interpretation of what you were told is that the concern about oppressive and bullying culture was that the Medical Director was responsible for it.
FORD: I don't know whether anybody ever said to me it was the Medical Director that was doing it, but we would have -- we would in the first instance have alerted the Medical Director for that.
DE LA POER: I am not saying that they did, but unless
somebody said it isn't coming from the Medical Director, then there exists a risk that that is what they are trying to tell you. I am just wondering, on reflection, do you think that that was a sufficiently robust response to those concerns and whether you should have, in fact, spoken to a spread of management to try and understand exactly where this was coming from and whether they understood as a board?
FORD: Yes, I see your point.
DE LA POER: Yes.
FORD: I think if I was going to escalate it any further, you are right, I should have, you know, escalated it to the Chair.
DE LA POER: Why do you think, then, that it wasn't escalated to the chair?
FORD: I think, at that point, we were confident or felt confident that the Medical Director would be as good as his word and tackle it. And I think what we should have done is, if it hadn't have been managed effectively and we felt that during the engagement, then we should have raised it with the Chair.
DE LA POER: But if the complaints had been about the Medical Director, he could have just said: "yes, of course I am dealing with this" --
FORD: But there are other indicators about -- there
are other indicators around medical culture that is available to us. So there would have been the feedback from junior doctors, the feedback from the Consultants, the medical engagement scores. There are other surveys and tools we can use to measure medical engagement. So I think we would have kept an eye on those as well, and if we were not satisfied, then we should have escalated to the Chair.
DE LA POER: Do you know whether or not Ms Lindley did follow up that particular concern as part of her relationship management role?
FORD: I don't know because I had moved into another role at that point.
DE LA POER: But you can say that you would have expected her to?
FORD: I would have expected all the findings of the inspection to be followed up.
MR DE LA POER: My Lady, those are all my follow-up questions.
LADY JUSTICE THIRLWALL: Thank you very much indeed. You are free to go.
FORD: Thank you.
MR DE LA POER: If I may, my Lady, I will turn over to Mr Carr now for our final witness today.
LADY JUSTICE THIRLWALL: Yes, Mr Carr. Just remain standing, someone will ask you to take the oath.
MS JULIE ANN HUGHES (sworn)
LADY JUSTICE THIRLWALL: Thank you very much. Do sit down.
HUGHES: Thank you.
MR CARR: Can we start, please, with your full name?
HUGHES: Yes, my full name is Julie Ann Hughes.
CARR: Ms Hughes, you have prepared a statement for the purposes of this Inquiry, have you not?
HUGHES: I have, sir, yes.
CARR: That statement is dated 28 August 2024.
HUGHES: It is.
CARR: Can you confirm that the contents of the statement are true to the best of your knowledge and belief?
HUGHES: I can, sir, yes.
CARR: You deal within your statement with your professional background and you explain that you have a Master's of Science degree in sociobiology?
HUGHES: Yes, I do, sir.
CARR: You have a postgraduate qualification in front-line management?
HUGHES: I have.
CARR: You are a Fellow of the Royal Society of the Arts?
HUGHES: Yes, currently, yes.
CARR: You were employed by the Care Quality Commission as an inspector for over a decade --
HUGHES: Yes, sir.
CARR: -- from June 2012 to June 2023?
HUGHES: That's correct.
CARR: You explain that, in that capacity, you conducted around eight inspections per quarter?
HUGHES: Yes, sir, yes.
CARR: So 32 a year.
HUGHES: (Nods)
CARR: As well as attending inspections, you would also be involved in the other aspects of CQC regulation, which was monitoring of Trusts?
HUGHES: Yes, sir, that's correct.
CARR: So attending engagement meetings of the Trusts and attending management review meetings --
HUGHES: Correct.
CARR: -- which were internal CQC meetings?
HUGHES: Yes, sir.
CARR: I want to look first, please, at your involvement in the 2016 inspection of the Countess of
Chester Hospital. You were part of the inspection team, weren't you, for that inspection?
HUGHES: I was.
CARR: You led the end of life team?
HUGHES: I did, sir, yes.
CARR: That team was concerned with the care and services provided to individuals in the last stages of their lives?
HUGHES: Yes, sir.
CARR: We can see from the notes that have been provided that you also took part in an interview as part of the Children and Young People Services?
HUGHES: Yes, sir.
CARR: If we can turn up the relevant page of the notes, it's at INQ0017339. If you turn, please, to page 31, we considered notes from this part of the inspection yesterday and that handwriting, it's not yours, is it?
HUGHES: No, no, it isn't, I'm sorry.
CARR: This looks like a note made by Helen Cain, and if we look in the middle of the page, "Relevant Core Service", that section, we can see "Children and Young People" circled. Put in the box below: "CQC inspection team attendees" it confirms that you attended along with Helen Cain --
HUGHES: Yes, sir, that's correct.
CARR: -- for this part of the interview, and the attendees at the interview, next box below, Vicky Higgins, a specialist children's community nurse, and Helen Griffiths, a diabetes specialist nurse. Now, we also see in the description of Ms Higgins' role what appears to say she was the lead for oncology and palliative care, and in the next box down, "Summary of points from the notes", first line: "EOL paed strategy". Does that stand for end of life paediatric strategy?
HUGHES: Yes, sir, yes.
CARR: Is that the explanation for how you came to be involved in this --
HUGHES: Yes, yes, it would have been -- it would have -- the paediatric aspect would have come under end of life services as a whole along with mortuary services and things like that, so we explored each of the areas within that core service.
CARR: Because this interview would engage both Children and Young Peoples Services and end of life, it was a joint interview?
HUGHES: Yes, it was an effective use of the time we had.
CARR: Now, you will have gone back and looked at this note for the purposes of preparing your evidence. The notes do not appear to record, do they, any discussion of issues concerning neonatal mortality?
HUGHES: No. No, sir.
CARR: Do you have any recollection of any discussion of issues concerning neonatal mortality at this meeting?
HUGHES: Not at all, I'm sorry.
CARR: Thank you. We can take this document down. I want to consider now your involvement at the inspection as part of the Trust wide team. The Trust wide team, are those inspectors that carried out interviews, which looked at matters across all disciplines in the hospital?
HUGHES: (Nods)
CARR: At paragraph 10 of your statement, you state: "My role in the Trust wide team was limited to leading focus groups."
HUGHES: Mm-hm.
CARR: You go on in the final paragraph -- sorry, final sentence of that paragraph, to say: "I did not participate in any of the Trust wide inspection beyond running focus groups and did not conduct any interviews."
HUGHES: No.
CARR: If we can get up another document, please,
it's INQ0017287. Now, there are a number of different versions of this table. This is the version that you refer to in your statement. This document sets out doesn't it the schedule of core interviews and of focus groups?
HUGHES: Yes, sir.
CARR: And if we just go through this document and see what the schedule provided for. This page we are looking at, we can see at the top, second box, "Wednesday, 17 February", so that's the date on which the interview set out on that page was scheduled, and we can see that your name is down for an interview with Hayley Cooper, halfway, roughly halfway down the page --
HUGHES: Yes.
CARR: -- which is highlighted and that was an interview that you were scheduled to conduct with Ann Ford and the "Additional Comments" box says "Chair of Staff-Side."
HUGHES: Yes, sir.
CARR: We will come back to this. If we can look at page 2 of this document now. At the top of the page, still dealing with the timetable for 17 February, there is an interview there for service leads for each of the core services and this is the end of leads, service leads interview?
HUGHES: Yes, sir.
CARR: Then, on 18 February, the box that follows, there are two interviews with Ian Harvey in which your name is included as the team member to conduct the interview, one at 11.30 that has been highlighted and another later at 14:30. Looking at that timetable, it does appear that you are involved in a number of the core interviews.
HUGHES: What would have happened, sir, I would have been there as a notetaker. As you can see by looking, there was always someone qualified to discuss at a strategic level the issue at hand. So in terms of the head of infection control, Dan Watson was with me and he would have led on that and I would have taken the notes. In terms of -- it was useful for me to be in with the board of director responsible for end of life care, because that just allowed me to hear that, that work. In terms of the complaints lead, that would have been led by Trish Rowson, with myself there as notetaker and an appropriate specialist adviser.
CARR: When you say in your statement you didn't conduct any interviews --
HUGHES: No, I wouldn't conducted --
CARR: -- what you meant by that was?
HUGHES: I would have taken notes, but I would not have led or conducted the interview.
CARR: If we look at page 3 of this document, please, this sets out the focus group, doesn't it?
HUGHES: Yes.
CARR: We can see that the Consultants' focus group was scheduled for 18 February --
HUGHES: Yes, sir.
CARR: -- at 8 until 9.30 and you were down with Michael Rees to conduct that focus group?
HUGHES: Yes, sir.
CARR: That appears to be the only focus group that you were scheduled to undertake?
HUGHES: Yes, sir.
CARR: If we can go back to page 1 of this document, please, the Julie Hughes interview. Sorry, the Hayley Cooper interview that you attended. You kept a note of that interview?
HUGHES: I would have taken the -- the minutes of that interview.
CARR: Well, as you will be aware, your notes have been lost, cannot be found --
HUGHES: Yes.
CARR: -- or were destroyed. What recollection do you have of what was discussed at that meeting?
HUGHES: The Staff-Side representatives generally because they are mostly -- it is in relation to obviously unions and the unions's perception of the Trust and what's happening in the Trust and staffing levels and staff surveys, and that's the type of issues that would have been discussed in a Staff-Side representative meeting.
CARR: Do you recall if any concerns were highlighted at this meeting as to issues in the neonatal unit?
HUGHES: I'm sorry, sir, I don't. I don't remember, I do apologise.
CARR: If we move forward now in the chronology, please, to the focus group -- and we can take this document down. Now, you attended the focus group with Michael Rees and you explain in your statement that he was a Specialist Adviser, so not a CQC employee.
HUGHES: Yes, sir, yes.
CARR: And his background was as a qualified surgeon?
HUGHES: (Nods)
CARR: Now, we do not have a full note of the focus group, do we?
HUGHES: All my notes would have been handed in to CQC and, as I have since left, I have no access to their system, so I don't know what's been provided.
CARR: What you say in your statement is that you didn't take a note of the focus group --
HUGHES: No, I wasn't the notetaker.
CARR: -- it was Cara Taylor --
HUGHES: Yes.
CARR: -- who was somebody who was shadowing you --
HUGHES: Yes.
CARR: -- who would have taken a minute.
HUGHES: Yes.
CARR: But you are aware, aren't you, that those notes have not been traced?
HUGHES: Yes.
CARR: Now, whereas the schedule indicated that the focus group was due to take place between 8 and 9.30 on 18 February, you state, at paragraph 15 of your statement, that you think the date recorded in your diary for the focus group is more likely to be accurate and that's 2.30 pm on 17 February.
HUGHES: Yes, I think so. I would say what I have written down daily was likely to be more accurate, yes, sir.
CARR: If you can help us with the purpose of the focus group; it was for Consultants across the hospital?
HUGHES: It was.
CARR: Not specific to any department?
HUGHES: No.
CARR: It is the whole point of being Trust wide, and what is the purpose of a focus group, what's it designed for?
HUGHES: The focus group is designed to have a confidential forum for staff to tell the regulator anything they think we should know, anything that's pertinent to the -- the inspection, any of their concerns or issues.
CARR: Do you recall whether any of the neonatal Consultants, paediatricians, attended?
HUGHES: I don't specifically. I think there was maybe 15, 14/15 people in the room, possibly.
CARR: So 14 to 15 people in the room?
HUGHES: Yes.
CARR: 14 to 15 Consultants?
HUGHES: Yes, yes, apart from ourselves.
CARR: Do you recall any individuals or specialties who attended?
HUGHES: Sorry, sir, I don't.
CARR: Now, there are a number of accounts as to what was reported at that focus group and what was done as a result, so we are going to look through what evidence we do have available --
HUGHES: Yes, sir.
CARR: -- and see if we can try and piece it together. Now, although the note that was taken hasn't been traced, what we do have are images of the brief notes that you made yourself --
HUGHES: Yes.
CARR: -- in your diary, and we will look at those first. It's INQ0017319. If we can turn, please, to page 2. Now that is your handwriting, isn't it?
HUGHES: It is, sir, yes.
CARR: Thank you. As I understand it, these were notes that you say you made during the focus group?
HUGHES: Yes, sir.
CARR: Can you take us through what those notes deal with?
HUGHES: Initially, the first set of notes, written in blue pen for some reason, deal with things I wanted to remind myself to check in terms of end of life care and that's why it is stuff like "incident report across EOL" is just an aide memoire for me to look at incident reporting. "Shadow staff" is fairly explanatory. I would want to spend some time shadowing a palliative and a general nurse dealing with patients at the end of their life. And the other one was to remind me to look at consent, and look at where that was at with consent.
CARR: Just pausing you there, those notes that you have just explained, are they matters that emerge from the focus group or are they points that --
HUGHES: No, they are just -- sorry, they are just my notes. The only thing that links to the focus group is the asterisk in themes.
CARR: It appears to read "bullying, lack of support, staffing".
HUGHES: Yes, sir.
CARR: Then the next two entries, 10.30, it looks "TC re: Pennine"; is that at all connected to the focus group?
HUGHES: I am so sorry. The --
LADY JUSTICE THIRLWALL: You don't need to be sorry. It's just that's what we've got.
HUGHES: My note diaries only made sense to me; I'm aware of that. It was just if I thought of something I needed to remember I would just write it on whatever day I was on.
MR CARR: The final line on that page, it's difficult to read, what does that say?
HUGHES: I think it says "Evidence review".
CARR: Okay. Does that relate to anything?
HUGHES: That relates to my end of life care.
CARR: At page 3 of this document, please, again can you help us with this; do any of these entries relate to the focus group?
HUGHES: No, sir. It relates to a separate service. One is a start time and others are just who I needed to call. One was Bridget at 12 and one was Helen at 2.30.
CARR: That is Bridget Lees, another CQC inspector?
HUGHES: And Helen, yes, just to remind me I need to call.
CARR: Helen Cain?
HUGHES: Yes, sir.
CARR: Now, she led the Children and Young Peoples Services?
HUGHES: Children and Young People, yes, sir, yes.
CARR: Do you recall why you needed to call her?
HUGHES: Sorry, no, I don't.
CARR: Page 4 of this document, please.
LADY JUSTICE THIRLWALL: I'm sorry, Mr Carr, what was the date of the diary there? Is that before the inspection started, the phone calls?
HUGHES: I think it probably is, because it says COC inspection, 6.50 am start.
LADY JUSTICE THIRLWALL: Yes.
MR CARR: We may make sense when we get to page 6.
LADY JUSTICE THIRLWALL: Thank you for that.
MR CARR: Before we do leave that page, the bottom entry "Re BPAS!"
HUGHES: That's regarding another service, namely the British Pregnancy Advisory Service which was something else that was on my portfolio and I needed to check back on.
CARR: Then if we move forward to page 5. This is quite hazy. What is being dealt with in this photograph?
HUGHES: This is note on the BME focus group which I was on that day, the Union one, which we have looked at with Ann, in red is Mortality Reviews, which was an area I needed to remind myself to go through.
LADY JUSTICE THIRLWALL: Mortality or what does it says?
HUGHES: Mortuary, sorry, "Mortuary reviews". I can't read my own handwriting, I do apologise. "Meeting in training room 2" and "Feedback to MD."
MR CARR: Again, nothing specific there to the Consultants.
HUGHES: I think the specific thing there is the feedback to the MD where we would have taken the themes that had arisen in terms of from the medical aspect of the Trust and fed them back for his attention.
LADY JUSTICE THIRLWALL: So does that say "Feedback
to MD" and then "Re: Consultants"? Is that what it says there?
HUGHES: Yes, yes.
LADY JUSTICE THIRLWALL: What does "SG" stand for?
HUGHES: "SG".
LADY JUSTICE THIRLWALL: Or is it 8?
HUGHES: It could possibly be a room number or a room, you know, and I have just put in brackets where I need to be.
LADY JUSTICE THIRLWALL: Yes, thank you. Sorry, Mr Carr.
MR CARR: Thank you. So far as "Feedback to MD", do we know what day this entry is for that we are looking at on page 5?
HUGHES: I would have -- I don't -- I can't say I remember clearly, but I think it would have been the day after or late or the same day as the focus group, once Helen the Specialist Adviser and I had our chance to have a chat and go through and agree the themes that we needed to feed back.
CARR: If we turn to page 6, please, which may help with identifying when some of these entries were made, we can see the top left-hand corner, it looks like it is an entry for a Monday, the 15th. That is the start of inspection week.
HUGHES: Yes, sir, yes.
CARR: It has those entries that we looked at, calls with Bridget Lees and Helen Cain. And then we see, on the other side of the page, the notes arising from the focus group, the bullying and then it's cut off by the photograph. Having looked at your diary, if we go back to page 2 of this document, the only entry that we have in these photographs dealing directly with what emerged at the focus group is that asterisk in black saying: "Themes: bullying lack of support staffing"?
HUGHES: Yes, sir.
CARR: To be clear, those notes would have been made at what stage? Or this note would have been made at what stage?
HUGHES: My personal -- whilst I was in the room whilst the issues were being discussed.
CARR: If we can turn now to page 1 of this document. This is a note of a telephone call with you, dated 7 July 2023.
HUGHES: Yes, sir.
CARR: You have seen this document again for the purposes of preparing your evidence, haven't you? Ms Hughes, you have seen this document for the purposes --
HUGHES: Yes, sorry, sorry.
CARR: It is a note that was made, as I understand it, by Kirstin Hannaford?
HUGHES: Correct, yes.
CARR: That is who you had the telephone discussion with?
HUGHES: I did, yes, sir.
CARR: And she is a media adviser at the CQC?
HUGHES: She is.
CARR: We can see the heading "February 2016 CQC Comprehensive Inspection of the Trust"?
HUGHES: Yes, sir.
CARR: It is a phone call to discuss the inspection in 2016. Now, can you help us with what prompted a telephone call in July 2023 to discuss the inspection in 2016?
HUGHES: I got first a text and then a call saying "if you are available" because I had left in June 2023, "we would like to have a chat with you about a Countess inspection", and that's what prompted that call.
CARR: Did you understand that the telephone call was with a view to preparing a press release?
HUGHES: I did because it was with Kirstin and I know she deals with media.
CARR: Because, July 2023, that was during and
towards the end of the criminal trial of Letby, wasn't it?
HUGHES: Yes, sir.
CARR: Prior to this telephone call from the media adviser, at any time following the inspection leading up to this, had anybody from the CQC sought to discuss with you that 2016 inspection and what had happened at the Consultants' focus group?
HUGHES: Not -- no, I don't think so. I -- myself, the Specialist Adviser, took what happened at it to the team room where the Trust, my team, were and it was these themes.
CARR: You are talking about at the inspection?
HUGHES: At the inspection, yes.
CARR: My question was about after the inspection, because we have the inspection, at some point --
HUGHES: Yes.
CARR: -- these notes go awry, they disappear. This is 2023, so between the inspection and 2023, did anybody at the CQC contact you and say "we don't have notes of this focus group, can you tell us what went on?"
HUGHES: Not to my knowledge, sir, no.
CARR: If we look at the note and what is recorded, the first bullet point deals with dates, 17 February 2.30 pm, so that accords with your diary but not the
schedule we looked at earlier --
HUGHES: Yes.
CARR: -- and we have addressed that. Then the next bullet point deals with the issues that arose. It says: "Some Consultants raised concerns relating to staffing levels, lack of staffing, bullying culture, senior medics who talked of a lack of support from leadership team." Now, those issues, staffing levels, lack of staffing, bullying culture, lack of support, those are matters which are dealt with in, in the note in your diary made at the time, aren't they --
HUGHES: Yes, sir.
CARR: -- which we just looked at. Then the next subparagraph, next bullet point, "Oppressive air at leadership level". Now, that phrase is not contained in your diary in the photographs we just --
HUGHES: No, correct.
CARR: -- looked at. The first question is: did you state during this call that Consultants raised concerns about an oppressive air at leadership level?
HUGHES: I don't think I said they raised it, I think in my conversation with Kirstin I was describing a general oppressive air because that is what came across, that they didn't feel supported to raise their concerns, they didn't feel listened to.
CARR: Okay. Looking at this note, it would be incorrect to the way it's been drafted to suggest that some Consultants raised concerns of an oppressive air at leadership level, you were describing that as your impression.
HUGHES: Yes, sir, definitely my impression.
CARR: Now, the next bullet point refers to a meeting with the Medical Director. It says: "A meeting was held with the Trust Medical Director that same day at 4.30 pm and the concerns expressed by Consultants were discussed." Now, the schedule that I took you to originally with those interviews with Ian Harvey, those schedule interviews weren't on 17 February, were they, they were on 18 February?
HUGHES: What -- the reason it wouldn't have been a scheduled discussion it was because we felt, as a group, the three of us who were in that Consultants' group, that we really need to flag this with the Medical Director that these Consultants are not feeling supported and don't feel listened to. So it wouldn't be a scheduled meeting as such, sir, it would just simply be a request to feed back some of
the issues that were emerging as part of the inspection process.
CARR: It is an ad hoc meeting?
HUGHES: It's an ad hoc meeting, yes. It wouldn't be scheduled.
CARR: You say "the three of us decided", three of you being?
HUGHES: Yes, what happens is you come out of the focus group, you all look at -- go through your thoughts and okay, these are the themes that we need to pick up on immediately, and the fact the Consultants were saying they didn't feel listened to, they didn't feel supported, that would have been fed straight back to the Medical Director.
CARR: My question is just trying to establish when you said "The three of us decided to raise with the Medical Director", you are describing yourself and which?
HUGHES: Myself, the specialist advisory and the notetaker because we all heard the same things in the room.
CARR: Sorry, I didn't quite catch that; the specialist advisory and who?
HUGHES: And the note take, Cara Taylor, who was a new inspector who was shadowing and taking notes.
LADY JUSTICE THIRLWALL: Carla Taylor, did you say?
HUGHES: Cara.
LADY JUSTICE THIRLWALL: Cara. Thank you.
MR CARR: Did the three of you decide then to go and speak to Ian Harvey?
HUGHES: It would have been myself and I'm not sure if the Specialist Adviser came with me who went to speak to the Medical Director.
CARR: Okay, we will come back to that. What I want to look at next, we can take this document down, please, and turn to the press release, INQ0104624, page 2, please. In the first paragraph on that page, second line down, the sentence that starts on the second line: "Inspectors also received some concerns from hospital staff about a lack of support from management when they tried to speak up which we highlighted directly to senior Trust staff as an issue that they needed to address." Then, if we turn to page 3, the second box, the second paragraph, that deals with the focus group as well. That second sentence: "Those concerns related to staffing levels, a lack of support from senior management and Consultants who felt there was a culture of bullying and were concerns
they could raise with management were ignored. We followed up directly with the Trust Medical Director that same day to relay those issues so that action could be taken in response." Now, this is the press release that was prepared by Ms Hanniford.
HUGHES: Yes.
CARR: Those sections would have been prepared on the basis of the discussion with you about the Consultants' focus group?
HUGHES: Yes.
CARR: We see reference in that press release to a lack of support when staff tried to speak up and that concerns raised with management were ignored. Now, again, just trying to get the best account of this that we can, your diary entry made on the day does refer to a lack of support, but doesn't say that concerns being raised by Consultants were being ignored?
HUGHES: Yes, sir, that's correct.
CARR: The basis of the contention that Consultants raised at the focus group, concerns were being raised but being ignored, what was that? Was it purely recollection or was it documented elsewhere?
HUGHES: I think it would probably be purely recollection of the whole conversation.
CARR: Did you tell Ms Hanniford in your discussion in July 2023 that that's what occurred at the Consultants focus group?
HUGHES: No, in my discussion with Kirstin last year I basically read out what was in my notes and what I had left in my memory.
CARR: The note that we have in your diary says: "Themes bullying, lack of support, staffing"?
HUGHES: Yes, sir.
CARR: That is what I am trying to work out how you have gone from there to Consultants say they are raising concerns and they are being ignored?
HUGHES: I don't have an answer to that, sir. I didn't see the press release prior to it being released because I no longer worked for CQC and I have not -- I had that conversation and I have not spoken to Kirstin Hannaford since.
LADY JUSTICE THIRLWALL: I think you said that it was the notes and I think you said "what I had left in my memory".
HUGHES: Yes.
MR CARR: If we can look, please, at how this is dealt with in your statement to the Inquiry. I will read paragraph 21, you say: "To the best of my recollection, the concerns
raised at the Consultants' focus group meeting were regarding a culture of bullying, the Consultants shared with us that they felt their concerns were not being listened to." Paragraph 22: "Despite my best efforts, I cannot recall the concerns raised in any more detail than this." At paragraph 24: "I am sure that there were no specific concerns raised about the neonatal unit." Paragraph 25: "I cannot recall any concerns regarding neonatal staffing being raised." Judging from your statement, it appears your recollection is limited to the fact that concerns were raised --
HUGHES: Yes, sir.
CARR: -- but you don't recall anything about what those concerns were?
HUGHES: No, sir.
CARR: If you don't recall what concerns were raised, what is the basis for saying you are sure that no specific concerns were raised about the neonatal unit?
HUGHES: Because in the focus group, Consultants from across specialties, what we would -- what I would ask
them is: "okay, what are the key things you need me to know? What can we do while we are on inspection? What are the key areas you want us to look at?" And their answers were things like, "we are not listened to. We feel that the management doesn't take our concerns seriously, doesn't listen to us, and we feel that the senior medical management has a kind of bullying culture". At that point, during that focus group, I can't say there was any single specialty Consultant who raised specialty concerns, so nobody said: "there is a real concern about neonates". Nobody said: "there is a real concern about oncology". It was a generalised focus group with a multi-disciplinary team of Consultants.
CARR: Whilst you now can't remember what the concerns were, do you remember if, during that focus group, you would have explored the concerns, so where a Consultant --
HUGHES: Yes, I would have asked: "is there anything you can tell me?" Given the nature of the group and the facts there was more than a number of people in it, one of the things which was standard at the end of the focus group was to say: "if you are really worried, you can always tell CQC anonymously using..."
CARR: Forgive me, my question was slightly
different --
HUGHES: Oh sorry.
CARR: -- and to be clear, the Consultants reported that they had concerns that senior management weren't listening to or weren't responding to them?
HUGHES: Yes, sir.
CARR: My question is: if you had been told that, would you have explored with the Consultants: "well, what are the concerns that management ..."
HUGHES: Yes, absolutely, and it would have been noted in my diary because that is exactly what I would have fed back to Ann Ford to Bridget and to ultimately to the Medical Director.
CARR: You say it would have been noted in your diary, but it is not noted in your diary. I have just looked at your diary and --
HUGHES: No, if anyone had said to me if I -- when we are having those discussions, it's like: "okay, what can you tell me? What are your concerns?" And what's in my diary is the concerns that were raised by the group. Any specific concerns in relation to speciality --
CARR: Again, we are slightly at cross-purposes. Let me put it this way. You would have said to the Consultants: "Do you have any concerns?"
HUGHES: Yes.
CARR: One of the responses was: "well, a concern that we have is that when we raise things with management they are not taken seriously, not listened to"?
HUGHES: Correct, sir.
CARR: What I am asking you is: would you then have gone on to ask the Consultants: "well, what are those things that you are raising with management that management aren't taking seriously?"
HUGHES: Yes, we would have said: "can you give us specifics?" We would have asked for specifics.
CARR: What was the response; can you recall?
HUGHES: I have no --
CARR: Do you recall whether at the focus group you were told that any Consultants had concerns with patient safety?
HUGHES: Not to my knowledge, sir, no.
CARR: You refer to a culture of bullying. Who was it that was being bullied?
HUGHES: The Consultant body felt that the senior medical managers -- they felt there was a culture of bullying within the medical faculty, sir.
CARR: Bullying of whom?
HUGHES: The Consultants felt they were --
CARR: By?
HUGHES: Senior medics and medicine, medicine leaders.
CARR: Now, again just trying to clarify one other point. We saw, didn't we, when I took you to those two sections in the press release --
HUGHES: Yes.
CARR: -- we saw an assertion which stated: "we highlighted directly to senior Trust staff as an issue that they needed to address..."
HUGHES: Yes.
CARR: Those concerns. And then in another section: "We followed up directly with the Trust's Medical Director." Now, the way in which you deal with this in your statement, it is your paragraphs 28 through to 31, you say at paragraph 28: "Following the Consultants' focus group I would have gone back to CQC's team room at the hospital and spoken to either Bridget Lees, inspection manager, or Ann Ford, Head of Hospital Inspection, regarding the concerns which had been raised. I would have informed Ann or Bridget that the Consultants had reported concerns about a culture of bullying at the hospital." You then say, paragraph 29: "Having regard to regulation 17 of the Health and Social Care Act 2008 (Regulated Activities Regulations)
2014, this would have meant that we, Ann or Bridget and I would have taken this concern to the Medical Director of the hospital. This would usually have been arranged via CQC's inspection planner." If I move on to paragraph 30: "Unfortunately I cannot recall this meeting with Ian Harvey. However, standard practice would have been simply to report what was said by the Consultants to the Medical Director." Paragraph 31: "Meeting with the Medical Director to report concerns raised in a focus group was fairly standard." What you appear to be describing in your statement is what standard practice would be having received the sorts of concerns that you did?
HUGHES: Yes, sir.
CARR: It sounds like you don't have any recollection as to whether that actually happened at the time; is that fair?
HUGHES: Yes, that's fair.
CARR: Do you have any recollection of a meeting with Mr Harvey, either on the 17th or of the scheduled meetings on the 18th, where you told him about the concerns that had emerged at the focus group?
HUGHES: I don't, sir, I'm sorry.
CARR: Your schedule meetings with Mr Harvey -- and I am sorry, I am calling them your schedule meetings, you explained you didn't conduct them, but you kept a note --
HUGHES: Yes.
CARR: -- those notes again that we do not have, do you have any recollection of the issues discussed at those meetings?
HUGHES: No, I don't have recollection of specifics, I am so sorry.
CARR: The standard practice that you have described at paragraph 28 to paragraph 31 of raising these concerns, these issues, with the Medical Director, would that have been appropriate in circumstances where the Consultants were reporting to you in a confidential focus group that they were being bullied by senior managers?
HUGHES: It -- it -- yes, it would have been appropriate to take it to the Medical Director as he carried overall responsibility for medics across the Trust and he was -- basically there was no one else to go to but the Medical Director at that point. It was to make him aware that the regulator was aware of these concerns and would be monitoring them going forward.
CARR: Did you raise -- do you have any recollection of raising the issues that arose in the Consultants' focus group about concerns of bullying or management not listening with the other sub teams?
HUGHES: I'm sorry, sir, I don't. I don't remember.
MR CARR: My Lady, I am conscious of the time I have one further short topic to explore.
LADY JUSTICE THIRLWALL: I am sure you would like to get finished before we break for lunch, so shall we do that?
HUGHES: Thank you.
LADY JUSTICE THIRLWALL: Mr Carr.
MR CARR: Thank you. I am going to move away now from the 2016 inspection. I asked you earlier about the other side of CQC regulation which involves monitoring of Trusts.
HUGHES: Yes, sir.
CARR: You were involved as a CQC employee in monitoring. Some of your monitoring activity involved the Countess of Chester Hospital, didn't it?
HUGHES: It did, sir, yes.
CARR: I want to ask specifically about an engagement meeting in December 2016, it's INQ0017298, whilst that is being brought up, to confirm again an engagement meeting is a meeting between CQC Inspectors --
HUGHES: Yes.
CARR: -- and the Trust?
HUGHES: Yes, sir.
CARR: This is the agenda for a meeting in December. We can see in box 1, can we not, the attendees, Ian Harvey, Alison Kelly, Sian Williams, Ruth Millward and then you and Debs Lindley on behalf of the CQC?
HUGHES: That's correct, sir.
CARR: Now, at this stage, the Care Quality Commission was aware that there was an increase or had been an increase in neonatal mortality?
HUGHES: Yes.
CARR: They were aware that the RCPCH had visited the hospital for the purposes of a service review. This agenda, which appears to incorporate a note is very brief. If we can look at entry number 2, please: "Areas for discussion. Action plan. Neonatal review. Novel Events and Serious Incident." In respect of the neonatal review, do you recall what was discussed about it?
HUGHES: I -- I recall this meeting, I can't say in great detail, but I do recall that we were asking where they were up to with that review, what any initial findings were and asking for anything they could share with us at that point in time.
CARR: What was the response that you got back?
HUGHES: I think it was fairly limited. I think it was a limited response. To -- my memory is we had not saw sight of the review at this time, but it was a standard agenda matter, so we could ask the Trust: "okay, where are we with this? What's happening?"
CARR: Mr Trenholm from the CQC, in his corporate statement to this Inquiry, states that at this meeting the CQC, so that is you and Ms Lindley, were informed that the RCPCH report was at the draft factual accuracy stage and that a request was made for that report?
HUGHES: (Nods)
CARR: Do you recall being -- whether you were told, that the report was at the draft factual accuracy stage?
HUGHES: I don't recall being told it was at draft, sir.
CARR: Now, we know from other evidence that we have seen that the RCPCH's final report was sent to the Trust on 28 November 2016, so prior to this engagement meeting.
HUGHES: Yes.
CARR: If the Trust had that report, was it your expectation that you would be told that they had the final report?
HUGHES: Absolutely.
CARR: Was it your expectation that the final report
would be provided and in a timely fashion?
HUGHES: Absolutely.
MR CARR: My Lady, thank you. Those are my questions.
LADY JUSTICE THIRLWALL: Thank you.
MR CARR: Subject to anything.
LADY JUSTICE THIRLWALL: Mr Deakin? No, thank you very much, and I have no questions. Thank you very much indeed for coming to help us today, you are free to go now.
MR CARR: My Lady, that concludes the evidence for today.
LADY JUSTICE THIRLWALL: Very good. Thank you. We will rise and start again at 10 o'clock on Monday morning.
(1.11 pm) (The Inquiry adjourned until 10.00 am, on Monday, 18 November 2024)
Witnesses:
Sharon Dodd: Specialist Nurse (Safeguarding Children)
Hayley Frame: Independent Chair of Child Death Overview Panel
Paula Sindall (née Lewis): Specialist Safeguarding Children’s Nurse
Dr Howyada Isaac: Consultant Community Paediatrician (Safeguarding)
LADY JUSTICE THIRLWALL: Ms Brown.
MS BROWN: Yes, we are calling Ms Dodd this morning.
LADY JUSTICE THIRLWALL: Ms Dodd, would you like to come forward?
MS SHARON DODD (affirmed)
LADY JUSTICE THIRLWALL: Do sit down.
MS BROWN: If you could please state your name.
DODD: Sharon Dodd.
BROWN: You provided a statement to the Inquiry dated 20 June 2024 and is that true to the best of your knowledge and belief?
DODD: It is.
BROWN: Turning to your qualifications, you qualified as a Registered General Nurse in November 1979 and as a midwife in May 1981?
DODD: That is true.
BROWN: You became a Registered Health Visitor in 1987?
DODD: I did.
BROWN: In terms of your career, from 1980 to 1987 you worked as a midwife at the Countess of Chester Hospital?
DODD: Yes.
BROWN: You subsequently worked as a health visitor?
DODD: Yes.
BROWN: Have you at any point in your nursing career worked on a neonatal ward?
DODD: Never.
BROWN: In 2010 you commenced your role as a specialist nurse in what is now the Cheshire and Wirral Partnership NHS Foundation Trust in the safeguarding department?
DODD: I did.
BROWN: You stayed in that role until 2019?
DODD: Yes.
BROWN: Are you still working within the NHS?
DODD: Yes. In 2019 I retired and then returned part-time to a slightly different role.
BROWN: Is that a paediatric liaison role?
DODD: Yes.
BROWN: So that is no longer within the safeguarding department and no longer within the CDOP?
DODD: I am actually based within the safeguarding team but I am paediatric liaison health visitor, yes.
BROWN: Do you still have any involvement with the Child Death Overview Panel?
DODD: No.
BROWN: Turning then to your role in 2015/2016, what safeguarding training did you receive for that role?
DODD: For the role of?
BROWN: The role where you were -- we will come to it, but paediatric liaison nurse but also you were working with CDOP, I think one day a week, the Child Death Overview Panel?
DODD: Okay. As a health visitor you receive -- as in any of my professional roles I have received quite a lot of safeguarding training. But for that particular role I was needing to, required by virtue of the role that I was doing to actually complete Level 1, Level 2 and Level 3 of safeguarding training, which is documented in the intercollegiate document and Working Together to Safeguard Children.
BROWN: Was Level 3, that was the top of the safeguarding training?
DODD: Yes, and in actual fact you can actually do Level 4 training, but I didn't at that time.
BROWN: In terms of how practically that happened, was that in-person training or online training?
DODD: No, so at that time it was all face to face.
BROWN: Can you recall when that was delivered and whether -- how often you would have updates of that training?
DODD: You have to have updates regularly and it was delivered regularly and actually as part of the safeguarding team I used to deliver the Level 3 safeguarding training as well at that time.
BROWN: When you say "regularly", how often are we speaking about?
DODD: Level 3 training is -- in that kind of role you would be expected to update every year.
BROWN: You said you were delivering the training?
DODD: I would deliver training as well, yes.
BROWN: Were you receiving training every year as well?
DODD: Yes.
BROWN: Who was giving you that training?
DODD: The -- my colleagues from the safeguarding team but also at that time from what was then called the LSCB, Local Safeguarding Children's Board, we would be expected to attend relevant training delivered by the Local Safeguarding Children's Board as well.
BROWN: When you are talking about your colleagues, specifically who was --
DODD: Within the safeguarding training where I worked we delivered the training as part of the safeguarding team.
BROWN: Who specifically was training you, do you recall?
DODD: Do you want names, or?
LADY JUSTICE THIRLWALL: Yes, please.
MS BROWN: Yes.
DODD: At that time in my team there was Satwinder Lotay, Jill Cooper, Karen Pygott, Steve Lee, there was a whole team of us.
BROWN: Was there anybody who was working at the Countess of Chester who was giving you safeguarding training?
DODD: No, nobody at all. We were completely separate. Cheshire and Wirral Partnership Trust deliver their own training, Countess of Chester deliver their own training, so there was no overlap in training.
BROWN: Within that training, and I am talking then about the training you were receiving but also the training you were giving, do you recall any training making reference to cases such as Beverley Allitt or Harold Shipman?
DODD: Absolutely. Actually, as part of delivery of training we would include relevant serious case reviews and relevant information that we would impart to people that we were training. But also we would be receiving that training from other areas, certainly the LSCBs to deliver a lot of training around, you know, serious case
reviews that were relevant.
BROWN: You say "serious case reviews", but very specifically were you trained and referred to the case of Beverley Allitt?
DODD: Absolutely, yes.
BROWN: So were you familiar -- maybe not with the number of the recommendation, but were you familiar with the recommendation of the Clothier Inquiry into Beverley Allitt that all those caring for children should be aware of the possibility of malevolent intervention as a cause of unexplained clinical events?
DODD: Yes.
BROWN: That was something that you were familiar with as a concept?
DODD: We were familiar with, yes.
BROWN: In your Child Death Overview Panel role, you were looking at the full range of causes of death of children: natural, accidental and deliberate harm?
DODD: Yes.
BROWN: I think you have probably given the answer but just to confirm was deliberate harm by a healthcare professional something that was alert to you as a possibility?
DODD: Yes.
BROWN: Just looking at how your role was divided,
I think your time was split and you worked four days a week as a paediatric liaison role; is that correct?
DODD: That's correct, yes.
BROWN: Very briefly, what did that aspect of your role involve?
DODD: The paediatric development role was developed as a result of the Victoria Climbié Inquiry many years ago and it stated at that time, amongst other things, that district general hospitals should have a paediatric liaison health visitor who would be the conduit between the hospital and the community in order to relay any relevant information around children's attendances. So that was the main thrust of the role that I would be looking at, A&E attendances, Accident & Emergency attendances for children under the age of 18 and giving some level of scrutiny to those attendances. And also within our Trust we also looked at children who potentially might have life threatening illnesses or long-term illnesses that might benefit from additional support within the community and therefore we would be relaying that information as well. So any child on the children's ward who may have a new diagnosis, say, of a malignancy we would be relaying that information quite quickly to their community practitioner so that they were aware of that
and could support the family more robustly.
BROWN: When you are talking about liaison there, the hospital you are talking about here is the Countess of Chester?
DODD: Countess of Chester but also regionally. So, for example, if a child attended an A&E department in, say, Devon, they would send me the information around that child's attendance and likewise if we had a child in the Countess of Chester who lived in Devon, for example, we would send it to them.
BROWN: Yes. Then turning to the one day a week that you were worked as a Child Death Overview Panel nurse. Did that division then, the four day/one day division, did that remain the same from 2010 to 2019 when you were in that role?
DODD: More or less. Some -- some weeks you would actually be doing more of one than the other but they did overlap quite nicely because of the -- being a conduit between the hospital and the -- and the community actually was quite -- quite seamless in that respect.
BROWN: The Child Death Overview Panel was a minority aspect of your role, was it?
DODD: It could -- it could be, but some weeks you might be doing more of that than paediatric liaison. It would just depend on what was actually happening at that time, so if there was a Rapid Review Meeting, for example, for a child death then you would prioritise that.
BROWN: Just so that we can understand the set-up, the Child Death Overview Panel that you sat on was the Pan-Cheshire Child Death Overview Panel?
DODD: That's correct.
BROWN: That covered four areas: Cheshire East Cheshire West and Chester, Halton and Warrington?
DODD: That's correct.
BROWN: They were the four areas. That Pan Cheshire Child Death Overview Panel was chaired by Hayley Frame?
DODD: At that time.
BROWN: At 2015/2016?
DODD: Yes, during that time I sat on the panel I think there were three or four independent chairs but at that time, yes, I think Hayley Frame.
BROWN: At that panel, when the panel sat, each of the four areas would be represented by a specialist nurse and you were the nurse for the Cheshire West and Chester area?
DODD: That's actually not quite true because not every area had a specialist nurse. So Warrington didn't
always have a specialist nurse but they did have a specialist nurse employed at some point during the time I sat on the panel and Halton didn't have a specialist nurse.
BROWN: But when you sat you were sitting specifically in relation to Cheshire West and Chester?
DODD: That's correct.
BROWN: Also on the panel there were designated doctors from different areas?
DODD: That's correct.
BROWN: Dr Mittal was the doctor from the Countess of Chester?
DODD: That's correct.
BROWN: As well on the panel there were local authority representatives?
DODD: Yes.
BROWN: And also police who sat on that panel?
DODD: Yes.
BROWN: One of the police members was Detective Superintendent Wenham?
DODD: That's correct.
BROWN: The panel, when they reviewed child deaths, they would meet quarterly; is that approximately right from your recollection?
DODD: More or less quarterly, yes.
BROWN: In terms of what the Child Death Overview Panel were doing, they were not determining the cause of death because that was for the Coroner or the doctor who signed the medical certificate?
DODD: That's correct, that's right.
BROWN: The Child Death Overview Panel sat and considered a case once all the other processes had happened so after an Inquest or after an investigation and then the Child Death Overview Panel came at the end of that process?
DODD: That's correct and it could actually be quite some time after the, the -- you know the child had sadly passed away, it wasn't always very quick.
BROWN: Just looking at the specific role that the Child Death Overview Panel was doing. That was set out in the Working Together policy and I think you refer to this in paragraph 9 of your statement.
DODD: Yes.
BROWN: But what the Working Together policy says is part of the role of the CDOP, the Child Death Overview Panel, was doing was to learn lessons to prevent further deaths and to identify any wider public health or safety concerns arising from a death or from a pattern of deaths?
DODD: That's correct.
BROWN: I think in your statement, you helpfully paraphrase it and you say it involves establishing and you refer particularly to any emerging patterns of death?
DODD: That's correct.
BROWN: Now in addition to sitting on the panel when that sat approximately quarterly with the other representatives we have spoken about including the local authority and the police, you say in paragraph 11 your role was to disseminate learning and provide training depending on what was identified in the panel. Who were you disseminating that learning to, who fell within your remit of people you were giving training to?
DODD: Because I was employed by Cheshire and Wirral Partnership Trust my -- my learning would be very definitely disbursed within Cheshire and Wirral Partnership Trust. However, because we were a Pan Cheshire panel, we would have wider training days and we would actually have conferences where anybody could attend who worked in that locality and, you know, multi-agency, multi professionals and we did actually have a few conferences where it was open for people to attend. It didn't matter what your role was but you could attend those panel -- those training events.
BROWN: So obviously we are concerned particularly with staff at the Countess of Chester. Would they be people that you would be disseminating your learning to or be attending those conferences --
DODD: I wouldn't specifically disseminate learning to the Countess of Chester but I would support Dr Mittal. If he wanted to do some training sessions then I would support him. But he would be responsible for disseminating learning in the Countess of Chester.
BROWN: Can you just give an indication of one or two of the sort of training or learning you are talking about here so we are talking in actual real events?
DODD: Some -- some of the training packages were about completing forms accurately and well so that the panel could actually review the case robustly really because there was there were in the beginning people didn't really fill in forms terribly well. So there was definitely learning needing to be disseminated around that so that we could actually review the deaths better. Because sometimes in the early days we didn't have electronic forms so people would have a paper copy and maybe just tick a box, there would be no sort of real dialogue in there. So some of the training involved completing forms, the relevance of completing forms and the purpose of
completing the forms, really, which I don't really think in the early days of CDOP panels people properly understood because --
BROWN: Sorry --
DODD: Go on.
BROWN: You mentioned speaking to Dr Mittal?
DODD: Yes.
BROWN: Can you recall any of the training that you did in conjunction with him?
DODD: He would be part of all of the training packages, particularly the ones where we did a whole day of training and we one of them specifically we did around bereavement as well, he was involved with that. He was involved with disseminating the information about the Form Bs. I do recall him spending an hour or so in the A&E department one morning at the handover for the doctors to actually discuss the actual whole child death protocol with them so that they fully understood it. I don't know what he did specifically in the Countess but I also did some training with him around the neonatal unit much later around --
BROWN: When you say "much later", when are we talking --
DODD: Probably about the end of 2017, I can't remember the date specifically -- I could probably go
back and look but I can't remember the specific dates without looking -- around the use of the SUDiC protocol because it had been identified by the CDOP panel that the SUDiC protocol was not always used correctly in hospitals.
BROWN: We will come to the SUDiC in a moment. But that -- you recall there being training that you and Dr Mittal did to improve that?
DODD: We did.
BROWN: At paragraph 12 you talk about the administrative aspects of your role as a Child Death Overview Panel nurse?
DODD: Mm-hm.
BROWN: And focusing specifically on deaths on the neonatal ward at the Countess of Chester. I just want to go through the stages of how the notification and the forms operated. Now, in very broad overview, and correct me if I get this wrong, Form A was the form that set out the details that the death occurred, that was the initial notification form?
DODD: Form A was the initial notification form and it was actually quite brief.
BROWN: Following Form A, Form B was then the form that would be filled out about the relevant
circumstances of the death and in the case of a neonatal death that would be predominantly by midwifes, obstetricians and the neonatal doctors?
DODD: Yes. The Form Bs from my perspective would be completed by health professionals. The Form Bs would also be completed by other relevant professionals, so they might also be completed by the police, they might also be completed by social care or education but my role was specifically around the Form Bs being completed by health professionals.
BROWN: Then the form C was what was filled in after the panel had considered the case?
DODD: That's right.
BROWN: I am just going to ask some questions as to how that operated in practice and to understand that process I think it's important and if you can confirm that the Child Death Overview Panel who would consider a case that was dependent on where the family lived, not where death occurred?
DODD: That's correct.
BROWN: Wales had a similar system but that was referred to as the Child Death Review. You may not be familiar with that?
DODD: Sorry, say that again?
BROWN: Wales had a similar system where Child Death Overview Panels, it was the Child Death Review?
DODD: Yes, I think Wales was actually called PRUDIC.
BROWN: I think that was for sudden death?
DODD: Yes.
BROWN: But in terms of the CDOP equivalent?
DODD: I -- I can't comment on that because I never had anything to do with --
LADY JUSTICE THIRLWALL: There is no need for you to --
DODD: -- the process in Wales.
LADY JUSTICE THIRLWALL: -- do that.
MS BROWN: We are going to go through now, Ms Dodd, the notifications that you received in this case and if I could just remind you not to refer to the actual areas that parents lived in, so we will use the terminology of parents living within the catchment area of the Pan Cheshire panel or outside the catchment area.
DODD: (Nods)
BROWN: So regarding first Form A. How would that in fact how would that information receive you, would it be emailed or --
DODD: At that time --
BROWN: -- sent to you?
DODD: -- it wasn't always by email. We had a lot of paper, unfortunately, still in 2015/2016. Now it would
all be electronic. But at that point it could be paper. But it might actually be a phone call. So sometimes if a child had died, for example in Alder Hey, they may ring me and say this is -- this child has sadly died and I would fill in a handwritten Form A but they would then forward theirs.
BROWN: We will come to that in moment but I think that is what happened in fact in relation to Baby A [Child A]?
DODD: It is indeed, yes.
BROWN: Would all deaths, all neonatal deaths that occurred at the Countess of Chester, always be referred to you in the first instance; regardless of where that child lived, would they always come to you in the first instance?
DODD: They might not come to any -- in the first instance they might have gone to Dr Mittal. He was the designated doctor for safeguarding and child death so he may have received the information before me. I would be the conduit to inform community practitioners, the LSCB and the designated nurses and my senior managers.
BROWN: So as the conduit, even if it was Dr Mittal who was informed first you were -- you were the central funnel; it would always come via you?
DODD: I would get those Form As, yes.
BROWN: So if there was a death in the neonatal unit,
you would be informed of it?
DODD: The Form As would come to me yes, that's correct.
BROWN: So going through now the specific babies that were on the indictment and that this Inquiry are concerned with, and this is paragraph 29 of your statement, it may be helpful if you have that in front of you?
DODD: Mm-hm.
BROWN: Baby A [Child A] we see as you have just alluded to, that in that case you were notified of the death by a nurse and you in fact completed the form?
DODD: That's correct. She then did send it to me afterwards.
BROWN: Then you subsequently received a completed Form B and then that was sent on to the Pan Cheshire Child Death Overview Panel because Baby A [Child A] did live in catchment?
DODD: That's correct.
BROWN: I think it would be helpful if we just look at these forms so we can see actually how this was operating. So if I could turn to INQ00001942 [INQ0001942]. My Lady, this is tab 7 at your bundle?
LADY JUSTICE THIRLWALL: Thank you.
MS BROWN: So we are going to have on the form here
in a moment what is Form B in relation to Child-A. And we can see there at the top we have got Child-A, in fact when that's been added as a redaction for the purposes of this Inquiry, but there would have been a number there so it was anonymised?
DODD: There would have been a number because when you reviewed the deaths at panel they were completely anonymous so nobody had an idea who that child was or where they were from.
BROWN: And working down that form, and this of course is the Form B that was subsequently sent to the Child Death Overview Panel we know on 4 August, we see where was the child at the time of the event in the middle of the form and that's marked as the neonatal unit, and then we see further down the circumstances of the death, and we see that the midwifery did fill in a section some of that's been removed because of sensitivities. Then HV, so that is the health visitor, and if we turn over the page, we can see no additional information is available, health visitor didn't have an involvement sadly with the baby had died in the hospital. Then the GP, again not aware of any immediate circumstances leading to the death but sets out some of the maternal history and then really the substance of the form is filled out by the hospital as one would expect with the neonatal death and they set out the circumstances and then there is a summary of the hospital report?
DODD: (Nods)
BROWN: Ensuring that that information was complete, that in a sense was a key part of your role, was it?
DODD: I would send out, as it's documented in Working Together that the designated person would actually send out those Form Bs and will identify who they should go to from the CDOP panel so the CDOP administrator would often send them out they would come back to me to make sure they were all completed and then the whole package would be then sent to CDOP. So we would resend the Form A and the Form B to ensure that the CDOP administrator actually had all the information that we could possibly give her. I didn't analyse the forms because they are not my information, so I would ensure that the people that had been sent them had returned them and if they didn't return them in a timely manner, we would chase them up.
BROWN: Then you would send it either on to the Child Death Overview Panel of the Pan Cheshire, if that was a within catchment baby, or to the relevant area if it was a without catchment?
DODD: That's correct.
BROWN: The form goes on to list -- we don't need to go to all the pages but it goes on to list details, for example family details such as siblings, the service provision, so whether for example the police had been involved, whether in certain cases a hospice would be involved and then maybe we could look at page 6, because you have referred to the bereavement services. We can see there is a section on bereavement services and that would be filled in and also to consider whether that was a positive or a negative experience so that was another section of the form?
DODD: That's right.
BROWN: Yes, that can go down now, thank you. We have seen and if we can turn to an email, this is INQ 0103110. I'm not sure if we have that on the system. We do. So this is an email, Ms Dodd, you have been shown this but you weren't copied into this email?
DODD: No.
BROWN: But I am taking you to it just because it does refer to you and it's an email exchange between Dr Mittal and Dr Gibbs with some other people copied in and it's discussing the filling out of the Form B and the essence of the email is that Dr Gibbs is saying we have all this information elsewhere, we have already
filled it in on other forms, can we simply forward that information to you as CDOP rather than filling in yet another form and I think we see from Mr Mittal that he had spoken to you and we have agreed we will not ask the paediatrician to complete Form Bs for cases where a postmortem has been requested, we will instead use the information from the dictated letter?
DODD: That's right.
BROWN: That was a practice you adopted?
DODD: Occasionally, yes, because the -- we would find that that information as Dr Gibbs had identified was duplicated. It's a lot of work for the paediatricians -- well, for anybody to complete the Form Bs, they really do need to be robust. So actually if they were completing a referral for a postmortem or for a discharge letter, for example, which may go even to the parents, there would be a lot, a lot of information in those referrals or letters and we would -- we did discuss that at CDOP panel and actually agreed that some of those letters actually had a lot more information in them than what some paediatricians would put in the Form Bs. So we agreed that they could be used in those circumstances and so what would then happen is they quite often used to go straight to CDOP, actually, very
often they didn't come to me, and they would be considered at panel, when we reviewed that child, all together.
BROWN: We can take that down now, thank you. At this point, so just the dates, so this was the end of September 2015 --
DODD: (Nods).
BROWN: -- that Dr Mittal is recording the fact that he had discussed with you about these forms. What was your relationship with -- your working relationship with Dr Mittal? How often would you be communicating with him?
DODD: I -- I would say that my working relationship with Dr Mittal was good. He would let me know if -- if things were going on. He would let me know of child deaths if he knew before I did, vice versa. I used to see him at all of the CDOP panels. I didn't see him on day-to-day basis by any means, I might see him once or twice a month maybe but yes, I would say that we did have a good working relationship.
BROWN: On this occasion, so in about September he's been discussing with you forms. Did Dr Mittal then in September -- we know now that by that stage there had been four neonatal deaths within a very short period, within a two-month period, in fact three of those deaths within an even shorter period. Did Dr Mittal discuss that with you, discuss concerns about the increased mortality or concerns about the number of deaths on the neonatal ward?
DODD: He didn't discuss any concerns as -- as I recall. We may have discussed that there were three or four neonatal deaths but we didn't discuss that there were any concerns around those deaths and certainly the information that I received didn't alert me to any concerns around those deaths and I do think he would have said so at the time. I do -- I would have expected him to and I would -- I would have thought he would have done.
BROWN: If we can go back, then, to page 6 of your statement, going through the receipt of forms. So we have looked at [Baby A]'s Form B and [Baby A] was communicated to you by phone and Form A completed and in due course Form B. Baby C [Child C], the Form A was completed and sent to you but that baby was out of catchment area, so those forms were sent to a different panel?
DODD: Yes.
BROWN: And Baby D [Child D] likewise didn't -- you were
informed but that was a baby that was out of area, out of catchment, so that wasn't dealt with by your CDOP panel?
DODD: No.
BROWN: Baby E [Child E], again you were informed the combined forms were sent and you forwarded those on accordingly?
DODD: Mm-hm.
BROWN: Baby I [Child I], like Baby A [Child A] was a within catchment baby, so Form A you say was completed, Form Bs were completed and they were sent to the panel on 26 November?
DODD: Mm-hm.
BROWN: Then Baby O [Child O] and Baby P [Child P], were you informed, were you the conduit for those?
DODD: No, I wasn't. I -- I don't know why I didn't, I wasn't informed about those. It may have been that I was on annual leave or it may have been that I was doing something completely different and my senior named nurse Jill Cooper dealt with those. I didn't have anything to do with them.
BROWN: So you personally didn't deal with those?
DODD: No.
BROWN: But they went through the same conduit?
DODD: They will have gone through the same system, yes, because my colleagues would have covered my role if
I wasn't there and indeed anybody within our safeguarding team could have done that.
BROWN: If we can go then to paragraph 20 of your statement. You say there and I am just going to read that out: "I kept a log of all forms received for the purpose of my role with CDOP whilst at CWP [Cheshire and Wirral Partnership] and as a result I became aware of 19 neonatal deaths between June 2015 and June 2016. Of those neonatal deaths, I was informed that 13 neonates died at the Countess of Chester Hospital neonatal unit." We have seen on the form that would be something that would be shown the place of death. Two died at the Countess of Chester labour ward, two neonates died at Arrowe Park neonatal unit, one neonate died at Liverpool Women's Hospital NNU and one died at Claire House Hospice in Wirral. So you were keeping a log?
DODD: (Nods)
BROWN: And that's a significant number of deaths, 13, and perhaps particularly significant set against the fact that just two neonatal deaths in Arrowe Park and one neonatal death in Liverpool Women's Hospital. You had been in the role since 2010. Had you ever seen that number of neonatal deaths coming from one unit
before?
DODD: No, there was definitely an increase and we actually did discuss that. We -- we as a safeguarding team we were responsible for providing an annual report and we actually did note it in the annual report as well and we made sure that the LSCB and the designated nurses were aware of that but unfortunately none of the --
BROWN: Just going back to that, so we can just take it in stages. When did you discuss it, when were you discussing the concern?
DODD: I think we have got the date in here actually that we discussed it with the Commissioners.
BROWN: Well, we discuss it much later, we will come to a meeting in March --
DODD: Yes, several months later --
BROWN: That was the one you are referring to the documents?
DODD: Yes.
BROWN: But not earlier than that?
DODD: Not that early on. I mean, I think the timescale was quite broad and certainly as well it spanned over two financial years which potentially may have made us not look at it quite as robustly as maybe we could have done at that time.
BROWN: What was the significance of a financial year when you had 13 deaths?
DODD: Because we will have kept our spreadsheets for in a financial year sort of format, if that makes sense.
BROWN: Well --
DODD: So we will have gone from 1 April until 31 March one year and then the 1 April until 31 March the next year and so CDOP would certainly count those if all of those baby deaths had been reviewed at CDOP they would all have been counted.
BROWN: Just -- just pausing there for a moment. So we have understood that they weren't all reviewed by the same panel because of the catchment area issue. But as far as you were aware, you had a list of 13 neonatal deaths?
DODD: Yes, we did.
BROWN: We have gone through the fact that the Child Death Overview Panel was there, one of its purposes was to spot a pattern. This was a pattern, wasn't it?
DODD: It -- it without question yes, and certainly with the benefit of hindsight you can look back and say yes, this was very alarming. At the time there was nothing to indicate to us that there was a concern and certainly nobody ever said to me that there was anything to be worried about on the
neonatal unit. Nobody ever mentioned that until much, much later on.
BROWN: Well, just looking at that a moment. The Child Death Overview Panel, because it was there to look at patterns, and because you have identified you as the conduit were the person who could identify that pattern you have identified it?
DODD: (Nods)
BROWN: Why were you not then referring that on in June 2016 or at some point before that once you started to become aware of a pattern as it built four then five deaths, and so on? Why were you not referring that, at that point, to the Child Death Overview Panel or to someone?
DODD: That's a very good question and I can't -- I can't say why we didn't do that at the time. I do know that part of the issue was that they didn't all live in our local area and therefore maybe we didn't see quite as robust a pattern as we potentially could have done. I think it's very difficult to answer that question for what we did at that time. I think now we would definitely act differently, I think every child death now would be referred to our CDOP panel. At the time that wasn't the process and I don't know why potentially
it wasn't. We did discuss the child deaths with Paula Wedd, who was one of the senior Commissioners, with Dr Mittal because she was questioning as well why we hadn't picked up something and actually we said --
LADY JUSTICE THIRLWALL: When was that?
DODD: I --we have got the date here.
LADY JUSTICE THIRLWALL: You are being asked at the moment about --
DODD: Yes, I know but 16 March 2017, it was.
LADY JUSTICE THIRLWALL: So that is quite a bit later.
DODD: Yes.
LADY JUSTICE THIRLWALL: But I think what you are being asked about is you kept a log of all the forms and you became aware of those 19 deaths?
DODD: That's correct, yes.
LADY JUSTICE THIRLWALL: I think that is the timescale I was asking you about, so if you can help us about that?
DODD: I -- we didn't have any indication that there was anything to be concerned about. The information that we had was that the babies were -- many of them pre-term, many of them unwell, many of them unfortunately quite sick. We didn't have any indication
that --
MS BROWN: Just pausing there a moment, Ms Dodd. You just explained that the Form Bs that came in with the details, that that was that something that you considered or was that something that you sent on for consideration?
DODD: We sent them on for consideration. It wasn't my role to analyse the Form Bs.
BROWN: You have been referring to "we" as being aware? You were the conduit and they came to you?
DODD: Mm-hm.
BROWN: Who else was aware of this log that you were keeping? Who else would have been aware of that log?
DODD: My managers, the designated nurse for safeguarding.
BROWN: Can you give names where possible?
DODD: Anne Eccles was at that time the designated nurse for safeguarding. She would have been aware of every single death, the LSCB would have been aware of every single death. Sian Jones, we used to copy her into every -- every single death.
BROWN: Would Hayley Frame as the Chair of the CDOP panel, would she have been aware of what was on your log?
DODD: No, she wouldn't have been, because that was -- the reason I kept -- we kept a spreadsheet log was purely to -- well, to understand who we were dealing with but also to manage the Form Bs so that we actually had a timeframe for the Form Bs to come back to us. So if they hadn't come back we would actually have a sort of a way of managing those because otherwise there is no way that you could possibly keep track of all the requests that you had ever made for all of the Form Bs. So we used to manage that -- we used to manage that spreadsheet purely so that we knew if we had a Form A we now if there was going to be a serious -- a Rapid Review Meeting, we knew who may have been invited, we knew who we had sent the Form Bs to and when we expected them back so that we could follow them up.
BROWN: Did you, once you had observed this as you have accepted I think pattern and the list -- the growing list of numbers, did you -- was that something you debated with Dr Mittal at any point?
DODD: We did discuss can with Dr Mittal, yes, and it was --
BROWN: In March 2017, but we are talking about in 2016?
DODD: I don't recall discussing a cluster of deaths with him. I don't -- I may -- I think we may have said
oh, not another neonatal death or something like that. But we never ever had the information that there was any concerns. So all of the Form As that we received didn't alert us to any concerns.
BROWN: They alerted you [to] a pattern but you say not to a concern.
DODD: Yes, and I think at the time because they didn't alert us to concerns, they didn't alert us to a pattern, if you see what I mean.
BROWN: Well --
DODD: I know that there was a number of deaths but we didn't see an emerging sort of pattern of deaths.
BROWN: Can we go forward then to September 2016 when you are interviewed by the RCPCH and this is INQ0014605 and that's tab 9, my Lady, in your bundle. So what's going to come up on screen here are the notes that were made by Sue Eardley of the RCPCH and this was an interview she had with you on 2 September 2016 and we can see your name -- sorry have we got the right -- sorry, it's page 19 of that document. We can see your name "Sharon" and your role "Paediatric Liaison CDOP Pan-Cheshire". Then I think the interview it seems starts with discussing your liaison role and in fact towards the end we see with the
exclamation marks: "Brilliant role ... Sharon has developed the role. Really good system, health visitors will call Sharon about any worries." That is what you started off your evidence with explaining the liaison role you did with the hospital and the community in terms of any concerns relating to children. Then if we could go over the page it seems then the interview turns to look more in relation to your CDOP, the Child Death Overview Panel, role and it says there four lines down: "Although nurse for CDOP, not good system for child death." You then go on to talk about bereavement support. Can you recall what you were referring to there when you are saying "not a good system for child death"?
DODD: This, this meeting was really brief, really brief and what they were asking me about specifically was my paediatric liaison role and I actually informed them about the CDOP role. They didn't ask me about it, I informed them. And so they basically were just asking me what the -- what sort of -- what I did about it.
BROWN: And what do you think, when you say "not a good system" do you think you said that and if you
did, what did you think was not a good system at the panel?
DODD: Not a good system for child death. I don't know what that, I really -- I don't know why they have said that, I --
BROWN: Did you at the time have reservations at all about the CDOP system?
DODD: I don't know what that really refers to, to be honest: "Although nurse for CDOP, not good system for child death. She doesn't do it but gets school nurse and health visitor to do that." I honestly don't know what that means.
BROWN: Did you though at the time have concerns about the CDOP system that you might have been referring to?
DODD: No, I don't think so. I -- I don't know what that -- I honestly can tell you now I don't know what that refers to. I don't know what it means. It is very sort of -- it doesn't have any context to it, does it?
BROWN: You go on to talk about bereavement. Just very briefly, what was your view of the bereavement services at the time in relation specifically to parents who had a child who died on the neonatal ward?
DODD: I personally don't think that the bereavement services at that time were very good and we really, really tried within the CDOP process to improve bereavement services and we developed partnerships with some other agencies, particularly Alder Hey. We just didn't have --
BROWN: When was that, when were these partnerships being developed?
DODD: Was it what, sorry?
BROWN: What timing are we talking about? You said you developed partnerships, when was that?
DODD: It was throughout the time that I was on the CDOP panel really and we actually did have -- we did go to Alder Hey to one of their bereavement panel -- one of their bereavement training sessions so that we could try and replicate it. We just we don't have specific bereavement services and we rely on charitable or other organisations to do that. Our community teams will visit families and offer support and we -- you know, if we have a child that dies in a -- you know an educational age, then I know that the Sky team will now provide help and support and signposting for schools, but at that time the bereavement services in my view at that time were not as good as they potentially could have been.
LADY JUSTICE THIRLWALL: Do you think that might be what that note is about?
DODD: I don't know, maybe that potentially is, yes. It doesn't make sense to me that sentence and I never got the minutes for this meeting and only saw -- I only saw the completed report months afterwards. And I literally was in and out of that meeting honestly in about five minutes.
MS BROWN: Because you go on to talk about bereavement so it's possible, is it, that what you felt was not a good system was related to the bereavement or maybe you can't assist.
DODD: Possibly, yes.
BROWN: And if we go on then at the bottom of that page you talk about the Form A and B explain Form A arriving quickly and then information on Form B is robust. Then there is an entry "across Cheshire", an upward arrow, so increase in number of deaths April 15 to 16.
DODD: Mm-hm.
BROWN: Then if we could go over the page: "Neonates seem to have had higher than average but none congenital abnormalities." This is you informing the RCPCH?
DODD: Yes.
BROWN: What did you understand the RCPCH review was doing?
DODD: I thought that I knew that the hospital had had an internal Inquiry because CDOP had been informed about that.
BROWN: What was that Inquiry?
DODD: Around the cluster of deaths and my understanding was that the review was on the back of that.
BROWN: So you are being interviewed about the cluster of deaths and you are saying --
DODD: I was being interviewed.
BROWN: Higher than average?
DODD: I was being interviewed at that time about the paediatric liaison role. That is what they asked me to attend for. They didn't ask me to attend in my CDOP role but I told them about it.
BROWN: And looking then just further down that note, having spoken about the higher than average neonatal deaths, you say they could speak to Hayley Frame, so you are referring them to speak to her if they wish?
DODD: Yes, because I think they -- I think I indicated to them that -- that the deaths wouldn't have been reviewed at panel at the time. So that the panel may have had the Form A and Form Bs but the deaths may not have been reviewed at panel and therefore that may be why I suggested to her that she spoke to
Hayley Frame.
BROWN: We see then down the note: "CDOP not worried nor is Sharon." Do you think, looking back now, you should have been worried at that point by the number of neonatal deaths?
DODD: I don't think I would ever have said that, that I wasn't worried, I -- I really don't think I would have said those words and I don't know why that's been documented. I -- I -- I never -- I had never saw the minutes for this meeting until I had them for the Inquiry.
BROWN: Did the meeting and fact that the RCPCH were looking at a cluster of deaths and you are being interviewed and you end up discussing CDOP, did that not act as an alert to you that maybe this is something that CDOP should be looking at because there was a pattern here and it was worrying?
DODD: Absolutely and it did get discussed at CDOP.
BROWN: But not until March and this was September?
DODD: I can't -- I honestly can't remember the dates that we did discuss things at CDOP without -- without looking at the actual CDOP minutes specifically but potentially not. But, again, even this, even the Royal College review didn't -- nobody ever said to me: we are very worried about these deaths, would you not be worried about them? Nobody ever said anything about being concerned about events on the neonatal unit.
BROWN: Then going down on that as well, it seems then there was a discussion about unexplained, we see are: "Any CDOP neonatal deaths unexplained?" Then there is reference to the Pan Cheshire SUDiC protocol. There is a comment: "Will look back and see what were UE [it is not clear whether that is unexpected or unexplained] from Form As." Is that a reference to you going back to see if some of those deaths were unexplained or unexpected?
DODD: I would imagine that must be what it meant. But it's just -- there's no context to the -- to the minutes, are there? I -- I assume these are the -- the only minutes that they have got.
BROWN: These are just the notes from --
DODD: Yes.
BROWN: -- Sue Eardley.
DODD: Because at the time, I didn't see them, I wasn't given them and only saw them when you sent them to me.
LADY JUSTICE THIRLWALL: Honestly, we do understand
that point.
DODD: Yes.
LADY JUSTICE THIRLWALL: I think they were in manuscript as well then have been typed up.
DODD: So it's very difficult looking at this now to say what these minutes actually completely meant. We can make assumptions, but I don't think we can --
LADY JUSTICE THIRLWALL: But I think you probably did say you would go back and see what were --
DODD: I potentially did.
LADY JUSTICE THIRLWALL: That looks likely, yes.
DODD: And I probably did, actually, I probably would have done because that's sort of person that I am, I would go and check something, I would robustly look at something.
MS BROWN: Do you think you would have reported back to the panel about this interview and the concerns that now are not only on your log but we are now -- you are now also aware that the RCPCH are carrying out a review in the hospital of the cluster of deaths?
DODD: I potentially might have spoken to Dr Mittal about it and actually said to him, you know, is there anything we should be concerned about? Is there anything going on? He never ever indicated to me that there was and he
never ever indicated at panel meetings either that there was.
BROWN: If we can just go to then see what the actual report said?
DODD: Yes.
BROWN: So if we could go to INQ 0009618 at page 21, so this is an extract --
DODD: Of the actual report, yes.
BROWN: -- from the RCPCH review, the October 2016 final copy confidential version. We see that they address -- it will come up in a moment -- the child death process. It says there in relation to unexpected -- under the heading "Child Death Process": "Where an unexpected paediatric death occurs the paediatrician contacts the senior investigating officer for neonates. The designated doctor is notified. He is responsible for advising Pan Cheshire Child Death Overview Panel." So that's Dr Mittal --
DODD: Yes.
BROWN: -- advising the Child Death Overview Panel whether the deaths are expected or unexpected. Was that operating in practice?
DODD: It should do, yes.
BROWN: Did it in fact operate in practice as far as you were aware?
DODD: I don't ever recall him having any concerns and saying anything. In actual fact, I don't know whether Dr Mittal was directly informed by the paediatricians of every unexpected death. I can't answer for him. That is the process and that is what should have happened or should happen. I don't know whether in reality it did because unfortunately these -- you know, the neonatal deaths occurred in the Countess. Dr Mittal worked in the Countess, I didn't.
BROWN: Then if we can go down, we see at 4.4.25: "The RCPCH Review Team was concerned that CDOP did not appear to be alert to the cluster of neonatal deaths and for at least some there should have been a Rapid Response Meeting for notification." Then: "In their recommendation CDOP should consider whether its processes could have detected the cluster of deaths and initiated external review more swiftly." Now, Ms Dodd, you were aware of the cluster of neonatal deaths. Do you think -- do you accept that that an external review should have been initiated more swiftly as a result of that knowledge of the cluster?
DODD: Absolutely. Looking back now, absolutely.
BROWN: There is also mention there in that report of the unexpected notification Rapid Response Meeting where there was an unexpected death. Turning to SUDiC, were you familiar with the SUDiC protocol?
DODD: Yes.
BROWN: What was your understanding as to whether the SUDiC process applied to the death of a neonatal baby born in hospital? Who died unexpectedly?
DODD: Well, it would apply.
BROWN: You were clear about that and throughout the period of 2015 to 2016 as far as you are aware there was an unexpected death in hospital, the SUDiC process should have been initiated?
DODD: Absolutely. The SUDiC protocol at that time was documented by the then LSCB. It was clear. It was quite a lengthy document and I understand that, you know, if you were on any kind of department or A&E it might -- you might need to spend some time looking through it. However, the actual process was clear. There was a flowchart which people could easily follow.
BROWN: If we can look now to a meeting that happened then on 16 September, so this was a panel meeting that happened shortly after your interview with the RCPCH, so at this stage you are aware of the number of deaths on
the neonatal unit, you are aware that the RCPCH are conducting a review and you have had this discussion with them?
DODD: (Nods)
BROWN: Now, that's INQ00178115. Now, in fact, Ms Dodd, this was -- we will see the attendance log -- a meeting that in fact you didn't attend, you were absent for this meeting. But I just want to look, so we see your name there a few lines down and we can see that you were absent at that meeting, if one works along. But this was chaired by Hayley Frame, we can see the other attendees where there is an R next to a name so for example Nigel Wenham is there with an "R". Does that mean they attended remotely or does R mean something else?
DODD: No, we wouldn't have anybody attending remotely there. He might have been a representative for somebody else.
BROWN: R means they --
DODD: He may have been representing Serena Kennedy.
BROWN: So "R" means you were there but you were representing someone else?
DODD: I think some of the minutes do actually document what those abbreviations stand for.
BROWN: Yes. Designated rep, you are quite right. On the following page, if we can go then to page 2 just to see what was discussed, because at that under review of children's cases, the second action point there is that you closed a case there and that's relations to Child-I?
DODD: Mm-hm.
BROWN: And it says the child case referred to once the College report is presented by Dr Mittal?
DODD: (Nods)
BROWN: Was it unusual that a case was being closed when the RCPCH report hadn't been received?
DODD: No, it would -- normally we wouldn't close cases until absolutely everything was received.
BROWN: Right.
DODD: And actually what we would do if we didn't think we had everything, we would refer back and get that information.
BROWN: You weren't at this meeting?
DODD: No.
BROWN: So we have to ask other people about that. But it also then says action item to be added to the November meeting, subsequent meeting to consider that unexpected deaths in hospitals should be referred for RR meeting, so Rapid Response Meetings?
DODD: Mm-hm.
BROWN: Do you think that action came up because the RCPCH had been asking you about whether -- whether the SUDiC system had been followed, whether there were Rapid Response or SUDiC protocols being followed, do you think you referred that to the panel?
DODD: It -- it may have been that or it may have been that Dr Mittal actually highlighted that -- the same sort of issue. I can't -- can't comment on which one it was, but I would assume it was either of those, yes.
BROWN: If we can then go to a panel meeting that you were at and this is the one you have referred to a number of times, the one in March, so that's INQ0012008. So just to situate that in the timeframe, this clearly is quite a few months after the RCPCH have interviewed you?
DODD: (Nods)
BROWN: We see in terms of attendees we have got Hayley Frame who's chairing it, you are attending, we have -- I can't see now but, yes, Dr Mittal, and Nigel Wenham who are all at this meeting and if we can then turn to page 3. We see there that at this point, in March, it does seem that there is a concern about the trends. It says: "The meeting discussed in depth the death, the geographical area the children lived and the CDOP processes and what could be done within the CDOP process to ensure that trends can be or should be identified by the Pan Cheshire panel." So I think it's at this meeting, is it, that they are recognising that the trends hadn't been picked up?
DODD: Yes.
BROWN: They make the point that the panel itself wouldn't have been seized of this but as we have discussed, there was an awareness of the number but the panel would only have been discussing the deaths within their areas. It said going down: "... Gill Frame asked can the CDOP be improved, suggested this Form A could be amended, a place of residence as well as a place of death would be collated." But in fact all the Form A material was already being collated by you, wasn't it, so although it was being pushed out to other areas, the Form A material --
DODD: We did have a log of them, yes.
BROWN: It goes on to say so they discussed the trends and the fact they hadn't been identified. At that meeting, did anybody raise the issue of
Letby?
DODD: No.
BROWN: At this point, were you aware of allegations or concerns about Nurse Letby?
DODD: I wasn't aware about the allegations about Lucy Letby for quite some time. In fact, it was when the media were at the hospital, that was the first time I heard her name ever mentioned.
BROWN: So the first time you heard the name was after the police were involved?
DODD: Yes.
BROWN: Did anyone discuss at this meeting -- we have seen who were the attendees, did anyone discuss concerns that a nurse or a healthcare professional might be involved?
DODD: No.
BROWN: Having spotted at this stage, we have spoken about your awareness earlier, but in terms of a panel discussion at this stage discussing a trend, and we have talked about the training you had had in relation to Beverley Allitt, did anyone say: one of the areas we should look at is whether a healthcare professional might be involved?
DODD: No, they didn't. And I -- I think that was as I say probably borne out of the information that we
received, which didn't ever indicate that there was a concern and only indicated that the babies that we were informed about were very sick.
BROWN: Then looking, looking a bit further down, because there's -- one concern is -- is the trend that's clearly was discussed, or the failure to spot the trend and then it talks about the SUDI, Sudden Unexpected Death in Infancy and Childhood, it says: "The panel discussed SUDI deaths within hospital and whether it was felt that deaths were not always treated with the same concern. If there was a concern over the death a SUDI protocol could be followed." I mean, it's not whether there was a concern, it's when it was unexpected, the SUDiC process?
DODD: It should have been followed, absolutely.
BROWN: It seems to be saying there that there was a concern that that wasn't happening, is that your recollection of the meeting?
DODD: Yes, that's right.
BROWN: Knowing that the SUDiC procedure hadn't been followed, did that cause anyone to think: we very much need to look at this pattern because if that process hasn't been followed, the checks and balances that should follow an unexpected death are absent?
DODD: I -- I think at the time we were concerned
that the SUDiC wasn't followed because of lack of knowledge and lack of education primarily and it was after that that we did do some training around use of the SUDiC protocol. I don't know why the SUDiC protocol wasn't followed because I would have thought that the paediatricians who were -- who were, you know, certifying a death or whatever it would be classed as should have spoken to Dr Mittal because he was the -- the designated doctor for safeguarding and child deaths and so he was the one who potentially could have said: you need to do a -- you need to follow the SUDiC protocol and have a Rapid Response Meeting.
BROWN: Was it any part of your role if you saw the word "unexpected" or "unexplained" death, was it any part of your role to check whether SUDiC processes were followed or not?
DODD: I would have spoken to Dr Mittal about that. There was some -- some areas in their SUDiC protocols actually have a clause that say something around if a child dies in hospital and they have previously been unwell, that you may not need to impose the SUDiC protocol but in Cheshire West that wasn't the case. Our SUDiC protocol, the LSCB SUDiC protocol in Pan Cheshire did specify that an unexpected death in hospital should be -- should be followed, you should follow the SUDiC protocol.
BROWN: So although you weren't reviewing the Form Bs for the content, so to speak, as opposed to whether they were completed if you saw that alerted you to unexpected or unexplained you would have said?
DODD: I would have said to Dr Mittal what's -- you know, do we need to have a Rapid Review Meeting for this baby? You would have done without question. We had done that before. There was -- there were times where there was some confusion around unexpected or an unexpected death, not especially for the neonatal unit but just talking generally and we would discuss it and we would have, you know, that kind of dialogue between professionals and certainly it wasn't something that wasn't discussed generally.
BROWN: Do you recall raising whether SUDiC had been properly followed in relation to any of the indictment babies, any of the babies' forms we have looked through?
DODD: I think at that meeting we probably had quite a long discussion around this. I mean, it doesn't indicate how long the time is that this discussion went on for, but I suspect that we would have actually said what did the Form As say.
BROWN: Because at that point, the realisation had
occurred to the Child Death Overview Panel, had it, that --
DODD: Something was going.
BROWN: -- their process to spot patterns had failed?
DODD: It -- it had and actually even I -- I don't know even if we would have sent every single Form A to Pan-Cheshire, I don't know whether the trend would have been noticed from a little while because of the timeframe of child death reviews. It's a difficult question to answer that.
BROWN: Let's just follow through what happened to Child-A because as well as these concerns about the trend and about the SUDiC process not being followed, this meeting actually looked at Child-A because by the time -- this time the other investigations, the Coroner's process had ended. So if we could go to page 11, we have the short summary of the cases that were considered and we have got Child-A, so page 10, there and we see cause of death at the top: "unascertained" and at the bottom: "Form C completed. Case closed. Unexpected death." So there's an acknowledgement there by the panel having considered it's unascertained and unexpected and yet there was no SUDiC process for A and neither was one
initiated here. Do you know why that was?
DODD: No. I can, I -- I -- I don't know why that would be. I can only assume that at the time the paediatrician who certified the death must have made no indication that it was completely unexpected. It would appear just reading that that maybe they had put on the Form A that the child was unwell prior to that, not -- not expected to die.
BROWN: But having just had a panel discussion that SUDiC wasn't being followed, having come to a conclusion that it wasn't, wasn't that the point to say: we need to now refer it?
DODD: Yes, you would think that -- that we should review that back, we absolutely should have done.
BROWN: And if we can just go on just to complete the picture to INQ 0001944, so this is the -- we look finally at Form C, so this is the end of A. So we had Form B where the information was sent and there was obviously a long -- Child-A was one of the cases where there was a long pause before you came to consider it, you were considering it now it was considered on 24 March and we see case summary there and that in fact is just in fact copy pasted, it's from the Form B, it's the summary from Form B. If we could go then to page 3, we see "Panel
discussion". The case had been delayed coming to panel, part of the neonatal review at the Countess of Chester. However, the outcome of the review did not find any issues with the death. The Coroner has given a verdict of unascertained and therefore the panel agreed the case could be closed. Again, this was not ringing alarm bells at this stage?
DODD: I think potentially it may not have running alarm bells at that time. I mean, it's a difficult thing to look back but this will have been quite a long discussion. The -- the cases will have been presented by a paediatrician. The way that the panels worked was that if it was a neonatal death, for example, it would be one of the paediatricians who presented the case to panel and went through the Form As and the Form Bs and they will have -- my guess now is that some of the information from the Countess review would have also been available at that time and I suspect that the reason we didn't go back with that case to question the unexpected death was because it had been through that review process. And as it clearly says on here that they didn't find any issues with the death and so we have clearly concurred with them having looked at the Form As and the Form Bs with the information that was available at that time.
BROWN: If we could just go on to page 5 then which is the final page of that form, we see how the Child Death Overview classified this death because -- and clearly the categorisation was important because that's also part of spotting patterns --
DODD: (Nods)
BROWN: -- to get the correct classifications and we see there that it has been classified as a perinatal neonatal Event 8?
DODD: And that would have --
BROWN: Why was it not 10, sudden unexpected, unexplained death?
DODD: That will have been because of the information that we had received. So if the information we had received on the Form A and Form Bs had not said "Sudden Unexpected Death", then that's not how it would have been -- and the actual CDOP had to categorise the death as the highest category that it was at the time.
BROWN: Well, we don't need to flick back, but the review we have just looked at --
DODD: I know it does actually say "unexpected death".
BROWN: Unascertained and unexpected?
DODD: I don't -- I can't answer why at that point as
a panel of 12, 15 people we came up with that. I -- I can't answer that. The only thing I can think is that it was discussed in detail, it would have been presented by a paediatrician, we would have looked at the Royal College information as well, we would have scrutinised the Form As and the Form Bs and that would have been the reason for the categorisation. But I understand what you are saying. And I understand that potentially it could have been 10. I think that the guidance for categorisation comes with whether is highest. So I assume that at the time having reviewed all the information, that was what we categorised it as because it was the highest category.
BROWN: Of course the category is significant because if it's been identified as a SUDiC, then there was the SUDiC process, which would have potentially involved the police.
DODD: Yes.
BROWN: So --
DODD: But the SUDiC process should have been long before the CDOP panel, it would not have been afterwards. The SUDiC process should actually be implemented at the time of death and that child death reviewed at a joint meeting with the police, with social
care, with everybody, usually within 48 hours of the death. So that doesn't happen after the CDOP panel. Because the CDOP panel meeting might be -- it could even be a year, it could be a long time, especially if there is going to be an Inquest, it could be a very long time after death.
BROWN: So the situation is, isn't it, Ms Dodd, that the CDOP panel at no point during this process either spotted a pattern or referred any of these the deaths that they were specifically considering Child-A or Child-I to the SUDiC process?
DODD: They wouldn't have done it at that point because the SUDiC process should have been implemented as soon as the child died. So doing it that far down the line is, is probably -- it may still be valuable, actually. When you think about it like that, it may still be valuable, but it's --
BROWN: Well, it may be valuable but at this point, the police hadn't become involved?
DODD: No and actually -- so I guess the police are there at the SUDiC -- at the CDOP panel meetings, the police are aware of -- of those deaths. It is a multi-agency meeting which is discussed in a multi-agency, a multi-professional way. So it's not down to one person to say what's happened, it's down to
that whole group of people.
MS BROWN: Yes, I have no further questions.
LADY JUSTICE THIRLWALL: Are there any other questions?
MS BROWN: I believe there are no questions from the Core Participants.
LADY JUSTICE THIRLWALL: No, very well. There was just one thing. Just one question, if I may, Ms Dodd, and it was going back to your discussions with Dr Mittal quite early on when you were at sort of three or four deaths and you say that "we may have discussed that there were three or four deaths", but I just wondered: do you have any memory of what you would have been discussing and why you would have even been discussing it?
DODD: I think -- well, I -- we did work very closely together.
LADY JUSTICE THIRLWALL: Yes.
DODD: And obviously we would be meeting for the CDOP panel meetings and within the hospital -- the hospital's small.
LADY JUSTICE THIRLWALL: Yes.
DODD: And, you know, any child death is devastating but actually to have three or four on our neonatal unit -- well, I say "our" neonatal unit, it's not mine, generically speaking. It would be tragic. And so I would probably say to him: oh you know, Rajiv, what's happening? You know, it's really sad, you know another -- another baby has died and that would probably be the context of the conversation. It wouldn't be a scrutiny from my part at that point.
LADY JUSTICE THIRLWALL: No.
DODD: I think it would probably just be that we are acknowledging that we have got some very sick babies and it's tragic that we have lost another one.
LADY JUSTICE THIRLWALL: Just stepping back now and doing the best that you can, I appreciate the looking back is always very difficult and putting yourself back. But you mentioned knowing about Beverley Allitt and the recommendation of the Clothier Inquiry?
DODD: Mm-hm.
LADY JUSTICE THIRLWALL: Have you ever been in a situation where it actually has come into your mind that maybe something's going on?
DODD: In my whole nursing career, I -- I don't think so. I have occasionally worked with people where I have thought their competence could be improved.
LADY JUSTICE THIRLWALL: Sure, yes.
DODD: And may have discussed that with my manager or
their supervisor. Even at the time of this -- of this time, I don't think at the time we ever thought that anybody could be doing something like that and --
LADY JUSTICE THIRLWALL: No, it is rather why I was asking if it ever occurred to you.
DODD: I think really that was also sort of supported by the fact that the information we received didn't indicate that there were any concerns. So whilst we had a lot of neonatal deaths, none of the information that we immediately received or we immediately had to hand gave us any indication that there was anything wrong and certainly nobody ever spoke about it, nobody ever said.
LADY JUSTICE THIRLWALL: You mentioned that and I absolutely understand --
DODD: Yes.
LADY JUSTICE THIRLWALL: -- what you say about that I was just wondering if there were any circumstances in which you ever thought the thing that may be unthinkable.
DODD: I have -- I have been aware of it but I have never thought about that in my -- there's never been a situation in my career where I have been seriously worried about a practitioner --
LADY JUSTICE THIRLWALL: Yes.
DODD: -- who may be causing harm.
LADY JUSTICE THIRLWALL: All right. That is very helpful.
DODD: Yes, I can't think -- as I say, I would -- there might be some competence issue, there might be something that would alert me to an issue with a practitioner that I might actually go to my manager or go to their manager and raise that, but I have never, ever thought that somebody is doing something unthinkable in an area that might have been working at that particular time.
LADY JUSTICE THIRLWALL: All right. Thank you very much indeed, Ms Dodd. Do you have any other questions?
MS BROWN: No.
LADY JUSTICE THIRLWALL: No. Well, then I am happy to say, firstly, that we will take the break and come back at 25 to 12 and, secondly, that you are -- thank you very much for coming to give your evidence and you are free to go.
DODD: Thank you.
(11.18 am) (A short break)
(11.35 am)
LADY JUSTICE THIRLWALL: Mr De La Poer.
MR DE LA POER: My Lady, our next witness is Ms Hayley Frame and I wonder if she might come forward, please.
MS HAYLEY FRAME (sworn)
LADY JUSTICE THIRLWALL: Thank you very much, do sit down.
MR DE LA POER: Please could you give us your full name?
FRAME: Hayley Frame.
DE LA POER: Ms Frame, is it right that you provided to the Inquiry a witness statement dated 30 June of this year?
FRAME: Yes.
DE LA POER: Is the content of that witness statement true to the best of your knowledge and belief?
FRAME: Yes.
DE LA POER: By way of your background, did you qualify as a social worker in 1995?
FRAME: That's true.
DE LA POER: Between 1995 and 2008, did you work in local authority children's social care?
FRAME: Yes.
DE LA POER: Were you predominantly working in child protection or safeguarding?
FRAME: Yes.
DE LA POER: Between 2008 to 2011, were you the child death manager for Nottingham City Local Safeguarding Children Board?
FRAME: I was.
DE LA POER: As part of that role, did you develop the Child Death Review process in that area?
FRAME: Yes.
DE LA POER: Pausing there for a moment. In that role, how did you find the cross-boundary working, by which I mean the areas surrounding that and the liaison between theirs and yours?
FRAME: Nottingham City is a unitary authority and then in terms of the cross-border, cross-authority it's with Nottinghamshire County Council, so the two councils work very closely together across the whole safeguarding agenda, they have joint safeguarding procedures. When the requirement in 2008 was made for there to be the Child Death Review process, it was agreed that there would need to be very close working between Nottingham City and Nottinghamshire County Council because most of the deaths would have occurred in the city because that's where the hospital was, the larger teaching hospital. So the -- all of the procedures were agreed jointly. Even deaths that occurred outside of the Nottingham City area would be referred into the
Nottingham City CDOP and we met jointly as a cross-authority CDOP twice yearly. We also looked at annual Thematic Reviews of neonatal deaths.
DE LA POER: In 2011, did you begin work as an independent Consultant?
FRAME: Yes, I was self-employed for 11 years.
DE LA POER: As an independent Consultant, were you appointed to be the independent chair of the Pan-Cheshire Child Death Oversight Panel in 2015?
FRAME: Yes.
DE LA POER: What you say in your witness statement was that your experience in Nottingham was key to that appointment?
FRAME: Yes, and when I became self-employed in 2011, the bulk of my work that I was completing during that period of time was I was the independent reviewer for serious case reviews, domestic homicide reviews and safeguarding adult reviews and I was also the independent reviewer for drug-related deaths in Nottingham City. So it wasn't just around the child death manager post that I had previously, it was in terms of my work in the reviewing of death and learning lessons and those statutory review processes. So that -- that was my experience that I took when
I went to interview for the independent chair role. I was also at that period of time providing expert witness assessments in Family Courts. So I suppose the point that I am -- I am stressing is that the independent chair role was one of many roles that I had during that period of time. It wasn't a full time job, it was chairing of meetings.
DE LA POER: How many hours per week or per month were you spending as the independent chair of the Pan-Cheshire CDOP?
FRAME: When I first was recruited to that role there was a very large backlog of child deaths that hadn't been through the process, the CDOP process, going back years. So it was agreed that we would meet, it was quarterly was the frequency of the meetings, but it was agreed that we would meet every other month to try and clear some of the backlog.
DE LA POER: So you have a meeting every other month. Outside of that meeting, how much time were you devoting to it, did you have an allocation of time or was it as the job required?
FRAME: As the job required. It was mainly, you know agreeing agenda setting, signing off of minutes, any actions that arose from the meeting that were assigned to me.
DE LA POER: Presumably scrutinising materials before a meeting took place?
FRAME: Yes.
DE LA POER: Are you able to give us any estimate of the approximate number of hours outside of meetings that you were spending on a weekly or monthly basis?
FRAME: A day a month would probably be a fair estimate.
DE LA POER: You have told us about the backlog and we will come back to that in a moment. But bearing in mind what you have reported to be a very positive experience in Nottingham about the cross-border cross-boundary working relationships, how did you find the Pan-Cheshire CDOP cross-boundary cross-border working relationships?
FRAME: Well, I suppose by virtue of the fact it was the Pan-Cheshire CDOP so that was four LSCB areas coming together, that was to recognise the fact that in isolation the numbers of Child deaths would be so small that it would be very difficult to identify any patterns and trends from such a small cohort and also a number of the statutory services worked across those boundary areas so that is why the Pan Cheshire came together from the four LSCB areas. In terms of liaison outside of that, there was the North West -- I'm sorry, my memory escapes me, I am sure I refer to it in my statement. I never attended the meeting which is why I am probably not remembering.
DE LA POER: North West regional?
FRAME: Yes, thank you. So that -- that was in place. We didn't -- at that point the requirements under Working Together to Safeguard Children had changed so whereas when I worked in Nottingham there was an expectation that you would be -- the CDOP would be notified of all deaths in that area, regardless of home address. That changed. So in the Pan-Cheshire CDOP we were only notified of deaths of children whose parents were resident in that area. So any child that would have been outside of the CDOP -- Pan-Cheshire CDOP boundary we wouldn't have been notified of. So there was minimal liaison.
DE LA POER: Well, bearing in mind that change, doesn't that change reinforce the need for very strong communication to surrounding areas?
FRAME: Yes.
DE LA POER: Was that something that as chair, you focused upon or tried to develop in any way over the time that you were chair?
FRAME: No. And I -- the reason for that was that when I was appointed as the independent chair it was because there was a significant amount of work to do to
get the CDOP to be fit for purpose in many ways. That was around -- a lot of that was around the backlog. The child death co-ordinator had only just started in post, there was a lot of work that needed to be done in terms of Terms of Reference, attendance, that -- there were certain things that the CDOP or the Child Death Review process didn't do. So, for example, it was well known from the outset that they weren't compliant in terms of Rapid Response arrangements at that point.
DE LA POER: Just pause there. Is that under the SUDiC process when you say Rapid Response?
FRAME: Yes, yes, I think -- I think the terminologies changed. I haven't worked in the field of child deaths since 2017 so I think it's like a joint response, Isn't it.
DE LA POER: It is the Joint Agency Response, JAR?
FRAME: Yes. Back then it was called a Rapid Response. The profile of the CDOP the quality of the information being submitted on the Form Bs, there was a lot of work that needed to be done to just try and get it up to speed. The CDOP didn't review deaths of babies less than 23 weeks, even if they had taken a breath, which again wasn't compliant with the statutory guidance.
So there was a lot of work to do to correct those processes internally before thinking wider than that.
DE LA POER: When you say the Rapid Review process wasn't being instituted, was that across all sudden unexpected child deaths, so in the community, in hospital or were there particular pockets or areas that didn't seem to be triggering that process?
FRAME: It was the issue around home visits. So the Rapid Response process is that the -- a relevant health professional, preferably a Consultant paediatrician, would do a joint visit with the police following an unexpected death.
DE LA POER: If I can just stop you there. You will appreciate the Inquiry's particular focus is upon hospitals?
FRAME: Yes.
DE LA POER: So I hear what you say about where -- where that identified problem area was. Can I invite you to consider whether the issue about SUDiC and hospital deaths was that an issue that you perceived as existing when you took over as chair?
FRAME: No, not when I took over, no, obviously there were discussions in relation to that into some of the panels that I chaired but no, not at the point that I took over.
DE LA POER: What was your understanding about whether or not there was a need for a Rapid Response Meeting under the SUDiC protocol if a baby was born in hospital and died on the neonatal unit?
FRAME: If death was unexpected, then the same process applies. We had had these discussions in my previous role in Nottingham and we agreed that it would need to be looked at on a case-by-case basis and be a proportionate response, but that the process would still be followed nonetheless.
DE LA POER: So would that mean that as a very minimum that for every Sudden and Unexpected Death the designated doctor would be notified of that?
FRAME: Yes, yes.
DE LA POER: And is it at that point that you were envisaging that there would be a discussion about whether or not that Rapid Response Meeting involving the other agencies should occur?
FRAME: Yes.
DE LA POER: Now, we have already had explained to us the purpose of the Child Death Overview Panel. Can I just invite you to consider this in summary: was one of its main functions to look for trends or patterns?
FRAME: Yes.
DE LA POER: In the two years that you were chair, were there any -- and you don't need to list them, but were there any trends or patterns identified by the Child Death Overview Panel?
FRAME: Not specifically in relation to neonatal deaths, no. We had a campaign around safe sleeping, we had lots of discussions around maternal smoking and obesity, so there -- definitely we were identifying some learning. But there wasn't -- it was very difficult in terms of like identifying trends because we were dealing with a backlog as well so we weren't reviewing the deaths in a timely way. So that obviously skews the data as well.
DE LA POER: The fact that you were dealing with that backlog and the confusion that that might lead to or the uncertainty that might do, did that require quite a systematic approach where you started to populate things on a year-by-year basis so that you could make sure that you were getting a clear view of deaths in context?
FRAME: I had to do a quarterly report, a quarterly chair's report which included the performance data.
DE LA POER: But if I can just stop you there. I am not just asking about reporting on the deaths that you were considering in that quarter but about putting those deaths into their proper context so that if they had
been -- taken 18 months to come through, that you were looking back to that earlier period to consider whether that death, at that time, formed part of a pattern; do you see?
FRAME: Yes, I do.
DE LA POER: Do you see what I am saying?
FRAME: I do.
DE LA POER: Yes, and did that process occur?
FRAME: No, it didn't.
DE LA POER: Bearing in mind the obvious challenge of clearing a backlog, do you think on reflection that should have been something that was occurring as an additional part of the process of clearing the backlog?
FRAME: Yes, I think that the driver was to just try and at least be -- there are statutory timescales in terms of the length of time it should take to review a death, and some of these deaths were like two years or more, so that the driver was to really try and get on top of it so that we could concentrate on the new notifications and complete those in a timely way. There was, there wasn't -- there was no -- there wasn't an action log in place, for example. So when a child death was reviewed and there might be actions there was no mechanism to actually track those. So that
was another thing that I brought into place.
DE LA POER: In terms of the drivers that you have spoken about, to clear the backlog?
FRAME: Yes.
DE LA POER: Just looking back on it reflectively, do you think there's any possibility that during the period that you were chair, there was perhaps too much focus on clearing the backlog so you could have a clean start and do it properly as you would want to as opposed to perhaps being as systematic as should have been the case with each of the backlog?
FRAME: I believe that we still reviewed each death with the amount of attention that it needed, based on the information that CDOP was provided with. So it wasn't like it was rushed, hence why we increased the frequency of meetings. But I suppose it did mean that the number of neonatal deaths was higher that we were reviewing as a CDOP because neonatal deaths fall into the greater category, the largest category anyway and so that would have felt like we were reviewing a lot of neonatal deaths and one of the things -- I am sure it's in one of the annual reports that I wrote -- talking about doing a Thematic Review, learning from what had happened in my previous roles in Nottingham and we also looked at the
modifiable factors of -- I can't remember which year it was, it might have been 13/14, we looked at all of the modifiable factors in terms of the actions relating to those to see what -- so the "so what" question: what happened? We made these recommendations as a CDOP and what action was taken to try and evidence the learning.
DE LA POER: Bearing in mind that the panel's function was to look for trends or patterns --
FRAME: Mm-hm.
DE LA POER: -- was it necessary for concerns to be raised as part of the forms being filled in or did the panel also have a function to stand back and say: well, there are perhaps too many deaths in this area compared to our expectation, so in other words the raw data itself rather than the detail of each case, was that something the panel was concerned with?
FRAME: The panel received that -- that data as part of my quarterly reports, so that had -- it had that data there in terms of the number of deaths reviewed. At no point were there any concerns raised in terms of clusters or -- or any patterns, no.
DE LA POER: But a cluster might be self-evident if you get a large number of deaths. Even if in the case of any given one of them, there is no specific concern raised, provided the panel is sighted on all of the deaths in that cluster, might that be something that the panel notices and says we have had a surprising number of deaths?
FRAME: Yes.
DE LA POER: That in itself is something that we need to investigate?
FRAME: Yes, if they were notified of them all, absolutely.
DE LA POER: So in other words you are not solely reliant upon people raising individual concerns, you do have a step back and look at the overall --
FRAME: Yes.
DE LA POER: -- picture --
FRAME: Yes.
DE LA POER: -- role. Now, a point you make a couple of times in your witness statement is that because of the way that the panel system was working at that time, not all of the deaths from the neonatal unit during the period we are focused on were deaths that the panel was scrutinising?
FRAME: Yes, that's right.
DE LA POER: We know that in fact it is only Child-A and Child-I who were the subject of a panel meeting?
FRAME: Mm-hm.
DE LA POER: The Inquiry has heard evidence from
Sharon Dodd this morning about the fact that all the Form As, regardless of whether or not the child ultimately was considered by the panel, passed through her hands, I think the exception being Child-O and Child-P, and that she kept a log or a tally. Now, her evidence was that she didn't tell you about that. Do you have any recollection at all about those Form As and any tally being kept or record?
FRAME: No.
DE LA POER: Is that something that you should have been told about, do you think?
FRAME: I think it's difficult, isn't it, because there was no longer the statutory requirement for the CDOP that covers the area where a child died to be notified. I think if -- if the concern is that there's actually a spike, then absolutely, then the CDOP should have had that discussion and I should have been notified. But there wasn't -- there wasn't a framework for that information to be routinely passed to the CDOP.
DE LA POER: In terms of your awareness of when there was -- that there had been an unexpected increase in the number of deaths on the Countess of Chester neonatal unit, when do you believe that was?
FRAME: Because I -- because I was self-employed
I didn't have, like, agency records, I haven't had anything to go back to. So I have been trying to think about this and obviously reading through the documents that I have been sent, because there was mention of the review when we were considering one of those two children because there was a discussion around that child being part of the cohort of children that were subject to the review. So that must have been the first time I knew about it, thinking about it.
DE LA POER: So if I can just help you with that, that's a meeting that took place on 16 September and we are going to look at the detail of that meeting?
FRAME: Okay, so that must be the first mention so -- I think. So that must have been when I first became aware that there was going to be a review. To be honest, I am just putting myself in my own shoes back then, given that more Thematic Reviews of neonatal deaths were seen as in a positive way because often with neonatal deaths, especially in cases of extreme prematurity, there hadn't any modifiable factors, there isn't huge amounts of learning, it's entirely due to a child's prematurity, so to look at them thematically in a larger cohort, and I think probably that is what I thought was happening at that stage. And then I became aware -- I think it was around
the time that the report -- the report was going to be published because they had made recommendations in it for the CDOP, so there was email correspondence there before the meeting in March when we went through it, yes.
DE LA POER: Again we will come to that. But we will add some detail around your answers there very shortly. Before we get to that stage of the chronology, I would just like to take you, please, to an interview that Ms Dodd conducted, or was the subject of, with the RCPCH?
FRAME: Okay.
DE LA POER: You have seen these notes already as part of your preparation but we will bring them up, INQ0014605 and we will go to page 21, please. Now, Ms Dodd has given her best recollection of what these notes may mean or what she says about them so I am not going to ask you to interpret them, just to treat them on their face. Firstly, we can see five lines down a reference I think to you, it is a misspelling but as chair of the CDOP and it would appear that Ms Dodd has suggested that you could be spoken to. Do you think that the RCPCH, knowing what you do now, should have spoken to you as the chair of the CDOP?
FRAME: Yes, and I think I would go further than that. I think that the CDOP and the wider LSCB should have been part of the Terms of Reference. It's -- the fact that that review was done completely in isolation and not in a wider partnership arrangement doesn't make sense to me.
DE LA POER: Now, again, we have heard what Ms Dodd's evidence is about this so I am not going to repeat that. But "CDOP not worried", just treating that on its face. At this point, right at the beginning of September 2016, so before that meeting involving Child-I, was CDOP -- you, the chair of CDOP, aware of the increase in mortality?
FRAME: No. So I can only assume that's what that means, "CDOP not worried". Well, we didn't know we had anything to be worried about. That -- that's my assumption. It's strange that -- the way it's set out, could talk to me, but then it talks about "CDOP not worried" as though they are two quite separate things. So I don't understand that but that can be my only sort of assumption.
DE LA POER: All that you can say is that it is literally right that CDOP wasn't worried but the reason for that is you didn't know?
FRAME: Yes.
DE LA POER: Thank you very much indeed. We can take that down. Just casting your mind back, did you know that Ms Dodd, who wasn't in fact interviewed in her capacity as her role on CDOP, but in fact an internal -- a paediatric liaison role that she had.
FRAME: Okay.
DE LA POER: Did you know that she had been interviewed by the RCPCH?
FRAME: I don't believe I did, no.
DE LA POER: Is that something that you should have been told as CDOP chair, do you think?
FRAME: Not necessarily. I suppose we were just awaiting the findings of the report. We weren't involved in the -- you know, the mechanisms of the review. As I say, you know, now thinking about that we perhaps should have been, but we weren't and there was nothing, no one had raised that there was any concern. So I suppose I didn't know that there was anything that needed to be scrutinised any further.
DE LA POER: Now, once Ms Dodd had been interviewed and it was plain that the RCPCH were there at the hospital investigating or conducting a review which arose out of an increase in the neonatal mortality rate, and it would appear that there was some discussion of CDOP, would you
have expected to have had a discussion following that with Ms Dodd so that she could tell you about the discussion that she had had and the fact that CDOP had come up?
FRAME: Yes, and we may well have done. I just can't, I can't recall that we did. I have not worked in the, in the field of -- of Child Death Review since 2017 so in many ways, you know, I -- I don't have the recollection of whether we did or whether we didn't and I don't have any agency records to go back to look to see if we had that conversation. I don't remember having a conversation with her.
DE LA POER: Because if a review is being conducted which encompasses a number of deaths, would it not be quite important for CDOP to know that so that there could be a very clear understanding about whether any particular death that has already passed through CDOP, whether that was subject to the review at any future death that is going to pass through?
FRAME: Yes, because thinking about it, you know, we perhaps should have shown more curiosity in terms of who are the children that are subject to this review and we didn't ask those questions. Whether I think we should have done, it's difficult with sort of hindsight bias, isn't it, because we didn't
know that there was any reason to ask those extra questions. But looking back now it would have been, yes, if we had would have been involved in the Terms of Reference, if we knew the children, how many had come through Pan Cheshire CDOP, how many had gone to other CDOPs, then absolutely, that would have been helpful.
DE LA POER: We will look now at the meeting on 16 September, INQ00178115 Now, against your name for this meeting there is an R which, if we go over the page, signifies designated rep?
FRAME: (Nods)
DE LA POER: Does that mean that you were representing somebody else or somebody else was representing you?
FRAME: Dr Mittal chaired in my absence, I wasn't present.
DE LA POER: I think we can see that from the next line just below. The fact that you weren't there, would you still have read the material ahead of the meeting?
FRAME: Yes, and agreed the agenda.
DE LA POER: Agreed the agenda?
FRAME: Mm-hm.
DE LA POER: Do you recall if you had any discussion with Dr Mittal ahead of the meeting given that he was representing you?
FRAME: I don't recall and I don't know why I wasn't there, if it had been -- if it was due to sickness and, you know, an urgent matter then probably not. But sometimes I couldn't attend because I was due to give evidence in court. So it -- I don't recall a conversation with him.
DE LA POER: Did you have a responsibility following the meeting even if you didn't attend to read the minutes and to understand what had happened?
FRAME: Yes.
DE LA POER: As chair if you were concerned about anything that you saw on the minutes, would it be your place to raise that and say: I just need to understand what happened at the meeting because I don't agree with it or I can't --
FRAME: Yes.
DE LA POER: I can't fathom it?
FRAME: Yes.
DE LA POER: Now, in section 3 on this first page, we can see Child-I's case was closed and: "The child details to be sent to the Coroner for review of case notes. The child case to be referred to once the Royal College report is presented by Dr Mittal."
Now, this case, as we will see on the Form C, was closed at this meeting, effectively as I understand it, meaning that the all of the data had been taken that needed to be taken for the Form C and that could then be entered on to the database for the pattern recognition; is that right?
FRAME: In part. And the reason I say that is because there were actions. So those actions would have then gone into the action log which was considered at every meeting. So the actions you would send to the Coroner for review of the case notes, that would have led to an action being logged on the action log. So although the case was closed, that should have been ongoing.
DE LA POER: What would you expect to happen? If the child's details were sent to the Coroner for review of case notes, what in practice was that going to lead to?
FRAME: I supposed -- just for assurance.
DE LA POER: So there was an expectation that the Coroner would receive that child's notes from CDOP regardless of whether they had otherwise seen anything about Child-I's case and review them and comment upon them?
FRAME: I assume so. It's difficult for me to -- I wasn't party to that discussion. But I assume that's what the thinking was.
DE LA POER: I mean, did you understand the Coroner to have an assurance role after a CDOP case was closed?
FRAME: No. We were -- we had worked quite hard on improving our relationships with the Coroner's office and we had representation -- I wonder if we did at that one. No -- yes, in attendance Christine Hurst. Without being present I don't know if there was a conversation between Dr Mittal and Christine about what the Coroner could do to help, I don't know. But I am assuming it would be for a review for assurance.
DE LA POER: What also seems clear from the face of the minutes, and in fact we know, is that the College hadn't issued its report which incorporated its consideration of the period that Child-I died during?
FRAME: Mm-hm.
DE LA POER: Do you think that in fact it was inappropriate to close Child-I's case whilst there was still a review that might shed some additional light which was ongoing?
FRAME: Yes.
DE LA POER: Because as we have understood it, CDOP, as in the panel meeting, represents the very end of the Child Death Review process?
FRAME: (Nods)
DE LA POER: And absolutely every investigation should have taken place and been resolved insofar as it could be by
the time that the panel closes the case; is that right?
FRAME: Yes, that's correct.
DE LA POER: So on the face of it, that isn't what happened here. Now, when you received these minutes, do you have a recollection of noting that point and wondering about it or having some curiosity about why a case has been closed in circumstances where firstly the Coroner appears to be looking at it, and the RCPCH still hasn't provided its report?
FRAME: I don't, I don't recall and I know that's not particularly helpful but I absolutely don't. But that -- that would have been of concern, that is of concern. So I would have hoped that I would have queried that. Without seeing the action log, I don't know what -- what happened as a result of that. But that would be unusual for the case to be closed and maybe I was assured by the action log, I don't know.
DE LA POER: It's unusual and sitting there now, although some time later, you don't have any recollection of having followed this up. Do you think that suggests that you probably didn't?
FRAME: I -- I don't know. If I didn't then I should have done.
DE LA POER: Page 5, please, we will see --
LADY JUSTICE THIRLWALL: Have you finished with this point, Mr De La Poer?
MR DE LA POER: Of course my Lady.
LADY JUSTICE THIRLWALL: Are you continuing with the same point?
MR DE LA POER: No.
LADY JUSTICE THIRLWALL: I wonder if I might ask something. I'm sorry, would you mind just putting that page back up again? I just want to ask a question for clarification. It's slightly odd to say -- if you look at the section 3 "Review of Children Cases", and then "3. Action: case deferred" and then we have "Action: closed case" rather than "case closed". And are you there looking at or are they there looking at a case which has been closed because it then says "child's details to be sent to Coroner" etc, etc and if we look further down "Action: closed", a different child "the CCG to be contacted to ensure that the RCA report" et cetera. Then the following one "closed case" "The conclusion of the Inquest report to be added to the Form C". What's not clear to me, having looked at them all while you are being asked about questions of the others, is what's being described there, information that's
going to be put into the files, where the cases have already been closed or do you always go closed and then add things to them?
FRAME: No. I think it's -- it's the case was closed. That was the --
LADY JUSTICE THIRLWALL: That was the action in that meeting?
FRAME: Yes, yes, close the case.
LADY JUSTICE THIRLWALL: So all of those cases --
FRAME: Yes.
LADY JUSTICE THIRLWALL: -- the cases were closed but with something else that has to be done?
FRAME: So it might be where there was information hadn't been put in the right form, so "the conclusion of the Inquest report to be added to the Form C". So that's obviously information that we had hadn't been input to the Form C.
LADY JUSTICE THIRLWALL: But when was that going to be done, after the case was closed or before the case was closed?
FRAME: Yes, so that would be what the CDOP administrator/co-ordinator would do.
LADY JUSTICE THIRLWALL: Would have done.
FRAME: In fact, yes, the actions -- those actions are for her.
LADY JUSTICE THIRLWALL: Just so I understand it, although a case was closed, in all of these examples further action was to be taken to complete the file in some way or another?
FRAME: Yes, there might still be actions, yes.
LADY JUSTICE THIRLWALL: Yes. Well, if Mr De La Poer wants to explore that any further obviously he will do, but that is sufficient for my purposes, thank you.
MR DE LA POER: My Lady, I certainly had in mind to ask Dr Mittal about that.
LADY JUSTICE THIRLWALL: Yes, I thought you might. Yes.
MR DE LA POER: Page 5, please, we will look at what is said about Child-I. We can see a little more detail about the Royal College. In fact it says in terms: "This child's death is subject to review at the Countess by the Royal College." So not just the period during which that child died, but that child's death itself?
FRAME: Mm-hm.
DE LA POER: Is that even greater cause for concern for you looking at this that it would appear that there is a direct investigation going on into that child's death
in circumstances where simultaneously the panel is closing the case?
FRAME: I suppose there's two -- two parts to that, isn't there? We didn't -- I didn't know as the Chair of the panel and it wasn't discussed within panel, so my assumption is that most panel members equally were unaware that there was a concern. So this child's death being subject to that review, given that there wasn't a concern about the review, probably meant that that didn't trigger any further discussion or scrutiny. However, the point is the same; that if a child's death is being subject to a parallel process, a review, then it shouldn't have been closed.
DE LA POER: We can see that there is an action which includes an item for: "The next panel meeting to discuss if unexpected deaths in hospital should be considered for an RR meetings, the child to be referred to once the Royal College report is presented by Dr Mittal"?
FRAME: Mm-hm.
DE LA POER: Now, you have told us that in your mind there should always be an initiation of the SUDiC process --
FRAME: Yes.
DE LA POER: -- in the event that the death is unexpected, even in a hospital. Does it surprise you that that appears to need to be a subject for discussion as opposed to: this is what the protocol is, we all just need to get on with it?
FRAME: I think seeing it in the context of even in unexpected deaths, the Rapid Response -- in the community, the Rapid Response process wasn't being followed. It just -- it just felt for me that there was so much that wasn't in place that should have been in place. You know, in other areas they will have a rota of on-call paediatricians so in the event of a -- you know, an unexpected death in the community or in hospital, that person will be contacted out of hours. That starts the process. There was lots of discussions and a business case put together with various different options for to be taken to the CCG, as was, around how we were going to meet that need within Pan-Cheshire because it was a funding issue. So there was so much that wasn't in place that should have been and was in other areas. So I suppose was I surprised that the Rapid Response process didn't happen for unexpected deaths in hospital? Probably not, because it wasn't happening robustly in the community
either. Well one, that, that element of a home visit, a joint home visit not being completed.
DE LA POER: Well, at all events it appears apparent from this record that in the context of Child-I's case there is a discussion about the SUDiC protocol and we will just briefly look at the Form C for Child-I, INQ0001946. We can see the start of the case summary has that word "Sudden"?
FRAME: Yes, yes.
DE LA POER: So on the face of it, a clue, would you agree, that this child's death ought to have been the subject of SUDiC?
FRAME: Yes.
DE LA POER: If we look at page 3, we can see under the issues identified the same terms which appear in the summary there about the RRM. Then finally if we go to page 5, I am just going to ask you a question that Ms Dodd was asked about, this tick box?
FRAME: It's wrongly categorised.
DE LA POER: Well, exactly so. Now I appreciate this isn't your meeting in the sense that you weren't there, but we have seen that there was plainly a discussion about RRM and sudden and unexpected, we can see the word "sudden" appears on the
face of it and item 10, do you agree, appears to fit that?
FRAME: Yes.
DE LA POER: Now, a point that Ms Dodd made and I seek your help on, if you look right at the top it says: "The classification is hierarchal. Where more than one category could reasonably be applied, the highest up the list should be marked."
FRAME: Yes.
DE LA POER: What was your understanding of how this form operated and how it was in a hierarchy and what was it trying to get at by ranking these different descriptors?
FRAME: Well, these were national descriptors and set out in that order. So that would have been Department of Health at the time, I suppose. When you look at it, it reads almost -- you start with what's potentially a safeguarding or a crime, don't you? It's deliberate inflicted injury, abuse or neglect. And then sort of go down in terms of moving more into conditions relating to the child. But if that was the case, if we were going from, you know, conditions related to the child, chronic medical conditions, cancer, up to trauma and inflicted, you would think that sudden and unexpected, unexplained death would be higher up, wouldn't you, because we don't
know why that child's died? It is always at the bottom and that doesn't really make a great deal of sense looking at it now. What Sharon said is right, absolutely, the highest up the list should be marked but it's the wrong category. It should be -- it should be 10.
DE LA POER: If one thinks about it in terms of the taking a step back role that CDOP had, lots of sudden, unexplained, unascertained deaths might be thought to be a major red flag; do you agree?
FRAME: If there were lots of them.
DE LA POER: If there were lots?
FRAME: Yes.
DE LA POER: But if consistently, as you point out, you are moving up the hierarchy because you might reasonably describe it as one higher up, you are going to miss that big picture because that -- that box 10 isn't going to be ticked in necessarily every case it could be?
FRAME: I suppose the other thing to remember, though, is by this point, because it is at the conclusion of the Child Death Review process, whether that was expected or unexpected death, we should know the cause of death so that's what this -- this -- this category is around. So you may have an unexpected death but the process itself, the Rapid Review process, has determined that it was due to infection or it was due to a chronic medical condition that people weren't aware of. So that -- that would be -- if you knew the cause you would then tick that box.
DE LA POER: Well --
FRAME: You wouldn't because every unexpected death, the purpose of the process is to establish the cause. So that might not be the case, you wouldn't tick that box for every single unexpected death.
DE LA POER: If I can just pause you there. In Child-I's case, at this time, there was a cause of death that was given, we have seen that in the form?
FRAME: Extreme prematurity was part of it, I think, wasn't it?
DE LA POER: Yes?
FRAME: Yes, so that would be why the panel will have lended themselves to 8.
DE LA POER: Thank you. We can take this down, we are going to move forward a few days to 26 September. And on this date, there was the Cheshire West Local Safeguarding Children's Board meeting and I believe you presented a draft CDOP annual report to that meeting, and I just want to ask you, please, about the circumstances before that meeting. These minutes were produced presumably within
a relatively short period of time of 16 September, was that the process?
FRAME: It -- it didn't take the administrator huge amounts of time to create the minutes, no.
DE LA POER: I suppose the question really comes down to this: would you have expected to have seen those minutes by the time you went to that safeguarding meeting?
FRAME: What's the time difference between the two meetings?
DE LA POER: We have got 10 days.
FRAME: Probably not.
DE LA POER: Probably not?
FRAME: No.
DE LA POER: So does it follow from that that you don't think that you would necessarily have been aware of what was said at the meeting you didn't attend about the Royal College report?
FRAME: Yes.
DE LA POER: In which case we can shortcut this. The draft report that you presented makes no mention --
FRAME: No.
DE LA POER: -- of an increase in mortality. Is the explanation for that based on what you have just told us that you at that point, 26 September of 2016, didn't know?
FRAME: I didn't know.
DE LA POER: I mean, had you known is that something that you would have included in the report?
FRAME: Probably not. Only as much as I would -- we would need more information and the annual report is talking about the previous year's performance as opposed to any current.
DE LA POER: Well it's 2015 to 16, the sudden unexpected increase in the neonatal mortality rate began in June 2015, so will have fallen within the period for your draft annual report?
FRAME: Had I known that then yes, it would have been included.
DE LA POER: Moving forward to 3 October. INQ0012781. Again we don't need to look at all of the detail of this because you have had an opportunity to refresh yourself and I would like it deal with it by way of summary. We can see that Ms Eardley has sent an email to -- presumably that is the CDOP general inbox that it's gone to? We don't see the whole of it there but --
FRAME: (Nods)
DE LA POER: -- it's not with your name on it?
FRAME: No, it's the inbox that Ann McKenzie had control over.
DE LA POER: And it is addressed to Ms McKenzie/you on the
face of it?
FRAME: Yes.
DE LA POER: And in that email, Ms Eardley points out that the RCPCH has been looking at the relatively high number of deaths during that period, June 15 to July 2016, and asking for you to share the CDOP report. Of course, that CDOP report doesn't make any mention of it because you didn't know anything about it?
FRAME: No.
DE LA POER: And also flagging in the second paragraph the need for a more systematic approach to neonatal deaths. We know that that turned out in the report as saying you need to follow the SUDiC protocol?
FRAME: (Nods)
DE LA POER: If we just go over the page to put the balance of the email in. And we can see there a little bit more information about what is effectively going to the SUDiC issue because it's about the definition of what is an unexpected death. And asking this question: how deeply the CDOP considers these deaths in terms of investigation recommendations given that many are unlikely to have a direct safeguarding element?
FRAME: Mm-hm.
DE LA POER: Flagging that there are 11 deaths which presumably at the time you would have recognised as being a significant number coming from the Countess of Chester?
FRAME: Yes. I don't believe I ever saw this email.
DE LA POER: We are going to come to that. But in terms of the face of it, that seems to be what Ms Eardley is asking about.
FRAME: Yes.
DE LA POER: If we go back up a page, we can see that Ms Eardley follows up on the 17th to the same inbox asking whether there is a chance to have a look at it and it also appears that she's telephoned because she says: I have also left a message. Now, that telephone number, is that just a generic inbox, mailbox?
FRAME: It would be the number for Ann McKenzie.
DE LA POER: And the following day, a response from Ms McKenzie talking about just one part of her email, namely the annual report, saying it hasn't been signed off yet, but not dealing with a number of other matters raised by Ms Eardley?
FRAME: No.
DE LA POER: Now, you have just said a moment ago that you don't believe you saw this email. Should you have been shown this email?
FRAME: Yes.
DE LA POER: And was that a satisfactory response that Ms Eardley received to all of issues that she was raising?
FRAME: No. It -- it just dealt with the annual report, didn't it, not the other issues.
DE LA POER: But we can see that one of the things that Ms Eardley is raising is the RCPCH's concern about the SUDiC process?
FRAME: (Nods)
DE LA POER: Well, we will see that theme developing?
FRAME: Yes.
DE LA POER: It was mentioned, as you will recall, in the 16 September meeting that you didn't attend. Let's move forward -- thank you, we can take that down -- to the meeting on 20 November, INQ0017817. As that's coming up, you will recall at the previous meeting they parked the SUDiC issue to this meeting, which is the one that follows?
FRAME: (Nods)
DE LA POER: We can see that you do attend this meeting towards the top right-hand corner. On page 2, some discussion about the SUDiC issue and it's headed specifically item 4 "SUDiC within hospital". "Should a Rapid Response Meeting be held each time
there is a Sudden Unexpected Death within a hospital? The meeting felt that the response should be on a case-by-case basis and the safeguarding doctor should be involved in the discussion with a designated doctor and a Rapid Response should be arranged if deemed appropriate. The meeting felt this process should be reflected in our procedures with clarification of best practice." So again, you talked about the other problems with the SUDiC process in the community but this appears to be a discussion focused upon SUDiC in hospitals?
FRAME: Mm-hm.
DE LA POER: Do you have a recollection of this discussion?
FRAME: I am just reading around it to see if it ... Yes, because I am sure we were talking about awaiting the Kennedy report and updating the procedures.
DE LA POER: The Kennedy report, being the updated RCPCH --
FRAME: Yes.
DE LA POER: -- guidance which came out in late 2016?
FRAME: '16, yes.
DE LA POER: But to your mind was there in fact on the existing guidance any doubt that at the very least the designated doctor should be contacted?
FRAME: No.
DE LA POER: There should be a proper discussion --
FRAME: Yes.
DE LA POER: -- about whether or not the Rapid Response Meeting needed to be convened?
FRAME: Yes.
LADY JUSTICE THIRLWALL: That sounds rather like what you described in Nottingham.
FRAME: Sorry?
LADY JUSTICE THIRLWALL: Is that rather like what you have described that you did in Nottingham?
FRAME: Yes.
LADY JUSTICE THIRLWALL: Yes.
MR DE LA POER: If we go back up the page just to the first page. We can see that Dr Mittal is present at this meeting.
FRAME: Mm-hm.
DE LA POER: Do you recall what his point of view was about the fact that effectively a discussion ought to take place with him for Chester every time there was a Sudden and Unexpected Death and that there should be a discussion about the Rapid Review Meeting?
FRAME: I don't recall what his views were in that meeting. But based on the -- based on the minutes of the discussion I would make, I would assume that he was in agreement with that.
DE LA POER: Now, at the previous meeting, the fact that there had been an increase in the number of deaths on the neonatal unit was flagged because there was reference to the Royal College report. I mean, at this meeting was there any discussion directly with Dr Mittal about well, what did you do during that spike? Were you involved? Did you talk about Rapid Review?
FRAME: I still don't think even at this stage that we knew that there was a -- that there was cause for concern. We were just waiting for the report and it did -- when I think back that probably was quite passive, we were waiting for this report, I suppose we trusted in the process that it had been, you know, obviously experts in the field would be completing this review and we were just waiting for that. So no, there weren't any the conversations took place after the -- after the report was received.
DE LA POER: Now, you have characterised that as being perhaps a bit passive and you have also made the point that there were no concerns flagged to you. But isn't a cluster in itself something that you should have been absolutely focused upon? So cluster that's taken place in your area, some of the babies that you are going to look at or have looked at form part of that cluster? Just help us to understand why it is that
you think that that wasn't something that was being discussed?
FRAME: Because the action was for there to be an independent review commissioned. So we were assured by that action. So -- and that that review would identify the cause of the cluster. So that's why we were waiting.
DE LA POER: So let's come to that report now. We can take that down. We know in early February 2017 what is called the dissemination copy of the Royal College report was published by the Countess. For your purpose you don't need to worry about the difference between the two versions that existed. Was that a report that you saw at the time that it was published or that was drawn to your attention?
FRAME: I saw I think I saw it around February time.
DE LA POER: Early 2017, that is when it was published, yes?
FRAME: Yes, because I remember -- I don't know if Ann had sent it to me but it was a really poorly scanned copy so then I went online to try and find it myself on the website and it was the same poorly scanned copy so yes, it had been published, not long after it had been published.
DE LA POER: INQ0001954, page 20. Now, we can see here
towards the second half of the page, firstly, that there is a concern that CDOP did not appear to be alert to the cluster of neonatal deaths and for at least some there should have been a Rapid Response Meeting within five working days of notification, so's effectively a criticism of the failure to provide the SUDiC process?
FRAME: Yes.
DE LA POER: And that there is a recommendation directed effectively to you and your panel that: "CDOP should consider whether its processes could have detected cluster of deaths and initiated external review more swiftly"?
FRAME: Yes.
DE LA POER: Now, a number of questions around that recommendation. Firstly, upon the evidence, it would appear that some of the Executives at least within the Countess of Chester received this report before Christmas of 2016, so in other words it wasn't published for at least a couple of months after they had it?
FRAME: (Nods)
DE LA POER: From your point of view as CDOP chair, how important was it that you knew about this recommendation made directly to you as soon as possible?
FRAME: Hugely important.
DE LA POER: Because this was in fact the very thing that
your panel had been discussing in September and November and this was separate and independent confirmation that there was a problem --
FRAME: Problem.
DE LA POER: -- with the approach that the Countess was taking. Did you ever follow up this particular recommendation in terms of looking at your processes and how it might detect a cluster and why it didn't?
FRAME: Yes, that was discussed at the next CDOP panel meeting.
DE LA POER: So we will come to that in March.
FRAME: And I think I had a conversation with Fiona Harvey as well, didn't I, around that time.
DE LA POER: I'm sorry, Fiona?
FRAME: Is it Fiona Harvey? No, it's not. Fiona ... Reynolds.
DE LA POER: And what was your discussion with Fiona Reynolds?
FRAME: Around that -- the recommendation.
DE LA POER: Bearing in mind that you will have been aware in general terms that the review had taken place -- the visit for the review had taken place in September because we can see that in the minutes of the 16 September the first discussions taking place, did you wonder why it had taken the best part of six months for this report to be produced into the public domain and into your hands?
FRAME: No, I didn't. Do you mean upon receipt of the report?
DE LA POER: Yes, upon receipt of the report?
FRAME: Sorry.
DE LA POER: Did you think: gosh, that's taken a very long time, I probably ought to find out why it's taken that long?
FRAME: No. I didn't.
DE LA POER: So let's move forward to the CDOP meeting on 24 March. INQ0001953.
FRAME: I do recall thinking -- remembering -- why haven't they come and spoken to us?
DE LA POER: Who do you mean by "they"?
FRAME: The Review Team because obviously they were talking about the process and talking about the role of CDOP but no discussions had with myself.
DE LA POER: Even at this stage were you unaware that Ms Dodd had had a short conversation with them and discussed CDOP?
FRAME: I don't believe I was aware of that.
DE LA POER: I am not suggesting that should have been the totality, I think your evidence was that you should have
been spoken to?
FRAME: Yes.
DE LA POER: So this is the meeting on 24 March. We can see that you are present, Dr Mittal is present, as are a number of other people including, as he was, detective chief superintendent Nigel Wenham?
FRAME: Mm-hm.
DE LA POER: In fact I think is Detective Superintendent there. If we go over the page to page 3, we can see that most of the page is devoted to the neonatal review and was this the first time that you gained further detail around what had taken place in the review and why it had been commissioned, or had you had any prior notification?
FRAME: I had had the report but this was the first time there was a discussion. My copy's a bit blurry, I don't -- here.
DE LA POER: I think that that's as we hold it, so I apologise --
FRAME: Okay.
DE LA POER: -- but we will do our best with it. Do you recall who made this presentation?
FRAME: It's so unfortunate that it's not minuted particularly well. I am assuming it was Dr Mittal. But
that's an assumption.
DE LA POER: We see the initials "GF" and at times "Gill Frame"?
FRAME: Yes.
DE LA POER: Now, who was she and why was she at the meeting?
FRAME: So Gill Frame was the independent chair of the Local Safeguarding Children Board and she had had some conversations, I believe, with the Medical Director of the hospital and she was aware of this recommendation around the CDOP processes, so she wanted to come along to this -- have this discussion around what action we needed to take. There was a suggestion that because the -- the review hadn't looked at the children's individual case notes that the Child Death Overview Panel would do that, but then Gill Frame had -- who was not related to me in any way by the way, Gill Frame had I believe spoken to the Medical Director and that was already being completed. So the discussion was around we would want to have sight of that as a CDOP to provide independent scrutiny. So it's a result of the report, its recommendations, any action we needed to take that Gill suggested that she came to that panel. She wouldn't ordinarily be there.
DE LA POER: She made a request of you in the last sentence, it would appear to: "... write to Alison Kelly outlining the recommendations the panel have made and confirm that the panel would not have had oversight of the death and an update to be added to the chair's report"?
FRAME: Mm-hm.
DE LA POER: Can you shed any light on that and what, if anything, happened as a result?
FRAME: Okay, this was as a result of the CDOP not being notified of all of the deaths so we didn't have that information over that period of time. If that action was there for me to write to Alison Kelly, I will have written to Alison Kelly. The -- I -- it would be the CDOP administrator that would have copies of those letters because I -- you know, I didn't even have a secure email account at this -- you know, I wasn't a member of staff so I can't look to see if that letter was written and sent but I am assuming that it -- it would have been because I wouldn't have left that action outstanding.
DE LA POER: We can see over the page that there is at item 7 further discussion about SUDiC in the context of a hospital and an unexpected death, so again it appears that that was also something that was under discussion separately at the meeting?
FRAME: Yes.
DE LA POER: Then finally for this meeting, if we go to page 10 --
FRAME: I mean, there is another action there on 4 for to write a letter. I remember writing that one, I don't know why I can't recall writing the other, but I am certain that I would have done.
LADY JUSTICE THIRLWALL: Is that the one at the top of the page, the action?
FRAME: There was -- no, it was relating to something else, it was around child protection concerns.
MR DE LA POER: Now, at the top, this is Child-I's(sic) case, as I understand it. We can see the cause of death is unascertained and that there was an inquest and further this case has been delayed coming to panel as it was part of the neonatal review of COSH and the case was closed unexpected death. Just a few points coming out of that. We know that the Inquest for Child-A took place on 10 October of 2016 which means that following that there was an opportunity at least to discuss Child-A's case on 20 November when CDOP met and on 20 January of 2017, when CDOP met. But it's not in fact until this meeting that Child-A's case was discussed.
Do you know the reason for that?
FRAME: Cases didn't come to CDOP until the Form B was fully populated, so that would probably be the reason.
DE LA POER: Isn't the Form B populated before the inquest takes place at the time of death?
FRAME: I -- I --
DE LA POER: So the inquest had taken place on 10 October 2016. The death was in fact in October 2015.
FRAME: Yes.
DE LA POER: I am just wondering --
FRAME: Why the delay.
DE LA POER: Why -- why did it take effectively until the third meeting after that inquest had been completed that CDOP was discussing the case, whether you have any insight into that?
FRAME: I -- I don't know the -- I don't know. I -- I would assume it would be around information not being gathered from all of the organisations, from all of the agencies. Often we had to send things back, the information wasn't sufficiently detailed or there was gaps. So it would take a long time to get something ready to -- and perhaps there might be because obviously it's -- the modifiable factors might be held within agency records that wouldn't necessarily form part of an inquest so I suppose that's why.
DE LA POER: Let's look briefly at the Form C for Child-A. INQ0001944.
LADY JUSTICE THIRLWALL: Just while that's coming up, Mr De La Poer, when you introduced this document you said it was Child-I.
MR DE LA POER: Did I?
LADY JUSTICE THIRLWALL: Just for the shorthand writer.
MR DE LA POER: No, that is entirely my error. This is Child-A.
LADY JUSTICE THIRLWALL: Yes, you have made it clear since. It's just for the record.
MR DE LA POER: Thank you very much, yes. So this is the Form C. Do you know when this form would have been completed?
FRAME: So what would happen is Ms McKenzie would pre-populate some of this, but it would be, the Form C would be completed in the meeting. But the cause of death, the case summary that would have already been completed and the list of anonymised documents will already have been -- she, she would collate everything into a combined Form B, so the front sheet essentially.
DE LA POER: So we have got the cause of death "unascertained" at the top and if we go to page 3, we will see that panel discussion as before under "Issues
identified", a confirmation of that verdict, unascertained, and following that: "... and therefore the panel agreed that the case could be closed." Now just help us to understand the approach of the panel. We have got: in the case of Child-A, it's gone all the way through the inquest process, the cause of death is "unascertained". It was a Sudden Unexpected Death. You know that the SUDiC process was not applied as it should have been in Child-A's case because you know by this stage that the Countess wasn't doing that. You have had no further light shed on why Child-A died by the Royal College review. Was it the right thing to do to close Child-A's case at this point or should the panel have thought about whether further information should be sought and if so from whom?
FRAME: I suppose again the panel would be reliant upon a concern being raised with them. So if the Coroner had raised concerns, had the designated doctor raised concerns, I mean obviously the police were present in that meeting too, weren't they? I -- I think that in cases such as this a neonatal death would be assumed to be the -- the cause. I'm assuming that's what's ticked on the next page.
DE LA POER: Well, if we go to page 5, we can see --
FRAME: Yes.
DE LA POER: -- "perinatal neonatal event" and let's just have a look at the text of that: "Death ultimately related to perinatal events." And some examples are given and what is included in that definition is also given. Now, the Coroner had conducted a full inquest and had reached a narrative verdict that said death was -- cause of death was unascertained. I mean, in reality, was that a box that could be ticked in this case because there was no information to say that it did relate to perinatal events?
FRAME: So if that was the professional judgment of the panel --
DE LA POER: But --
FRAME: -- but in terms of categorisation, I mean it's stated, isn't it, "unascertained" in 10.
DE LA POER: Well, it's repeated throughout the documentation this is an unascertained death. And so I appreciate this is a panel decision, but it needs to be hung on something, doesn't it? There needs to be something within the information that the panel can say, "This was a perinatal event that caused this death."
And having had your chance to look at it all now and focus upon it, can you point to any perinatal event that applied in Child-A's case?
FRAME: Can we go back to the first, the front sheet, please?
DE LA POER: Yes, page 1.
FRAME: The panel was very reliant on the designated doctors that were part of that panel to interpret medical information to us. But, the cause of death was unascertained, so that should have transferred through to the final box on the -- the form.
DE LA POER: Now, we've got one more matter to discuss briefly but before we come to it, I would just like to pause now. As part of this meeting where Child-A's death was -- case was closed and where the Countess was discussed, we saw on that page that Ian Harvey was to be invited to the next --
FRAME: Yes.
DE LA POER: -- CDOP meeting, which was due to take place in June. If I can just provide you with a bit more information, some of which you may already know. We know that the Consultants raised in June of 2016 their concern that a member of staff may be responsible
for the deaths?
FRAME: Mm-hm.
DE LA POER: Was that something that you were ever told?
FRAME: Never, until the meeting that I attended at the hospital.
DE LA POER: Which we will come to in a moment, 27 April.
FRAME: (Nods)
DE LA POER: Should you have been told that?
FRAME: Yes.
DE LA POER: Why do you say you should have been told that?
FRAME: The Child Death Overview Panel needed -- should have been notified of all of the deaths and should have been notified of the concerns. Obviously the police sit on the Child Death Overview Panel. However, there were other people that should have been informed before me, so that, you know, if there was those concerns they should have been reported to the police at the time, the local authority should have been informed, so that their Local Authority Designated Officer would be involved because it's a person working in a position of trust, so there were other investigative processes if those were the concerns that should have been the priority. My -- I would have wanted to know because of my role in terms of chairing the Child Death Overview
Panel.
DE LA POER: And whose responsibility was it, was there any particular person with any particular role who had a responsibility to tell you?
FRAME: To tell me?
DE LA POER: To tell the panel, yes, about these concerns?
FRAME: I don't know how much the designated doctor was aware because obviously he was a panel member.
DE LA POER: Well, if I just pause you there. We will hear from Dr Mittal on Wednesday. But do I infer correctly from your answer that what you are saying is that the designated doctor is the conduit that you would expect such information to be passed to the CDOP?
FRAME: Yes.
DE LA POER: Well, we will hear from Dr Mittal about what he did and didn't know.
FRAME: However, that doesn't take away the need to escalate if you are feeling that your concerns aren't being heard or are being blocked. You know any, every -- Working Together to Safeguard Children is really clear in terms of safeguarding being everybody's business and those concerns could have been reported to the police and the local authority by anybody working within that hospital.
DE LA POER: We are going to come now just to the final meeting that I am going to ask you about. You tell us in your witness statement that you had a telephone conversation with Mr Harvey on 20 April?
FRAME: Yes.
DE LA POER: And I will just remind you of what you say: "Mr Harvey stated that he was keen to learn lessons and wanted to be transparent in terms of the neonatal deaths within the hospital, hence contacting me in my role as CDOP chair. I believe we had a conversation about the modified Rapid Response for unexpected deaths in the hospital going forward. I recall Mr Harvey talked about the RCPCH report and they were assured that there was nothing to be concerned about but going forward the hospital would escalate any concerns to the CDOP in a timely way."
FRAME: Yes, because they hadn't.
DE LA POER: Because they hadn't. Now, in that meeting, did he tell you what concerns hadn't been escalated in a timely way?
FRAME: No. It was a very brief phone call.
DE LA POER: But did he give you to understand that there were some concerns that he wanted to tell you about?
FRAME: It -- no. It's as a result of the recommendation in the report about the hospital not
escalating. The conversation that I had had with Fiona Reynolds, which again was around the hospital not escalating the concerns, and the discussion that had taken place in the Child Death Overview Panel. So it was on the back -- it was, that's what he was referring to; that they hadn't raised any concerns with the CDOP around the cluster of deaths in a timely way and that they would do so going forward.
DE LA POER: Were you then asked to attend a meeting on 27 April?
FRAME: Yes.
DE LA POER: And were you asked if you wished to bring anybody else from the panel with you?
FRAME: Yes, because it was just a meeting that I was invited to initially.
DE LA POER: And did you decide to bring Detective Superintendent Wenham?
FRAME: Yes.
DE LA POER: And, briefly, why did you choose a police officer?
FRAME: Firstly, as a member of the Child Death Overview Panel because the question was whether I wanted to bring anyone else from the Child Death Overview Panel and I suppose given that it was in respect of child deaths, from my point of view the three key agencies are
health, police, local authority. I may well be the independent chair but I am a social worker. So that would seem, if we are going to be talking about any concerns in relation to deaths, we would have the three key agencies there. So that's why I asked if Nigel would come with me.
DE LA POER: As you know, we have Detective Superintendent Wenham's notes of that meeting. Have you had a chance to look over those?
FRAME: Yes.
DE LA POER: And do they accord with your recollection of what was said?
FRAME: I don't remember any reference to angel of death and I think, I think I would. It may be that that happened at the end of the meeting and I wasn't ... I don't know. But I don't, I don't recall that.
DE LA POER: But other than that detail, do those notes represent your recollection?
FRAME: It's far more detail than I recalled because I suppose the meeting very much was reassuring that, you know, there had been this thorough investigation and review they had looked at the case notes as well now; nothing of concern. And then it shifted when there was this -- it was stated that there was -- they have looked at rotas,
staff rotas and that there was one member of staff who was on shift during each collapse and it was a note -- and then of course you're thinking: What, what are we being told here? This, this is gravely concerning. So all of Nigel's notes, which obviously I am assuming were contemporaneous notes that he was taking, around everything before that I don't remember that. What I remember vividly is that conversation and then it being clear that the reviews that had taken place so far hadn't ruled out anything untoward.
DE LA POER: What you tell us in your witness statement is that Dr Jayaram -- well, you tell us. What was Dr Jayaram's position in that meeting about whether further investigations were required?
FRAME: Yes, he felt that they, they did.
DE LA POER: And what was agreed between you and Detective Superintendent Wenham about what would happen next by the end of the meeting?
FRAME: It was agreed that -- so Nigel spoke about how this was very much a matter for his officers, that they needed to secure case files and then I think he was -- he had another meeting some time after that and that obviously started the investigation. But I was clear coming out of that meeting that there was something very worrying and Nigel had the same view and the fact that this was the first time that we knew this.
DE LA POER: Were you given any explanation as to why you had not been told until that point?
FRAME: Not that I recall.
MR DE LA POER: Ms Frame, thank you for answering my questions. My Lady, those are all that I have for this witness.
LADY JUSTICE THIRLWALL: There are no more from anyone else?
MR DE LA POER: No.
LADY JUSTICE THIRLWALL: No, and I have no questions -- no, there was one thing actually, sorry, and it's really an administrative point. You have said a number of times that you were an independent chair, so self-employed and you had no access to the systems that everybody else was using.
FRAME: No.
LADY JUSTICE THIRLWALL: So how were you given information?
FRAME: So I think the -- it was like a secure portal. I'm sure it was called Cryptshare. So the papers for the meeting would be sent to me, I could then read them, but then they -- so I wouldn't be able to access them
now because it would time out in terms of the secure link to it. So that's how I received papers. Often I would travel to Sandbach and meet with Ann and we would go through things face to face. But, yes, that was an ongoing challenge because I wasn't an employee, I didn't have a secure email address.
LADY JUSTICE THIRLWALL: That's what I was about to ask you. Could you receive emails?
FRAME: As long as it didn't contain any identifying information, then everything else would go via the Cryptshare. So this is why I have sort of struggled to go back and see did I send that letter, because it would be sat on a system in Chester's local authority.
LADY JUSTICE THIRLWALL: Yes, I understand that --
FRAME: Yes.
LADY JUSTICE THIRLWALL: -- from the perspective of trying to put together a statement. But in terms of doing the role, was that a disadvantage, not having, you know --
FRAME: Yes.
LADY JUSTICE THIRLWALL: -- the usual communication channels?
FRAME: Yes, I think so and not being able to look at data, I suppose. You know, not being able to -- it wasn't there at my fingertips, I would have to request
something.
LADY JUSTICE THIRLWALL: And so in terms of --
FRAME: That was a challenge.
LADY JUSTICE THIRLWALL: Thank you. So in terms of looking at something on the portal, you could look at it obviously while you were online, but there was no -- were you permitted to download things from the portal and keep them?
FRAME: No, I never did.
LADY JUSTICE THIRLWALL: No. All right. Thank you. Sorry, Mr De La Poer, is there anything you want to add to that?
MR DE LA POER: Not at all. No, thank you, my Lady.
LADY JUSTICE THIRLWALL: No. In that case we will rise now and start again at five past 2. Thank you very much indeed for coming. You are free to go now.
(1.04 pm) (The luncheon adjournment)
(2.05 pm)
LADY JUSTICE THIRLWALL: Ms Brown.
MS BROWN: If we could call Ms Sindall, please.
LADY JUSTICE THIRLWALL: Would you like to come forward.
MS PAULA SINDALL (affirmed)
LADY JUSTICE THIRLWALL: Do sit down.
SINDALL: Thank you.
MS BROWN: Could you please give your full name?
SINDALL: It's Paula Margaret Sindall.
BROWN: I think at the time of the events we are looking at, your name was Paula Lewis?
SINDALL: That's correct.
BROWN: You have provided a statement to the Inquiry dated 29 May 2024, is that true to the best of your knowledge and belief?
SINDALL: Yes, it is.
BROWN: Turning to your qualifications, you qualified as a Registered General Nurse in 1985 and worked on as a nurse on medical and surgical wards and on intensive care; is that correct?
SINDALL: That's correct.
BROWN: Did you ever work on a neonatal unit?
SINDALL: No.
BROWN: You qualified as a health visitor in 1992?
SINDALL: Yes.
BROWN: And then worked in the community as a health visitor and that I believe involved working with families where there were some safeguarding concerns?
SINDALL: Yes.
BROWN: In terms of your employment with the Countess of Chester Hospital, in 2009 you started working at the Countess as a full time Band 6 nursing post, I think later promoted to Band 7. That role was to support Karen Milne, who was the named lead for safeguarding children and domestic abuse?
SINDALL: That's correct.
BROWN: If we could just very briefly look at the safeguarding team at the Countess of Chester at that time. Alison Kelly the Director of Nursing, she was the Executive lead for safeguarding children?
SINDALL: Yes.
BROWN: What was the extent of the contact you had with Alison Kelly in relation to safeguarding issues?
SINDALL: She was always the Chair at the Safeguarding Strategy Board meetings, so I knew her then, but apart from that my direct management was -- responsibility, my manager was Karen Milne.
BROWN: Yes, so you would -- if you had an issue it was Karen Milne you would be speaking to; you wouldn't be discussing day-to-day safeguarding issues with Alison Kelly?
SINDALL: No.
BROWN: Do you yourself ever refer an individual case
to Alison Kelly?
SINDALL: I'm sorry?
BROWN: Do you yourself ever referring an individual case to Alison Kelly?
SINDALL: The only time I may have referred something directly or informed Alison Kelly indirectly about something was in Karen Milne's absence. If she was not available and there was what I considered to be an important issue occurring in the hospital, I would email Alison Kelly to inform her.
BROWN: But there's -- just to be clear, there is no issue related to what we are looking at in this Inquiry where you contacted Alison Kelly about?
SINDALL: No, none.
BROWN: In terms then, so Alison Kelly as the Executive lead, then Karen Milne you have spoken about, who was the designated nurse?
SINDALL: She was the named nurse and named professional.
BROWN: She was your immediate boss?
SINDALL: She was my immediate manager.
BROWN: In terms of the paediatricians there was Dr Mittal who was the designated doctor for safeguarding?
SINDALL: Correct.
BROWN: I think he was the doctor on the Child Death Overview Panel and also had responsibility for the Sudden Unexpected Death in Childhood process?
SINDALL: Yes, he did.
BROWN: Then Dr Isaac had responsibility -- she was the named doctor for safeguarding children and had responsibility for supporting medical staff, particularly the paediatricians, in terms of their safeguarding responsibilities?
SINDALL: Yes.
BROWN: In terms of the two designated roles, Karen Milne and Dr Mittal, how did they --
SINDALL: Karen Milne had a -- was the named role, the designated nurse sat with the CCG.
BROWN: Sorry, the named nurse. Her interaction with Dr Mittal, how did that operate?
SINDALL: It was a professional relationship. We could communicate with Dr Mittal and -- if we needed to.
BROWN: In terms of other individuals involved with safeguarding, we have seen that there are nurses, for example on the Accident and Emergency Department, who would spend some days with the safeguarding team in order to take expertise and safeguarding into the Accident and Emergency Department?
SINDALL: Yes, she spent one day a fortnight with us so
that she had those additional skills and knowledge.
BROWN: That was Vivien Beswick?
SINDALL: That's correct.
BROWN: Then in terms of other individuals with some involvement, there would have been -- we don't need to go through the names but people who had some involvement in domestic violence, children in care, adult safeguarding, those would be the other sort of people other roles in safeguarding that would be attached to your unit.
SINDALL: In safeguarding but the adult safeguarding was separate to the children's safeguarding team.
BROWN: So in terms of the children's safeguarding team, we have got the two paediatricians, Dr Mittal, Dr Isaac, yourself and Karen Milne and Alison Kelly as Executive lead, so a relatively small team?
SINDALL: Yes, I think so.
BROWN: Did you consider that that was a sufficient sized team to manage the caseload that you had to manage?
SINDALL: No, it would be my opinion really that it wasn't. I think we were an unusual set-up within the Countess in that Karen Milne had a dual role as both the named midwife for safeguarding and the named professional for safeguarding. In other Trusts they had two distinct roles with the named midwife and the named professional but Karen carried out responsibilities of both of those roles on four days a week and I thought that that was -- that put a lot of pressure on her and on the team really in terms of resource.
BROWN: So what did you consider was in fact required in terms of staffing levels within the safeguarding team?
SINDALL: Well, I left my role in the safeguarding team in 2022 and the size of the team at the point that I left was greatly increased from how it was in 2015 and has continued to increase since.
BROWN: So just talking about when you left, "greatly increased", what do you mean by that, doubled?
SINDALL: So three times the number of hours in the safeguarding children team as it stands now compared to how it was in 2015.
BROWN: Given the size of the team when you were there, what was the extent of the discussions between the four of you, did that mean there were a lot of discussions, were you a close team?
SINDALL: Well, I shared an office with Karen, we were -- Karen was responsible for my supervision and we had day-to-day informal supervision, if you like, if -- if I had any queries, we worked very closely together.
The paediatricians, the named and the designated nurse -- doctors weren't -- weren't in the same office as us, they were situated with the paediatricians. But they were accessible, we could walk to their office and discuss any issues but we tended to communicate with them mainly by email.
BROWN: How often would you meet as a group or would you meet as a group, the four of you?
SINDALL: Really the only time I think that we met as a group was at the Safeguarding Strategy Board meeting.
BROWN: Did that cause a problem in terms of you being kept up to speed with safeguarding issues, looking back now?
SINDALL: I don't think so. I don't know what I don't know. So I am fairly sure that -- you know, that Dr Isaac and Dr Mittal would -- you know, they were mainly responsible, I think, for supporting the paediatricians and I wasn't party to how that took place.
BROWN: And in terms of your -- now looking at your day-to-day role, you refer in your statement to responding to enquiries and concerns raised by staff, would that be safeguarding concerns raised by either doctors or nurses?
SINDALL: Mainly nurses. Other therapists, although
people throughout the Trust as well as nursing staff, occasionally I would have a query from one of the paediatricians. The community paediatricians would more frequently make contact to discuss concerns. But it was mainly the nursing staff and the other professionals apart from the medical staff.
BROWN: Was that because doctors would tend to go to Dr Isaac; is that your understanding?
SINDALL: I don't know but, but that would be my assumption.
BROWN: In practice, would that be nurses coming to your office or would you be going to the ward when they raised a query? How would it work in practice?
SINDALL: Well, we had a formal referral process. But we also -- so we would pick up daily referrals, we also had a telephone, a designated telephone with an answer phone facility, so 3 am messages were not unheard of. We also carried a bleep as well. But we were actually only on site in office hours.
BROWN: You say as well in your statement you had an open-door policy and that you and Karen Milne strove to maintain a very visible presence across the hospital. In practice, how were you doing that, how were you maintaining a visible presence?
SINDALL: It was -- well, I used to call and pick up the
referrals from A&E every morning, we tried to call into the children's unit every morning as well.
BROWN: Just stopping there for a moment, obviously we are very interested in the neonatal ward. How often would you visit the neonatal ward?
SINDALL: We -- we visited -- I didn't -- we didn't visit the neonatal unit unless somebody raised a concern but we were geographically situated very near to both the children's unit and the neonatal unit. I can't remember but I think in 2015 we were actually on the corridor between the two, between the children's unit and the neonatal unit. We moved upstairs but we were still in the women and children's building.
BROWN: So whereas you would go to the paediatric ward on a regular basis, on a daily basis --
SINDALL: Yes.
BROWN: -- the neonatal was as and when you were requested to go there?
SINDALL: Yes.
BROWN: Approximately how often would that be, do you think? Once a month, once a week?
SINDALL: Probably at least once a week. And we tended to attend meetings regularly on the neonatal unit in relation to babies that were being discharged home where there were some level of safeguarding concern.
BROWN: The sort of safeguarding concern that you were coming across most frequently in terms of the neonatal ward, what would that have been?
SINDALL: Sometimes it was about babies that we knew there were safeguarding concerns antenatally and those babies were now born and on the neonatal unit so we would be helping the staff to manage the safeguarding aspects and the safe discharge from the neonatal unit. But sometimes it would be that there were babies that weren't known to our team but a concern had arisen on the neonatal unit, for example there may have been some interactions between parents that had caused concern or some aggressive behaviour or something like that and the neonatal unit would seek support from us in -- in dealing with that from a safeguarding perspective.
BROWN: So broadly the safeguarding concerns were ones that were concerns about parenting of the child when discharged to that home environment?
SINDALL: If the -- sometimes we had babies on there who weren't going to be going home with parents and occasionally we used the neonatal unit as a safe place for this child to remain until the local authority could obtain the necessarily legal orders for discharge but -- but otherwise it was mainly about concerns within the
family and to make sure the baby was being safely discharged into their care.
BROWN: You say in your statement that you would visit the A&E and the children's unit in response to safeguarding concerns which is obviously a reactive-- when you were called --
SINDALL: Yes.
BROWN: -- you went, but you are saying that you would go as a matter of course every day, would you, in any event or would you just go when there was a requirement?
SINDALL: To the neonatal unit?
BROWN: No, to the A&E and the children's ward?
SINDALL: In 2015 the referral process to our team from A&E was a paper-based process, so we had to go into the -- to pick up those referrals. It's not now, it's electronic, but 2015 it wasn't.
BROWN: What about poster campaigns, other ways in which you would raise the profile of safeguarding, were any of those means employed?
SINDALL: Every clinical area was required to have a Safeguarding Board and the neonatal unit had one, the paediatric unit had one, A&E, and all the adult wards as well on which was detailed what to do if you feel a child's being abused. The flowchart -- I don't know if you have seen that, and the policy --
BROWN: Yes, we are aware of that.
SINDALL: That was on there, we would put regular updates on there, contact numbers. We also sent out communications electronically about new initiatives within safeguarding that we felt the staff needed to be aware of.
BROWN: In terms of those notice boards was there ever any notices that you put up that dealt in particular with concerns that individual may have about a member of staff, healthcare staff, working with children?
SINDALL: Allegations?
BROWN: Yes.
SINDALL: Not that I -- not that I recall.
BROWN: Training, if we can turn to that. One of your roles was delivering face-to-face safeguarding training from staff. It appears from your statement that that was in fact a major part of your role; is that fair?
SINDALL: Yes. There's a mandatory requirement for all staff across the hospital to have a level of safeguarding children training. So our Group 3 staff had face-to-face training --
BROWN: Just --
SINDALL: -- in addition.
BROWN: So we understand that Group 3 staff, that those are charged with regular contact with children and
families, so neonatal staff would be Group 3?
SINDALL: Group 3, yes.
BROWN: In terms of the training, you say that Karen Milne, she would do some of the training as well; is that right?
SINDALL: Well, Karen Milne designed the training and the content of the training but she wouldn't have had the capacity. We used to deliver training separately to the midwives and midwifery and Karen would deliver that training and then the rest of the -- the Group 3 staff across the Trust, I would deliver that. We called that the generic safeguarding children training.
BROWN: You say it was Karen Milne who was responsible for the content of the training, what input did you have as to deciding the content of the training?
SINDALL: Well, when -- Karen updated the training annually and -- and I always understood the rationale between what was included in that training and could make suggestions if I -- if I was -- if I wanted to, if I felt there was an issue that I had become aware of that needed to be included, but it was Karen that determined the content.
BROWN: But I think it was Karen Milne, your boss, and she gave the safeguarding training to the senior Executives, to Ian Harvey and Tony Chambers. Why was she delivering that training, not you?
SINDALL: It would have just been that she had the capacity to do so and that was the best use of the resources at that particular time.
BROWN: But the training would have been in a sense standardised training, the standard safeguarding training, would it?
SINDALL: I -- I am not -- I have seen only from the package what was in the training that went to the Executives and I think that was -- I think the Executives have a Level 1 training, it wasn't a Group 3 training.
BROWN: In terms of Dr Isaac and the training, we have seen some PowerPoints that you, it appears, delivered some of the training with Dr Isaac. She was -- was she generally providing the training to doctors and you generally to nurses, was there that divide or --
SINDALL: Usually, yes. Some of the paediatricians did attend the generic training events that I put on as well, but mainly I think it was Dr Isaac that delivered to the paediatricians.
BROWN: From looking at the PowerPoints in broad terms, it appears that the training given to doctors and the training given to nurses, say for example doctors may be referred to the GMC, for example, but broadly the
training was the same for Group 3; was that your understanding?
SINDALL: I wasn't always aware of the content of the training that Dr Isaac was delivering, it wasn't -- I think we had delivered joint training a couple of times only but in between, I -- I wasn't aware of what training.
BROWN: When you did deliver joint training, was the training that she was giving consistent with the training that you were giving broadly to nurses?
SINDALL: It was definitely in my opinion more focused towards paediatricians and their responsibilities towards non-accidental injuries. The training that I delivered to staff didn't just feature -- didn't feature that as heavily and can I just say the -- the training that I delivered had to be delivered to a broad group of people who would be attending and so it would be that there might be bits in the training that were relevant to some staff, yet other staff would need more in certain areas and so, you know, I would always have to signpost staff to where they could get additional training as per their clinical role.
BROWN: But the Group 3 staff, so those involved with children on a day-to-day basis, they would be given specific training for their -- for Group 3 staff?
SINDALL: For Group 3 staff, yes.
BROWN: In terms of training to people who were not healthcare professionals, so for example Non-Executive Directors or volunteers, were you involved in training in terms of safeguarding any of those individuals or were you just focused on healthcare professionals?
SINDALL: Just focused on healthcare professionals.
BROWN: Just so we can have an overview of the training that was compulsory at this time, you address this in your statement and you say Group 3 staff, so that would be the staff working on the neonatal unit, whether nurses or doctors, they had to have Level 3 annual face-to-face training?
SINDALL: They had to have Level 3 but in addition they had to do the e-learning Group 2 because there is a requirement within the intercollegiate document for them to have so many hours of training so they completed the Group 2 e-learning and in addition annually Group 3.
BROWN: The e-learning, that was once every three years, that was a more --
SINDALL: That was once every three years.
BROWN: In terms of the frequency that you were putting on this training, how often were you putting on the training, how far often was there an opportunity to go --
SINDALL: Monthly.
BROWN: Was that because of the turnover of staff?
SINDALL: The turnover of staff and the fact that obviously staff work weekends, nights and what have you. So they had to have an opportunity for it to fit in with their -- their working patterns, really.
BROWN: In terms of compliance, so the fact that staff had to do this training, you say that in terms -- in 2015/2016, the Group 3 staff, compliance targets were 80%. Now, 80% doing the training of course means 20% were not. So one in five were not. Did you consider 80% was an appropriate target?
SINDALL: At the time, I -- I didn't question it and it was subsequently raised by the CCG. It was a target set by the CCG for us to achieve.
BROWN: You say you didn't question it at the time. Looking back now, do you think 80% was adequate for -- this is training for staff who are working on a regular basis with children?
SINDALL: I think it had to take into consideration people who were on maternity leave, people who were on long-term sick leave, turnover of staff, I thought at the time 80% was -- was reasonable.
BROWN: In terms of compliance, that was managed by staff managers, so on a -- for nurses that would be the ward manager, would it?
SINDALL: Yes. And I think the experience would be when they had their annual appraisal that there's a part of the appraisal would consider whether or not staff were compliant with their mandatory training requirements which would include safeguarding children.
BROWN: But that compliance, who had trained, who hadn't trained and what consequences there were of not training, that wasn't something that you got involved in?
SINDALL: No. We sent the figures to the HR training department who then shared the figures with the managers in the clinical areas.
BROWN: So you recorded in effect who attended training and then you sent on those figures for someone else to deal with?
SINDALL: Yes.
BROWN: You talk as well about a bi-monthly review of safeguarding issues and training that was done, you refer to a paediatric peer review by Dr Isaac. That was every two months, was it?
SINDALL: I --
BROWN: About?
SINDALL: I recollect that it was every month -- every other month but I can't be 100% sure on that.
BROWN: That training, that was training where they would consider cases that had been dealt with the hospital and the learning obtained from those cases; is that correct?
SINDALL: That was my understanding. I attended I think two of those peer review because we were invited but our caseload was -- so our workload was so heavy at times that I couldn't often attend.
BROWN: Because if those bi-monthly meetings were looking at the learning from the cases and your work pressures meant that you could only do so infrequently, was that a concern, does it mean that you weren't in fact involved in the learning from cases that came in?
SINDALL: A lot of the learning for the peer review sessions that I attended was around how the medical staff had managed the cases in terms of investigations, looking at X-rays. It seemed to be very medically orientated.
BROWN: But in terms of if you were the port of first call some of the safeguarding would it not have been important that you as the safeguarding team were on top of the current issues that were coming through the hospital?
SINDALL: I think if -- if we ever had a child that was attending where there were safeguarding concerns that
required medical input, we would be involving the named doctor for safeguarding anyway as a matter of course.
BROWN: The fact that you say you weren't able to attend those meetings because of caseload, is that an indication perhaps that the team was overstretched?
SINDALL: In my opinion, yes.
BROWN: Just looking at external training, you represented the hospital at the Local Safeguarding Children Board Training and Development sub group. What was the purpose of that group?
SINDALL: The purpose of that group was to pick up sort of lessons to look at multi-agency training that was available, to consider lessons and whether the lessons from events that had happened should be included in training and what kind of training that -- that would take.
BROWN: Did that -- you say multi-agency, did that training look at issues such as the requisite level of concern needed before going to the police, would that be something that would be covered in that training?
SINDALL: I -- no, I wasn't aware of that. I never came across that training.
BROWN: What about training about in what circumstances the Local Authority Designated Officer, the LADO, should be informed about a member of staff,
concerns about a member of staff; would that be covered in that training?
SINDALL: No, I already -- that was in Working Together. So we were already aware of what the requirements around referral to LADO was and it was in our Safeguarding Children policy.
BROWN: In terms of the Group 3 staff, and you have spoken about the fact they needed to do the two and a half to three hours face-to-face training and e-learning, would they also attend -- I think they could attend the LSCB training. Was that something that regularly in fact occurred, that staff would incur this additional training?
SINDALL: Yes, yes we had staff that maybe had dealt with a case around, for example, domestic abuse and the impact on children and the LSCB hosted additional training on that. There was additional -- the LSCB had a very good -- we had a link on our intranet to the LSCB training that our staff could access, so there was very good training on female genital mutilation, lots of additional skills that our staff might have felt relevant to them in their role.
BROWN: So that additional training was available but it wasn't monitored who was doing it; is that correct?
SINDALL: That's correct.
BROWN: In terms of your liaison role, you talk about liaising with other agencies and you speak particularly about -- that that involved liaising with the police. What was your understanding about the level of concern you needed before the police could be contacted in a situation where you were concerned about potential harm to a child?
SINDALL: Well, I was aware of what was in the safeguarding policy at that time and in Working Together around if there was a concern about a child, a deliberate harm to a child that that would necessitate a referral to the LADO and that would then involve a strategy discussion about whether the police should be involved at that point that you didn't need to wait for the outcome of an investigation. The LADO wouldn't do an investigation anyway, she would oversee a process but you shouldn't wait for the outcome of an investigation before you make that contact.
BROWN: So to paraphrase, tell me if I am wrong, your understanding was where you had a concern you referred that and you didn't need to wait for an outcome, you didn't need evidence; it was a concern that triggered it?
SINDALL: You didn't need evidence. That wouldn't be something that I would do. I mean if -- if that had
come to me in my role as a Band 7, I would have escalated it to Karen Milne and would have expected an escalation then to the Executive lead for safeguarding and a strategy discussion fairly quickly and referral to possibly the police but definitely to the LADO would be a part of that strategy discussion.
BROWN: So if someone had come to you and said "well, I have got a concern but I have no evidence", you would have put them right that that was not the safeguarding approach?
SINDALL: Yes.
BROWN: In terms of contact with the LADO, you say that you had contact with the LADO about safeguarding concerns from other agencies but you never made a referral to the LADO yourself. We know in the case concerning Letby that it was eventually Alison Kelly who referred Letby to the LADO, but that didn't occur until 27 March 2018. Did you consider that referral of a member of staff to the LADO was something that had to be dealt with at an Executive level or was that something that you -- you could have done? Or indeed anyone could have done?
SINDALL: I think that if -- I think it would have to be done with the -- with knowledge of the Executive lead for safeguarding, it's quite a serious thing to do and
so there would definitely would have had to have been some discussion with the Executive lead for safeguarding.
BROWN: If we can just look at some areas of policy then. You have referred a few times to Working Together so if we could just turn to INQ0014575 at page 54. So this is --
SINDALL: Sorry, my screen --
BROWN: It will come up.
LADY JUSTICE THIRLWALL: It just takes a few seconds.
MS BROWN: It just takes a little moment. What you are going to see coming up in a moment is an extract from Working Together that sets out the requirements the obligations placed on the NHS under section 11 of the Children Act 2004.
SINDALL: Yes.
BROWN: The third bullet point down, the third black dot says there clear policies, so the obligation is to provide clear policies in line with those from the LSCB for dealing with allegations against people who work with children. Then it goes on to say what an allegation is: "An allegation may relate to a person who works with children who has behaved in a way that has harmed
a child or may have harmed a child, possibly committed a criminal offence or related to a child or behaved towards a child or children in a way that indicates they may pose a risk." So that I think is what you were explaining; that it's suspicions, it's may have harmed, may pose a risk?
SINDALL: Yes.
BROWN: That would was the test, where you have got concerns about someone working with children?
SINDALL: Yes.
BROWN: If we can go then to the hospital safeguarding policy to see how it was set out there. If we could turn to INQ0014165. This is -- it went through a number of drafts but this is the Safeguarding and Promoting the Welfare of Children policy that is going to come up on your screen in a moment. If we can go there to page 3 first. We see there this policy at the top, under the Executive introduction: "This policy reflects the standards set in the Cheshire Local Safeguarding Children Board, the LSCB, manual of procedures." Going down: "Every adult has a responsibility to protect children and as employees of the Trust we are duty bound always to act in the best interests of a child about whom we may have concerns." We see then this is the September 2015 policy and signed by Alison Kelly?
SINDALL: (Nods)
BROWN: Who makes clear is the Director of Nursing and the Executive lead for safeguarding children. If we can go on then to page 4. It says there a phrase that we have heard in this Inquiry: professionals needed -- this is under where it says "Serious case review", professionals needed to think the unthinkable?
SINDALL: Yes.
BROWN: Were you aware of the case of Beverley Allitt?
SINDALL: Yes.
BROWN: Were you aware of Recommendation 13 -- you may not know the number but the principal recommendation -- one of the recommendations of the Clothier Inquiry into Beverley Allitt 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?
SINDALL: Yes.
BROWN: You say yourself in your statement at paragraph 35 that:
"For such a vulnerable children to come to harm at the hands of someone entrusted to care for them is horrifying and has resulted in staff such as me having to think the unthinkable." That rather suggests that in 2015 and 2016, you weren't focused or maybe were not sufficiently alert to the possibility that a member of staff could harm a child. Is that the case?
SINDALL: No and I think that that comment in my -- at 35 it should have had: staff such as me having to think the unthinkable again. I don't believe that I wasn't thinking the unthinkable in 2015.
BROWN: In 2015/2016 you recognised, did you, that suspicions about a nurse harming babies, if that had been communicated to you was a safeguarding issue and that that should have triggered safeguarding processes?
SINDALL: I would agree with that.
BROWN: Because we have heard from a significant number of witnesses to the Inquiry who said that they received no training on what to do if they had concerns about a staff member harming a child and certainly from going through the PowerPoints, it doesn't appear that there's any reference to the possibility of harm by a healthcare professional or what steps to take if there were such concerns?
SINDALL: I think there was a certain, although we, the policy was -- the training was updated annually, there was the core part of the training that talked about professional responsibilities and talked about harm and what would constitute harm and it wasn't explicit at that -- within that about who would cause the harm.
BROWN: Looking back now, given that phrase "think the unthinkable", given the evidence that people find that a difficult concept, to imagine that a nurse or a healthcare professional might be harming babies, and given the learning from Beverley Allitt, looking back now, should that have been made more explicit in the training?
SINDALL: I'm not sure about referral to Beverley Allitt and I guess that was in 1991, 1994 the Clothier report. Maybe we should have included a scenario that involved where a child had been harmed by a professional but in terms of children that come to harm, significant harm and are killed, they are much more likely to be harmed by people within the family or more recently a greater awareness of extra familial harm rather than harmed by somebody tasked with -- with caring for them within the --
BROWN: So the training focused on the more likely scenarios and didn't in fact cover this unlikely
scenario?
SINDALL: That would be correct.
BROWN: If we can just go back to the policy and if we can go to now page 30. So this there under the italicised paragraph, the next paragraph down, it says: "If at any point a member of the Countess of Chester staff feels that their concerns about a child are not being acted upon appropriately, they must discuss this with the safeguarding children team who will take responsibility for ensuring the case is appropriately managed." This, from what we can see, wasn't explicitly covered in the training and we know in fact that staff at certain points did have concerns that their concerns weren't being acted upon appropriately and didn't come to you as the safeguarding team. Why do you think that was? Why did that -- that system fail it is in the policy that if you have got concerns and you don't feel it is being appropriately managed, you come to safeguarding team and no one did come to you -- to the safeguarding team about those concerns; that is correct, is it?
SINDALL: That is correct, yes.
BROWN: Do you think looking.back. there is a reason for that, why that mechanism wasn't working?
SINDALL: I think I have learnt a lot from reading the transcripts as they have gone on. But I think the paediatricians were following the Speak Out Safely guidance and -- and that.
BROWN: If you could just maybe confine it to what -- why you feel as a trainer at the time people weren't coming to the safeguarding team with this concern?
SINDALL: I -- I don't know and I'm surprised.
BROWN: If we can go then down because this then does -- to pre-empt you -- talk about the Speak Out Safely policy and it stays there: "From time to time staff may have concerns about care or treatment given to any patient." And it goes on: "Managers have a particular responsibility to protect patients and to handle concerns about their care in a way that will encourage the voicing of genuine misgivings while at the same time protecting staff against unfounded allegations." So it does -- this policy does envisage the possibility of allegations against staff but this policy itself doesn't set out what to do, a step by step guide about what to do if you had concerns about staff?
SINDALL: No, it doesn't.
BROWN: And as far as you are aware, was there any
training or guidance or flowchart that set that out?
SINDALL: There were -- I thought there was a link, actually, to the allegations policy, the LSCB allegations policy.
BROWN: Yes, yes. So we see the LSCB, but in terms of the training that was given to Countess of Chester by the safeguarding team?
SINDALL: No.
BROWN: If we could then just turn over to page 32, we see under the heading "Human Resources Department" --
SINDALL: Yes.
BROWN: -- "The Trust will act with speed to any allegations of professional abuse. The Countess of Chester will identify a senior manager who will have responsibility for referral and ongoing liaison with the Local Area Designated Officer regarding any allegation made against a Countess of Chester member of staff." I think you have already said that referral to the LADO wasn't something that was in the training, the Group 3 training, safeguarding training?
SINDALL: No.
BROWN: In this case, we know that the referral to the LADO happened at a very late stage, 2018?
SINDALL: (Nods)
BROWN: Do you have any explanation as to why? We
will see your statement, you say that your response, had you been aware of these concerns, would have been to go to the LADO; that's not what happened here?
SINDALL: Mm-hm.
BROWN: We are trying to understand why what thought was instinctive as a safeguarder didn't happen in practice. Can you shed any light on that?
SINDALL: I don't know that. I mean, all I would think as well in that a two and a half to three hour training it is very difficult to cover every single eventuality and scenario and the -- you know, as part of the training we always signposted staff and made sure they were aware of the policies that supported safeguarding across the Trust. But why? So I don't know whether staff don't read policies. That would be a possibility. And I am not -- you know, because it was in the Speak Out Safely, there was information about the LADO in that as well and very clear about the times when a referral to LADO must be made. Yet I don't know.
BROWN: When you became aware -- and we will come to that in a moment, but when you became aware of the concerns about Letby, and I think we will see that but that was shortly I think you say before the police were involved, so late, but nevertheless a year before the
recommended, the information was sent to the LADO, did you not think at that point: we need to take this to the LADO, I need to make sure that this is being done?
SINDALL: I can't remember the exact timeline but I think --
BROWN: Well, the timeline is that we will come to it but you were aware, it seems from your statement, shortly before the police were involved, so 2017, spring 2017?
SINDALL: (Nods)
BROWN: And the referral to the LADO took place in 2018, I think March 2018.
SINDALL: Right, okay.
BROWN: So a year later in effect.
SINDALL: I think that I assumed then that once the police were involved, that the appropriate processes in terms of investigation would be taking place.
BROWN: If we can just go to some of the PowerPoints -- one of the PowerPoints. So INQ0108339. So what's going to come up here is a PowerPoint in a moment, this is a 2013 one, this has been picked because this is a Group 3 one. There is a number of PowerPoints, I think you have seen?
SINDALL: Yes.
BROWN: All slightly, slightly different but the key slides remain the same. If we can go to page 2, we can see there the requirements, just to reinforce what you have said, that Group 3 staff need to complete the Level 2 e-learning model every three years and attend a face-to-face training session each year and the 80% compliance is set out there. If we can then go to page 5. We see the principles that you have referred to from Working Together that everyone shares a responsibility for safeguarding and promoting the welfare of children irrespective of individual roles and that obviously was a key part of your training; that's correct?
SINDALL: (Nods)
BROWN: Then if we can look at 6, page 6, the last bullet point on that: "It is simpler to lift the telephone than live with the regret of not doing so." To what extent was that part of a discussion, that bullet point, of the point we have been discussing, that you don't need proof but once you have got a concern, you should act? Is that the point that's being made in that bullet point?
SINDALL: Yes. I would rather if someone had a concern that they pick it up and discuss it with us before we decided if it met a threshold to take additional
actions.
BROWN: So that can go down now. So to witnesses who say that they couldn't take action without proof, you would say, would you, that to some extent when we see that bullet point that was something that was covered in your training, albeit not explicitly in relation to staff members but the idea of acting picking up the phone as a principle was something that was covered?
SINDALL: Yes. Can I say as well if we are looking at training, that we have made the point that staff -- Group 3 staff also had to do the Level 2 e-learning.
BROWN: Yes.
SINDALL: Now, the Level 2 e-learning, Level 2 staff, one of the core competencies per intercollegiate guidance is that they understand professional abuse. I don't know whether the Level 2 e-learning addressed professional abuse, I don't know what the content of that training was. So we can't just assume that because it wasn't in the face-to-face training that it wasn't in the Level 2 e-learning.
BROWN: Would it not have been important for you to understand what was in the e-training so that you --
SINDALL: I -- I did the e-learning training but I can't remember in 2015 whether it covered professional abuse, I'm sorry.
BROWN: What do you consider would have been the correct response if a nurse or a doctor had come to you saying they had concerns about a nurse, because they were always on duty when there were unexpected and unexplained deaths? What as a safeguarder would you have said to that?
SINDALL: It would have set a level of concern but it could be at that point if they were always on duty when, when there was an unexpected death, whether there was an issue around clinical competency, possibly. That would be very different to coming and saying: we think that this nurse may be deliberately causing some harm.
BROWN: Yes. They are clearly different but if the nurse -- if the professional came to you and said "we have concerns because the deaths are unexpected and unexplained and they are always on duty", so that is specific, so they are not saying we have seen anything, but they are concerned because the deaths are unexpected and unexplained and the same nurse is always on duty, what was the correct, would you say, safeguarding response to that?
SINDALL: I think I would -- I mean, obviously I would be escalating that to Karen. But I would want to understand more in relation to whether there was a clinical competency issue and issues like that as
well.
BROWN: So you would refer it to someone more senior --
SINDALL: No --
BROWN: -- first of all?
SINDALL: -- I would --
BROWN: To Karen?
SINDALL: No, I would discuss it with Karen but then we would have a discussion, and a pretty quick one about, you know, what else had been considered, was this -- was this nurse -- were there any concerns about her competency, irrespective I think of, of what might have been occurred, I think one of the first things we would have thought about was: well, should that nurse be working there from this day while we think about whether the clinical competency is an issue?
BROWN: If we can go to paragraph 26 of your statement, you deal with this to an extent and you say: "In the event of suspicions or concerns being raised with me about a member of staff being involved in deliberately causing harm ..." So this is sort of one ramp up from a scenario I have put to you, but if the concern was deliberately causing harm to a child as opposed to suspicion that there is a correlation, you say you would have escalated that immediately and would have: "... expected the Executive lead for safeguarding would be notified, consideration of the need for an onward referral to the Local Authority Designated Officer and police would take place as a matter of urgency." You use the word there "consideration" of the need. Are there any circumstances if there was a concern about deliberately causing harm to a child where it wouldn't go to the LADO?
SINDALL: No, not.
BROWN: You don't there, but I think you have made it clear in your answer, refer to any immediate action in terms of removing the individual from --
SINDALL: That would be -- I would expect there to be a strategy discussion initiated with a matter of urgency. We would need to -- the first thing to do would be to establish immediate safety in relation to any other children, so that would form -- that would be the initial thing. How can we make the situation safe now and what do we need to be doing in terms of referrals to LADO and possibly the police if -- if there is suspicion of criminality?
BROWN: So, Ms Sindall, your response is admirably clear about what you felt were the stages to take but we
know that when Dr Jayaram raised a concern, in fact a specific concern that he was concerned about harm being caused to one of the Triplets after their sibling had died, that none of those steps were taken; that the nurse wasn't removed from the situation, there wasn't an immediate referral up. Have you got any insight from your position as the safeguarding team who were doing the training of the staff of why -- why that occurred, why the nurses, senior nurses, Karen Rees, Eirian Powell, Alison Kelly it appears didn't view that as a safeguarding concern?
SINDALL: I don't know and I'm very surprised.
BROWN: In terms of the police, at what point would you have been considering the police in that scenario, so we have got a precise scenario in fact because we have got a Consultant who's concerned about a nurse, who's been present at a number of unexpected and unexplained deaths and then is talking about a specific concern related to a specific baby on the ward at that time?
SINDALL: That -- immediate I would have thought. It would need to go to the -- if you are talking about deliberate harm to a child and that's been witnessed.
BROWN: Well, I don't think anyone is suggesting witnesses --
SINDALL: When you talk about Dr Jayaram --
BROWN: Dr Jayaram was expressing his concerns --
SINDALL: His concern.
BROWN: So no suggestion of anybody witnessing, but simply a concern --
SINDALL: Right. Okay.
BROWN: -- that these -- a child or children in that case were considered at risk?
SINDALL: I think that that would form part of a discussion with the LADO and the LADO should have been informed really immediately and part of the -- because they are available on the phone as well, the LADOs, and I have spoken to them on the phone, so you would be able to pick up the phone, speak to the LADO and say: we are going to make a formal referral but this is the concern. And I'm fairly sure, knowing the LADOs that I have had contact, with that they would have been discussing the need to inform the police.
BROWN: If we can just look at something slightly different now, the Safeguarding Strategy Board. So if we could go to INQ0102620, so this was the -- it's going to come up in a moment, the Terms of Reference for this board, Ms Sindall. This was a board that you sat on as the Safeguarding Strategy Board?
SINDALL: Yes.
BROWN: These are the Terms of Reference, so it just sets out what that board was intended to do. It met every two months, we will look at the attendees in a moment but you attended as did Karen Milne, Dr Isaac, Dr Mittal, Alison Kelly, Sian Williams, Julie Fogarty and the Deputy Director of Human Resources, Dee Appleton-Cairns. Just before we look at these terms of reference, why was there the Director of Human Resources, Dee Appleton-Cairns, what was the relevance of her being on a safeguarding -- it may seem obvious to you but why would you have someone from human resources on a Safeguarding Board?
SINDALL: Because there has been recommendations before around staff recruitment, Disclosure and Barring Service and also because HR would be involved if there were any sort of allegations against staff. So it's important that HR policies have a link up in some way with safeguarding.
BROWN: If we can just look at that, it's come up now. So the sixth bullet point down. At the very top it says the purpose, it reports to the Quality & Safety Patient Experience Committee, responsible for ensuring safeguarding is the strategic objective within the Trust. Then it talks about the duties. The sixth bullet point is: "To ensure that the Trust is reporting effectively to external agencies when we have safeguarding concerns." So to that extent, in terms of the duties and what it was trying to achieve, the Safeguarding Strategy Board in this case, it failed, didn't it?
SINDALL: Yes.
BROWN: If we can just then turn to the INQ0043309, so this is just an example of an agenda for the Safeguarding Strategy Board on 15 April. We can see there that at point 9, LADO cases -- sorry it's just come up -- would be considered?
SINDALL: Yes.
BROWN: Lessons learned. I think compliance is generally discussed. We see at 10, the fourth bullet point down, learning from significant incidents, local/national. So learning from other incidents was something that would be on the agenda and if we could then go over to page 3. So what this pack of documents appears to be is there is an agenda and then attached to the agenda in the normal way are the minutes of the last meeting --
SINDALL: Yes.
BROWN: -- and then some other documents?
SINDALL: Yes.
BROWN: If we just look at the minutes there of the meeting, we see -- actually if we can go on to page 4. We see there compliance, for example, is one of the things that would be discussed and it says there Group 1 and 3., so Group 3 is what we are interested in for the neonatal unit, neonatal are above 80%. Then in terms of the other documents that were attached to this, do you remember when you received agendas and minutes receiving other documents?
SINDALL: Yes.
BROWN: Attached?
SINDALL: There would be a big bundle of attachments.
BROWN: In this document, one of those attachments and if we could turn, be calling up while I am setting this out, page 102, one of the attachments here was a set of PowerPoints that came from another Trust in which there had been a concern about a member of staff harming patients and in fact who was later convicted of sexual abuse in that case that was the harm being caused to the patients in there and this PowerPoint set out key points. Now, I think your evidence is that you don't actually recall seeing this at the time, this PowerPoint?
SINDALL: I don't.
BROWN: But had you had a pack with documents you would presumably have normally have read it?
SINDALL: I would try to before the meeting.
BROWN: Looking there, though key points, what's your view about those points, do you agree with that, bearing in mind this is talking about what were the key learning points from this Trust in relation to a situation where concern was raised about a member of staff harming patients, in fact harming children?
SINDALL: Well, it has --
BROWN: Yes, do you agree with it, do you feel these are useful points?
SINDALL: Yes.
BROWN: Just going through them, we see there escalation at early action as per safeguarding policy; early disbelief must be an explanation, communications with patients and families, and they note: superb support from the police at the beginning of the year-long experience. That is what I think we have established you would expect to happen where there was a concern about a staff member?
SINDALL: Yes.
BROWN: So the question is it would appear that this
learning was being shared and we saw from the agenda that one of the items was learning lessons from other areas, learning from significant incidents. This was in April 2016, so before for example Child-O and Child-P had died, had been murdered. Do you think there was a failure to incorporate that learning into the training?
SINDALL: That PowerPoint to my knowledge, I had never seen it until it came through in my bundle, so I don't recall there being any discussion of it at the Strategy Board meeting at all.
BROWN: Setting aside that, so you don't recall it, but do you think in fact that is the sort of thing that should have been within the training, thinking now?
SINDALL: The whole PowerPoint or the --
BROWN: Not necessarily the whole PowerPoint but those messages that don't appear in the PowerPoint at the Countess of Chester?
SINDALL: Yes, some of those messages could have been incorporated into the training.
BROWN: Is there any one you want to pick out in particular or broadly, is that the message, I am not saying that PowerPoint, but those --
SINDALL: I think escalation and early action as per safeguarding policy, so it's clear that somebody understood the safeguarding policy at that hospital Trust.
BROWN: Just returning to when you first recall being made aware that there were concerns about harm being done to babies, just take it in stages. When did you first become aware that there were increased mortality and concerns about that?
SINDALL: I had -- I was aware that there was a review that had been ordered by the Royal College of Child Health and Paediatricians in relation to increased mortality.
BROWN: Was that the first time because of that review that you learnt about increased mortality or --
SINDALL: Yes, and I don't know how I learnt about that review. But -- but that was the first time I was aware that there was increased mortality on the neonatal unit.
BROWN: And did you at that point think were you aware that those were sudden and unexpected -- unexpected and unexplained deaths or --
SINDALL: No.
BROWN: -- did you not have that level of knowledge? Had you known that those were unexpected deaths, what would your view have been about the SUDiC procedure, would you have considered that should have taken place?
SINDALL: We didn't really in our side of the team, Karen and myself, have an awful lot to do with SUDiC, we very much saw it as a responsibility of Dr Mittal.
BROWN: Was that the case also for the Child Death Overview Panel?
SINDALL: Yes.
BROWN: Did you understand SUDiC was the process would take place if there had been an unexpected death in hospital?
SINDALL: No, I didn't.
BROWN: You didn't think SUDiC was -- took place where death had been in hospital or you didn't know, sorry?
SINDALL: I didn't -- I knew it took place. I mean, the experience that I had had around SUDiC in relation to attendances at the hospital were those deaths that occurred outside of the hospital and came into the hospital.
BROWN: If someone had come to you and said "there's been an unexpected, unexplained death" what would you have done? Would you have referred that to Dr Mittal is that your evidence?
SINDALL: I would have thought that the paediatricians would be involved anyway.
BROWN: So you -- is it right to say you didn't have involvement with SUDiC?
SINDALL: No.
BROWN: But the understanding you had insofar as you had an understanding was that it wasn't put in place where the death occurred in hospital?
SINDALL: I -- I --
BROWN: You just didn't know?
SINDALL: I just didn't know.
BROWN: In terms of when you recall first being made aware that there were concerns that a nurse was possibly harming babies, when did you become aware of that?
SINDALL: When Karen Milne returned to the office after she had a one-to-one with Alison Kelly, which was a routine -- her supervision was with Alison Kelly and I noticed a real change in her demeanour when she came into the office. She seemed really quite upset and I said: how did your one-to-one go? And she told me that Alison had discussed with her not that she was seeking advice but had discussed with her that they were going to call the -- either had already or were about to call the police in relation to concerns that somebody was -- that a member of staff was involved in harm to the babies on the neonatal unit.
BROWN: It is that detail that helps us to date it because that would suggest that this is March/April 2017 if it was just after or just prior --
SINDALL: I don't know, I don't know when it was.
BROWN: But as far as you were concerned, it was either just after or just before the police were involved?
SINDALL: It was either at the time or a day or two before.
BROWN: So just looking at that, by this stage, by March/April 2017, we have had the RCPCH review and Letby in fact was moved off the ward back in July 2016. There's been the RCPCH review, there's also been a grievance procedure. Were you aware of the grievance procedure?
SINDALL: Not until I received the bundle.
BROWN: There's been significant numbers of meetings between the paediatricians and the Executives and there is clearly a huge issue and a huge safeguarding failure that has occurred to get to the stage where the police are being called at this event in 2017 and I am just wondering if you can assist on the apparent disconnect between you delivering safeguarding training once a month, attending a Safeguarding Board and yet the safeguarding team, certainly in terms of you and Karen Milne, were unaware, completely unaware that there were concerns about a nurse harming babies?
SINDALL: I do wonder whether the status of the safeguarding team within the hospital wasn't as -- as high as it should be, that would have made it a more natural thing, maybe for the paediatricians to think. So, for example, head of safeguarding or something like that, there were just the two of us getting on with the day-to-day work and I don't think that our status within the hospital or our importance within the hospital was as it should have been.
BROWN: You are clear, are you, that despite getting on the neonatal unit, you say you worked proximity, you didn't hear anything about nurses talking about a nurse being moved off the unit or --
SINDALL: Nothing whatsoever.
BROWN: Can we just go to the last document then, INQ0004715. This is the annual report, the Safeguarding Children's Annual Report for 2016/2017 what involvement, if any, did you have in drafting that?
SINDALL: This was a document that was put together by Karen Milne that she relied on other people providing information contained within it. So, for example, for CDOP she would go to Dr Mittal and say: do you need to put any -- you know, do you have any information around CDOP? I would put in -- she would ask me for information about the LSCB quarterly audits that I attended and any
learning from them that could go in the report or any new initiatives around early intervention, I would. So it was a document that was pulled together by Karen but it contained information from lots of different people.
BROWN: If you can just go to page 19, so just to set this in context as well. So this was dated July 2017, it's -- so by July 2017 the police are involved. It was clear that multiple individuals had not reported their concerns about Letby to the LADO, in fact, they still hadn't taken place, that -- certainly for a prolonged period it hadn't been referred to the police and in essence there had been a safeguarding failure. It hadn't been picked up as a safeguarding issue. We look then at the little paragraph there under "Countess of Chester neonatal unit investigation", it says: "There were a cluster of neonatal deaths identified between June 2015 and June 2016 at the Countess of Chester which are being investigated by the Cheshire Police. As a result of this Inquiry some changes have been made to the Pan-Cheshire CDOP process called ..." The SUDiC protocol and then it goes on. But there is nothing in that report by way of serious reflection as to what's gone wrong with
safeguarding and was that really adequate in what was the annual report of safeguarding, given what had occurred?
SINDALL: My understanding of that paragraph from discussion with Karen Milne is that she was given.
BROWN: Sorry, discussion at the time?
SINDALL: No, not at the time. Subsequently. Or I can't remember exactly when, not relatively recently but some discussion when that was put in there, that Karen told me that she was given that paragraph verbatim by either Alison Kelly or the Mel Kynaston, the Associate Director of Nursing, to put this in verbatim.
MS BROWN: Well, we can ask Alison Kelly about that. Thank you very much, Ms Sindall. I have no further questions and there aren't any questions from any Core Participants.
LADY JUSTICE THIRLWALL: Thank you, I have just got one question, if I may, Ms Sindall. Could we bring up on the screen INQ0043309. It was a single page of a PowerPoint presentation.
MS BROWN: I think it is page 102.
LADY JUSTICE THIRLWALL: Thank you, Ms Brown I omitted to make a note of that.
That's it. Now, that was something that was provided at the time but you didn't see it?
SINDALL: No.
LADY JUSTICE THIRLWALL: And have no memory of looking at it?
SINDALL: That wasn't discussed at the strategy board.
LADY JUSTICE THIRLWALL: No.
SINDALL: I don't recollect it being discussed.
LADY JUSTICE THIRLWALL: You don't remember it, no all right. So just the short question from me is they have got the starting point and then the second bullet: "Early disbelief -- must be an explanation."
SINDALL: (Nods)
LADY JUSTICE THIRLWALL: Which -- I mean, you tell me what you think. It seemed to me that what that's saying is at the beginning people just don't believe the allegation and that there must be some other explanation.
SINDALL: Yes.
LADY JUSTICE THIRLWALL: Is that something which in your experience can affect the way people approach concerns?
SINDALL: I think so, yes. I do. And it's very hard to think that somebody in a position of care and that's trusted to provide that care and to -- to provide safe care would deliberately want to harm, yes, I think that it's -- it's a natural thing for people to say "surely not".
LADY JUSTICE THIRLWALL: I suppose that's why training is important, isn't it, to remind people as you put it, thinking the unthinkable.
SINDALL: And I think that's why it was in the policy, we need to think the unthinkable.
LADY JUSTICE THIRLWALL: Yes. Thank you. Have you got anything else, Ms Brown?
MS BROWN: There is nothing else. I think I have covered it in my questions but Ms Sindall, was there any other reflection you wanted to add? I omitted to ask the question.
SINDALL: Just I wasn't aware that -- when I got that PowerPoint through, I wasn't aware that it had been sort of sent as part of a bundle, so my question was around the PowerPoint: how, I guess when we are aware when, there is a multi-agency working and a child dies there is a serious case review, there is a clear process to, you know, discuss whether or not it becomes, does that child becomes the subject of a serious case review, there's certain learning that takes place that is then readily available via the NSPCC host, a repository of
all the serious case reviews, so that people who are wanting to learn and maybe to pass on that learning can access that learning that way. When it happens in the NHS, and it may be my naivety around serious cases, but when there's only -- a tragedy like this where children come to harm, there is only one agency involved, I don't know whether these children become subject to a serious case review and if they don't, then the investigative process and the learning from that isn't available or is it available? Is there some national initiative or some national mechanism around patient safety where incidents like this when they occur, that learning that occurs as a result of it is then available for, across the NHS? I -- it might be my naivety, maybe it is. The learning from Thirlwall will be available publicly for people to reflect on and include in their training but, you know, this one from Cambridge, yes, they took it upon themselves to send out a PowerPoint or was there, I would wish to understand the mechanism by which learning around serious incidents like this, serious safeguarding incidents, whether there is an established mechanism for sharing that across the NHS.
LADY JUSTICE THIRLWALL: Yes, thank you. We know
that this certainly was shared.
SINDALL: Yes.
LADY JUSTICE THIRLWALL: We know how far it got, certainly as far as you were concerned.
SINDALL: Yes.
LADY JUSTICE THIRLWALL: Yes, but thank you for that and we have got your other reflections already. So those are my questions. No one else has any questions, so you are free to go and we will break and we will start again at 20 to 4.
(3.22 pm) (A short break)
(3.40 pm)
LADY JUSTICE THIRLWALL: Yes.
MR DE LA POER: My Lady, our final witness for today is Dr Isaac. I wonder if she might come forward.
DR HOWYADA ISAAC (affirmed)
LADY JUSTICE THIRLWALL: Do sit down, doctor.
ISAAC: Thank you.
LADY JUSTICE THIRLWALL: Yes, Mr De La Poer.
MR DE LA POER: Please could you give us your full name?
ISAAC: Dr Howyada Isaac.
DE LA POER: Can you confirm please that you gave a witness
statement to this Inquiry dated 25 June of this year?
ISAAC: I confirm.
DE LA POER: Is the content of that true to the best of your knowledge and belief?
ISAAC: Yes. There is a slight error with the date I was appointed as a Consultant, in the second paragraph, I think.
DE LA POER: I am sure we will be able to correct that but other than that, is the content true to the best of your knowledge and belief?
ISAAC: Yes, it is.
DE LA POER: Let's deal with your background. Did you qualify as a doctor in 1986?
ISAAC: Yes.
DE LA POER: Have you worked in paediatrics since 1990?
ISAAC: Yes.
DE LA POER: Did you become a member of the Royal College of Paediatrics and Child Health in 1998?
ISAAC: Yes.
DE LA POER: I think you first became a Consultant in 2005; is that right?
ISAAC: Yes, that's correct.
LADY JUSTICE THIRLWALL: 2005.
MR DE LA POER: That's correcting the error in your witness statement, I hope?
ISAAC: Yes.
DE LA POER: Did you join the Countess of Chester in 2012?
ISAAC: That's correct.
DE LA POER: Did you join both as a Consultant and as the named doctor for safeguarding?
ISAAC: Yes.
DE LA POER: Now, in terms of what that role meant, was it your responsibility to ensure that the organisation you were working for, the Countess of Chester, met its safeguarding responsibilities?
ISAAC: That's right.
DE LA POER: Did that include the Countess of Chester's responsibility to protect children from harm?
ISAAC: That's correct.
DE LA POER: Now, being the named doctor for safeguarding is, would you agree, an important role?
ISAAC: Yes.
DE LA POER: It is a role which is identified in statutory guidance, isn't it?
ISAAC: That's right, yes.
DE LA POER: Just tell us very briefly, please, between the difference between the role of named doctor for safeguarding and that of the designated doctor?
ISAAC: So the named doctor for safeguarding, I work for the Trust and I ensure the standards of safeguarding
within the Trust are met. The designated doctor works for the CCG and looks into safeguarding within the primary care and outside of the Trust.
DE LA POER: We know --
ISAAC: And also other agencies including -- works very closely with social care, which we do as well.
DE LA POER: Now, we see from your witness statement, we don't need to go through it, but you undertook a very substantial amount of training for the role of named doctor; is that right?
ISAAC: Yes, correct.
DE LA POER: During the period 2015, 16 and 17, approximately how much time per week or per month were you spending on the role of named doctor?
ISAAC: So I am given two programmed activities per week which is equivalent to one day per week.
DE LA POER: Did you find that that was sufficient for your safeguarding role?
ISAAC: Yes, it was.
DE LA POER: In terms of the safeguarding structure at the Countess of Chester, Alison Kelly was, as we understand it, the Executive lead for safeguarding?
ISAAC: That's right.
DE LA POER: Just help us to understand, that isn't a role named in statutory guidance unlike yours. Who had
overall responsibility for safeguarding at the Countess of Chester?
ISAAC: So I would have responsibility for the clinical, for the strategic, but Alison Kelly would be the head of safeguarding as my line manager with regards to the safeguarding part of my role.
DE LA POER: In practice if there was a disagreement between the two of you about how to respond in the safeguarding setting, who has the final say on what should be done?
ISAAC: So Alison Kelly would be the Exec team, so she would be above me. But if I -- if we disagreed, there is a method of escalation so I could escalate.
DE LA POER: And so does it follow then that if she said no, we are not going to do that and you disagreed with her, you could nevertheless take another route to ensure that your view was carried forward?
ISAAC: I could escalate but it would be hard.
DE LA POER: And who would you escalate it to?
ISAAC: So I could talk to Dr Mittal the designated doctor or I can and -- and through him escalate to the LADO.
DE LA POER: Now, in terms of your line management by Alison Kelly, did you have one-to-one meetings with her as part of your safeguarding role?
ISAAC: No, I didn't.
DE LA POER: We have heard that other roles did have one-to-one meetings with their line manager. Why didn't you have one-to-ones with Alison Kelly?
ISAAC: I only met her in the Safeguarding Strategy Board meetings but we never had one-to-one --
DE LA POER: But was that something you ever asked for?
ISAAC: No, I haven't.
DE LA POER: Why not?
ISAAC: I tend to have safeguarding supervision through Dr Mittal, designated doctor for safeguarding and it's more around the medical aspects of the service and it's not something that she has offered me either. I don't think there was a close relationship between us in that sense.
DE LA POER: Can I just ask a direct question then. I mean, there wasn't a close relationship between us. Is that a euphemism for the fact that the two of you did not get on professionally?
ISAAC: No, no, we just didn't meet -- we only met in the Safeguarding Strategy Board meeting.
DE LA POER: If Alison Kelly became aware of a safeguarding issue, did you have an expectation that she would tell you?
ISAAC: It's not something that had happened whilst I was there.
DE LA POER: I understand that but you are the named doctor?
ISAAC: Yes.
DE LA POER: You are the person who is charged with in the statutory guidance to ensure that the Countess meets its safeguarding responsibility. Doesn't that mean that you should know about every safeguarding issue within the hospital?
ISAAC: I expect to know, yes, especially things that would be within my role.
DE LA POER: I am not suggesting anything that Alison Kelly came across, but if it is a safeguarding issue or potentially a safeguarding issue --
ISAAC: Yes.
DE LA POER: -- although she may be senior to you in management terms, the responsibility sits with you, doesn't it?
ISAAC: Yes.
DE LA POER: And therefore you should be told everything, shouldn't you?
ISAAC: Yes, I couldn't possibly manage everything on my own because that's why we have safeguarding nurses and they deal with other issues as well. But yes, definitely we should have been discussed serious things,
yes.
DE LA POER: We are going to have a look at three policies in a moment just briefly, but before we get to that, as part of your safeguarding training and no doubt your wider medical training, were you aware of previous situations where a member of staff had harmed patients deliberately?
ISAAC: Within the Trust?
DE LA POER: No, not within the Trust within the NHS. I am here thinking about Harold Shipman, Beverley Allitt, Colin Norris, Victorino Chua?
ISAAC: Yes.
DE LA POER: Were you aware of all four of those cases?
ISAAC: I was aware of Harold Shipman and Beverley Allitt.
DE LA POER: Does it follow from that that you weren't aware that a nurse at a hospital not too far from the Countess of Chester was sentenced in May of 2015 for murdering two patients with insulin and poisoning others; did you know about that?
ISAAC: I have -- I have -- I have heard about it in Stockport, yes.
DE LA POER: Yes.
ISAAC: I have heard about it but not in detail.
DE LA POER: So was that not a case that was circulated on
the safeguarding circuit as an opportunity to remind safeguarders that they needed to be looking inward towards members of staff as well as outward?
ISAAC: No, this is -- wasn't included in any safeguarding training. It was my knowledge through these cases was through the media.
DE LA POER: We are going to look now at Working Together. INQ0014575 and we are just going to look at four pages, we will start at page 2 and just run through with you, if we may, Dr Isaac, how we get to page 54, so 52 first. So we can see this is under the chapter "Organisational responsibilities" and this is really just so that we can track through how we get to an important part of this document. It begins by saying at paragraph 3 that section 11 places a duty on, among other things, NHS organisations; do you see that?
ISAAC: Yes.
DE LA POER: If we go over the page, we will see that paragraph 4 says: these organisations should have in place arrangements that reflect importance of safeguarding and promoting welfare of children. Then it gives a list of effectively what, among others, NHS organisations should have. Now, one of those, we can pause briefly on, is the third bullet point from the bottom which is a designated
professional lead for safeguarding. And here that's referring to a role such as you had, the named doctor role; is that right?
ISAAC: Yes, for health providers it is named doctors, yes, named professionals.
DE LA POER: Yes, and we see that in the brackets. There is one other matter that appears under that heading at 4 of what organisations should have, it is just over the page, we have looked at it many times but I would like to look at it with you: "NHS organisations should have clear policies in line with those from the local Safeguarding Children's Board for dealing with allegations against people who work with children." There is then a list of three bullet points of the way in which an allegation against an individual might be framed. The language, as we have observed many times, is "may" or "possibly" or "may pose a risk". Did that accord with your understanding at the time in 2015/16/17 of the way in which safeguarding allegations should be thought about?
ISAAC: Yes.
DE LA POER: Now, just reflecting back on it. Did the Countess of Chester have a clear policies in line with the local safeguarding children's board in terms of how such allegations should be dealt with?
ISAAC: Yes, it was written in the safeguarding policy and welfare of children.
DE LA POER: So we are going to get that that in just a moment; that is where the clear policy is to be found, is it?
ISAAC: Yes.
DE LA POER: Before we get to that, one final element of this just to bookmark, page 57. We can see the third and final bullet point on this page, that: "A named doctor should be identified as well as a named nurse." Then four lines up from the bottom -- five lines up from the bottom: "Named professionals have a key role in promoting good professional practice within their organisation, providing advice and expertise for fellow professionals and ensuring safeguarding training is in place." So did it form part of your role to give advice from a safeguarding perspective to your colleagues within the hospital?
ISAAC: Yes, it was.
DE LA POER: That's a role that you have by virtue of being a named doctor?
ISAAC: That's correct.
DE LA POER: Thank you, we can take down Working Together. The next policy we are going to look at is the Cheshire West and Chester Council Interagency Policy, INQ0007918. Now, is this a document that you are familiar with?
ISAAC: No, is this part of the LSCB, is it on the --
DE LA POER: This is Cheshire West and Chester Council.
ISAAC: Right, okay.
DE LA POER: It is the Threshold for Initiating Safeguarding Procedures?
ISAAC: Yes.
DE LA POER: It is an interagency document?
ISAAC: Yes.
DE LA POER: If we look at the large paragraph in the centre: "Determining whether or not abuse of a person has taken place is not always a straightforward matter, particularly when concerns relate to neglect. A judgment will be required about whether an act or omission has caused significant harm. The multi-agency arrangements for responding to concerns exist to establish whether or not abuse has occurred. It is very important that these arrangements [and it talks about the discussion and the meeting at a strategy level] are
triggered if there is a possibility that abuse has occurred." So again summarising that: was it your understanding that whether or not abuse had occurred is a matter for the multi-agency response. What's important is that if there is a concern it is brought forward to the multi-agency level?
ISAAC: Yes.
DE LA POER: So the final policy to look at is the Countess policy, INQ0014165. If we look at page 3, I am sure you can tell us as that comes up that there seemed to be a number of fairly similar version of this document from around this time that we have invited you to consider ahead of time. Do you know why the policy appears to have been amended and updated a number of times?
ISAAC: I don't know but usually it's every couple of years, so I'm not sure why there are so many versions of it.
DE LA POER: Can you confirm that there are a number of versions with, for example, this September 2015 date as we see in the centre of page 3?
ISAAC: Yes.
DE LA POER: So if we go to page 11, is this series of bullet points the process that you were talking about
that is contained within this policy?
ISAAC: Talking about with regards to?
DE LA POER: Working Together says there needs to be a very clear policy --
ISAAC: Yes.
DE LA POER: -- at the local level about what it do if abuse is suspected, if an allegation is made?
ISAAC: Yes.
DE LA POER: Is this the process, is my question?
ISAAC: Yes, there's a flowchart as well about how to escalate and what to do.
DE LA POER: Is that the flowchart that we have heard spoken about as being put up on the walls?
ISAAC: Yes.
DE LA POER: When we look at what's contained within the policy, this part of it appears to focus upon a starting position of when a child is suspected to have been abused is admitted to the hospital; do you see that?
ISAAC: Yes.
DE LA POER: So it seems to start from an assumption that the suspected abuse is from outside?
ISAAC: Yes.
DE LA POER: I mean, do you think that the Countess' policy dealt adequately with the thinking that perhaps it could be a member of staff who was responsible for harm?
ISAAC: There is a section -- another section as well about the whistleblowing policy.
DE LA POER: Yes.
ISAAC: If you suspect there is a member of staff who are concerned. But over here, I think we are looking at the common scenarios, this is a very uncommon scenario, this is very rare and when we are looking at this policy it was looking into most of the cases that we do get are children who come in with bruises or injuries and as paediatricians or nurses or medical staff or clinical staff we have to deal -- and we suspect abuse and it's never been, never -- you never for certain in child protection, there is no certainty and it's all on the balance or probability and suspicion. And this is the commonest scenario that we do get.
DE LA POER: I was just going to ask about that because the phrase "balance of probability" you use in your witness statement. Balance of probability ordinarily means more likely than not, or greater than 50% chance, whereas "suspicion generally" or "possibility" or "may" allows for a lesser degree of certainty?
ISAAC: (Nods)
DE LA POER: Which did you think was the correct level of test that needed to be applied before you had a safeguarding concern that you had to respond to?
ISAAC: We get safeguarding concerns and we assess the probability and we will -- with regards to escalation, we don't have to be certain to escalate but we have to have a degree of suspicion.
DE LA POER: Yes, but do you need to have so much suspicion that you are right at the start saying it's more likely than not that this is the explanation or can you have a lesser degree of suspicion?
ISAAC: We can have a lesser degree of suspicion. And when in this particular case when you get somebody coming from outside, you will see all cases and decide yes or no on balance of probability less likely, there are different balances, or more likely or probable. So it, it's -- we would assess and then when we produce our report we will say on the balance of probability we think this is likely or unlikely, yes.
DE LA POER: When you get to the back end of the process as to making a finding as to whether or not there has been abuse or neglect, then you are applying that standard, is that what you are saying?
ISAAC: Yes.
DE LA POER: But at the start of the process in order to --
ISAAC: Yes.
DE LA POER: -- raise it with safeguarding and for safeguarding to say this requires an investigation,
potentially take it to the LADO, that doesn't require balance of probabilities at that stage, does it?
ISAAC: No, you have concerns, yes.
DE LA POER: Now, we have heard already about the Safeguarding Strategy Board which as we understand it is a board that reported to QSPEC; is that right?
ISAAC: Reported to?
DE LA POER: To the QSPEC meeting, the Quality Safety Patient Experience Committee?
ISAAC: (Nods) I didn't attend that committee.
DE LA POER: Well, let's have a look at the document behind it, INQ0102620. Now, when you say "I didn't" -- as that is coming up, you didn't attend QSPEC but did you attend the Safeguarding Strategy Board?
ISAAC: Yes.
DE LA POER: So if, as we bring that up, we have looked at this already, we don't need to go over what we have already looked at, it starts at page 16 within this document. There's just one part of it that I wanted to ask you about, which is at page 19. We can see there under "frequency of meetings", there is a provision within this policy for an emergency meeting, do you see that?
ISAAC: Yes.
DE LA POER: Now, presumably an emergency meeting might be
called if there was a very serious safeguarding concern which was emerging at the hospital?
ISAAC: Yes.
DE LA POER: So does it follow that although this is a strategy board for safeguarding concerns of the most serious type, as in a particular case this board could also discuss that?
ISAAC: It can, but I would expect to have discussed it on a one-to-one before bringing it to such a large group.
DE LA POER: Now, we will come back in a moment to a particular Safeguarding Strategy Meeting, I just want it ask you briefly about training. Again the Inquiry has heard a lot about training. There's one document I want to take you to, INQ0108344. Now, this has got your name attached to it. Do you see that towards the top?
ISAAC: (Nods)
DE LA POER: To whom were you providing this training?
ISAAC: As far as I remember, I was doing it jointly with Paula Lewis to hospital staff. I don't think it was specifically for medical staff, I think it was generic training.
DE LA POER: There is only one slide -- and we have already looked at it once today -- I would like you to look at, page 74. This appears to be, if you like, the sign-off slide, the closing message, the "if you take away one thing from this talk, it is this", is that fair?
ISAAC: Yes.
DE LA POER: That is how you are signing off to everybody?
ISAAC: Yes.
DE LA POER: That it's everybody's business, if you have suspicions pick up the phone?
ISAAC: Yes.
DE LA POER: Presumably when you are telling all the people you are training: pick up the phone, you are telling them: pick up the phone to me or my colleagues in the safeguarding department?
ISAAC: Yes.
DE LA POER: Is that right?
ISAAC: Yes.
DE LA POER: When you provided training, was that the sort of message that you were giving at the end of every presentation that you made?
ISAAC: Yes, it's -- to raise awareness of safeguarding is everybody's business.
DE LA POER: Thank you. We can take that down. We are just going to look at somebody else's slideshow here. INQ0043309 and I think you heard questions after your colleague earlier this afternoon, so you will know the
document we are going to have a look at, it is at page 102. It formed part of a pack for a Safeguarding Strategy Meeting in February of 2016 and it would appear that your colleagues in Cambridgeshire had provided this slideshow which they were circulating about an experience that they had had. Do you have a recollection of having seen this slide which forms part of about a 10-slide presentation?
ISAAC: No, I can't remember.
DE LA POER: It's provided to the Safeguarding Strategy Meeting as part of the material for that meeting. I mean, was there an expectation that you would read all of the enclosures for a meeting?
ISAAC: Yes.
DE LA POER: So if it forms part of the enclosures, would you expect that you did read this at the time?
ISAAC: Yes, I would try my best, yes.
DE LA POER: In terms of good practice, we can see "escalation and early action in accordance with the safeguarding policy and immediate suspension"; presumably you would regard that as a very important albeit neutral step in a safeguarding investigation?
ISAAC: (Nods)
DE LA POER: That the moment there is concern about an
individual in this case a member of staff, they need to be suspended?
ISAAC: Yes.
DE LA POER: Is that the sort of advice that you would have been prepared to give back in 2016/7 if someone had brought such a concern to you?
ISAAC: Yes.
DE LA POER: We can see early disbelief must be an explanation. Did you have any experience of allegations being made against a member of staff and the reaction of people around as to whether it may or may not be true?
ISAAC: Yes, I think that is a very natural reaction; that people don't think of somebody caring for children would harm children and especially when you think what's the motive. So yes, of course people will resist and will think there must be some other explanation.
DE LA POER: So that is the staff and colleagues. Is it important for the safeguarders to think a little more clearly about it though?
ISAAC: Yes, and we have been taught to think the unthinkable because the same thing happens when you get a parent coming with a child and a person doesn't want to think that the parent could be harming the child because that's not natural, but we were taught you have
to think the unthinkable.
DE LA POER: Thank you and we can obviously see in this case that there was police support from the very beginning. In the case of an allegation of a crime, would you expect the police to be involved at the very start?
ISAAC: I would.
DE LA POER: Thank you. We can take that down now. So we are going to turn now to events at the Countess. The first thing is just to understand your geographical situation. We have heard from Dr Holt that you and she shared an office; is that right?
ISAAC: Yes, Dr Holt was a new Consultant so she came in later, maybe when I was reading through the document, it was towards the end of the process.
DE LA POER: So it was March 2016, I think that she --
ISAAC: Yes.
DE LA POER: -- joined?
ISAAC: Yes.
DE LA POER: Dr Holt replaced Dr Newby. Did you share an office with Dr Newby before Dr Holt started or did you just have your own office?
ISAAC: No, I didn't share an office with Dr Newby.
DE LA POER: Did you share it with any of the consultant paediatricians before Dr Holt?
ISAAC: Yes, I did.
DE LA POER: Who did you share it with? Do you want to just check the cipher list to make sure if ...
ISAAC: Yes, it is V something. ZA.
DE LA POER: Dr ZA.
ISAAC: Yes.
DE LA POER: So that position, did that apply up until March of 2016 when Dr Holt arrived?
ISAAC: Yes.
DE LA POER: So in the period that you were sharing an office with Dr ZA, did you become aware of the increase in mortality on the neonatal unit?
ISAAC: I can't remember the exact date when I came aware of the increased mortality, but it was late and I definitely wasn't aware of the concerns of my colleagues until I met with Steve Brearey and his appraisal and that was the time when I was really aware of what was going on but before that I -- I wasn't really -- I may possibly have known about the mortality because there was the Royal College review, so I probably knew at that point. But I can't pinpoint a specific date --
DE LA POER: But my question was directed to the period before March 2016 just thinking about the time that you were sharing an office with Dr ZA and whether you ever
spoke to her about it or whether she ever mentioned in passing to you that there had been an increased number of deaths; do you have any recollection of that at all?
ISAAC: No, I wasn't aware.
DE LA POER: Once Dr Holt joined, but before June of 2016, do you have any recollection of hearing about it from Dr Holt?
ISAAC: No, I don't.
DE LA POER: Looking back on it, does it surprise you that that wasn't bearing in mind that you are sharing an office with people who are experiencing that every day in terms of the thoughts about it, the discussions that they have told us they were having that nobody mentioned it to you?
ISAAC: I -- we all -- we were all in a corridor, we had offices in a corridor and there was lots of doctors in that corridor, we all shared offices there. I think there were five offices and I possibly heard a baby died, heard something like that, but not heard the full story, not -- wasn't aware about the full extent of their concerns and their suspicions. You know, they discuss cases all the time, they discuss, you know, issues, they will stand in the corridor and talk but I wasn't aware of -- of the degree of their concerns. It -- I don't think they at that
point during that time -- I don't know how much they were aware either because, you know, it was an evolving picture.
DE LA POER: The Inquiry heard a great deal of evidence from them. From your point of view. In the event that your Consultant colleagues were discussing a particular member of staff, and discussing between themselves whether or not the association that member of staff had may be sinister, is that the point that they should have been talking to you?
ISAAC: Yes, but I have not heard them discuss about a member of staff on the corridor.
DE LA POER: Were you aware of the downgrading of the neonatal unit in July of 2016?
ISAAC: I don't know when I became aware of the downgrading of the neonatal unit.
DE LA POER: Well --
ISAAC: I can't remember.
DE LA POER: Were you aware that the Trust in the first early days of July 2016; were operating what it described as a Silver Command?
ISAAC: Yes, I -- I have not heard that term but I knew that they were.
DE LA POER: Looking at the list of invitees, it doesn't appear that any member of safeguarding was invited to
any of those what were very large meetings, we have heard 36 people in one room. Should safeguarding have been invited to that -- to those meetings?
ISAAC: Which meetings?
DE LA POER: The Silver Command meetings. There was a period of three days as consideration was given to downgrading the neonatal unit and setting in train a series of investigations and reports?
ISAAC: I wasn't aware of those meetings.
DE LA POER: Should you have been aware?
ISAAC: If there are safeguarding concerns they should have let us aware, yes.
DE LA POER: We know, for example, at the end of June just before that process started, that Dr Jayaram had conducted research about whether air embolism, the deliberate administration of that could be responsible for some of the deaths, so in other words he was investigating a possible murder method. Should you have been made aware that that was a piece of research that he was conducting?
ISAAC: The first time I have heard of that was during the trial. I don't know when he was conducting that research, what period do you refer to?
DE LA POER: You can take it from me that it was 30 June of 2016.
ISAAC: Right, okay.
DE LA POER: Should you have been told about that?
ISAAC: Yes.
DE LA POER: Now, you were interviewed by the Royal College on 1 September?
ISAAC: (Nods)
DE LA POER: In the morning, Dr Jayaram and Dr Brearey, with support of the other five paediatric Consultants, had told the reviewers about their concerns that Letby may be deliberately harming babies. In your meeting with the Royal College that afternoon, were you told about those concerns?
ISAAC: No.
DE LA POER: Should you have been told?
ISAAC: Yes.
DE LA POER: In fact, if we just have a look at one perhaps striking example, INQ0014604, page 25. These are notes taken by the Royal College as part of their review. Do you see where it says the word "TOM"? In fact we have established that should say "team", that's just a mistranscription. This is the lunch time meeting of the reviewers. They spent part of the lunch discussing ways in which deaths may have been caused deliberately. You can see there "INS", "INS". We are not going to go into the
detail of that. It should in fact say "insulin injection" or "air embolism". So they were discussing that at lunchtime. Can you that the very next thing that they record doing under that line is that they came to speak to you?
ISAAC: They came to speak to me?
DE LA POER: If we look, we can see that after they'd had that lunchtime discussion they met with you and with other safeguarding colleagues?
ISAAC: Yes, yes, a joint meeting.
DE LA POER: Yes, in the joint meeting.
ISAAC: Yes.
DE LA POER: Should they have told you about their discussion that they'd had at lunchtime bearing in mind your safeguarding role?
ISAAC: Yes, yes, but that was not mentioned at all in our meeting. It was all general safeguarding policies and procedures in the Trust.
DE LA POER: Thank you. We can take that down. So we are just going to spend a moment or two looking at your appraisal with Dr Brearey. You have told us that that took place on 22 November 2016 and you weren't meeting him as a safeguarder, but as a professional colleague conducting his appraisal?
ISAAC: (Nods)
DE LA POER: What did he tell you in that appraisal about the concerns that he had?
ISAAC: So -- I went back for the purpose of this to read -- I remember that he told me about the increase in mortality rate going up to 13 babies from being 1 to 3 and that this nurse was on duty every time a baby died and they've had concerns. And he's done some reflection notes there as well, which I have read through, and -- and how he has escalated it to the managers but they haven't responded to him and at the time he was -- and he was concerned as well because of -- there was a grievance coming up and that he would be asked to sit in a mediation for several hours for this mediation process and grievance.
DE LA POER: Now, in terms of what he told you about the increase in mortality, the fact that there was an association with a member of staff, and that he was concerned about that I mean he was telling you, wasn't he, that he was worried that that member of staff may have murdered babies --
ISAAC: Yes.
DE LA POER: -- is that fair? And that is a clear safeguarding concern, is it not?
ISAAC: So at the time that wasn't regarded as
safeguarding and I suspect that's why my colleagues haven't approached me as a safeguarding lead. The typical safeguarding scenario, like you pointed out, is a child coming through the door with bruises or injuries and you deal with that as a clear safeguarding case. But a member of staff causing harm to babies and murdering babies was thought to be like more of a crime that would require police investigation.
DE LA POER: You --
ISAAC: My colleagues are all very experienced in safeguarding and none of them had come to the safeguarding team and I -- I suspect, obviously I am not talking on their behalf, but I suspect it's because it wasn't as clear-cut as what we think now.
DE LA POER: But you have --
ISAAC: Another -- another thing I would like to point as well is at the time when I knew about it, this had already been escalated to the highest level. The senior management, the top, you know, in the hospital were aware of it and Lucy Letby had already been removed from the neonatal unit. So when we talk about safeguarding, we talk about children who are still alive and we are safeguarding them. But in this case, she had been already removed, the children were safe in the unit and we were dealing with child death and that's a different process to the safeguarding.
DE LA POER: But by the end of November of 2016, plans were afoot to return Letby to the ward. Doesn't that just demonstrate why you should have intervened at that stage?
ISAAC: Yes. If she were to be returned to the ward, I definitely would have escalated it.
DE LA POER: But you didn't know unless you went and found out what was going on and what the plan was?
ISAAC: But I was -- you know, I -- I had talks with Dr Brearey at the time and -- and I was waiting to see what would come out of the reports because you say you don't have to be sure to raise the alarm bells, which is correct, if you have suspicions, that's correct. But when you are making a referral you want to give a good quality referral. And a lot of people were saying at the time and would say, "This is just a coincidence, you can't blame a member of staff because of rise of mortality. You need to look into medical causes first. You need to look into competencies. There could be other possibilities." But now, with the benefit of hindsight, we know that she was guilty but at the time we didn't.
DE LA POER: But --
ISAAC: And -- and it's that sort of information I was waiting for so that to escalate I would have that to back me up.
DE LA POER: Well, did you ask Dr Brearey what his Consultant colleagues thought in paediatrics on the ward?
ISAAC: What they thought about ...?
DE LA POER: Yes, whether they agreed with him, whether they were worried?
ISAAC: Dr Brearey told me that they, he -- they were worried, that Dr Jayaram and himself were regarded as troublemakers because of escalating this or raising concerns. He was the head of the department, so he was talking on behalf of everybody else. So he -- I don't know if the rest were worried or not, but I know that, you know, I -- that he was, he was sincere in what he was saying and I'm not saying that in any way he was, he was wrong. No, on the contrary, he stood up for the children. What he did was right. And they had already escalated it and they had already gone up to the chief Exec and the Medical Director and they had -- weren't listening to them.
DE LA POER: But bearing in mind what you have told us about the fact that any serious safeguarding concern, even if it's communicated to Alison Kelly, should be given to you, were you not concerned that there had been a failure here to notify you about this?
ISAAC: Yes. As a safeguarding lead, like I say Dr Brearey, when he spoke to me, he wasn't referring to me for safeguarding -- to -- for a safeguarding process to be followed. He was telling me this as part of his appraisal.
DE LA POER: If somebody tells you a safeguarding concern in any context, you have a responsibility to act upon it, don't you?
ISAAC: Yes, definitely. Yes.
DE LA POER: And looking back on it, do you think that in fact at that moment, in November, you should have immediately contacted Alison Kelly and said, "I'm the named doctor. I need to know what's going on here"?
ISAAC: Yes, and -- and that's why I sort of wrote a letter to Alison Kelly and to express concerns about safeguarding the children. However, I didn't send that letter. I was waiting for more evidence from the reviews. I knew that the babies were safe and that Lucy Letby was working in a clinical -- in a non-clinical area.
DE LA POER: Well, by January, it had been resolved at board level to seek to return her to the ward. You hadn't asked any questions, so you couldn't have known that. Didn't you need to find out about what the plan was?
ISAAC: Yes, but I -- I knew that this is a possibility and I would have escalated it if that were to happen. In retrospect now, with the benefit of hindsight, I, you know, I do wish I had sent that letter sooner and I wish I had escalated it as soon as Dr Brearey told me about this issue.
DE LA POER: Well, in fact you typed the letter on 7 February of 2017, so that was, well, over two months later. I mean, do you think that that was an acceptable period of time to leave it before you started writing that letter?
ISAAC: No. In hindsight, I should have escalated it earlier.
DE LA POER: Well, let's have a look at what was in your mind on 7 February, INQ0102620, and we will need to go to page 22. So it begins with you making clear the capacity that you are writing in and that was entirely appropriate for you to do so, wasn't it? You were perfectly entitled to write to an Executive Director in those terms because this is your responsibility, isn't it?
ISAAC: Yes.
DE LA POER: And you are enquiring about the outcome of the investigations. So at this stage all you are trying to do is find out what's happening?
ISAAC: Mmm mm.
DE LA POER: And you pose two questions, which include whether the reason has been identified at the second one and if there has been an increase in risk to babies on the neonatal unit and you conclude by saying: "If these questions cannot be answered, then further investigations may be warranted to ensure that we are safeguarding children in our care and to ensure we can protect our babies from future risk."
ISAAC: Yes.
DE LA POER: Now, all you are doing is asking questions at this stage, aren't you?
ISAAC: Yes.
DE LA POER: Why didn't you send this letter?
ISAAC: I was debating whether to send it or not and then I knew the investigation has happened, there was an investigation, we are going to get a review, and if we get a review and these deaths are confirmed as
unexplained, unexpected -- they are not due to medical causes -- then we -- there is more evidence to escalate it higher and there will be a stronger basis for doing this. And the review had already happened. We were just waiting for the report, so it's, you know -- and the babies were safe, as far as I knew, at that point in time. I would have known if they -- if Lucy Letby were to go back because I was in contact with Steve at that point. So once, you know -- I didn't know that they were withholding the neonatal case review report. I wasn't aware of that until I read all the emails, but I expected that as soon as that review was done the report would be available and I didn't know that was going to be delayed and that it was being withheld.
DE LA POER: You say you would have known if Letby was returned to the ward. It would be too late once she was actually returned to the ward, wasn't it? You would need to know at the point that the decision was being made --
ISAAC: Yes.
DE LA POER: -- so that you could have an input in it?
ISAAC: Yes.
DE LA POER: Did you know that in fact it was decided to
return her to the ward and a date for that was set by the Executives? Did you know that?
ISAAC: No, I didn't. I knew there was talks about the possibility of her returning after the grievance process, but I didn't know there was a date set.
DE LA POER: Again, looking at the situation as you now understand it to be, doesn't that rather tend to suggest that you not intervening and trusting that Dr Brearey would report to you what was going on wasn't really an adequate response by you given what was at stake here which was the safety of children? Do you agree with that?
ISAAC: I agree.
DE LA POER: Now, the final thing I want to ask you about is the Local Children's Safeguarding Board and related to that the safeguarding report that was prepared by your colleague Karen Milne. So we will deal firstly with the Local Children's Safeguarding Board. They should have been notified of what was going on at the Countess, shouldn't they?
ISAAC: But that would have been through Alison Kelly.
DE LA POER: But was it not your responsibility, as named doctor, to make sure that they knew?
ISAAC: Yes.
DE LA POER: And at any point in this time -- here we are
talking from November through to the time we know the police became involved at the end of April -- did it occur to you to think: I really must make sure that the Local Children's Safeguarding Board is aware?
ISAAC: So that is what I was trying to do by sending the letter to Alison Kelly because I would expect to discuss it with her first before escalating to the local Safeguarding Board or to LADO. That would be a discussion. I wasn't -- I didn't know at that time. I think she knew about everything all along but at that time, I didn't know what she knew and therefore I felt that I should talk to her first before the escalation because that is the process, to go through your safeguarding lead and at least have a discussion there and if she doesn't agree then that's something else you would escalate by a different means.
DE LA POER: We know you didn't send the letter. Did you speak to Alison Kelly about this before 27 April of 2017?
ISAAC: No.
DE LA POER: Why not?
ISAAC: Well, I was sending the letter as a means of opening a discussion but that never happened.
DE LA POER: Well, why didn't you send the letter?
ISAAC: Because I was waiting for the neonatal report, I was waiting ... There was also a culture of fear as well. So it's a very sensitive issue. The Consultants were threatened to lose their jobs, they were told that a red line is drawn under this and they didn't want any more discussions about this and they all didn't know what to do. So there was sort of -- I had to take it sensitively and I wanted more evidence to support me.
DE LA POER: I mean, you are the person as the named doctor to ensure that this organisation meets its safeguarding responsibilities. Wasn't it your responsibility to become involved as soon as you could and to stay involved to make sure that that obligation was discharged?
ISAAC: Yes, I agree, I should have escalated it earlier.
DE LA POER: The second part is the safeguarding report, INQ0004715. Now, this is for 2016-17. Now, it's authored by Karen Milne, but presumably it is a document that you will have read and potentially contributed to as it was being drafted?
ISAAC: Yes.
DE LA POER: And we will just look at page 7 first, paragraph 6.3. Described in it, not by any particular
reference to any particular event, is the description of the LADO, the local area designated officer -- the Local Authority Designated Officer. We can see at the second sentence: "The LADO must be contacted within one working day in respect of all cases in which it is alleged that a person who works with children has behaved ..." I mean, that's a perfectly conventional understanding from a safeguarding perspective, isn't it?
ISAAC: Mm-hm.
DE LA POER: And you knew in this case that the LADO had not been contacted within 24 hours of the allegations being raised, didn't you?
ISAAC: Yes, but it wasn't as clear-cut as this because it -- they were told that it's a coincidence, it's increased mortality and you can't blame somebody because of statistics. And so it, it wasn't clear allegations, it wasn't -- initially they were looking for medical causes as well. So it wasn't as clear-cut as where there is a clear allegation or a clear incident and that's why they didn't raise it as safeguarding.
DE LA POER: Dr Isaac, you have told us that you as a safeguarder had special training to understand that as we saw at Addenbrooke there will be "initial disbelief -- must be an explanation."
You knew that your role was to see past that and to focus single-mindedly upon the safety of the children. Do you think that you did that?
ISAAC: No, I should have escalated it earlier, I agree with that.
DE LA POER: Page 19, please. I think we are looking at paragraph 11.5. We can see under the heading "Neonatal Unit Investigation" that there is a short summary given of events. What is not there is anything about the concerns of the Consultants or the fact that a safeguarding issue had been raised. Should that have been included otherwise, isn't this misleading?
ISAAC: Yes. I didn't contribute to this. I don't know who, who did, whether -- I have heard my previous colleague Paula Lewis who said that to Alison Kelly, or it could have been somebody else, or whether it's Dr Mittal. I don't know who's put that paragraph there.
DE LA POER: But presumably you read it though at the time?
ISAAC: Yes.
DE LA POER: And presumably you knew from what you had been told by this stage that it was misleading in the sense it didn't include that additional detail?
ISAAC: Yes.
DE LA POER: Knowing that it was misleading, did you say
anything?
ISAAC: No, and I can't remember when I read this either.
MR DE LA POER: Thank you very much indeed for answering my questions, Dr Isaac. There is one permission, but I don't know whether or not all matters have been ... I am told there is one short matter.
LADY JUSTICE THIRLWALL: Would you like to come forward.
MS WOODS: Thank you, Dr Isaac. My name is Leanne Woods, I am asking some questions on behalf of a group of Families. I have just got one matter I wanted to deal with you, please. I have read your witness statement, others have read your witness statement and I want to ask you about some of the reasons for your inaction after you learnt of Dr Brearey's suspicions and I think also the inaction of others that you have given in your witness statement. So as I read your statement, you are saying, amongst other things: this was unchartered territory, you and others were not clear about what to do. Do you agree with that?
ISAAC: Yes.
WOODS: You also said that the various hospital boards and committees were not suitable for examining these kinds of issues, including because of the sensitivity of the matter, is that right?
ISAAC: Yes.
WOODS: Would you also agree that if there is a suspicion that a healthcare professional may have committed what was an incredibly serious criminal offence against babies that Executives are not equipped to investigate this kind of thing?
ISAAC: (Nods)
WOODS: Just for the record, if you could answer rather than simply nodding.
ISAAC: So I would say, like we discussed previously, the escalation process would be the Freedom to Speak and discussion with referral to LADO; that would have been the right route to follow.
WOODS: Okay. And part of the reason is that if people are thinking that there may be these incredibly serious criminal offences being committed, Executives/healthcare professionals just don't have the skills or the equipment to investigate that kind of thing, do they?
ISAAC: No.
WOODS: Given those factors, do you agree that this
is -- what was encountered with Letby was exactly the kind of circumstances where safeguarding professionals like you and Executives should be looking outside of the Trust?
ISAAC: Yes, yes.
WOODS: And you should be looking to the local multi-agency safeguarding arrangements that already existed and that specialise in responding to and investigating safeguarding concerns?
ISAAC: The local -- sorry?
WOODS: The local multi-agency safeguarding arrangements. So things like, well, we've talked about the LADO already?
ISAAC: Yes, yes.
WOODS: The local safeguarding children's board?
ISAAC: Yes.
WOODS: CDOP, if relevant, and of course also the police, do you agree?
ISAAC: Yes, yes.
WOODS: And of course that is what would have happened if healthcare professionals or indeed Executives in the hospital had had concerns that a child was suffering harm or was at risk of harm at home in the community?
ISAAC: Yes.
WOODS: Because healthcare professionals in the Trust
in those circumstances wouldn't seek to keep the concerns in-house, would they? They would go out to the established multi-agency arrangements?
ISAAC: Yes.
WOODS: And that's what should have happened here?
ISAAC: Yes. Yes.
MS WOODS: Thank you, my Lady. Thank you, Dr Isaac.
LADY JUSTICE THIRLWALL: Ms Woods, thank you very much.
ISAAC: Thank you.
LADY JUSTICE THIRLWALL: I have no questions for you. Thank you very much indeed for coming, Dr Isaac.
ISAAC: Thank you.
LADY JUSTICE THIRLWALL: Thank you. So we will rise now until 10 o'clock tomorrow morning. Thank you all.
(4.43 pm) (The Inquiry adjourned until 10.00 am, on Tuesday, 19 November 2024)
Witnesses:
Dr Nim Subhedar: Clinical Lead, Cheshire and Merseyside Neonatal Network. Advised Dr Brearey in his Thematic Review of neonatal deaths (Feb 2016).
Dr Rajiv Mittal: Designated Doctor for Safeguarding and Child Death Overview Panel (Countess of Chester Hospital)
Former Detective Chief Superintendent Nigel Wenham: Police representative on Child Death Overview Panel
LADY JUSTICE THIRLWALL: Mr De La Poer.
MR DE LA POER: My Lady, our first witness is Dr Subhedar and I wonder if he might come forward to the witness box, please.
LADY JUSTICE THIRLWALL: Do come forward.
DR NIMISH SUBHEDAR (affirmed)
LADY JUSTICE THIRLWALL: Do sit down.
SUBHEDAR: Thank you, yes.
MR DE LA POER: Please could you state your full name?
SUBHEDAR: Nimish Subhedar.
DE LA POER: Dr Subhedar, is it correct that you provided to the Inquiry a witness statement dated 20 June of this year?
SUBHEDAR: That's correct.
DE LA POER: Is the content of that witness statement true to the best of your knowledge and belief?
SUBHEDAR: Yes, it is.
DE LA POER: Did you qualify as a medical doctor in 1988?
SUBHEDAR: That's right.
DE LA POER: Did you become a Fellow of the RCPCH in 1998?
SUBHEDAR: That's correct.
DE LA POER: Was it that same year that you were appointed as a Consultant neonatologist at Liverpool Women's Hospital NHS Foundation Trust?
SUBHEDAR: Yes.
DE LA POER: Does your work there involve you working across two sites?
SUBHEDAR: That's right, yes.
DE LA POER: One of those being Liverpool Women's Hospital, the other Alder Hey Children's Hospital?
SUBHEDAR: Yes, that's right.
DE LA POER: For the period 2010 to 2024, were you the Clinical Lead for Cheshire and Merseyside Neonatal Network?
SUBHEDAR: Yes, I was.
DE LA POER: In terms of the workload of that role, approximately how many hours per week or month did you devote to it?
SUBHEDAR: It was a role that required one session a week which is four hours per week on average.
DE LA POER: Did you find that that was sufficient time for you to discharge your duties under that role?
SUBHEDAR: The weekly work was longer than four hours but yes, I was able to do that, that work in my working week.
DE LA POER: Dr Subhedar, I wonder if I could just invite
you to move very slightly closer to the microphone; that would be kind, thank you very much.
SUBHEDAR: Is that better?
DE LA POER: Yes, thank you. In practical terms, what did the role of clinical lead for the network mean?
SUBHEDAR: Yes, I was offering clinical support to members of the network as -- as a practising neonatologist who had experience of neonatal care. Specifically my roles within the network were that I would chair the Clinical Effectiveness Group meetings, I was a member of the Neonatal Steering Group, the Network Steering Group, but I didn't chair those meetings, I was a -- one of the members of that, that group.
DE LA POER: I think your colleague Dr Yoxall was the chair of that group; is that correct?
SUBHEDAR: No, it was someone called Julie Maddocks who was the network director who chaired the Neonatal Steering Group.
DE LA POER: So far as the meeting that you chaired, the Clinical Effectiveness Group, what was the function of that group?
SUBHEDAR: The primary role of that group was sharing and learning, really. Learning from Incident Reviews and
Mortality Reviews that were conducted by neonatal unit providers and sharing best practice. So that might mean learning that came from those reviews, it might mean setting up audits, creating guidelines, those sort of things.
DE LA POER: How frequently would that group meet?
SUBHEDAR: That was a bi-monthly meeting.
DE LA POER: So that we are clear, because different people mean different things, every two months?
SUBHEDAR: Held every two months.
DE LA POER: Every two months?
SUBHEDAR: Yes.
DE LA POER: In terms of the structure of the network, is it right to say that it consisted of nine neonatal units?
SUBHEDAR: So the -- there are differences in terms of what people mean by "networks". There was the overriding, overarching operational delivery network which was across the North West but within that network there are three locality networks. Cheshire and Merseyside was one of those three locality networks and within Cheshire and Merseyside, there were nine neonatal units -- nine neonatal provider units.
DE LA POER: So is a correct description the local network to mean --
SUBHEDAR: We sometimes call it the locality network.
DE LA POER: The locality network. By that we mean the Cheshire and Merseyside Neonatal Network, the network you were the clinical lead for?
SUBHEDAR: That's correct.
DE LA POER: And the network which had the Clinical Effectiveness Group meetings that we have talked about?
SUBHEDAR: Yes, that is right.
DE LA POER: Well, please help us to understand where, if it is the operational delivery network we are talking about, that that is made clear. Now, within the locality network of nine neonatal units, one of them was the Countess of Chester?
SUBHEDAR: That's correct.
DE LA POER: Is that correctly described as a Level 2 unit?
SUBHEDAR: People used to describe it as a Level 2 unit or that was a previous classification. More recently around this time it would have been termed a local neonatal unit, which is distinguished from a neonatal intensive care unit which is, if you like, the old Level 3 unit and beneath that would be a special care unit of which there weren't any in Cheshire and Merseyside at that time.
DE LA POER: Well, we have seen used around this time talk about the classification of Level 2 and Level 1. We
have seen a press release from 2016 that talks in those terms, so if we can, we will just refer to those terms I think we are all very familiar with them.
SUBHEDAR: Okay, that's fine.
DE LA POER: Was it the case that in the event that a Level 2 unit had a particular baby that had needs that they could not address adequately that they would transfer such babies to the Level 3 units?
SUBHEDAR: That's right. That would be called an uplift in care and there was set criteria. So, for example, a Level 2 unit would only be able to provide short term intensive care, so if it was anticipated that a baby may only need intensive care for a day or two then it would be acceptable for a local neonatal unit, a Level 2 unit, to look after that baby but if it was clear that this baby was going to need ongoing intensive care it would be transferred to a neonatal intensive care unit.
DE LA POER: Was there also advice sought from Level 3 neonatologists by those working in the Level 2 care centres?
SUBHEDAR: Yes, that -- that happened not infrequently.
DE LA POER: Now, if we return to the subject of the Clinical Effectiveness Group meetings and just look in a little bit more detail at the sort of things that were discussed every two months at these meetings.
Is it right that Mortality Reviews that were conducted at the hospital level would be brought to those meetings for discussion?
SUBHEDAR: That's correct, yes, yes.
DE LA POER: Was there an expectation that every Mortality Review would be brought for discussion or only those that the hospital doctors thought ought to be shared with the wider group?
SUBHEDAR: No. All Mortality Reviews would be expected to be discussed at some level at the Clinical Effectiveness Group but we would have spent more time talking about those where the reviews had identified deficiencies in care and learning and perhaps new ways of working, changes in practice.
DE LA POER: Now, you have had an opportunity to look at the minutes of the three Clinical Effectiveness Group meetings in particular?
SUBHEDAR: (Nods)
DE LA POER: I will just give the dates of those 16 September, 12 November both of 2015 and 21 January 2016.
SUBHEDAR: Yes.
DE LA POER: One of the things you tell us in your witness statement that you looked for was whether Mortality Reviews from the Countess of Chester were brought to any
of those meetings?
SUBHEDAR: I did, yes.
DE LA POER: As you acknowledge candidly in your statement you don't in fact have a recollection of some of the detail that you have seen in the minutes but you have been able to check them for us?
SUBHEDAR: That's right, I relied on the minutes themselves and the information contained therein.
DE LA POER: So if we go to the Clinical Effectiveness Group meeting for 16 September 2015, what you tell us in your witness statement is that Dr Brearey informed the meeting that there were three deaths under review to be presented at a subsequent meeting?
SUBHEDAR: Yes. I'm assuming it was Dr Brearey who brought that information it doesn't actually say that in the minutes but I would expect that if he was there, he would have been the one bringing that information to the group and the minutes suggest that there were three deaths that were notified and it was said that they would be brought back at the next meeting once reviews had been completed.
DE LA POER: Now, I don't know whether you will be able to help with this, but I will ask you in any event. We understand that those deaths related to [Child A], [Child C] and [Child D], deaths which occurred in June of 2015. Do you know whether that detail is correct or not?
SUBHEDAR: Sorry, I can't confirm that, but I can say that we didn't have any patient identifiers brought to us when cases were presented, we were just told that there were deaths and some basic information about those deaths.
DE LA POER: I am sure there will be a different way for us to check that and that's certainly the present understanding. But at all events, three Mortality Reviews acknowledged as being in process, but not presented at that meeting for the stated reason that they weren't yet ready to be presented?
SUBHEDAR: That's correct.
DE LA POER: What you tell us is that it wasn't unusual to expect the review at the local level to be completed before it reached the locality network?
SUBHEDAR: That's -- that's correct. Usual process would have been that we would have been notified that those babies had died or we might have already known that because we would have had that data at network level so that list of babies who had died would have been compiled together with the -- the local neonatal unit. And then we would have expected them to go away, do the review, wait until perhaps a postmortem was done or if it went to be a Coroner's case, to see what the
Coroner said and then come back with a focus on the learning and whether there was any change in practice that was put in place which may have had a wider message for other local neonatal units, other neonatal units full stop, yes.
DE LA POER: So that brings us to the meeting of 12 November of 2015. Again you have considered the minutes for us and you tell us that three Mortality Reviews were presented and discussed?
SUBHEDAR: That's right.
DE LA POER: We will come to a little bit more about that. But in terms of those three, do you know whether it was the three that were trailed in the previous meeting or whether it was one or two of those or none of those three or again are you not able to say because of the lack of detail?
SUBHEDAR: Well, I am unable to say but I would have expected it to have been those three but at that time at network level we didn't keep a log of exactly which cases we were expecting to have presented at future meetings. I mean, that does happen now, there's a far clearer way of logging which babies have died, whether they have been notified at CEG and whether then the review has been completed. So that level of detail is available now, but it wasn't then.
DE LA POER: Do you think it's a fair criticism to say that it was a shortcoming of the system that was being operated by the locality network at that time that such audit was not so readily straightforward?
SUBHEDAR: I think -- I think that's fair but it's fair to understand that was an evolving process around that time so it was -- I agree with what you have said that it wasn't as robust as it could have been.
DE LA POER: So by November of 2015, so far as the network is concerned, three cases have been brought to it from the Countess of Chester and they have been discussed with the object that you have described, namely to derive learning, particularly learning that might assist other units?
SUBHEDAR: That's right. I think if I remember correctly two of the cases involved babies who had had congenital malformations, so to a certain extent were expected to die. But there was a third where a postmortem report was still awaited, so that couldn't have been reviewed in full because we didn't have all of the information.
DE LA POER: Now, the Inquiry knows that by November 2015, there had been significantly more than three deaths on the neonatal unit and if I just work through them?
SUBHEDAR: (Nods)
DE LA POER: There were the three deaths of A, C and D in
June of 2015. The death of [Child E] in August of 2015. There were then two non-indictment baby deaths in September of 2015 and then the death of [Child I] towards the end of October 2015. Now, at this meeting, the Network Clinical Effectiveness Group were discussing three deaths. Would you have expected the fact that those three sat as part of an expected increase in the mortality rate to be raised in the discussion that was taking place?
SUBHEDAR: No, not necessarily. And I say that because the focus of the Clinical Effectiveness Group was that of learning from reviews that had been completed, identifying any changes in practice the local neonatal unit had recommended, and then to disseminate that information to other local neonatal units. So the purpose of CEG wasn't to monitor rates of death and numbers of death, more to receive information once the reviews had been completed and that could come back to CEG -- that sort of information could come back to CEG in piecemeal fashion sporadically depending on when the reviews had been completed, when the postmortem results were available and, if necessary, when the Coroner's Inquest had taken place.
DE LA POER: Acknowledging what you say about the big picture not being for this particular group, but just adding a little detail to what I have told you already. We also know at the end of October of 2015, Dr Brearey, who was the lead for the neonatal unit, had had a discussion with Eirian Powell and I think both of those people were present at this November meeting; is that right?
SUBHEDAR: I would have to consult the minutes again but, yes, my understanding is there were.
DE LA POER: And as a result of that discussion, we know that Eirian Powell produced a spreadsheet, or a table, which contained a total of eight neonatal deaths and that that table had analysed which of the nursing staff were present and you saw a later iteration of that table so you know what I am talking about because it was appendixed to the Thematic Review?
SUBHEDAR: Yes.
DE LA POER: Now, that occurred on the day of [Child I]'s death and so it would appear, and the Inquiry has already received evidence about this, that there was some consideration of the big picture and in particular what -- whether a staffing feature may be relevant to the mortality of each of those babies?
SUBHEDAR: Okay.
DE LA POER: Bearing in mind that that work was done, just two or three weeks before the meeting that you had,
would you have expected any mention of that to be raised, acknowledging that you are looking at individual cases but those individual cases had been part of that analysis before your meeting?
SUBHEDAR: I don't know. I don't think so. I don't think it would necessarily have been relevant to the purpose of the Clinical Effectiveness Group in the sense that at that point there wasn't -- if there was any learning, specific elements of learning that were relevant to other local neonatal units, I think I would have expected them to have been brought back but the fact there was some sort of attempted overview of the deaths this had occurred I don't think that was necessarily the role of CEG.
DE LA POER: If I just put it directly, it is my last question on the topic. In the case of each of those three babies that you were discussing, consideration was being given for each of those three deaths as to whether or not a staffing factor may be relevant to the death?
SUBHEDAR: (Nods)
DE LA POER: So setting aside the big picture in the case of the case that was being discussed, that was under active consideration it would appear at that time. Again, might that be something to be mentioned as part of the review; that this is something that we are
considering at the moment for that child?
SUBHEDAR: No, I would have been surprised if anyone had said that at that meeting only because I'm not sure -- again, focus on learning and sharing, I don't think that was relevant to that. But, yes, so I -- I wouldn't have expected that level of detail and especially how sensitive that would have been to come across at the Clinical Effectiveness Group.
DE LA POER: Just help us because we have heard that phrase, or a variant on it, a number of times, you say given how sensitive that is, what do you mean by that and how does that sensitivity prevent or inhibit discussion?
SUBHEDAR: So the sensitivity because individual staff members are being scrutinised, if that was the case. Therefore the care that they were being -- the care that they were providing for babies who had died would have been scrutinised and that is sensitive in the sense that, you know, people don't like to -- to talk about that because it makes for uncomfortable listening and hearing. Also in terms of the Clinical Effectiveness Group, that doesn't really impact on other units and what they should be doing. So that's why I don't think it was
necessarily relevant to bring that to the Clinical Effectiveness Group meeting.
DE LA POER: Do you think that in general terms that sensitivity prevents discussion happening when it should happen?
SUBHEDAR: I think it probably does. People do feel nervous about attributing poor care to an individual or groups of individuals and especially when a baby has died, to -- to think that that might have been because of the care that was provided by -- by staff members. That is uncomfortable and people do feel sensitive about talking about that.
DE LA POER: Do you think that that is a feature of the culture that needs to change in the interests of the patient?
SUBHEDAR: I think we need to be open, especially when there are concerns like that. But equally we need to be fair to individuals involved as well and there needs to be due process. But if it means that care will be improved and if we are more open, and talk about individuals and groups of individuals, teams, giving best quality of neonatal care yes, I think that could be improved.
DE LA POER: The final meeting to ask you about is the 21 January and at this meeting, you say that the minutes record that one death was presented?
SUBHEDAR: (Nods)
DE LA POER: So it would appear that up to the date of 21 January 2016, four of the deaths which occurred on the neonatal unit at the Countess of Chester had been brought to the Clinical Effectiveness Group. Now, you tell us in your statement that this is the first time that you had a conversation with Dr Brearey about the mortality rate; is that correct?
SUBHEDAR: As far as I can recall, yes, that is correct.
DE LA POER: And was there any particular reason why you -- your recollection is that it's that meeting in January as opposed to, for example, the November meeting?
SUBHEDAR: It's because I have read the email that Steve Brearey had sent to colleagues which was in my initial bundle of information, which referred to him having spoken to me after that meeting. So that email was dated on the 22nd.
DE LA POER: We are certainly going to have a look at that email, but that's how you root yourself in time?
SUBHEDAR: Yes, yes.
LADY JUSTICE THIRLWALL: Is there a dispute about that?
MR DE LA POER: I don't believe that there is, my Lady. At one time there may have been.
LADY JUSTICE THIRLWALL: Thank you.
MR DE LA POER: Certainly no dispute about the email. So just tell us as far as you can recall what it was that Dr Brearey told you?
SUBHEDAR: So I can't, I can't remember exactly what he said at that time, but my recollection in general terms is that, that he -- that there were a number of deaths that had occurred at Chester, that they had reviewed those deaths and would I act as someone external, in my role as clinical lead for the network, to come and look at those their review of deaths and they hadn't been able to identify any clear cause of death and could I be, if you like, a second pair of eyes looking at, at all of those deaths again and giving my view.
DE LA POER: And was there any discussion between the two of you on 21 January about a particular staff member being associated with those deaths?
SUBHEDAR: No, no, I cannot recollect that at all.
DE LA POER: So we are going to come now to the Thematic Review, but before we get to the detail of that and the email that you have told us about already, what was your impression of the culture of the Countess of Chester's neonatal unit?
SUBHEDAR: So the people I had most dealings with were
Dr Brearey and Eirian Powell because they are the ones who represented Chester at either the Clinical Effectiveness Group meetings or the Neonatal Network Steering Group meetings and I had always respected Dr Brearey in the -- in terms of his dedication and diligence in his duties and his engagement with the neonatal network. My view of the neonatal service at Chester was that they operated well, that they had good clinical governance underpinning their activities. They contributed to network activities such as guidelines, incident reviews, they represented their unit regularly attendance at either steering group or Clinical Effectiveness Group wasn't mandated and yet they were there reliably on just about every meeting.
DE LA POER: So let's look at the email that you have told us about, INQ005643 [INQ0005643]. So the email we are looking at is as you have told us the day after that Clinical Effectiveness Group meeting, but before we look at the detail of this I would just like to look at the preceding email in the chain which you are not sent directly but which is forwarded to you. So we can see that was sent three days earlier and it's from Eirian Powell to Dr Brearey, copying in two nurses, the deputy unit manager and the head of the
children's service and we can see that what Ms Powell is talking about is that she has: "... amended the last list to ensure we have included all babies that have died on the unit within this timeframe"?
SUBHEDAR: Yes.
DE LA POER: Now I have told you already that there was a first version of that list created which had eight babies on it; that was in October 2015. This is the updated list which had 10 babies on it and so that's the email which --
SUBHEDAR: Yes.
DE LA POER: -- Dr Brearey replies to but he has a number of other people added to this email. Is this the email that you received?
SUBHEDAR: No, I don't think I was on the circulation list, but I have seen that because it appeared in my bundle of information.
DE LA POER: Right. And we can see that you don't appear to be indicated as one of the recipients but so far as our purpose is concerned, we see that Dr Brearey is saying that he discussed increased mortality with you after the network meeting yesterday and that you would be happy to be an external panel member for a Mortality Review but seemed a little bit reluctant to commit more than half a day. He thought some of his colleagues would be willing or he could ask outside the network. He goes on to attribute a number of other things to you. In the second paragraph: "He suggested [so that's you] maybe just reviewing the cases we are uncertain about the diagnosis for." And he makes a point about a particular case which is not an indictment baby, saying he doesn't think it will help to review that again. He comments about having already reviewed [Child A], [Child C] and [Child D] in some detail and being dubious about the benefit of that and goes on to say that the focus would then be on six babies to review. Now, did you know any of the detail -- that detail at the time of your discussion or was it simply as he's recorded it here; that you made a suggestion that there needed to be focus in the meeting because it was only going to be half a day?
SUBHEDAR: I don't recall the details of our conversation, certainly not numbers and individual cases. But I can imagine saying that, that I could offer half a day just because of other work pressures and that we needed to be focused about what exactly they were asking and whether we could rationalise the number of cases to -- to discuss, yes, I can -- I can imagine
saying that.
DE LA POER: Now, if we just bring up the document which is attached to this as a convenient way of addressing this issue, so the attachment to this forwarded email and indeed to Ms Powell is INQ0003190. This is a document I think you have been shown by the Inquiry; is that right?
SUBHEDAR: I have seen a number of versions of this. I did want to emphasise that the version that I had didn't have names highlighted in red, but it was certainly dated 19 January.
DE LA POER: So the same date as this but as it appears on the screen, no -- no names highlighted in red as we can see here?
SUBHEDAR: Correct.
DE LA POER: Thank you, we can take that down. Now, as I understand it, you were sent a version of that document. Was that ahead of the meeting or on the day of it?
SUBHEDAR: No, no, it was a few days ahead of the meeting.
DE LA POER: Did it just come as that table or was it attached to any other document?
SUBHEDAR: It was attached to an email, I think.
DE LA POER: So it was an attachment to an email but it
wasn't part of a larger document, it was just that table?
SUBHEDAR: I think it was that, I think it was the three-page table.
DE LA POER: And did you consider that document before the meeting?
SUBHEDAR: I am -- I would have looked at it, yes.
DE LA POER: And when you saw that document and saw that it was only looking at nursing staff and that it was differentiating between those who were allocated to the baby and those who were on duty at the time, did it occur to you to wonder why that was being provided to you?
SUBHEDAR: To be honest, I wouldn't have paid much attention to that. I think I would have been focused on the embedded documents of the reviews and I would have focused on -- on those in particular. So I don't recollect paying any specific attention to the columns with the names on them.
DE LA POER: You were being invited to a Thematic Review meeting?
SUBHEDAR: (Nods)
DE LA POER: Would it ordinarily be the case that a chart with staffing would form part of that Thematic Review?
SUBHEDAR: No. With the benefit of hindsight it does
seem a bit strange that there were names of individual staff members included in that table, but again my focus was trying to find out whether the causes of death as attributed and the findings of the each individual review were appropriate or not. So hence my focus away from those columns.
DE LA POER: Do you think you should have been more curious about why you were being sent that document to try and understand what the thinking that lay behind it was?
SUBHEDAR: Of course with the benefit of hindsight now looking at it, it does seem curious that those names were there. But at the time, I didn't think anything of it. It didn't occur to me as being really unusual that those were there.
DE LA POER: So we come to the meeting itself and we have a record of the meeting but I just wish to seek your impressions before we go to the detail of it.
SUBHEDAR: Yes.
DE LA POER: Was it a good and effective constructive meeting from your point of view?
SUBHEDAR: As far as I remember, yes, I don't recollect the details of exactly what happened but I would have thought that each case was presented in, you know, an overview of the case rather than a blow-by-blow account. We weren't expected to review all of the case with all of the case notes there and -- and repeat the review, but to get some sort of overview of each case and whether we -- whether I -- I was obviously a panel member, I didn't convene the meeting and didn't chair the meeting but whether I agreed with their conclusion in each case.
DE LA POER: Was there any discussion of the version of that document, the staffing table, at the meeting?
SUBHEDAR: Not that I recollect, I don't remember any discussions about staff members, if that is your question.
DE LA POER: Well, firstly staffing in general, whether that was discussed?
SUBHEDAR: No, no. I can't -- I don't remember it being discussed, no.
DE LA POER: Did anybody at any stage say that they were concerned or had noticed an association between one member of staff and the babies who died?
SUBHEDAR: Not in such stark details, but at some stage I became aware that they were concerned about staff, a staff member or staff members because between the end of that Thematic Review and by the time that Steve Brearey had emailed me with the draft report, I obviously wanted to emphasise an aspect that I thought was important, which was the unexpected and unexplained
deaths and the fact that I believed that a more detailed review was required, but I don't remember exactly the point at which I became aware that they were concerned about a staff member.
DE LA POER: Are you able to say with any certainty whether it was during the meeting itself when everybody was sitting in the room together?
SUBHEDAR: No, no. I can't remember that. I think that would have been unusual, possibly noteworthy, if they had mentioned that. I -- I am aware that either in Dr Brearey's statement or his evidence yesterday that he said that he had mentioned after the meeting to me that there were concerns about a staff member and that it could have been then. I think it's more likely it was then.
DE LA POER: That was what I was going to say. Is that the probability that that --
SUBHEDAR: I think -- I think so.
DE LA POER: When you were told about his concern, as you just told us about the sudden and unexpected deteriorations and -- and deaths, and the association, if that's a fair way of neutrally describing what he was suggesting to you, was that something that gave you cause for concern?
SUBHEDAR: It -- yes, it would have done, yes. It would
have concerned me, but I think at that time I would have still wanted to press for a detailed review of broader staffing flows, for want of a better word, because clearly there was only -- it was only a summary of the nursing staff members that were on duty at the point at which various babies died, there wasn't any mention of medical staff, there wasn't any mention of who had cared for babies in 12 or 24 hours prior to that, all of those I think were relevant.
DE LA POER: He has told you those two facts that he's worried about: the sudden and intended deteriorations and deaths and that there is a member of staff who appears to be associated with all in fact bar one according to the chart. I mean, did you understand at the time that that implied that there was a possibility at least, in Dr Brearey's mind, that that member of staff may be responsible for the deaths because otherwise it's a meaningless additional fact, isn't it?
SUBHEDAR: I think I would have been aware of that. But it's not something that was top of one's list when you are considering why babies might have died. It's -- there are other explanations including perhaps individuals giving care that wasn't of the standard rather than wilfully doing any harm to babies.
And from time to time, there are cases where a death occurs in a neonatal unit and we have got no good explanation for. It doesn't automatically mean that there is someone trying to do harm to that baby.
DE LA POER: No, but the fact that it's a possibility, doesn't that raise a safeguarding issue?
SUBHEDAR: Yes, if -- if an individual is concerned that someone is harming a baby, yes, it does raise a safeguarding issue.
DE LA POER: And -- and did you say to Dr Brearey, "Isn't this a safeguarding issue, don't you need to raise it as such?"
SUBHEDAR: No, I didn't say that to him. If he had been concerned I would have expected him to have raised a safeguarding issue at a local level, at the Trust level and followed safeguarding, their safeguarding policy. But I didn't specifically say that to him, no.
DE LA POER: Do you think that's something that you should have said to him? Based -- not with the benefit of hindsight but based on the fact that he is telling you that he's worried about these deaths, the fact he has drawn to your attention there is an association which implicitly carse the possibility that that individual is deliberately causing harm, isn't that enough to say: this is safeguarding, we need to engage those mechanisms?
SUBHEDAR: I suppose it is. I would say that I would have expected him, if he had that level of concern, to have triggered the safeguarding policy that was in operation. My view was the pressing need for more information in terms of a detailed staffing review.
DE LA POER: But seeking more information, do you agree, doesn't keep babies safe in the meantime?
SUBHEDAR: No, I agree, that doesn't. But I suppose I would want more information about why he was concerned about an individual and whether that was an appropriate, was the appropriately -- it was appropriate to be concerned about one individual when a detailed review of other individuals who had been providing care at that time hadn't been conducted.
DE LA POER: Did you seek to explore it with him any further than you have just described?
SUBHEDAR: No, I -- I didn't, except to say that in the draft report that he sent me I asked for greater emphasis to be put on the fact that there were a series of unexplained and unexpected deaths and that would provide justification for this internal review that I expected was one of the action points.
DE LA POER: Let's just work through the documents briefly.
We will start with the first draft of the Thematic Review and we have looked at it many times, we can just go quite surgically to particular parts of it, INQ0003217 and if we go to page 7, please. We can see at item 4 in this draft is the timing of the arrests. Do you recollect a discussion in the meeting about the timing?
SUBHEDAR: I'm afraid I don't recollect that, no.
DE LA POER: So that didn't stand out for you if it was -- if it was discussed?
SUBHEDAR: I don't remember it being discussed, but I can see that it's there in as an identified theme so it's quite possible we discussed it, yes.
DE LA POER: In connection with the timing, the action point is: "To review focusing on nursing observations in the four hours before arrest, aim to identify if unwell babies could have been identified earlier." And then finally this: "Identify any medical or nursing staff association with these cases." Do you recall that action point being discussed in the meeting as you were all present?
SUBHEDAR: I can't personally recollect that but, you know, I accept that that was one of the themes that was
identified, so it probably was discussed. But I don't think it just applies to those babies, it applies -- I would say it applies to all of the babies that -- in whom there was an unexpected and unexplained collapse.
DE LA POER: So you were expecting that to go beyond the babies listed that had been discussed at the meeting and up?
SUBHEDAR: I think so, yes. Yes, I don't see why it should just apply to those babies that died in that four-hour window.
LADY JUSTICE THIRLWALL: Sorry, I think you might be at cross-purposes. So because it says six babies had arrests, and then there is the reference to reviewing all these cases, are you reading that as meaning only the six rather than all the cases?
SUBHEDAR: Yes, I thought that was the question. But I am saying that it should have been extended to all.
LADY JUSTICE THIRLWALL: All the ones you were reviewing.
SUBHEDAR: Yes, well, all the ones we were reviewing where there wasn't an explanation for.
LADY JUSTICE THIRLWALL: Yes, thank you.
MR DE LA POER: Thank you, my Lady. Now, appended to this draft report is that table which appears to be
a table identifying the nursing staff association, do you agree?
SUBHEDAR: Well, I haven't got it in front of me but yes, I am familiar with the table, yes.
DE LA POER: You are familiar?
SUBHEDAR: With those columns.
DE LA POER: Was that the sort of thing that you were expecting would be produced as a result of this action point?
SUBHEDAR: Well, in part. But also medical -- similar I think all people, all staff members, be they nursing or medical, who had cared for those babies at around the time of death and in the hours preceding that is what I would have suggested.
DE LA POER: Thank you, we can take that down. Then we come to the email that you have referred to, INQ0102684, and we go to page 214 for this, please. So down one more page. So we can see quite late at night on 8 February, Dr Brearey sends out the draft and invites suggestions and you reply on 10 February to say this: "One additional comment that you might consider adding somewhere that relates to the theme of some of the cases involving babies that suddenly and unexpectedly deteriorate and in whom there was no clear cause for the deterioration/death identified at postmortem." You attach a paper. Is that -- is that paper anything to do with your preceding comment or is that something else that was discussed at the meeting?
SUBHEDAR: Something else that was discussed and I promised to forward on.
DE LA POER: Fine. So in terms -- and you have told us something about this already, in terms of your thinking behind adding that just, just work us through exactly why you thought that that needed to be added?
SUBHEDAR: Well, the purpose of me being there and for us to be having that Thematic Review was to confirm the suspicion in Chester, when they had done their reviews that there were still some cases where there was no clear explanation for a baby's collapse and/or -- and/or death. I think what we decided at Thematic Review was that was correct that there were certain cases that were -- remained unexplained and yet in the draft that Dr Brearey had created it didn't spell that out so I felt it was important to highlight that. Because one of the actions that came from that was this in-depth review and there needed to be some justification for why there was going to be that in-depth review.
DE LA POER: When you say the in-depth review, what exactly were you expecting would be done and by whom?
SUBHEDAR: Well, it was this medical and nurse staffing review, a more detailed review about which members of not just nursing staff, not just those who were allocated, who were actually delivering care at the time and perhaps in the preceding shift, something like that.
DE LA POER: What was your expectation that if that review was conducted and that one member of staff who was identified right at the start of your understanding about what Dr Brearey was concerned about, remained the only member of staff associated, what would you expect to happen at that point?
SUBHEDAR: Well, I think that would escalate the level of concern, had I been Dr Brearey, for example, that the level of concern in my own mind about my concern about the care that is being provided, whether intentionally or unintentionally, that that staff member was providing for the babies at the time.
DE LA POER: And -- and on your understanding of what you were told, does it at that stage reach the safeguarding threshold?
SUBHEDAR: I think it does, yes. At that point, when you have excluded other possibilities, I think that -- and you are concerned about an individual's care for a --
for a baby, yes, that, that does.
DE LA POER: Now, somebody who hadn't participated in the conversations that you had had with Dr Brearey may not immediately understand your thought process behind that; do you see that? That by adding that phrase you are not saying -- associating it with the staffing analysis, do you see what I mean?
SUBHEDAR: Right. Possibly, it was my intention to link the two, yes, but I can understand that it may not have been clear.
DE LA POER: So we can have a look at INQ0006817 and again we can go to page 7. So we can see that this is the version that it is finally circulated. Your entry now takes number one spot. But there's no action associated with it. The action continues to be as it was in the draft against timing of arrests. So do you think that there has been a miscommunication between you and Dr Brearey in terms of what you were intending to be linked and to be justified in a particular way and what actually appears in the final version?
SUBHEDAR: I appreciate that it looks as if there is no action from point number 1 on that, on that page. But I think the action under point 2 encompasses both points 1 and 2 or at least that would have been my intention
and I think there is an action plan that goes along with this document which --
DE LA POER: Yes.
SUBHEDAR: -- also summarises that action. So while I appreciate that it doesn't explicitly say what the action from point 1 is, I think it's encompassed under point 2.
DE LA POER: Because of course this was a document that you understood would be -- would have a wider audience?
SUBHEDAR: Well, yes, I didn't know who this would have been circulated to, but yes.
DE LA POER: But it wasn't just being held within the group of you who had discussed it. This was -- this was --
SUBHEDAR: No, probably not, no.
DE LA POER: So we can look at that action, page 10. Is this the action list that you were referring to?
SUBHEDAR: That's right, yes, it's at the bottom there.
DE LA POER: We can see that it's marked as complete as at -- this will be 2 March of 2016.
SUBHEDAR: Yes, well I can see that it's marked as complete, yes.
DE LA POER: And so, I mean, in your mind this was an important action that needed to have a proper justification. When that was sent to you, did you have a look to see where Dr Brearey had got to with the issue that he raised with you he was concerned about and that you had given had him advice about and that had led to the amendment of the draft?
SUBHEDAR: So I -- this is the first time I have noticed that that says "complete", it's not something that's occurred to me previously. This is the final draft of the action plan that comes from the Thematic Review so I wouldn't have really expected any of these actions to be properly complete and I don't think that between the review and receiving the final draft that all of the actions would have been completed. So that's probably why I didn't see that and make any -- I didn't look at the word "complete" and think that: oh, yes, all of that's completed now.
DE LA POER: Did you ever follow up with Dr Brearey about the advice you had given him and the sudden collapses and the staffing analysis to say: Dr Brearey, did you ever put to bed that worry that you had, or is it still a concern?
SUBHEDAR: No, not -- I didn't personally follow that up until many months later when we had meetings with the team at Chester because I was under the impression, and I think this is supported by an email that Dr Jayaram had, that I have seen, which said that there was some sort of internal review. So I assumed that there was
some sort of internal review that was ongoing.
DE LA POER: So that internal review doesn't start, if it's the same one, until July. Do you think you should have followed up -- given that Dr Brearey had raised this with you, do you think you should have followed up to say what was the final conclusion of the Thematic Review about the staffing analysis?
SUBHEDAR: I think again with the benefit of hindsight I wish I had done that but that was really -- it was the ownership of this document and the action plan was the team at Chester is how I saw this, that they had a number of actions that they should complete and that was one of them.
DE LA POER: But this one was slightly different, do you agree, to others in the sense that you would actually encourage an amendment to the report in order to provide a robust justification for it?
SUBHEDAR: Yes, yes, I would accept that, yes.
DE LA POER: Do you think the Thematic Review should have been more explicit about the concern which existed at the time that it was undertaken about a particular member of staff. When I say the Thematic Review I mean the report itself.
SUBHEDAR: Well, as I said before I don't think we discussed a member of staff at the Thematic Review, so I
don't think it would have been correct to state in those plain terms that there was concern about the care provided by a single member of staff seeing as we hadn't discussed it in any detail in the -- in the meeting itself.
DE LA POER: But the document itself says that no themes were identified but in fact you knew that a theme, a particular member of staff, had been identified at the time of the meeting?
SUBHEDAR: No, that's not quite correct. Well, not during the meeting but I understand that Steve had expressed -- Dr Brearey had expressed concern after the meeting about a member of staff which he told me informally.
DE LA POER: Well --
SUBHEDAR: But I don't think that was discussed at the meeting itself. In fact, I don't remember any discussions about staffing at the meeting.
DE LA POER: Again just looking at it from the point of view of you know that this is a document that's going to go into wider circulation. Doesn't the reader need to have that spelt out for them? Instead of as the reader would: "there was no common theme identified in all cases"?
SUBHEDAR: Sorry, I haven't got that page in front of me,
so I can't --
DE LA POER: It's page 7.
SUBHEDAR: I mean, it does say there was no common theme identified in all the cases and I have -- I have said some of the babies suddenly and unexpectedly deteriorated. I think those are consistent, although I hear what you are saying, a very important theme that was identified was the sudden deterioration and a very important action that followed that theme was the review of medical and nursing staffing, so if your question is should we have made it clearer, should it have been clear, I think you are probably right, it should have been.
DE LA POER: The Inquiry has received evidence that this document was taken at its face as saying there was no common theme.
SUBHEDAR: Well, if you read the first sentence and the first sentence only, then -- then that would be correct. But in the context of the first theme that was identified, it may not have been common to all of the babies but it is the first theme that says sudden deterioration and -- and that there was no clear cause for the deterioration or -- or collapse or death. So I think in that respect it's clear.
DE LA POER: I think in fairness to you, Dr Subhedar, I just want to acknowledge you and I have both been working on this being the version sent to you but I have noticed as we were flicking on the previous page that there was a date of April 2016 which postdates the version. So can I just give you this undertaking that we will double-check the version that you were sent in terms of whether that action was marked as complete at the time it was sent. I just want to acknowledge that to you in fairness to you?
SUBHEDAR: Okay, thank you. I do appreciate there are a number of different versions there and I can't remember which one I received.
DE LA POER: Well, we will be able to find it. So I would like to move on from the Thematic Review, so please could we take that down and just briefly summarise your understanding of the second half of 2016. Were you aware of the downgrading of the unit in July of 2016?
SUBHEDAR: Yes, I was.
DE LA POER: Were you aware that the Royal College was commissioned to undertake a review?
SUBHEDAR: I -- I was aware of that but fairly close to the point at which the review was going to happen because I didn't have enough time to change my diary and
I was away at that time so I couldn't participate in that.
DE LA POER: There was an idea that you might participate in the Royal College's review; is that right?
SUBHEDAR: There was -- I was invited to fairly late on. I couldn't go but the director of the network, Julie Maddocks, did attend on behalf of the network.
DE LA POER: Bearing in mind -- and this isn't a criticism of your unavailability, but bearing in mind that you had been involved in the Thematic Review and so and you had had those conversations with Dr Brearey about this very topic, do you think it would have been better if the Royal College had spoken to you?
SUBHEDAR: Possibly. But the network director, Julie Maddocks, I had had discussions prior to the Thematic Review about Chester wanting me to attend and we had agreed that that was reasonable and I would have spoken to her in the intervening months about -- about what was happening at Chester and the fact that the RCPCH review was happening, she would have been aware of that. So I think she could have deputised but I can see some benefit of me having been there, yes.
DE LA POER: Were you aware of Dr Hawdon or perhaps just a neonatologist being instructed to conduct a detailed
forensic Casenote Review?
SUBHEDAR: I was, but I -- I don't know when that would have been. Some time in the autumn perhaps, so later on in 2016.
DE LA POER: Did any of those events give you cause for concern or cause you to think that on behalf of the network you needed to find out what was going on at the Countess of Chester?
SUBHEDAR: Not cause for concern, quite the opposite. I would have been pressing for a more detailed review, so I welcomed the reviews that were ongoing. We weren't party to the Terms of Reference of either review. But I was grateful for there being external scrutiny and what I hoped was a more detailed review which is something we had been asking for from the point of the Thematic Review onwards.
DE LA POER: Now, the Inquiry knows that the Consultant body, particularly Dr Brearey and Dr Jayaram, said in no uncertain terms that they -- to the Executives in June of 2016, that they were concerned that Letby may be murdering babies. They said as much again in September to the Royal College. Was that a concern that the network should have been notified about?
SUBHEDAR: I don't know. I was -- I have never been in
that position before. I'm not sure that was necessarily the network's role but I know that when the paediatricians at Chester asked for us to attend meetings with the Chief Exec -- with the Executive Team at Chester, we were happy to do so but more in terms of providing support for the paediatricians rather than having an independent role ourselves.
DE LA POER: Now, that brings us to February 2017. The Royal College report was published on the Internet. Did you have an opportunity to read it?
SUBHEDAR: I read it because it was sent to me by Julie Maddocks and I think she received it from Chester at that point. But it hadn't been shared prior to -- to then.
DE LA POER: Now, you will have noted that there was recommendation to the network within that report, wasn't there?
SUBHEDAR: There was. Sorry, you would have to remind me of what the recommendations were specifically?
DE LA POER: I certainly can, although perhaps the detail isn't important, but you have asked so INQ0001954, pages 21 and 22.
SUBHEDAR: Thank you.
DE LA POER: So this is in relation to the transport service which is operated at a network level?
SUBHEDAR: That's right.
DE LA POER: Now, there is evidence to suggest that this report was finalised in this form in November of 2016. Should you have been told about this as soon as that report was finished?
SUBHEDAR: I think we should have been and I don't know whether that's the responsibility of the Executive Team at Chester or the College to have given us access to that report but, yes, if there were recommendations for the network, we should have seen it.
DE LA POER: Well, the transport service continued to operate in the period November to February. If there were improvements presumably you would want to know about those as soon as possible?
SUBHEDAR: Yes, that's -- that's true.
DE LA POER: Now, thank you, we can take that down. You also received Dr Hawdon's report and we don't need to go to the document, but did you reply to the email from Ian Harvey that sent that to you enquiring about Dr Hawdon's Terms of Reference?
SUBHEDAR: I did.
DE LA POER: Why did you want to know Dr Hawdon's Terms of Reference?
SUBHEDAR: I wanted to -- I wanted to know what she had been asked to do and what information she had been able
to access and -- and to whom she spoke to, to be able to compile her report.
DE LA POER: One of her Terms of Reference which in fact she said she couldn't undertake but it was there on the face of the Terms of Reference was she was asked to consider which staff had access to the neonatal unit. So not just who's supposed to be caring for the baby but who had access. Is that the sort of enquiry that a neonatologist would be expected to be able to answer?
SUBHEDAR: I'm not sure I understand what that term means, having access to the neonatal unit. That suggests on the face of it people who can literally get into the neonatal unit, that doesn't sound like a job for a neonatologist and I am confused by why that would be in the Terms of Reference stated as such.
DE LA POER: Did you ever receive a response from Ian Harvey in relation to your request to clarify the Terms of Reference from Dr Hawdon?
SUBHEDAR: No, I didn't.
DE LA POER: Now, having considered Dr Hawdon's report, did you conclude that there were -- as it was presented to you there were four cases that she said further forensic review should take place in relation to. Did you identify three more?
SUBHEDAR: Yes, I did.
DE LA POER: And we don't need to go into the medicine. But in simple terms, why do you think that there were three additional cases that were requiring further investigation, what was it about them?
SUBHEDAR: Again because they were unexpected and unexplained.
DE LA POER: Was that particular feature something that you would ordinarily look for or was it something that you had in your mind from the Thematic Review that you had already participated in?
SUBHEDAR: I think it must have been from the Thematic Review but also I wasn't clear whether Dr Hawdon had been able to -- had been given access to all of the cases that we had been concerned about following the Thematic Review.
DE LA POER: You attended a meeting on 28 February. That meeting included a number of paediatricians and Ian Harvey; is that right?
SUBHEDAR: That's correct.
DE LA POER: What was the tone of that meeting?
SUBHEDAR: I think one of concern that was expressed by the paediatric Consultants at Chester. I think it was a perfectly civil meeting, I don't think there was any unpleasantness, for want of a better word. But yes,
that's my recollection of it.
DE LA POER: Was there discussion in the meeting about the Consultants' concerns about an individual member of staff?
SUBHEDAR: I can't remember. I -- I can't remember if that was the meeting where there were minutes but if there were minutes I would like to have a look at them to -- to remind myself whether that was discussed.
DE LA POER: There were emails exchanged about this meeting that you were copied into. The one email I would like to take you to is the one that you sent following the meeting, INQ000 -- I will start that again. INQ0006105. So Dr Brearey at the start of this had sent you a summary of the meeting which is just over the page.
SUBHEDAR: Yes.
DE LA POER: We will see that in a different context. Dr Gibbs has gone through it and amended it and your response above the page is to say that you are not going to co-sign it but you would like an addition and if I can summarise this, I hope I do so completely, your position was the Countess of Chester was not an outlier from an acuity or staffing perspective as compared to the network?
SUBHEDAR: That's correct.
DE LA POER: So insofar as it may be suggested that that could explain the increase, you were giving a bigger picture to say to your mind it couldn't?
SUBHEDAR: That's correct. Just to -- just to be clear, at that time, most neonatal units weren't compliant with the national standards for nursing numbers and ratios, but Chester didn't -- wasn't an outlier compared to other local neonatal units within the network.
DE LA POER: We see that that text was included in the email sent, INQ0003395. The email summarising the position is over the page and your text was included, I think it's the next page down. There we are, the final substantial paragraph lifted into Dr Brearey's email and we can see that what Dr Brearey is saying is if we go back up the page, that there are eight babies, so four started with Dr Hawdon, you in fact thought it was seven, Dr Brearey is now saying eight. The only question I want to ask you about this is what Ian Harvey says in response to the paragraph that you added in --
SUBHEDAR: Yes.
DE LA POER: -- which is on the page above. And in the -- I think it's the fourth paragraph --
SUBHEDAR: Yes.
DE LA POER: -- where Ian Harvey comments -- and I'm sorry, I have just lost my place, forgive me.
LADY JUSTICE THIRLWALL: It is the third paragraph.
MR DE LA POER: It is the third -- three lines down the paragraph beginning "Contrary"?
SUBHEDAR: Yes.
DE LA POER: He agrees that you did say that, but then goes on to say: "I have seen no evidence to confirm this nor have I seen anything to indicate that there was the same trajectories that we had in the period leading up to 2015/16." Now, did Ian Harvey ever ask you for data or to assist him further?
SUBHEDAR: No, he didn't.
DE LA POER: Was the network data available?
SUBHEDAR: Yes. Staffing occupancy levels, all of that sort of data is included in an annual report that the network provided called -- we call it the ACD report, the Activity Capacity Demand report, which contains those that sort of level of information.
DE LA POER: And had you effectively as clinical lead summarised that information as you understood it into that paragraph that you drafted?
SUBHEDAR: Yes, I had.
DE LA POER: Thank you very much. The final meeting to ask you about is on 27 March 2017. There is a record made
of this meeting.
SUBHEDAR: Yes.
DE LA POER: I don't think because there is only one matter in particular that I want to ask you about that's recorded in the minutes that you refer to in your statement, it's recorded that Dr Brearey said the matter needs to be escalated to the police. Do you have a recollection of a discussion about whether or not the police should be contacted at that meeting?
SUBHEDAR: Not a detailed recollection but I am aware that the -- a referral to the police was discussed at that meeting.
DE LA POER: What was your impression of Ian Harvey's -- who I think was also present at that meeting -- reaction to that?
SUBHEDAR: Sorry, I can't remember exactly what his reaction was, him personally.
DE LA POER: Do you recall whether the meeting ended with a plan to call the police or was that still an open question or had a decision been made not to do that?
SUBHEDAR: No, as far as I remember, there wasn't a firm decision made that they were going to go away and consider it.
DE LA POER: You were invited to meet Simon Medland QC, as
he was, the barrister instructed by the Trust, but you decided to decline that invitation; is that right?
SUBHEDAR: That -- that's correct, yes.
DE LA POER: Why did you think it wasn't appropriate to go?
SUBHEDAR: I discussed it firstly with Julie Maddocks, the network director, and we came to the conclusion that whatever decision they -- the team at Chester came to would be their decision and I didn't want the network -- we didn't want the network -- to be supporting a decision which, whichever way they -- they went because if we had been attending the meeting then by virtue of the fact that we were there it would have suggested the network was supportive of whichever direction Chester took following that meeting, whether to involve the police, which is what we were pushing for or equally not to involve the police at that time.
DE LA POER: Finally this. You reflect in your statement and I will just read it out to you: "I believe the overall role and performance of the locality network in relation to monitoring and oversight of neonatal mortality in 2015/16 could have been improved." Can you tell us why you say that and what improvements you think there may be?
SUBHEDAR: Yes. So the way I see the role of the network is in part to -- to provide the best quality of care for babies who are being looked after in that region and also to monitor performance which means not only activity and staffing levels but also outcomes and benchmarking outcomes and the starting point for that is to collect and report data, good quality data, consistently, and I think we failed in that -- in that role because in the Neonatal Network Steering Group meetings we didn't provide that data. To be fair, it was an evolving process and I think that we at that time and in the years that followed, the North West operational delivery network as a whole was ahead of other networks, so we weren't the only network who didn't provide good quality data but given that that was part of our Terms of Reference, that's what we should have been producing and we didn't. So I would apologise for that because I think that is a weakness, a failing, of the network's role.
MR DE LA POER: Dr Subhedar, there will be some further questions but, my Lady, I wonder if this might be a convenient moment for a break?
LADY JUSTICE THIRLWALL: Very well. We will take a break of 15 minutes and we will start again at 25 to 12.
(11.19 am) (A short break)
(11.35 am)
LADY JUSTICE THIRLWALL: Ms Rong.
MS RONG: Dr Subhedar, I ask questions on behalf of two of the Family groups and just want to explore a few issues that are of particular interest to them. You have already given evidence this morning that your involvement in the chronology of events that concerns this Inquiry was in your role as the clinical lead of the neonatal network; that's correct, isn't it?
SUBHEDAR: That's correct, yes.
RONG: As part of the overall structure or function of the network, there is the Clinical Effectiveness Group and a steering group?
SUBHEDAR: That's correct.
RONG: Now, first of all let's look at the Clinical Effectiveness Group Terms of Reference. If I could have INQ0102684, page 4 [not found], please. Thank you. Section 2.1, second section on this page, the vision statement, it explains: "To be clinically driven and operate within and support a culture of collaboration; to engage and interact with other stakeholders, member organisations and families, to deliver agreed outcomes".
So that is the Terms of Reference for the CEG?
SUBHEDAR: (Nods)
RONG: Let's now turn to page 10, please, which is part of the Terms of Reference for the steering group. And it's page 10. Thank you. Section 2.2, it explains the operating principles for the neonatal ODN and says they are adapted and adopted from NHS England values. So these are core NHS values, do you agree?
SUBHEDAR: Yes.
RONG: I just want to take you to two specific principles in that list, the first item, first bullet point: "We will put the interests of patients and their families and carers at a centre of our activities." The third bullet point: "We will be clinically led with an equal voice for babies, their families and carers alongside clinicians and managers." So it is clear from these Terms of Reference that the babies and the families who have received care and treatment within the network is at the centre of what you do?
SUBHEDAR: I would agree with that, yes.
RONG: The guiding principle is that they should have
SUBHEDAR: equal voice alongside clinicians and managers within the Trust, would you agree?
SUBHEDAR: Yes.
RONG: Now, we know that from the evidence you gave this morning, Dr Brearey first brought to your attention his concerns after the CEG meeting on 21 January 2016, we know that because we have seen the email correspondence and he asked for your input and I think you put it this morning as a second pair of eyes or a fresh pair of eyes to essentially sense-check whether their concerns that there were unexplained, unexpected deaths on the unit was confirmed, was something that was accurate?
SUBHEDAR: Yes, that's right.
RONG: You thereafter, we know, attended a Thematic Review meeting on 8 February 2016 and you gave evidence this morning that shortly afterwards there was I think you say a separate conversation you had with Dr Brearey when the nursing concern or the association with a member of staff were discussed?
SUBHEDAR: That's right.
RONG: Now, the takeaway from those discussions, by which I mean the Thematic Review meeting and the subsequent discussion you had with Dr Brearey, was that there were internally within the Countess of Chester NNU concerns that they were having increased numbers of deaths, but not just that, that those deaths were unexplained and unexpected?
SUBHEDAR: I only knew that Steve was -- when you say "internal concerns", I only knew that Dr Brearey was concerned and that he was concerned about some of the deaths that were unexplained and unexpected.
RONG: That's the reason why he came to you in the first place?
SUBHEDAR: Well, yes.
RONG: Yes?
SUBHEDAR: Yes.
RONG: That was your view after the Thematic Review, you agreed with him: yes, what you are concerned about is valid?
SUBHEDAR: Yes.
RONG: Based on a clinical review, I appreciate it was only a brief discussion in that meeting, but from what you were aware of, from the point of view of the network, you did not think any other factors such as acuity or level of activities on the NNU or any nursing competency issue could immediately explain those concerns?
SUBHEDAR: At the Thematic Review some of those things you have mentioned weren't discussed. It was the
clinical care stuff such as an individual nurse's competency, broader staffing factors. Those weren't -- those weren't discussed at the review.
RONG: They were or were not?
SUBHEDAR: Were not.
RONG: Were not. But nothing that was brought to you or you had seen around that time, both in the meeting itself and during your subsequent discussion with Dr Brearey, it wasn't -- okay, we have identified the reason now, it's acuity, it's nursing competency; nothing --
SUBHEDAR: That's correct.
RONG: -- to explain it away?
SUBHEDAR: That's correct.
RONG: And that was not an acceptable state of affairs, by which I mean there was clearly a patient safety issue that needed further investigation, further review; that was your view, was it not?
SUBHEDAR: It was, yes, that -- that needed further detailed review, yes.
RONG: Now, Dr Brearey's evidence to the Inquiry yesterday was that as far as he was concerned, by the end of that Thematic Review, you had or he had looked at most of the other things you might wish to consider and those things have already been excluded.
Now, I do not know of course whether he expressed those thoughts to you at the time, but when you gave evidence this morning when asked when the threshold would be reached to escalate the level of concern, and your answer was: when you excluded other possibilities?
SUBHEDAR: Yes, yes.
RONG: So if that was the frame of mind for the paediatricians, Dr Brearey in particular at the end of the Thematic Review, you would expect escalation at that point, would you not? That threshold has been crossed?
SUBHEDAR: If an individual believes that there is no other explanation then that threshold would have been crossed.
RONG: If we take a step back, your recommendation was we need to look at it further, that's the action plan that was drafted by Dr Brearey afterwards to see whether there was a theme regarding staffing issue, but those reviews take time and when we are in a state of affairs where there was a concern, a valid concern, we do not know what it was, it might take time to get to the bottom of it, does patient safety not demand immediate action to protect the patients whilst those reviews are ongoing?
SUBHEDAR: Well, I think it does. But we have to ask -- you can't put safeguards if you don't know what the
problem -- where the problem lies, so you have to go through a process and that's what I was asking for that, a detailed review needed to be performed to get to the point at which you conclude there are no other explanations here and that it is perhaps a staff member and the care that that staff member is delivering, either intentionally or unintentionally, to that baby that's causing the problem. So you can't jump to that conclusion without having gone through that process.
RONG: But the unit didn't jump to that conclusion. Work had already been done before they came to you. Now, I am not suggesting for a moment that you ought to act alone and put in measures, it wasn't your job but they had already reviewed, they have raised a concern, they have confirmed with a fresh pair of eyes that that was a valid concern. So whilst whatever further work might be undertaken, might be required to confirm or exclude that factor, immediate action needed to be taken, did it not?
SUBHEDAR: Well, again, if that individual was convinced that there was no explanation then to protect patient safety, yes, action will have needed to be taken. The difficulty is knowing what action in those circumstances and I can't answer that question because I wasn't in that position with the benefit of the knowledge to have made that decision.
RONG: One of the options would be to involve the police and when you gave evidence earlier, when in the context of explaining why you declined the invitation to take part in the meeting with Simon Medland QC, in April 2017, and your answer towards the end was: you didn't want to give credit to or legitimise any decisions that they may make, one of which might be to involve the police, and you said "which is what we were pushing for". Now, when you refer to "we" in that sentence, to whom are you referring, is it the paediatricians, the network, who was pushing for involvement of the police?
SUBHEDAR: So I was referring to the meeting that we had, I can't remember the date, I'm afraid, with the Executive Team where Dr Brearey and his colleagues were suggesting that this needed to be escalated to a referral to the police.
RONG: That is the March 17 meeting?
SUBHEDAR: Yes. So we were there to support their view and from a network point of view we were still demanding a more in-depth detailed review, however that was conducted and by whomever that was conducted. So really I suppose what I am saying is we were
supporting the paediatricians in their view that this needed to be escalated to a police matter.
RONG: But the features which were pointing, as far as the paediatricians were concerned, towards calling the police or involving the police at that stage, all of those factors, save for the number of babies who had already been killed or harmed at that stage, were already present by the time they sought your advice in January 2016, were they not?
SUBHEDAR: Well, I don't know that because I -- I can't speak to that because I wasn't aware of all of the information that they had available. Potentially, yes.
RONG: Now let me deal with very quickly with the parents' involvement and taking a step back in terms of looking at the lessons that can be learned from all of this. Going back to the Terms of Reference that we looked at earlier, giving parents a part, giving them an equal voice, now, would you agree that when concerns were identified regarding the care that the babies on the unit had received, the parents ought to have been consulted from the point of view of provision and gathering of information. Let me expand on that. There are two parts to it. The first is to be
notified or to be informed that there might be an issue with the care their children had received?
SUBHEDAR: So at that point where there is concern and the process has been completed, in terms of gathering the information, then yes, I think we as professionals have a duty of candour, a responsibility to let parents know and that's true for -- this -- only when a death has occurred, when significant harm has occurred in whatever setting.
RONG: There doesn't have to be confirmed -- the cause doesn't have to be confirmed. All that requires or triggers the duty of candour is there might have been gaps in the provision of care, there might have been shortcomings in the provision of care, would you agree?
SUBHEDAR: Yes, but that would apply -- at the moment I'm aware that the duty of candour responsibility is -- needs to be discharged when there is at least moderate harm and clearly all deaths would -- would qualify for that which means that you would have to go through a process like that for every baby that's died prior to any review having been conducted.
RONG: But apart from provision of information, the other element or the side of the coin which is equally important is the gathering of information because we are not talking about adult patients where you can take the
history directly from them, the parents whose children these were, they might and it's reasonable to expect, have valid and useful information to contribute towards the process of investigation; would you agree?
SUBHEDAR: Yes, I would agree with that. And you are right that that didn't happen during this process and as far as I know doesn't happen regularly. There is a little bit of involvement with -- with respect to parents, in PMRTs, which are Formal Mortality Review processes now, where parents are asked have they got any specific questions they would like addressed during those meetings. But in terms of gathering information, for example, when there has been an incident that doesn't involve parents at the moment.
RONG: No, but when we are talking about the history of care with these babies being on units, some of them for weeks, that they might have information to give?
SUBHEDAR: Yes.
RONG: Some of the evidence given by other witnesses to this Inquiry I think it is the approach of: we don't want to upset parents, we don't want to tell them anything until we knew. But that is not the right approach because the parents, if I can put to you, one has a right to know; and two, might have their own input in what investigations they want taken, what information, for example, records they want to seek, what independent advice they want to seek themselves if they are not happy with the hospital's approach, would you agree with that?
SUBHEDAR: Yes, yes, I would agree with that. I think we have to take into account the anxiety and distress that some parents might experience. But equally I don't think we can take a paternalistic view and say we are trying to protect them from that and therefore we should exclude them from those reviews.
RONG: The clinicians or the Execs shouldn't say "we know better"?
SUBHEDAR: Correct.
RONG: And that, would you agree -- and again I am not suggesting you have spearheaded some sort of communication plan alone, but this -- looking back on the chronology of events in this case, that patient-centered approach was lacking in this case, was it not, such that the parents were left on the outside of the perimeters of investigation until very, very late in the day?
SUBHEDAR: Yes, I agree with you that the parents weren't involved in any of the reviews or those discussions,
yes, I agree.
MS RONG: Thank you. Thank you, my Lady.
LADY JUSTICE THIRLWALL: Thank you, Ms Rong. Mr Skelton.
MR SKELTON: Dr Subhedar, I ask questions on behalf of all of the Family groups. Can I ask you first about your background and expertise. In your statement you mention your posts within your hospital but you don't mention I think that you are clinical lead, I think for risk management and clinical governance; is that right?
SUBHEDAR: I was lead for clinical for, for clinical governance and risk management about until about around this time, I think. It was the last few years that I haven't been so, probably from about 2017 I think I might have stepped down from that role within out Trust.
SKELTON: So at the time that you and Dr Brearey were dealing with the issues you have been talking about today you were clinical lead?
SUBHEDAR: I would have to check but yes, I think I probably was at that time.
SKELTON: Is it right you also have a special clinical interest in patient safety?
SUBHEDAR: Twinned with that role as safety lead within the -- within the Trust, yes, I had a had an interest in patient safety.
SKELTON: If in 2015 a child had died unexpectedly without immediate medical explanation in your unit, what investigations would you have initiated?
SUBHEDAR: There would have been a review process that would have been undertaken which is the same as for all deaths and then if we had concluded that there was an unexpected and unexplained death in 2015, if it was an isolated incident, I think that happens from time to time, I don't think it would have necessarily taken -- gone -- been taken any further. At the time, sort of in real-time, I think that a Coroner might be involved. I think I would have expected if there was the clear cause of death we would have made a referral to the Coroner.
SKELTON: What about the SUDiC process?
SUBHEDAR: The SUDiC process to my mind at that time wasn't relevant to babies who died in neonatal intensive care. It was the sort of thing that was triggered if a baby died at home as a cot death, I am pretty sure that the national guidance at that stage referred to Sudden Unexpected Postnatal Collapse in individuals at term, babies at term who were born in a good condition
and then secondarily collapsed. So I don't think -- I am pretty sure we weren't using the SUDiC protocol in neonatal intensive care.
SKELTON: Were you aware that Dr Garstang who gave evidence about her experience in a similar setting not too far from your hospital, thought that SUDiC was appropriate for deaths in hospital, for sudden --
SUBHEDAR: I wasn't aware of that, no.
SKELTON: If you suspected that a member of staff had harmed a patient, what was the process that you would have initiated as the safeguarding lead in your own hospital?
SUBHEDAR: Depends on my level of concern but the way you state it, if I was really concerned that someone had harmed a baby --
SKELTON: Murdered?
SUBHEDAR: Well, that would have been a very serious event, obviously, I would have involved the safeguarding team and taken advice about involving the police there and then.
SKELTON: It's right, isn't it, that one of the axiomatic principles of safeguarding is that it's everyone's responsibility?
SUBHEDAR: Yes, it is.
SKELTON: Not one person; every one that's aware of that information, that concern, has a responsibility to act?
SUBHEDAR: Yes, I would agree with that.
SKELTON: As I understood your evidence, you had been provided with the mortality table in early 2016 which listed the deaths that were going to be considered by the review and also the staff allocation and people who were present, the staff members present?
SUBHEDAR: Yes.
SKELTON: Again as I understood your evidence earlier, it was unusual to have the staffing as part of the information provided into an investigation into a child's death?
SUBHEDAR: I think I said that with the benefit of hindsight it was unusual. Looking back now, I would wonder why those names were there.
SKELTON: Why didn't you ask?
SUBHEDAR: I didn't really pay much attention to those columns with the names in there. I was focused on the embedded documents which was the summary of the clinical case and the causes of death.
SKELTON: Dr Brearey's evidence, have you read his principal statement to the Inquiry?
SUBHEDAR: I have, yes.
SKELTON: So his evidence at paragraph 199 is that during the Thematic Review meeting that you attended,
Lucy Letby was not discussed. He didn't want to introduce any bias into the process of discussing the children, the individual babies, and then he says that after he discussed, or: "... we had discussed every case, I then raised the issue of the staffing analysis and association with a nurse. We also discussed that six of the nine babies had collapsed between the times of 0000 to 0400 hours." So his recollection in his statement, which he then reaffirmed yesterday, was that there was a discussion at that meeting of the staff association that had been identified in the table. Is your recollection that you can't remember that or you are sure that he didn't do that, say that?
SUBHEDAR: Would you mind bringing that up, so I could have a look at that part of his statement.
SKELTON: The statement, yes, it's -- give me one second for the reference --
SUBHEDAR: Because I would like to read the context.
SKELTON: It's INQ0103104. And if we could go to page 33, please, which is the section where he deals with this meeting. So at the bottom, you can see there is a heading "Thematic Review" and you can see that you are listed as one of the attendees along with Steve Brearey --
SUBHEDAR: Yes.
SKELTON: -- Dr V, Eirian Powell Anne Murphy, Ms Eagles and Ms Peacock?
SUBHEDAR: Yes.
SKELTON: Then if we go on to the next page, the paragraph I read out if you want to just take a moment to have a look at it, it's paragraph 199.
SUBHEDAR: Yes.
SKELTON: So essentially it seems there are almost two parts to the meeting, there is the first part where you discuss the babies without mentioning the staff. Then at the end of that discussion, it appears that he raises the staffing issue, which of course was already embedded within the table that you had received that you hadn't analysed. Do you remember that?
SUBHEDAR: I don't remember that but I can see that he's stated that and I know that around that time, whether it was during the meeting or immediately after the meeting, I think either in his statement somewhere or perhaps in his evidence yesterday he talked about speaking to me after the meeting to let me know about the concerns about an individual. So I'm not sure exactly when that was but I understand that around that time, he must have made me
aware or I was made aware that there were concerns about a member of staff.
SKELTON: Did you say to him: Steve, do you think the staff has negligently harmed these children or are you saying it was intentional or are you thinking it was intentional as a possibility?
SUBHEDAR: I didn't say either of those things.
SKELTON: Do you recognise that you should have done?
SUBHEDAR: I recognise that what was important was to understand why he was concerned about a member of staff and why that would have been a particular nursing member of staff when I don't see that there was any review of other staff members delivering care to -- to those babies such as medical staff. I think that's why we concluded that an in-depth review of all staff was important.
SKELTON: But in respect of the single staff member that he mentioned at the meeting or at that time to you, why didn't you ask: what do you think she's done?
SUBHEDAR: No, I -- well, it didn't occur to me that anyone would want to wilfully harm babies, that the most likely explanation, if anything, was that the care that was being provided for that -- for those babies wasn't of a high standard, whatever that might mean from a nursing perspective. But it didn't occur to me that I needed to ask in such explicit terms to why he was concerned, at least until a review had been undertaken of all the staffing members.
SKELTON: It may be right that it's more likely that a staff member is negligent than criminal. But it was a possibility, wasn't it?
SUBHEDAR: Yes, it was -- well, especially with the benefit of hindsight yes, of course it was a possibility. But we wasn't thinking that way at that time.
SKELTON: Without the benefit of hindsight, if a nurse is associated with a large number of child deaths, it is possible that is because of deliberate conduct?
SUBHEDAR: Yes, of course it's possible.
SKELTON: That is a matter that needs to be ruled out for patient safety reasons urgently?
SUBHEDAR: Yes, I would agree with that, that it needs to be ruled out after a proper review, but an urgent review, yes.
SKELTON: You, over this period of time, and indeed before this period of time, and throughout 2016 and 2017, are the wise person to whom Steve Brearey is going, the person outside his own hospital, for advice. Can you explain why you didn't ask him about his concern
about this nurse or advise him to trigger the usual processes that would apply?
SUBHEDAR: I was asked as someone external to that neonatal unit to provide an overview, Thematic Review, and to look at all of those cases and that's what I believe I did as part of the Thematic Review. I think it was reasonable to suggest a detailed staffing review. I highlighted the concerns that were expressed during that review, during the Thematic Review of the fact that there were some unexplained and unexpected deaths and I think that was the right thing to do.
SKELTON: But you didn't really follow that up, did you? I mean, the detailed staffing analysis demonstrated that she was in fact present?
SUBHEDAR: Well, that's not what I meant by a detailed staffing analysis. It was more than just having names who were looking after that baby at that time. There was names, it was flows of staff, both medical and nursing, at the time and prior to that time as well which was important. I didn't have that level of detailed information.
SKELTON: But as far as you were aware, after the -- after this Thematic Review meeting, did the investigations that you set in motion or assisted to set in motion ever identify a common cause for these
children's deaths?
SUBHEDAR: I knew that there was a review ongoing or I suspected there was a review ongoing. I wasn't party to what the review found. So I can't -- I'm not sure I can answer that question.
SKELTON: Well, the answer's no, isn't it? As far as you were aware, there was no common cause identified medically to explain these children's deaths?
SUBHEDAR: There was no common cause found medically, yes, that's correct.
SKELTON: How had you in your mind excluded the possibility that the nurse had acted criminally?
SUBHEDAR: I wasn't able to do that. I wasn't in a position to do that. I was asking for a detailed review to be done of -- of all staff at that time and I didn't know whether that was being done or whether it had been done and that had resulted in concerns about a single member of staff or continued concerns about a single member of staff.
SKELTON: But if this had happened in your hospital, many more children than usual dying, no identifiable common medical cause, exclusion of the usual causes but a commonality of a single member of staff, you would have acted with urgency, wouldn't you?
SUBHEDAR: If all of those things that you have said were
in place, yes.
SKELTON: But you never advised Steve Brearey to do that?
SUBHEDAR: I didn't know all of those things were in place. All of those things that you have mentioned about a single member of staff being identified after a thorough review, if that had happened in my hospital we would have demanded a thorough review, first of all, there would have been an urgent review and if at the end of that review there was only one member of staff that was still implicated then, yes, that would have demanded further action.
SKELTON: When do you say Steve Brearey or anyone else first made it clear to you that the suspicion was in fact of deliberate harm, murder, by that nurse? When in this whole chronology did that occur?
SUBHEDAR: That was, those words were never used by Dr Brearey to me. There was -- I was aware of a concern about an individual, I didn't know specifically the level of concern and so, for example, I didn't know whether that was about clinical care or whether it was actively wanting to harm babies. So -- but I knew that there was concern. What had prompted such concern I wasn't aware of.
SKELTON: Throughout the entire time into 2017?
SUBHEDAR: Well, by -- by the time we met with the Exec Team at Chester and Dr Brearey and the team were concerned enough to want to involve the police, I knew at that stage that there were -- there were concerns about a member of staff having murdered babies. But, but not before then.
SKELTON: When you found that information out, did you think to say to Steve who you knew very well, professionally: why didn't you tell me? Why am I only finding out now in 2017 that you suspected this nurse for two years?
SUBHEDAR: I didn't ask him that specific question, no.
SKELTON: Why not?
SUBHEDAR: Because I knew there was a process that was -- well, I assumed that there was a process that had been followed with external reviews. What I didn't know was whether an internal review had been undertaken and what that had shown and whether there were other events that had prompted their concern, but I was aware of their concern.
SKELTON: Do you recognise now that a series of reviews that drifted into weeks to months to years was not the appropriate response to a concern of that gravity?
SUBHEDAR: Yes, I -- I would accept that. I think it demanded an urgent detailed review with -- by either an
external body or something similar which had some independence and that should have been done much more quickly.
MR SKELTON: Thank you, thank you my Lady.
LADY JUSTICE THIRLWALL: Thank you, Mr Skelton.
MR DE LA POER: My Lady, I have no questions arising.
LADY JUSTICE THIRLWALL: I have no questions either so thank you very much indeed, Dr Subhedar, you are free to go.
SUBHEDAR: Thank you very much.
MR DE LA POER: My Lady, our next witness is Dr Mittal. I wonder if he might come forward, please.
DR RAJIV MITTAL (affirmed)
LADY JUSTICE THIRLWALL: Do sit down.
MR DE LA POER: Please could you state your full name?
MITTAL: Rajiv Mittal.
DE LA POER: Dr Mittal, you provided to the Inquiry a statement dated 7 June of 2024?
MITTAL: That's correct.
DE LA POER: I understand that there is a correction that you wish to make before you confirm its content to be true. I think it's paragraph 16 that you want to take
us to, so I wonder if you might just do that now and just explain to us what it is that you wish to correct?
MITTAL: So, my Lady, the paragraph 16, there were no formal minutes of that meeting which were shared with me. After looking at the minutes from Mr Stephen Cross' statement, I realised that there are a few things which are incorrect in my statement, so it was not Dr Brearey, it was Dr Susie Holt who was in that meeting.
DE LA POER: If I can just pause you there, just so that we all know, those who don't have your statement in front, you are speaking about a meeting on 27 April of 2017; is that right?
MITTAL: That's correct.
DE LA POER: It's a meeting that you deal with at paragraph 16. You have just told us that you have seen Stephen Cross' notes of that meeting which were not a document that you had access to at the time that you made your witness statement?
MITTAL: (Nods)
DE LA POER: You have told us that you are correcting your recollection that it was not as you say in your statement Dr Brearey, but instead it was Dr Holt who was present. Is there any other matter within your paragraph 16 that you wish to correct?
MITTAL: And also there was a mention of a member of the staff linked to deaths in that meeting so that was the first time this was mentioned in that meeting. So this is -- in correcting my statement.
LADY JUSTICE THIRLWALL: So your statement says there was no mention, but --
MITTAL: Sorry, my Lady?
LADY JUSTICE THIRLWALL: Is what you are correcting the first line on page 3?
MITTAL: And then the second one there was a mention of the involvement of a member of staff in that meeting definitely.
LADY JUSTICE THIRLWALL: So should we delete the word "no"?
MITTAL: Yes, yes, my Lady.
LADY JUSTICE THIRLWALL: Thank you.
MR DE LA POER: Thank you, Dr Mittal, we will come to that meeting in the course of your evidence but taking into account the corrections that you have just made about paragraph 16, is the statement otherwise correct to your knowledge and belief?
MITTAL: Yes, my Lady.
DE LA POER: Now, Dr Mittal, this isn't dealt with in your statement but can you just give us some idea of when you qualified as a doctor?
MITTAL: So I qualified -- I had completed my MBBS in 1992 and since 1992 I have been working as a paediatrician in various roles.
DE LA POER: You became a member of the RCPCH in 2009; is that correct?
MITTAL: In 2003 I became a member of the Royal College of Paediatrics and Child Health.
DE LA POER: Thank you. Did you join the Countess of Chester Hospital in 2009?
MITTAL: That's correct, I joined Countess of Chester in March 2009.
DE LA POER: Was that as a Consultant paediatrician?
MITTAL: That's correct.
DE LA POER: Was your area of work the community?
MITTAL: That's right, so I am a neuro-developmental paediatrician and I mainly do ADHD autism assessments and cerebral palsy and children with development delay.
DE LA POER: Can I ask you just to slow down very, very slightly, I think that will just help with the echo.
MITTAL: Sure.
DE LA POER: Now, as part of your role, did you also become what is known as the designated doctor?
MITTAL: That's correct, my Lady, yes.
DE LA POER: Now, we need to be clear about where you were the designated doctor of. Were you the designated
doctor for Cheshire West and Cheshire Vale Royal?
MITTAL: From 2009 I had been working as a Designated Doctor for Safeguarding and Designated Doctor for Child Deaths.
DE LA POER: For Child deaths, but was that for the Countess of Chester that you were working in that designated doctor role or was it for a wider area?
MITTAL: My Lady, that was for ICB. It used to be called CCG before, Clinical Commissioning Groups, and now they are called ICB, Integrated -- Integrated --
LADY JUSTICE THIRLWALL: Care Board.
MR DE LA POER: Care Board.
MITTAL: Integrated Care Board, so they are the same but yes, that was on behalf of them.
DE LA POER: So were they funding that part of your job?
MITTAL: Yes. My Lady. So I get four hours of my which is one session per week which is paid by ICB for my Designated Doctor for Child Death role.
DE LA POER: Just to look at it in a practical real world context, if there was a safeguarding issue at the Countess where you were a Consultant paediatrician, would you be the person to be spoken to about that or was there another person who should be spoken to?
MITTAL: So, my Lady, it would be the named doctor for safeguarding which is Dr Howie Isaac. She would be
contacted first and I would be contacted if it is in the local authority in different hospitals or GPs or health visitors, they would contact me, if it is outside the hospital.
DE LA POER: But presumably the Countess of Chester fell within the area that you had responsibility for. So just as other hospitals might have a named doctor for the hospital, your responsibility for the -- at the CCG level included the Countess of Chester?
MITTAL: That's correct, my Lady.
DE LA POER: So does it follow that in terms of a safeguarding issue that was raised with you, because that's being raised at a CCG level, you aren't in fact answerable to anybody at the Countess of Chester in terms of how you deal with that; is that right?
MITTAL: That's correct, my Lady, so for my -- this role, there is a director of quality in ICB, she is called Paula Wedd, she is my immediate manager for this role.
DE LA POER: Now, as far as the SUDiC process was concerned, what was your understanding in 2015/16 as to whether SUDiC applied to unexpected deaths of neonates who were born in hospital and were moved to the NNU?
MITTAL: So, my Lady, I would like to just spend a couple of minutes on SUDiC process because this has
evolved from 2004. Originally it was only for infants up to two years of age, it was only for infants who died at home unexpectedly, so this process was started in 2004 because only for those babies. So gradually the remit has increased and it increased from up to two years to 18 years of age. Previously it was only like for deaths which were outside the hospital but gradually it has included any death anywhere in the hospital or outside in the community; if it is unexpected, then a SUDiC process should be initiated.
DE LA POER: So you have described an evolution which I think brings us up to the present day; is that right?
MITTAL: That's right.
DE LA POER: So the resting position today is that SUDiC applies to every death regardless of where it takes place and regardless of the circumstances?
MITTAL: Just I would like to make one comment here my Lady, that this is a process. So the way it is followed is still like Dr Subhedar also mentioned. It is still people think that if a death is outside the hospital in community, then SUDiC process is followed. If it is an in-hospital death although for unexpected in-hospital deaths SUDiC process should be followed, but it is still people's presumption that in-hospital death there is a separate process, so SUDiC is not followed. And in 2015 again like people thought again it's a training issue and it is a national issue, so in my 15 years in the Countess of Chester Hospital I haven't come across a single death where we have done a SUDiC meeting for in-patient hospital deaths. And I was reading our expert Dr Garstang's statement and she was saying last year, which is 2023, in Birmingham, which deals with a much larger population and much larger neonatal deaths, she said out of 18 neonatal deaths, she was only involved in one death, one neonatal death, which was an in-hospital neonatal death, where SUDiC process was initiated. So it is unusual still and I -- I agree that it should have been initiated but it is more like a training issue and practice issue and it is a national thing. This is being discussed in the national meetings as well, that people are really not following the SUDiC for in-hospital deaths.
DE LA POER: Dr Mittal, I just want to get down to, as my question began, with what your understanding you have described how your colleagues who are not necessarily specialists in SUDiC may have misunderstood it and you have been very clear about that. But you are the designated doctor for the CCG, as it was then.
In 2015, did you think that SUDiC applied to unexpected deaths in hospital?
MITTAL: Yes, my Lady.
DE LA POER: You did?
MITTAL: Yes.
DE LA POER: So if any Consultant paediatrician in the Countess of Chester had told you that they had an unexpected death of a neonate, would you have advised them to initiate the SUDiC process?
MITTAL: So I would just like to explain a bit more about answer to this question. So in my Designated Doctor for Child Deaths role there are two ways I get information. First is like the Form A which has been mentioned which is a notification form which is for all deaths, all routine deaths. In 2015, it used to come to me, either via phone or in a paper copy or it could be an email. So the process was not very structured and it could be sometimes a couple of days before the information came to me, in 2015. The system has changed now but at that time it was very -- it was not very systematic at that time. So this is for all deaths. But if there is a SUDiC death I get phone call from the police officer, if it is in community the police
officer will ring me directly or if it is a health professional they are not sure whether the SUDiC should be started or not, they would come to me, they will come to me, they will contact me if it is a paediatrician or A&E Consultant, they will come to me and then they ask me whether we should be doing a SUDiC for this death or not.
DE LA POER: Dr Mittal, my question just to ask you to focus on it, please, was if you had been asked for your advice, that would have been --
MITTAL: Yes.
DE LA POER: -- if this is an unexpected death, we need to initiate the SUDiC protocol which would involve using the language of 2015 a Rapid Response Meeting which would be multi-agency; is that correct?
MITTAL: That's correct, yes.
DE LA POER: Now, did any of your colleagues at the Countess ask you about any of the deaths that they dealt with whether or not the SUDiC protocol applied?
MITTAL: No.
DE LA POER: Now, you have told us that you saw the Form As, we are not going to look at the detail of any, but in terms of your responsibility if any of those Form As mentioned that the death was unexpected, did you have a responsibility to notice that and to go back to
the neonatal unit to say: has this death been considered for SUDiC?
MITTAL: So, my Lady, there are three different types of forms. The Form A which is a notification form, it just states that so and so baby has died and these were the problems. It doesn't mention much in detail whether it was unexpected or unexplained. That is in the Form B or which is a reporting form. So the Form A notification form comes straight away within 24 to 48 hours of the death, although it was coming late at that time because the system was not very structured but the details about the death they come in the Form B, which is like four to six weeks after the death that Form B comes. But for SUDiC, if anybody wants us to initiate the SUDiC, coming to me for SUDiC means that we are involving the police and it should -- they should be coming straight because SUDiC needs to be initiated within 72 hours to five working days, we cannot wait later than that so that's the guideline.
DE LA POER: So you, if I may say so, Dr Mittal, appear very clear in your own mind about what should have happened in 2015 in the case that a Consultant paediatrician identified that the death was unexpected. And you have described that it is a training issue if somebody didn't realise that they needed to contact you. Whose responsibility was it to ensure that the Consultant paediatricians at the Countess of Chester were properly trained?
MITTAL: So, my Lady, just -- just to clarify. It was -- the way the SUDiC was followed up all over the country, just not -- Countess was not an outlier in that, so it was the whole country.
DE LA POER: Dr Mittal, we have had that point very clearly. My question is about who had responsibility to ensure that the Countess of Chester Consultant paediatricians knew which process they should follow?
MITTAL: So there was an overlap at that time because there was no named doctor for child death in the Countess at that time. Now, they have appointed a named doctor for child death who's paid by Countess to look into the child death process but at that time I was only person, all the Countess was not paying me for this role, I was the only named person in the hospital because I was employed by Countess and my role was to check that Countess is doing this or not. So I was delivering training but it was ad hoc, it was not like every three months I was doing, so I was delivering training to paediatricians and other
Consultants in the hospital.
DE LA POER: So we know that the first death of a child named on the indictment was towards the start of June 2015 and the final death was in June of 2016. Were you delivering training to the Consultants at the Countess of Chester during that year-long period?
MITTAL: So it is difficult for me to remember when I delivered the training. It was more like an ad hoc thing that in the departmental meeting I used to deliver some training about CDOP in that, in the meeting. And I used to call Mrs Sharon Dodd, who is -- who used to be our named nurse for CDOP. She used to join me for delivering those sessions to paediatricians or to A&E but I don't remember the dates when I delivered those trainings.
DE LA POER: We know now, and it's clearly established from documentation at the time, that the Consultant paediatricians did identify a number of these deaths as being unexpected and you have told us none of them contacted you. This is over a period of a year --
MITTAL: (Nods)
DE LA POER: -- and it's across the Consultant body at the Countess. Do you think you have a responsibility for failing to ensure that those Consultants knew which
process they should follow?
MITTAL: I would accept that there is some -- some responsibility on my part and for not being clear at that time that in-hospital deaths should be followed with the same rigorous way, the way we used to follow the out of hospital deaths for initiating the SUDiC process. But I was only getting one session of four hours for dealing everything doing everything in addition to delivering training.
DE LA POER: So is your position, just to summarise what you have just told us, that you accept that that was a failure on your part, but that you are drawing attention to the amount of time that you had and that that is an explanation or part of the explanation for why you think you failed to ensure they knew what to do; is that fair?
MITTAL: Also like I was employed by ICB which was CCG. So Countess was not paying me for to do this role so actually I was supposed to check on Countess to make sure that the paediatricians are doing -- they know about the -- this training and everything else. So it should be Countess engaging somebody to do this, to pay somebody to deliver that training. But because I am based in Countess, that is why I also take
responsibility that I should have also delivered that.
DE LA POER: Another way of looking at it is that you had a responsibility to ensure that everybody within your area, including the Countess, understood which way which process to follow in those circumstances?
MITTAL: That's correct.
DE LA POER: So is that a fair way of looing at it?
MITTAL: That is a fair way, yes.
DE LA POER: Now, the RCPCH report, just staying with the topic of SUDiC, made a recommendation, I am sure you will remember it, that the SUDiC process needed to be improved. That report was published in February of 2017. Was that a recommendation that you needed to know about as soon as it was made?
MITTAL: So, my Lady, I was called by the RCPCH team to speak to them. They never asked me much, they were more interested in knowing my role what I do.
DE LA POER: Dr Mittal --
MITTAL: But it was not shared with me formally.
DE LA POER: No, no and I was not seeking to suggest otherwise. If you just listen to my question. The report contained a recommendation that the SUDiC process at the Countess of Chester needed to be improved. That report was published in February of 2017. Nobody is suggesting that you were told that before that. My question was: was that a recommendation by the Royal College that you needed to know as soon as possible?
MITTAL: Yes, my Lady, I should have but I don't think that I really followed that or really like did anything for that.
DE LA POER: Now, the subject of SUDiC was raised at a number of the CDOP meetings, the Child Death Overview Panel meetings?
MITTAL: (Nods)
DE LA POER: We will just bring, up focusing at this stage just on SUDiC, INQ00178115, and we will go to page 2. What you are going to see, Dr Mittal, is the 26 September 2016 meeting. It's a document you have seen before. So that is the meeting as we will see on page 2 that you were asked to chair in the absence of the independent chair, Ms Frame, and she's already given us some evidence about that. So page 2, please. We can see that marked towards the top left-hand corner. If we look at the third action, we can see that one of the matters discussed at the meeting to be added for the November meeting was asking if the panel
consider that unexpected death in hospitals should be referred for a Rapid Review Meeting. So it would appear that at a meeting that you chaired dealing with the whole area covered by the CDOP, the Pan Cheshire area, that this was something that the panel was discussing; is that right?
MITTAL: So, my Lady, from my recollection there are, there are two parts of this meeting, so one part is a clinical meeting where we discuss cases and the second part of the meeting is a business meeting where we discuss if there are any issues around this. So this was discussed in the second part of the meeting and it was because I was called by the Royal College of Paediatrics team, that's why I raised this here as well; that -- and I have raised this so many times in various fora that in-hospital patient deaths should be dealt with the same vigour as out of hospital deaths. So this is what I -- I think I raised it, because I had -- fresh from the -- from meeting the Royal College team.
DE LA POER: Yes. And so does it follow then that in September of 2016, you knew that there was a problem at the Countess, because that is where the Royal College had been, about the SUDiC process?
MITTAL: It was more about the cluster of deaths
which -- which happened in the neonatal unit and that was the main reason why I was saying that cluster of unexplained deaths and nothing has been happened nothing has happened and this has not been raised to us.
DE LA POER: We are going to come to the wider CDOP picture in terms of the death. Just finishing this point. I mean, it's been pushed down the road, this discussion, because it's not being discussed at this meeting, it's been pushed off to November. But is this fair, Dr Mittal: in fact, it is very simple, you have just told us in a sentence SUDiC applies in hospital?
MITTAL: Yes.
DE LA POER: There's no discussion to be had, is there; that is what the protocol was at the time?
MITTAL: (Nods)
DE LA POER: You understood that?
MITTAL: Yes.
DE LA POER: So why wasn't that just -- the item just put to bed there and then in September, you are the designated doctor, you are the chair of the meeting: this is the position, we don't need to discuss it any more, everyone needs to get on with it?
MITTAL: So, my Lady, the SUDiC meetings happen within 72 hours to the five days, within the five working days. So this was too late and we didn't have any facts at
that time. So usually we do not initiate SUDiC meetings if a year or two years after the death.
DE LA POER: Forgive me, Dr Mittal, I wasn't suggesting that the SUDiC discussion needed to be focused upon the deaths that were mentioned by the Royal College. This appears to be of general application to the whole area and instead of just saying: this is very straightforward, everybody, I am the designated doctor, it applies in hospital, everybody here needs to know that and tell everybody about it ... you seem to just be passing the issue on to the next meeting as if there's some legitimate debate to be had about it?
MITTAL: So I would say a couple of things here like I am not the only designated doctor in this panel, there are two more designated doctors who have neonatal responsibilities, whereas I do not go to the neonatal units in my clinical role. So they also attend this meeting and we all knew that this is a national problem so the reason why I was raising here was to raise awareness and to raise this issue that in hospital deaths should be dealt in the same rigour as out of hospital deaths to initiate SUDiC meetings, so that was the reason I raised this in the meeting.
DE LA POER: Well, the way the action is phrased is asking if the panel consider that the unexpected deaths in hospital should be referred to. The way it's phrased suggests that there is some legitimate debate to be had one way or the other rather than you just saying: this is how it is. Do you know why it's phrased in that way, as if there is a discussion to be had about it?
MITTAL: So I'm not sure how this has been phrased like this. But it was more about raising awareness about this issue. That was the reason why we discussed it in there.
DE LA POER: We don't need to go to it, but I am sure you can confirm the subject of SUDiC was discussed at the November meeting, wasn't it?
MITTAL: Yes.
DE LA POER: We see also that it came up again at the March meeting?
MITTAL: (Nods)
DE LA POER: Thank you very much indeed, we can take that down. The final question that I have for -- topic of questions that I have for you about SUDiC is about a form that was filled in about [Child C]. I wonder if we can bring that up, please, and it is very important that we don't bring up anything other than this page, INQ0000108 and we are going to go to
page 178, 178, please. Now, again, just refamiliarise yourself with this. The heading of it is "Sudden Unexpected Death in Infancy and Childhood Initial Strategy Meeting". Now, does that heading -- ignore for a moment what the content is and who attends this, just that heading. Is that the meeting, the initial strategy meeting, that would that you would expect would take place with you as the designated doctor?
MITTAL: So, my Lady, this is a template for the SUDiC meeting but it looks like Dr Gibbs has used this template for SUDiC meeting to discuss this case with the --
DE LA POER: Dr Mittal, I'm sorry to cut across you, you are doing what we will come to, which is you are looking at the text which I have asked you to ignore. Just focus, please, on the heading, the "Sudden Unexpected Death in Infancy and Childhood Initial Strategy Meeting", would that be the meeting that would take place with you, that is what you would expect under the SUDiC as designated doctor?
MITTAL: That's correct. That is the template for the SUDiC meeting.
DE LA POER: Exactly. So the circumstances in which you would expect this form to be used as designated doctor
is once the paediatrician has phoned you said that we have had an unexpected death, we need to within that initial two to five hour window, I think you told us; is that right?
MITTAL: That's correct.
DE LA POER: Have a meeting, obviously you need to make record of that meeting and this is the template which would be followed at that meeting?
MITTAL: And there is usually 10 to 15 people in that meeting, so there are only two people in this meeting.
DE LA POER: Yes. Now, Dr Gibbs has given evidence broadly along the lines that you have just told us, which is that this absolutely was not a SUDiC meeting as far as he was concerned, that he just used this form as a record for what happened?
MITTAL: (Nods)
DE LA POER: From your point of view as a designated doctor, do you regard that as something which shouldn't have happened, that we shouldn't have forms for such a serious meeting being used to record for a different purpose?
MITTAL: So, my Lady, this form is public so it is everywhere like online, on the website, on the Countess internet website, so it is for people to -- again
I cannot say why this form was used, but this form is easily available on Internet.
DE LA POER: But what you can say, perhaps Dr Mittal, is as the designated doctor, this form should not be used for anything other than a meeting with you?
MITTAL: That's correct.
DE LA POER: Dr Gibbs spoke to some of the content, in fact he candidly drew attention to one part of the form so let's have a look at it, over the page, please. We can see that as part of the meeting that you would expect to have with you looking at the template, that there is a discussion about the strategy and Dr Gibbs has recorded a strategy meeting was not held. We can see that there is a discussion about what agencies have been involved. 6 requires consideration of safeguarding issues for surviving children and then we have a section for the Coroner. In terms of helping us to understand how these meetings should happen, not the way that Dr Gibbs was running it, but would they run through this template having a discussion at each and every stage about each of the boxes and what needs to be said and populated?
MITTAL: That's correct, my Lady, this is a very structured meeting and all these headings we covered in the meeting.
DE LA POER: So we can take that down, thank you very much indeed. Now, we are going to widen the questioning not just to SUDiC but to the CDOP role and all child deaths and return to an answer you gave us a moment or two ago which is that all of the Form As with limited information, as you have told us, passed through your hands?
MITTAL: Yes.
DE LA POER: Now, we know from contemporaneous documentation that the mortality rate on the neonatal unit was between two and three per year up to June of 2015?
MITTAL: (Nods)
DE LA POER: We know that there was a very significant increase in that and it depends on how you identify the period whether you do it by annual year or you work from a different number. But we are at a level of somewhere around 17 or 18 deaths which then occur in the following year and so that's a very significant increase in the number of Form As, isn't it?
MITTAL: So can I elaborate this further?
DE LA POER: If it's relevant to answering my question then of course you must say?
MITTAL: So just to give a bit of background about
this. So not all deaths -- like we have about 20 deaths per year in the Cheshire area. Out of 20 deaths, about 50% are neonates but most of these deaths happen in Liverpool Women's Hospital so they don't happen in Countess, so Countess there are only two to three deaths per year. but the Countess babies they are transferred to Liverpool Women's and then the babies die elsewhere. So the number of neonatal deaths are more than two to three per year but they don't happen in the hospital, so -- because the sick babies they are transferred to patient centres and then deaths happen there. But they constitute the majority of the deaths in Chester. So out of 20 deaths, more than 10 deaths, they are neonatal deaths every year. So yes, I agree that in that year, in 2015 and 2016 over the two financial years, the number of deaths in Countess were much more than what we would normally expect in a year.
DE LA POER: Was that something that you noticed, bearing in mind that you were looking at each of these Form As?
MITTAL: In hindsight I should have but I did not -- not notice at that time.
DE LA POER: You didn't at the time but you accept you should have?
MITTAL: Yes, and I can give some reasons as well.
DE LA POER: Please?
MITTAL: Because the way they come to me is like I didn't record them anywhere on my system for these deaths. So all these deaths were recorded by Sharon Dodd, so I didn't have an admin or secretary who should be recording all these deaths. So all these forms were going to secretary who was based with the Mrs Sharon Dodd in Cheshire Wirral Partnership. So the system was not very structured. It has changed a lot. But every two months or one month I will get an email or a phone call or like informing me different ways, then it used to go to the admin in Cheshire Wirral Partnership to Mrs Sharon Dodd's office. So there was no structured way -- I admit that I should have looked at the pattern but because they were coming from all over like some deaths were in Liverpool Women's, some were in Arrowe Park Hospital and some were in Manchester, there was one death in Manchester. And -- so there was no structured way for me to look at because I didn't have a database in the hospital to look at this. So I did not recognise the trend until I was called by the Royal College about that cluster of deaths.
DE LA POER: So your recollection is the first time you became aware of the fact that there had been an increase
in the number of neonatal deaths was in September 2016?
MITTAL: I was aware that the number of deaths are more and I think Mrs Dodd also said in her evidence to the Inquiry that we had some discussion what's happening, why there are so many babies dying. So it was more like ad hoc discussion in one of the meetings but we didn't go anything further, it was just saying that the numbers are more than what we normally -- would normally deal with, that's all we discussed. We didn't go any further than that.
DE LA POER: Where were you physically based at this time?
MITTAL: So I was based in the Countess and Mrs Dodd is based in a different --
DE LA POER: Were you based on the same corridor as the --
MITTAL: Yes.
DE LA POER: -- other Consultant paediatricians?
MITTAL: That's right.
DE LA POER: So having had this conversation with Ms Dodd about there's been an increase, I wonder what's happening, did you go and ask any of your colleagues what is happening on the neonatal unit, we have noticed an increase?
MITTAL: I -- I don't think that I went to any of the Consultants to ask specifically for this.
DE LA POER: Given your role as designated doctor and given that the Countess fell within that, and given that as you have told us that you wondered about it and noticed it and discussed it with Ms Dodd, do you think you should have gone to ask your Consultant colleagues who were on the same corridor what's happening?
MITTAL: In hindsight, yes, I should have.
DE LA POER: Well, I mean, at the time didn't you have enough information to make that judgement?
MITTAL: No.
DE LA POER: Why?
MITTAL: I just knew that the number of deaths are more because of the notification forms but I didn't have any -- any other information.
DE LA POER: But the people who could have given you that information were just next door, weren't they?
MITTAL: Yes, but in hindsight I think I should have explored these more. But I don't think that at that time I went to the Consultants and asked them: okay, what's happening?
DE LA POER: We are going to have a look at an email. INQ0103110. This is an email in September 2015, it is an exchange between you and Dr Gibbs about filling in forms?
MITTAL: Yes.
DE LA POER: I am sure you will recognise it when it comes
up. And so the email thread starts at the bottom with Dr Gibbs raising a concern about the effectively excessive paperwork and if I summarise what he says, so we don't need to look at it, what he is saying is we are filling out the same information in multiple places, is that the thrust of it?
MITTAL: That's correct, yes.
DE LA POER: So information that needs to go in the Form B is having to be typed out elsewhere as well and --
MITTAL: Yes.
DE LA POER: -- that is plainly not very efficient?
MITTAL: That's correct.
DE LA POER: And so you reply but before we get to that. Let's just have a look at the very first line of his email that we can see. We have had another neonatal death, he says. So I appreciate you have made your own observation from the number of forms. But do you agree this appears to be an occasion when Dr Gibbs is drawing your attention to the fact -- well, that there appears to be a developing trend is one inference from him having started an email with that fact, do you agree?
MITTAL: Yes.
DE LA POER: Do you think that that was a sufficient prompt
for you as designated doctor to be curious about it and say: do you think we need to have a chat about what's going on on your unit?
MITTAL: In hindsight, yes, yes.
DE LA POER: That statement he makes is not something that you respond to in your email but what you do say is that effectively to make the form filling easier, that information populating a letter can just be copied across into the Form B; that is the thrust of it, isn't it?
MITTAL: That's correct.
DE LA POER: That is you effectively trying to make the admin less onerous?
MITTAL: That's correct.
DE LA POER: On that topic, do you think the administrative burden from your point of view as designated doctor is too great on Consultant paediatricians?
MITTAL: I would say yes because admins, they don't get that much admin support, so yes, there is a lot of burden on Consultant paediatricians.
DE LA POER: So this was clearly your attempt in 2015 to ease that burden, so far as your particular area of work is concerned?
MITTAL: That's correct.
DE LA POER: Are there further improvements that can be
made to that?
MITTAL: So yes, my Lady, now everything has become electronic, so they get an email directly from -- so there is a central admin for CDOP and then the emails come directly from there and then they just need to complete the online form and it automatically goes back to CDOP. So I don't get involved in this, it directly goes to CDOP.
DE LA POER: So as things stand now, you wouldn't get the Form A?
MITTAL: So the Form A goes to many people.
DE LA POER: Yes.
MITTAL: But it -- there is a central place now in the CDOP office where they are the main people who look at. I get a copy of the Form A as well so it goes to many people like the named nurse for child death and also to me. But there is a central office now in CDOP where electronically all notifications go and then they look at everything now.
DE LA POER: Just to invite you to consider another event. We can take that down, thank you very much indeed. We know that the neonatal unit was downgraded in July of 2016, to use the language of the time, to a Level 1 unit from a Level 2?
MITTAL: That's right.
DE LA POER: Was that something that you were aware of at the time?
MITTAL: Yes, I knew.
DE LA POER: At the time did you understand that that was because of an increase in the mortality rate?
MITTAL: That's correct.
DE LA POER: So again if we think about when you were aware of the mortality rate, we have got your observations, we have got Dr Gibbs's email which appears to refer to it directly. Obviously at the other end we have got the Royal College, when you are meeting them in September, but in July as well, quite a dramatic step from the point of view of a hospital to downgrade its unit because of an increase in mortality, would you agree?
MITTAL: That's correct. Yes.
DE LA POER: And do you think that that was a prompt for you to go or should have been a prompt for you to go and find out what was going on with your colleagues on that corridor?
MITTAL: In hindsight, yes.
DE LA POER: Did you do that?
MITTAL: No.
DE LA POER: And why do you think that you didn't seek to find out more about why the unit had been downgraded and what the concerns were?
MITTAL: I don't think I have an answer for that.
DE LA POER: Now, we know that at the end of June 2016 and at the beginning of September 2016, firstly to the Executives and secondly to the Royal College, concerns were raised by your Consultant colleagues that they thought a member of staff may be murdering babies?
MITTAL: (Nods)
DE LA POER: And that that was the explanation, or might be the explanation for the increase in mortality. When did you first learn of those concerns?
MITTAL: So this was kept very confidential from me because they knew that the moment I get involved, the police will be involved and because the first --
DE LA POER: Can I just stop -- can I just stop you there. Is that your assumption that as soon as --
MITTAL: That's my assumption.
DE LA POER: That's your assumption. No one has ever told you that that's the reason you weren't told?
MITTAL: No, no. That's an assumption because the way we work for SUDiC or the way we work because I am an outsider basically, because I am from CCG or ICB looking at. For this role, I am not part of the paediatricians, I am an outsider or like my role is to scrutinise the work which is done there. So everything was kept very confidential from me
and I was not involved in any of those discussions.
DE LA POER: Was a consequence of you being outside of the management structure of the Countess that insofar as you were concerned, it wouldn't matter whether the Executives did or didn't want to involve the police; you would make your own judgment about that as designated doctor and if you thought the police should be called, you would call the police?
MITTAL: Could you please ask me the question again?
DE LA POER: Of course. Was one of the effects of you being outside of the management structure, just picking up on your answer a moment ago about you would call the police, that it wouldn't matter to you or it wouldn't determine your decision if the Executives didn't want to call the police; you are independent of them for this purpose, you are there representing the CCG, if you want to call the police, you'll call the police?
MITTAL: Yes, after establishing the facts, and if I am concerned that, yes, there is something like this, yes, I would speak to them.
DE LA POER: So just going back to my question. When do you think the first time you became aware of the concern that a member of staff may be responsible for the deaths?
MITTAL: So from my recollection the first time
I became aware of this was in that meeting in April 2017, which was in the CEO's office.
DE LA POER: That was the meeting at which a police officer attended?
MITTAL: That's right.
DE LA POER: Well, we will get to there shortly. But let's just look at what's happening in the CDOP and in particular two meetings before we get to that point. So the first meeting is the September one. We have already looked at one aspect of this, this is INQ00178115. This is the meeting that you chaired and [Child I]'s case we know was considered at this meeting. If we go to page 2, we can see above the action that we previously looked at, so this is action number 2: "Child's details to be sent to Coroner for review of case notes. The child's case to be referred to once the Royal College report is presented by Dr Mittal." A reference to you. All of that detail follows the assertion "closed case". Do you see that?
MITTAL: Yes.
DE LA POER: So was the case of [Child I] closed so far as the CDOP was concerned at this meeting?
MITTAL: So, my Lady, the way the system works -- again I am just explaining it from my recollection -- one thing is although I was chairing the meeting, but there are other designated doctors as well who have got more neonatal experience; they were there in the meeting as well. The other thing is there was nothing in the paperwork, you know, the Form Bs which are completed by the paediatricians about clinical management to be suspicious about. And this baby had medical problems already, like lots of comorbidities were already there in this baby. So the way which I think must have happened at that time is -- so we have an action log for CDOP like actions to be completed, so we put that as an action in that action log, and then we might have agreed at that time that we should close the case. I agree, in hindsight, we shouldn't have done that.
DE LA POER: Well --
MITTAL: But that's what I think must have happened at that time.
DE LA POER: On the face of it, of this record, there was to be a further investigation into [Child I]'s death in the form of the College report?
MITTAL: (Nods)
DE LA POER: In addition, as we can see from the following
action, we know that there was concern about whether SUDiC had been followed in relation to the cohort that the RCPCH were looking at. That's why you have told us you brought it up --
MITTAL: So can I just clarify this point here? I think the way this has been done or taken is not the correct way. So basically this was a general discussion about in hospital deaths, whether RRM should happen or not, not specifically related to this case. But I do not know why this has come up here as like this. But the discussion was not specifically related to this case because we do not do Rapid Response Meetings like straight away.
DE LA POER: Let --
MITTAL: So it was a general discussion about in hospital deaths, why we are not doing this, but not specifically related to this case.
DE LA POER: But did you know from the Royal College that their review had identified that SUDiC hadn't been followed in relation to the deaths that they had looked at?
MITTAL: So I -- the report, at this stage the report was not shared with me at that time.
DE LA POER: And they hadn't said anything to you about it?
MITTAL: No, not to me.
DE LA POER: But at all events, [Child I]'s case is recorded as being closed, when it shouldn't have been. I mean, Ms Frame has told us about the very substantial backlog -- I think she used the phrase "huge backlog" -- that she inherited in 2015. Did you feel under pressure to close cases as quickly as possible so as to be able to set the committee on its right footing?
MITTAL: So, my Lady, I was not the only one. Like it is always a unanimous decision in the panel. Like, I was just one of the member. So it was everybody in the panel because there was nothing suspicious in the Form B from the hospital and because it was a neonate and then we thought that, like, we are not picking up anything, any theme from that. That's why the panel agreed.
DE LA POER: Dr Mittal --
MITTAL: Let's close the case and keep it as and action for later on.
DE LA POER: You will forgive me, I hope, for interrupting you. My question was whether you felt under any pressure to close cases quickly as part of the effort to clear the backlog; that's the question. Did you or did you not feel under that pressure?
MITTAL: It's difficult for me to remember, but I think it was one of the pressure at that time, that we had too many cases pending.
DE LA POER: Now, the final matter to deal with just before I ask the Chair to consider taking a lunch break is evidence that we received from Dr Isaac. Are you aware of what Dr Isaac told the Inquiry on Monday?
MITTAL: Not fully.
DE LA POER: No. Well, let me -- let me help you. Dr Isaac told the Inquiry that in February of 2017, having become aware at a time earlier than that of the concerns of Dr Brearey, that she drafted a letter as the named doctor for safeguarding for the hospital that she was intending to send to the Executive lead, Alison Kelly, and she told us that she didn't send that letter and part of her reason was that there was a culture of fear?
MITTAL: (Nods)
DE LA POER: That's what she told us. Did you know anything about Dr Isaac intending to intervene in what was going on between the Consultant paediatricians and the Executives?
MITTAL: I had some, some impressions, so not -- I didn't know exactly the full facts, but I had some inkling that there is something going on.
DE LA POER: Doing the best you can, was that around early 2017 --
MITTAL: Yes.
DE LA POER: -- does it seem to you?
MITTAL: Yes.
DE LA POER: So about the time that she's contemplating. Did you know that she was thinking about writing a letter?
MITTAL: I think she did mention to me that, yes, she want to contact.
DE LA POER: And did she ever tell you whether she had sent that letter?
MITTAL: Not exactly, but I knew that there is a tension going on between the paediatricians and the management because people were applying for jobs elsewhere at that time.
DE LA POER: Wasn't that a very significant red flag for you as the designated doctor for the area? You've got the named doctor for safeguarding thinking about, talking to you about intervening, you have got an apparent breakdown in relationships such that people are thinking about moving. Isn't that a very significant concern or shouldn't it be a significant concern for you?
MITTAL: In hindsight, yes. In hindsight, yes.
DE LA POER: And did Dr Isaac tell you what she was going to put in the letter?
MITTAL: Not specifically what she was going to put in the letter.
DE LA POER: But it would, given that she was named doctor, it would be to raise a safeguarding issue, is that right?
MITTAL: That's right, yes.
DE LA POER: Did you think it was important that as the named doctor for safeguarding that she should act fearlessly and raise any concerns that she had?
MITTAL: Yes, she should.
DE LA POER: Did she tell you that she didn't send the letter?
MITTAL: So NHS, like it's a very hierarchical structure. So --
DE LA POER: Can I just ask you to focus on my question. Did she tell you that she hadn't sent the letter?
MITTAL: No.
DE LA POER: Did she tell you about what factors she was weighing in the balance in terms of whether she would or wouldn't send the letter?
MITTAL: I didn't know exactly what was ...
DE LA POER: Well, did you understand that she was fearful
about the consequences to herself?
MITTAL: Must -- that must be one of the reasons, yes.
DE LA POER: So you knew that?
MITTAL: Yes.
DE LA POER: And did you say, "It is your responsibility, as named doctor for this hospital, that you do something if you are worried, nevermind the consequence to you"?
MITTAL: From recollection, I said, "You need to speak to Alison Kelly", who is the head of safeguarding, because that's our immediate line manager. So "Speak to her about your concerns".
DE LA POER: Now, Dr Isaac is telling you that she is unsure what to do. Did you follow up with her to make sure that she had been brave and raised the safeguarding concern that she was thinking about?
MITTAL: No, I didn't.
DE LA POER: Bearing in mind that Dr Isaac sat within the management structure of the Countess and you did not, so far as being designated doctor, wasn't that the moment for you to say, "Tell me what you are worried about, I will go and raise it. I am the designated doctor. They can't do anything to me"?
MITTAL: In hindsight, I should have.
DE LA POER: Did you even speak to the Consultant paediatricians at that time that she had been speaking
to to find out what they were worried about?
MITTAL: I didn't do it at that time.
DE LA POER: Dr Mittal, just being blunt about it, was that a significant failing on your part, not to intervene at that stage?
MITTAL: In hindsight, like with all this awful tragedy which has happened, I should have been more proactive at that time.
DE LA POER: Isn't the point of view -- I know you've hindsight and we know that their fears were justified -- but in safeguarding, you never know whether the fears are justified, do you, but you act anyway?
MITTAL: That's right.
DE LA POER: Is that fair?
MITTAL: Yes.
DE LA POER: And in a sense from a safeguarder's perspective, it doesn't matter whether it's true. What matters is that patients are protected from a risk?
MITTAL: Yes, that's correct.
DE LA POER: And so again, setting aside hindsight, was that a significant failure on your part not to intervene at that time?
MITTAL: I would say, yes, I should have intervened at that time.
MR DE LA POER: Yes. Well, Dr Mittal, I have a small amount of further questions for you, but, my Lady, I wonder given the time whether that would be a convenient moment.
LADY JUSTICE THIRLWALL: Yes, thank you. So we will take a break and we will start again at 5 past 2.
(1.05 pm) (The luncheon adjournment)
(2.04 pm)
LADY JUSTICE THIRLWALL: Mr De La Poer.
MR DE LA POER: My Lady, thank you. Dr Mittal, we have just looked at the meeting of the CDOP --
MITTAL: Yes.
DE LA POER: -- in September of 2016 and discussed the letter that Dr Isaac wrote but didn't send in February of 2017. Another event in February 2017, as we have already touched upon, was the publication of the RCPCH report. Now, the Inquiry knows that there are two versions of that, one confidential which mentions the Consultants' concerns about Letby, and the other marked the dissemination copy and that's the one that was published on the Internet. Did you ever see a copy of the confidential version of the RCPCH report?
MITTAL: This was never shared with me.
DE LA POER: Now, as the designated doctor and person responsible for the area in which the Countess fell in, should you have been provided with a copy of that confidential report?
MITTAL: So it should be as a panel like we should have chased it from the panel as well.
DE LA POER: You should have chased it --
MITTAL: Yes.
DE LA POER: -- from the CDOP panel?
MITTAL: From the hospital yes.
DE LA POER: So is it your view that not only as the designated doctor but also that the CDOP panel needed to see the confidential version?
MITTAL: Yes.
DE LA POER: Is that right?
MITTAL: That's right, yes.
DE LA POER: Did you know that there was a second version of the report?
MITTAL: I was never aware that there were two versions of the report.
DE LA POER: This brings us now in the timeline to the CDOP meeting in March of 2017. If we bring that up INQ0001953. We will go to page 3, please. Now, at the September meeting, when [Child I]'s case was closed, there was a note indicating that there would
be a return to [Child I]'s case when you make a presentation about the RCPCH report and this here is your presentation about the RCPCH report; is that right?
MITTAL: I wouldn't say that this is a presentation for RCPCH report. This is more like a general discussion in the business meeting about the same issue again, about SUDiC meetings for in-hospital deaths.
DE LA POER: We can see that it's focused upon the substance of the RCPCH report which obviously had been published just a month or so before. I suppose another way of asking the question is: did the panel ever go back to [Child I]'s case as seemed to be indicated in September once the RCPCH report was published?
MITTAL: From recollection I don't think we looked at that again.
DE LA POER: And do you know why?
MITTAL: I'm not sure about that.
DE LA POER: Was it a -- I mean, on the face of the notes from September, you have seen them just before lunch?
MITTAL: Yes.
DE LA POER: It appeared that there was an intention to go back to that case even though it was closed. But an oversight by the panel, a failure to do what it set out to do, can you offer any different explanation?
MITTAL: I don't have any explanation for that.
DE LA POER: Now, we also know that [Child A]'s case was discussed and we will bring up the detail. It's page 10. So the case at the top there is [Child A]'s case. Now, as we can see from the record of the meeting, [Child A]'s case was closed at this meeting. Now, at the time that the panel closed [Child A]'s case, did you know that Dr Hawdon, a neonatologist, had conducted a review following the RCPCH and had concluded that [Child A]'s case needed further investigation?
MITTAL: We didn't have that detailed information at that time.
DE LA POER: Did you know because on the face of the RCPCH report there was a recommendation that a Casenote Review --
MITTAL: Yes, I knew that.
DE LA POER: So you knew there was a Casenote -- did you ever find out what the Casenote Review concluded?
MITTAL: I didn't know specifically about the case like which cases were reviewed by her. But I only knew that following the report a neonatologist has been instructed to look into some cases in more detail.
DE LA POER: From a CDOP point of view isn't it quite important if there is to be another investigation that you know whether any of Dr Hawdon's cases are those going before CDOP so that you can find out what she said about them?
MITTAL: In hindsight we should have done that.
DE LA POER: Because in fact although CDOP closed this, as at the date that CDOP closed it, Dr Hawdon's view was that [Child A]'s case needed further investigation and that shouldn't happen, should it?
MITTAL: That's right yes.
DE LA POER: CDOP should be the end of the process of investigation, not part way through it?
MITTAL: I agree, yes.
DE LA POER: Now, we can see the cause of death here is given as unascertained and if we go to the Form C for [Child A], INQ0001944, we will get a little bit more detail. So we can see the case summary and from the narrative we are given, it appears there is no expectation that [Child A] was going to collapse --
MITTAL: Yes.
DE LA POER: -- do you agree?
MITTAL: Yes.
DE LA POER: And so on the face of it we have a child who has unexpectedly collapsed in circumstances where the cause of death is unascertained. Now let's have a look if we may, please, at page 5 of this. We can see there is a category for such children, which is category 10, Sudden Unexpected Unexplained Death. Do you agree the
information presented to the panel means that that category could be ticked?
MITTAL: So, my Lady, we were falsely reassured at that time that because we were not the expert -- because CDOP is not an investigative panel.
DE LA POER: Well --
MITTAL: It is more about learning the trends and in the panel we were reassured that because the Countess is looking into this and neonatologists are looking into this and nothing has come to us so we wanted reassurance from Countess but we were not thinking the unexpected; which is Sudden Unexpected Death. So that may be the reason which, from my recollection, that we didn't pick number 10 because there is nothing in the records at that time which were in front of us which were pointing towards Sudden Unexpected Deaths.
DE LA POER: Well, my question was: do you agree from the information you were presented with that box 10 could have been ticked?
MITTAL: In hindsight, yes.
DE LA POER: The box that was ticked was 8, perinatal neonatal event. Ms Frame, the independent chair, told us when I asked her about this that lay members of the panel were quite dependent upon the clinicians for their
interpretation of the medicine to help fill in this form and is that a fair observation by her?
MITTAL: That's correct, yes.
DE LA POER: So what category A requires is that death related to a perinatal event and examples are given. Now, if we go back to page 1, just to help us from a clinical perspective how this information would be analysed, are you able to identify for us what the perinatal event was from the description that you are given?
MITTAL: So the perinatal event is like at the time of death and immediately after birth within a week --
DE LA POER: Yes.
MITTAL: -- if there is any event---
DE LA POER: An event, yes.
MITTAL: -- which is responsible for the death.
DE LA POER: Yes.
MITTAL: So when this baby was born, there was -- this baby was given inflation breaths, the baby was preterm, the weight was low and this baby had -- had CPAP and lines. So this baby had co-morbidity as a preterm and also in the records which were in front of us, there was no such suspicion from the paediatricians that they were thinking that it could be something else because these
are the common scenarios which we have in panel, the neonatal deaths are the commonest. So I am just assuming because there were three designated doctors in the panel and I am the one who doesn't deal with neonates, there are two who deal with neonates, and everybody agreed that, yes, we can close it. So that's my assumption.
DE LA POER: Just to help us, bearing in mind the Coroner who has had a postmortem and investigated it at an Inquest has concluded the cause of death is unascertained, isn't that an indication -- you tell us -- that really perinatal event can't be said to be related to the death?
MITTAL: So, my Lady, like just from my recollection I am not the neonatologist, but there are many deaths where we see unascertained from the Coroner and we still we don't tick them in Sudden Unexpected Death, we still tick them in other categories but it all depends on the scenario, on the context. So certainly like in hindsight now what we know about this case, yes, it should be in number 10. But at that time, we didn't think about that this should go in number 10.
DE LA POER: Of course your evidence this morning was that as at the 24 March, you did not know about the concerns of your Consultant colleagues?
MITTAL: That's right, yes.
DE LA POER: The final question about this particular meeting is we know that the Inquest hearing for [Child A] took place on 10 October. Do you know why it took until March for this case to get before the panel?
MITTAL: So the way the panel works is we need everything in front of us, like the case has to be prepared with all information, if there is any inquiry or any investigation going on everything should be complete. Only then CDOP is the final end. So my only guess is that it must have taken that much time to prepare the case by the admin team and that's why it took so long to come to the panel.
DE LA POER: We can take that down and I just have one final general question about CDOP. Thank you. We have looked at [Child I], we have looked at [Child A], we have seen both cases are closed. There is some commentary associated particularly with [Child I]. How long in this meeting is the discussion about an individual case before a conclusion is reached? I appreciate it will be case-specific, but is it as little as a minute sometimes and as much as an hour? What's the sort of time range that is spent in this meeting going through each of these cases and deciding
closed or not closed?
MITTAL: So, my Lady, it depends upon the case. Like there are some cases we spend sometimes up to an hour or like 40 minutes and some cases like we close them within a minute or within two minutes. So it all depends on the context and it depends on the information which is in front of us. So it is difficult to give a definite or general answer that every death we spend that much time. It all depends on the paperwork which is in front of us. But we rely on the professionals completing those forms and sending information to us.
DE LA POER: Is the material available to the panellists ahead of the meeting?
MITTAL: Yes.
DE LA POER: And is there an expectation that every panellist will read all of the information provided to them?
MITTAL: Yes, yes.
DE LA POER: Looking -- you have told us already that you had limited time, was that something that you were always able to do, to read the entirety of a pack for every meeting before it?
MITTAL: I always tried to do it but, yes, sometimes there are some times like I may not have read the full
papers. But I do try my best to read all the papers.
DE LA POER: Now, we have heard from Ms Frame that following this meeting there was contact with Ian Harvey and that led to an invitation for her to a meeting and she's told us that she invited Detective Chief Superintendent Wenham to come with her. Now, you were at the meeting on 27 April 2017 at the Countess; is that right?
MITTAL: So I was not formally invited by the -- they didn't think that I should be there but it is our chair, she thought that it would be better that I accompany her to support her. So it was at her request I went with her to the meeting, but I was not invited for that meeting.
DE LA POER: Now, your initial recollection as recorded in your witness statement, we dealt with this right at the beginning, was that there was no mention at that meeting of the involvement of a member of staff in the increased mortality, that is what you believed when you wrote your statement and you have since seen the records which demonstrate that that issue plainly was raised. Do you agree it's quite a significant thing to be said in a meeting, "I think a member of staff might be involved in the deaths of these babies"?
MITTAL: (Nods)
DE LA POER: So given that you agree that, why do you think that you had forgotten that that was said in this meeting, are you able to help us with that?
MITTAL: So from my recollection in that meeting a very small amount of time was spent on that part and more discussions were: what should we do next? So that's all I can remember, I don't know why I missed that in my recollection. But it was only like brief, like not a significant part of the meeting was spent on the staff involvement.
DE LA POER: Going out of the meeting, what did you think was going to happen?
MITTAL: So in the meeting only like we are going to hear from Mr Wenham, so there was a discussion whether there should be SUDiC or it should be -- it was asked to me whether the SUDiC should be started on this and I said that now that the police is involved, it should be -- SUDiC is separate from criminal investigations. So that's why like they were thinking more about criminal investigations.
DE LA POER: So was it your expectation at the end of the meeting that the police were going to have a think about what they wanted to do --
MITTAL: Yes.
DE LA POER: -- with that information?
MITTAL: Yes.
DE LA POER: So that is what the police are doing. Now, you are the only safeguarder at this meeting; is that right?
MITTAL: That's right, yes.
DE LA POER: You had been invited effectively in that role to the meeting. The Consultants' concerns as they were reported to you in that meeting were a safeguarding issue, do you agree?
MITTAL: Yes.
DE LA POER: And whilst the police are going to take it away and think about what they are going to do and that will take as long as it takes, do you agree there was still an issue for the hospital from a safeguarding perspective?
MITTAL: In hindsight, yes. But at that time because the police was involved and such a high level meeting was there, so I thought it is now for the higher authorities to now address this. This is a very sensitive issue and it should be dealt with at high level.
DE LA POER: But --
MITTAL: But I agree that yes, there is a safeguarding as well in this.
DE LA POER: Let's just untangle that, Dr Mittal. You
operate at a high level, you represent the CCG?
MITTAL: Yes.
DE LA POER: What the police are not doing in the early stages as they think about what they are going to do from a police investigation, is making sure that babies were safe. That wasn't what they were telling you they were going to do, they were going to go away and think about it?
MITTAL: (Nods)
DE LA POER: So I think you have agreed with this: didn't there need to be a safeguarding response from you in this meeting?
MITTAL: Can you clarify what exactly from a safeguarding perspective?
DE LA POER: Well, a discussion saying: this is a safeguarding issue, we need to understand how we are going to keep babies safe in the future, we need to contact the LADO, to make sure the LADO knows about it, and we need to think about any formal action we need to take in relation to the member of staff that the concern is about to make sure that any risk that that person may pose is prevented from occurring?
MITTAL: So, my Lady, at that stage I thought it is being now at much higher level than -- this should -- I should have thought about this in February but not
because in April it was like CEO of the hospital, Medical Director of the hospital and the police and then the chair of the CDOP there. So I thought that this has now gone at a higher level. So I didn't even think at that time that I should be dealing with it at safeguarding level --
DE LA POER: Do you agree you should have been thinking --
MITTAL: Yes, I agree that, yes, I should have.
DE LA POER: Now, the final topic is the safeguarding report of 2017. It's INQ0004715, and we will go straight to page 19, where we will see your name. So at item 11.5 you are providing a Child Death Overview Panel update, do you see that?
MITTAL: Yes.
DE LA POER: I am not by any means trying to take a cheap point here, Dr Mittal, it may just be a matter of formatting. But under that heading, albeit in bold, we see the Countess of Chester neonatal unit investigation added. So it isn't marked out as a separate item, it appears to fall under the item, but as I say it's not intended as a cheap point. The heading is CDOP. My question is: were you responsible or taking responsibility for the addition Countess of Chester neonatal unit investigation?
MITTAL: I was not taking any responsibility for neonatal investigation. This was following this meeting and once the police decided to take it further, I was asked by the police for Operation Hummingbird, so any neonatal death in the hospital I need to ring 101 and inform the police and Alison Kelly asked me to fill a Datix form for every death after. But this all happened after this meeting. Not before that. So that is what is here that until end of 2017 I was informing the police and to the Exec of any death which I come across.
DE LA POER: So you didn't type this or have anything to do with the wording, is that right, or did you?
MITTAL: It might be me. But I can't really -- I can't be sure.
DE LA POER: You see, this is a safeguarding report. I mean, it mentions the fact that the police are involved, but it doesn't actually say anything about what the safeguarding response is and I am just wondering if you were the author of that, as it seems to have been inserted into your section, that this was an opportunity to reflect on the need for a safeguarding response to make sure that any risk that the member of staff may pose was being addressed at a safeguarding level?
MITTAL: So if I remember, this report is after that meeting, after that high-profile meeting.
DE LA POER: It is, yes, yes. And we can see that because it begins in the first sentence with mentioning the fact that there's an investigation started by Cheshire Police which only happened after -- after that meeting?
MITTAL: Yes. So usually our named nurse Karen Milne used to ask me if something needs to go in this or not. So I used to send her information from the CDOP report, but I can't remember specifically what information I sent at that time. But I used to provide information for the annual report from -- from the CDOP annual report to the safeguarding report in Countess.
DE LA POER: Bearing in mind what was known by you at the time of this report, do you think there in fact should have been more information provided in this -- in this report, or do you think it was adequate just to describe it in that way?
MITTAL: I was not sure whether it should be me or it should be from somebody else who should be talking more about once the police has taken over this investigation.
MR DE LA POER: Thank you, that can come down. Dr Mittal, thank you for answering my questions. My Lady, those are all the questions I have for Dr Mittal and although permission was granted, it has just been communicated to me that there are no questions from Core Participants.
LADY JUSTICE THIRLWALL: All right. Very good. I have no questions for you, Dr Mittal. Thank you very much indeed, you are free to go now.
MITTAL: Thank you.
LADY JUSTICE THIRLWALL: I was asked if we would take a break --
MR DE LA POER: Yes.
LADY JUSTICE THIRLWALL: -- before the next witness, although I think it was thought we were going to be a bit longer with the last one. So shall we say 10 minutes, come back in at 20 to.
(2.30 pm) (A short break)
(2.39 pm)
MS LANGDALE: Mr Wenham, please.
FORMER DETECTIVE CHIEF SUPERINTENDENT NIGEL WENHAM (sworn)
LADY JUSTICE THIRLWALL: Do sit down.
MS LANGDALE: Mr Wenham, you have provided a statement to the Inquiry dated 20 June 2024. Can you confirm whether the contents are true and accurate as far as you are concerned?
WENHAM: Yes.
LANGDALE: Do you have it in front of you?
WENHAM: I do, yes.
LANGDALE: You tell us you commenced your career as a police officer in 1989 and retired on 22 April. During the timeframes that are relevant for the purposes of this Inquiry, between 2015 and 2017 you worked as a Detective Superintendent and Detective Chief Superintendent. You also, in November 2012, were promoted to Detective Chief Inspector and became head of the Constabulary Strategic Public Protection Unit, you tell us that at paragraph 5. It was in that context that you became involved in the Pan Cheshire Child Death Overview Panel, is that right, in that role?
WENHAM: That's correct, yes.
LANGDALE: In January 2015 you were temporarily promoted into the role of Detective Superintendent and deputy head of the PPD. Can you tell us something about the PPD, please, Public Protection Directorate?
WENHAM: PPD stands for Public Protection Directorate. At that time within Cheshire Constabulary that was an area of business with about 400 officers and staff that looked after all areas of vulnerability and risk, for example child protection, child abuse, rape, sexual abuse.
LANGDALE: Indeed at paragraph 10 you set out what that PPD was responsible for and it's a wide range of multi discipline meetings, for our purposes including Local Safeguarding Children Boards and the Child Death Overview Panel. Can we perhaps have paragraphs 23 and 24 on the screen of your statement, please, INQ0102367, page 6, so that everyone can follow. While we are retrieving that, Mr Wenham, you say that the purpose, at paragraph 23, of the police representative role at CDOP was to represent the police and to fulfil the police roles and responsibilities outlined in the protocol and the police representative would have been there in a position of rank that empowered them to take responsibility to make appropriate decisions. So what are you referring to there? What kind of decisions in all of these various meetings where a police representative is present might be being taken?
WENHAM: Yes, it's so the individual is empowered to actually make the decisions on behalf of the Constabulary, so that he can answer yes or no to something that a decision needs making and you don't take to take that decision back within the Constabulary in order to get that issue resolved.
LANGDALE: This is rich coming from me, but you might need to go a bit slower if you can?
WENHAM: Okay.
LANGDALE: So if you look at paragraph 24 --
WENHAM: Yes.
LANGDALE: -- you set out how cases were reviewed and the subject of reviews each month in CDOP and that: "The cases were fairly old in terms of the actual date of death and the date of review. It is not unusual for cases to be reviewed that were sometimes over 12 months or longer. Neither I nor Cheshire Police had any involvement or responsibility identifying the cases that would be reviewed at each CDOP. I do recall the issue of the delays of these cases being brought to CDOP and raised on several occasions in order to try and narrow the time from the death to the review." Do you consider when you look at that, or did you consider at the time, it was therefore ineffective in identifying patterns of unexpected or unexplained deaths because of the manner in which cases were brought to it and considered?
WENHAM: It was recognised -- through the period I was present and attending CDOPs it was recognised that there was an issue with delays by the chairs and they did try to take steps through the CDOP, through the business
support, in order to try and improve the timeliness. Some of the issues that caused the delays were outside of the CDOP's control. For example, they could be waiting on Inquests or other factors relating to that individual case. So many issues were probably related to process within the relevant local safeguarding local authority areas and some of the issues may be to do with the business side of the CDOP but the chair recognised that and particularly Hayley tried to reduce the delays and I think she did achieve some success in that.
LANGDALE: That can come down thank you. Paragraph 33 of your statement. You say: "I was not made aware during my attendance at the CDOP from 2015/2016 that there had been an increase in the number of deaths at the Countess of Chester neonatal unit. Any increase in neonatal deaths would be unlikely to have been identified from the CDOP as a standalone process." You say: "Again, I don't think so that the structure of the meetings and reviews would have made it easy to identify that there had been an increase ... several reasons for this assertions." You have just set out some, are there any more reasons you would identify? For example you say the
number of cases that are listed for review for each meeting would frequently be into double figures. so how much time does that give you with each case?
WENHAM: The CDOP meetings were generally a full day, the first -- it was Part A or a Part B. Part A was generally the policy strategy steering exercise and governance for the meeting and that was normally in the morning and Part B was the case reviews. At any one time there could be anything from 10 to 20 cases to be reviewed on a particular meeting. I remember frequently the panel members would sit through the lunch and eat their lunch whilst they were reviewing the cases because there was such a large volume to get through. But each case could be discussed from anything from 15 minutes to maybe an hour on an individual case so if there is 15, 16 cases, it would be four to five hours that afternoon reviewing all the cases.
LANGDALE: You also say in this paragraph that each of the cases were mostly reviewed in isolation from each other.
WENHAM: The cases would have been listed without any correlation or relation to each other. My understanding is the cases would be managed through the business support for the CDOP and the cases listed on the basis
of: the ready to be listened and presented to CDOP. So my understanding there was no -- no reason why we would consider there is an immediate relationship between any of those cases that are being discussed unless there was something obvious standing out. For example, if we had done some research and a family and we knew there was a familial link between a case, we would disclose that on the form and that would be discussed in the meeting.
LANGDALE: You tell us at paragraph 35: "I can be very clear and specific when I first became aware of the increase in the number of deaths on the Countess of Chester neonatal unit. It was effectively 24 March 2017 ..." You say prior to that meeting you weren't aware of any increase in the number of infant deaths or any other issues. Should we go to that meeting note, please, on the screen, INQ0012008, page 3. So just to orientate yourself, Mr Wenham, when it comes on the screen this is an extract of the minutes of that meeting and item 5, Countess of Chester Neonatal Review. So have a look at that top paragraph. "The Countess of Chester has carried out a review of the neonatal department following a cluster of deaths over a 16-month period." Now, we heard evidence from Sharon Dodd yesterday who was a member of CDOP and she had become aware because of the forms that are filled in that there were 13 deaths in the period that we are concerned with. She was aware of 13 neonatal deaths in between June 2015 and June 2016. Do you remember if a number or figure was raised in this discussion? It is not minuted but there's reference to a cluster of deaths over a 16-month period. Do you remember how big or significant a number it was?
WENHAM: I can't remember that being specifically mentioned. It possibly was because if you read the report that was presented which I would have read prior to the meeting and at the meeting, I think it makes reference to 13 or 11.
LANGDALE: Yes, yes.
WENHAM: So I would have had knowledge of it but I am surprised it isn't referenced specifically in the meeting but whoever has wrote them minutes at the time.
LANGDALE: But you were aware, as you say, someone there had that number and you have seen that's in the errata, so you wouldn't be surprised if that was mentioned. Do you remember if there was any discussion about how that featured, set against previous years -- would you have understood what 13 represented in terms of a change in
significance from previous years or not?
WENHAM: From recollection -- I mean, I clearly left that meeting with some concerns. But from recollection, I can't remember if that was discussed specifically other than what the contents of the report was that was presented.
LANGDALE: Was the report provided to you, had you seen the RCPCH review, we assume they are referring to there. Did you ever see a Royal College report on paediatric child health?
WENHAM: I saw the one that was part of the minutes -- sorry, part of the agenda, because the papers are provided in advance.
LANGDALE: Yes. And that version that you saw, did it contain any reference to a nurse or concerns about a nurse and an HR process being necessary? Did you get the version with that in it or was that redacted and not available to you?
WENHAM: I -- I think the version that came to the CDOP was not -- did not make any reference to the -- to the nurse.
LANGDALE: If it had made a reference to a nurse and concerns about a particular nurse, what, if anything, would you have thought about that in the context of everything else you were being told here?
WENHAM: Well, my concerns were raised anyway because of the content of the nature of the report as it was, it was presented. If it had also included the redacted or the -- the unpublished version, then my concerns possibly would have been even more heightened and increased.
LANGDALE: In terms of the CDOP process, and making contact with the police, at an earlier meeting, I don't think you were present at it, but I am going to ask for it to go on the screen so you can see the issue readily. So that can come down, please, and can we have instead INQ0017817, page 2. This is an earlier meeting, 20 November, there is an R next to your name. Is that when someone else comes to represent instead of you?
WENHAM: Yes.
LANGDALE: So you weren't there but there is clearly a discussion about SUDiCs generally, you see there number 4: "SUDiC within the hospital." "Should a Rapid Response Meeting be held each time there is a Sudden Unexpected Death within a hospital. The meeting felt that the response should be on a case-by-case basis and the safeguarding doctor should be involved in the discussion with the designated doctor and a Rapid Response should be arranged if deemed
appropriate. The meeting felt this process should be reflected in our procedures with clarification of best practice. "Action: ensure that when the Pan Cheshire procedures are reviewed Sudden Unexpected Deaths in hospital are identified". So there seems to be a discussion about the suitability or otherwise of Sudden Unexpected Deaths procedures, when babies die in hospital and we know they weren't used in this case in these neonatal deaths. Were you aware in the other child protection work you were doing across other committees and generally that there are close liaisons sometimes between for example local authorities and the police where there is an officer from the force and somebody from the local authority who can readily reach out to each other at an early stage for guidance or just to discuss things if they are worried about them. Do you think that kind of process whether you call it a Rapid Response Meeting but something with the police early on would be useful to have a conversation with a liaison officer?
WENHAM: Can I just clarify exactly, are you talking in specifically around individual cases of a death or in general?
LANGDALE: In individual cases of Sudden Unexpected Deaths in hospital. So a baby dies in hospital, the SUDiC form and process wasn't used and assume for a moment it is bureaucratic in part. Is there another way of communicating directly with the police at the time that might be useful outside the processes that clearly were proving challenging for a number of people?
WENHAM: At the time, I felt as though across Cheshire we had a really strong partnership at a safeguarding and child protection level, both local safeguarding children boards, and a range of other partnership structures where we were able to work together effectively. There were -- there was always that opportunity to engage with another professional from another agency all the time. It was just a case of the willingness of those individuals involved just to reach out and engage with those other professionals.
LANGDALE: Did that include doctors or people within the hospital? I mean I understand when there's deaths in the community and suspicious deaths in the community but in terms of dealing with hospitals where there were concerns about a member of staff in a hospital would it be the same ease of reference who you should contact or who you might contact?
WENHAM: I am a bit unclear in terms of are you -- are
you suggesting whereby it's -- a doctor's got concerns about a particular individual?
LANGDALE: Or just the circumstances of a death, a Sudden and Unexpected Death, they are not quite sure what happened. They don't at that stage know what's happened but they want to share any information they have about it.
WENHAM: Then the answer to that would be pick up the phone and contact the police and a professional police officer will attend and normally from the specialist department. You know, we are there all the time to respond. It obviously leads into the -- the understanding around the Sudden and Unexpected Death in Infants and Child protocol or procedures that were in place around that time.
LANGDALE: We know that following that 27 March meeting, soon after that, in April, if we go to INQ0102758, page 4, Mr Harvey is asking Hayley Frame for a meeting as soon as possible and has invited her to attend. If we go to page 3, the page before. He suggests you might like to invite others and we see at the top Hayley Frame says: "I wonder whether we should invite Nigel from Cheshire Police and Gill Frame, independent chair of
Chester. Please can you canvas Mr Harvey's views." Page 2. Mr Harvey agrees they should be invited: "Would you be able to arrange this with them as I don't have contact details?" Then over the page, page 1, you are invited and you confirm that you will attend and so there is a meeting on 27 April, which you address at paragraph 50 of your statement. The emails can go down now, thank you. You say at 51: "I recall I would have been involved in the planning of the meeting but I cannot recall or don't have access to how precisely this was done or if there were formal minutes from the meeting." You set out, and again it might be useful to have your bullet points of your notes from your statement, INQ0102367, at page 13, the bullet points you identify from the meeting. If we just have the bullet points at the end there, please and the two -- that is helpful thank you -- or three on the next page. You have looked at the key points of the discussion and these are the key points. If we could now go to the meeting notes of Mr Cross, and I can just ask you to pick up a couple of matters that you have identified there, but I will give people a chance to read those. So the meeting then, please, is INQ0102292,
starting at page 2, and this meeting of course is a combination -- you have got Stephen Cross, Ian Harvey, this is a meeting that's a combination of doctors, the paediatricians and the Executives. So if we go to page 2 first. You have Dr Jayaram referring to "one member of staff. Concern Beverley Allitt". Can you see at the beginning?
WENHAM: Sorry I missed that.
LANGDALE: Halfway down, "Association of one member of staff. Concern Beverley Allitt" in that middle section. So on the one hand you have got a doctor there at the beginning telling you clearly that that's what the doctors are worried about and then straight underneath you have got Mr Harvey saying: "Nurse. Full-time, overtime, allocated sick and poorly babies." Then you have got at page 3, at the top, Dr Jayaram: "Particular nurse days and nights. [More of] nights and then no incidents on nights."
LADY JUSTICE THIRLWALL: "Moved off nights".
MS LANGDALE: "Moved off nights", thank you: "... then no incidents on nights." "Since level change no real incidents." We have got Mr Harvey talking about very hot unit, staff working under pressure. If we go over the page to page 4. That reference at the top: "NW reports: Royal College -- Dr Hawdon not widely shared." Had you seen the Dr Hawdon report? It appears to be you that's commenting on that, but I don't know if you remember whether you commented on things not being widely shared?
WENHAM: I think at that point I hadn't seen it. The only report that we had had sight of was the RCPCH one.
LANGDALE: The redacted version?
WENHAM: Which went to the CDOP and one of the actions that came out of this meeting was for the professionals -- sorry, the Executive Team to share those reports with the police.
LANGDALE: Did you have a sense, you have got a doctor telling you "Beverley Allitt", you have got a Medical Director saying "this is a busy unit, this is a hot unit", et cetera. What was the impression you got in the meeting, did you appreciate the width of opinion between them or not?
WENHAM: It's quite difficult trying to reflect back because it was obviously some time ago. At the time, I just remember those present, I think I put it in my
statement that those individuals were professional, they were engaging, and there was -- there were, I think it's reflected in the information that's been shared, there was a difference in terms of interpretations and concerns. So maybe the Executive Team were a bit more satisfied things were being managed, whereas the -- some of the doctors present were clearly concerned and that's reflected my notes at the time which I have documented. And that clearly informed my mindset moving out of that meeting for the next steps.
LANGDALE: If we look at page 7 of this meeting, we have: "Ian Harvey: Grievance -- HR process. Recommendation of mediation. Behavioural issues. No previous ..." I don't know what that means afterwards, on: "... nurse skills or ... Trust criticised for what we did ... to be reintroduced." What do you remember them saying about the grievance HR process and behavioural issues?
WENHAM: My notes are fairly detailed and I haven't got reference to that so I can't remember that specifically being discussed. Clearly it was. But it would have been part -- part of that discussion around when the nurse was being discussed by those present but I don't
disagree that it would have been discussed, I just can't remember that specific point.
LANGDALE: Did you get an impression or not about what the Executives thought about the behaviour of Consultants?
WENHAM: Not from that meeting, no.
LANGDALE: If we go over the page to page 8, there's reference to under "Ravi: blue and white tape everywhere". Do you remember how it was described that the police might become involved and the way they might becoming involved if they were contacted?
WENHAM: Sorry, can you repeat the question, please?
LANGDALE: Yes. Were you aware of any description of how if the police became involved, there would be blue and white tape everywhere, it would be disruptive for the unit, that that was discussed in some way, the concerns about how the police would manage an investigation or being invited in to look at the situation?
WENHAM: I can't remember the detail. I am just trying to reflect my statement what I recorded because it would have been reflected in some of my notes.
LANGDALE: Do you mean your statement of the meeting?
WENHAM: Yes, my statement that I have written for the Inquiry which would have been drafted --
LANGDALE: Okay --
WENHAM: -- Using reference to my notes.
LANGDALE: Let's go to a different question or a different way of approaching it. Would it be a realistic expectation at this time, when you are discussing it, that if the police were contacted about allegations that a nurse had harmed babies on a neonatal unit, that they would come in and close the unit, tape it off and be very visible in their investigative work to staff and families trying to use the hospital? How would the police go about it?
WENHAM: No, in terms of I -- I would have reflected what our response would have been, but I would have been very cautious in that meeting about --
LANGDALE: Sorry, that is not you. I am not suggesting you said anything about blue and white tape at that meeting?
WENHAM: Right.
LANGDALE: I am saying if somebody said -- the Inquiry has heard evidence that Mr Cross, who had worked with the police --
WENHAM: Yes.
LANGDALE: -- had said or made reference to blue and white tape and how the hospital might face the reality of an investigation on a neonatal unit. So you don't remember that being referred to, whatever this note says about blue and white tape, so forget that and I am just asking you now: how did in fact the hospital go -- how did the police go about the investigation and was there blue and white tape and was the unit shut?
WENHAM: When the decision was made to launch the investigation, the key focus was immediately round the needs of the families and communication, engagement and support to the Families. We also then focused on the needs of the individuals working in the hospital to ensure their welfare was addressed and those individuals were supported. But that would have been all covered by the SIO, the senior investigating officer, as part of the investigation plan, investigation strategy. But there would have been an assessment around it I think I have made some reference to this in one of my notes that the unit had been risk-assessed and managed and in terms of the individual who was felt to be the risk had been removed, then the operational activity at the Countess could continue. So it wasn't a case of the police going in, sealing things off, crime scenes. It was a case of support, engagement, gathering evidence, gathering files, securing information, because a lot of the information was two to three years old and it's not
just at the Countess, it was in pathology, it was in postmortems, it was in, you know, other, other hospitals.
LANGDALE: And plain clothes officers?
WENHAM: Sorry?
LANGDALE: Plain clothes officers going into the hospital?
WENHAM: Well, it had been detectives generally who would lead them or carry out the enquiries, yes. But it would have been very much initially a low-key -- not a visible investigation. It would have been sitting in the background of the work going on at a pace. But very much focused around initially engaging with the Families because once that decision -- once we made the decision to go live with the investigation, we didn't go public for 36 hours because the next day, it was a family liaison strategy and engaging and knocking on the doors of all those Families, you know, to bring the news of what was happening.
LANGDALE: So the suggestions around how it might have been done were simply wrong, this blue tape?
WENHAM: It could be seen as scaremongering, I suppose now, looking back with hindsight. You know, but --
LANGDALE: To put people off wanting to go?
WENHAM: Potentially looking at it now with fresh eyes
but at the time if it was said I would have just dismissed it and again remained very professional and outlined exactly what our processes would have been in reality, not like what you see on the TV.
LANGDALE: That can come down, thank you. If we go back to your statement, Mr Wenham, at paragraph 68, you move on from that meeting we have just been looking at, 27 April, and refer to another meeting on 5 May, which you and other police colleagues had with Tony Chambers, Stephen Cross and Ian Harvey. You say at paragraph 69 you would have briefed your colleague: "... and we would have agreed the need for this meeting in order to continue to gather further information regarding events at the Countess of Chester." The meeting notes, if we can go to them, please, are INQ0102298, beginning at page 2. You have again done notes, Mr Wenham, at the time, but I am going to the ones that are longer, if that's okay?
WENHAM: (Nods)
LANGDALE: So we see attending at the meeting Tony Chambers, Stephen Cross, Ian Harvey. At that time, this is solely Executives. Is there a reason for going just to the Executives at this point, is that because
they are the decision-makers or why -- why is it that we see no doctors or Execs at this meeting?
WENHAM: I suppose the best way to describe this is post the CDOP. The Constabulary was on a sort of a journey to gather information and the ultimate goal was to lead to a decision and to get to that point of decision-making was meeting with some individuals who had relevant information. And I think from my recollection certainly with the assistant chief constable who chaired and led the meeting, it would have been around the Constabulary to meet with those involved at an Executive level from the Countess and I think it was the right thing to do.
LANGDALE: If we look at page 3, let's see some of the things that you were told there. So the reviews -- the Families are all aware two reviews have been conducted, the Dr Hawdon review and the Royal College review. Had you seen those yet, do you remember, or not? You have seen the redacted RCPCH one but do you think by this point you have seen the other one or not?
WENHAM: I would have to check the timeline but they would have been shared because they were asked for by myself to Ian Harvey after the meeting on the 27th and I -- I think, I think, I'm not sure, but in the meeting prior to this which I would have had with -- in house effectively within the Constabulary I think we discussed some of these documents because we had more knowledge at that point. So those I am going to say I am reasonably confident that at that point those documents would have been in the Constabulary but not the Letby -- not the one with reference to Letby. I never seen that, never.
LANGDALE: You see further down it says: "A criminal QC was instructed by the Trust who after consideration of the relevant papers advised that there was no evidence to suggest criminal activity." What weight would that have, what weight would you have given that at the time if you are being told a criminal QC has looked at the relevant papers and said no evidence to suggest criminal activity?
WENHAM: I think it's relevant information for those to have shared to the Constabulary. In terms of the weight, we would make our own decision and I would suggest not be influenced by that specific piece of information.
LANGDALE: But when it says after consideration of the relevant papers, did you think that they had just had the same as you or they might have had more or did you not really give further thought to that at the time?
WENHAM: I can't remember in terms of these because
these are the minutes which are from that meeting and it is reasonably detailed and I just can't remember.
LANGDALE: And we see at the bottom: "Nurse. As part of the reviews, staffing was looked at. There was a notable high statistical relationship between a member of the nursing staff and babies deterioratingn in the unit. There is no evidence other than coincidence." If we go over the page to page 4: "She had been moved from nights to days, redeployed off the unit whilst the review was taking place for her protection. The nurse has a 'Qualification in Specialty' so was therefore more likely to be caring after the sickest babies on the unit." And then we see the summary: "If Cheshire Constabulary are involved it would be deemed an 'investigation'. COCH would need to assist with clinical expertise, guidance. An investigation would be to identify, gather facts to evidence and establish cause of death. Also if applicable identify any criminal activity. There are no significant concerns to suggest any unlawful acts, it appears a series of anomalies that needs to be investigated further." So that was your impression or the group's
impression after the meeting with the Executives recorded there?
WENHAM: Yes, I mean that's the closing statement well the closing record from the Chair of the meeting as, as documented. But again I would emphasise that I think there was an -- still an element of caution in terms of the Constabulary. It was a case of let's just slowly, slowly gather this information. And when I say "slowly, slowly" let's get the information at the Constabulary so we can make this decision. Because again if you look below that there is a reference to drafting a Terms of Reference for an investigation. Now we wouldn't be drafting a Terms of Reference for an investigation if we were thinking there isn't going to be an investigation because my view is we were very much moving in that direction and that was the direction we were -- we were going.
LANGDALE: You then tell us at paragraph 73 of your statement, and we will put them up, that you received an email from Dr Ravi Jayaram. So that document can come off the screen, please, and instead please can we have INQ0102300, page 3. We see at the bottom: "Confidential. Hello, Superintendent Wenham. "I met you a couple of weeks ago at the Countess
during our discussions about the unexplained neonatal deaths and collapses. I am aware the Trust have sent you copies of the RCPCH report and the Independent Casenote Review from Jane Hawdon as well as the results of internal reviews ..." Pausing there. When did you meet Ravi Jayaram two weeks before? Was that you and Hayley Frame having a conversation with him?
WENHAM: No that would have been the meeting at 27 April at the Countess.
LANGDALE: So the 27 April meeting. So he has sent this to you. If we go overleaf, documents data from the regional neonatal network report looking at intensity staffing and mortality in the period January 2015 to July 2016. And if we see what he attaches please at INQ0102301, page 2, we see this is reasons for concerns. They have put together the Consultants, their concerns. If we trace through the document, please. They list various babies, concerns, when we get to page 12, survival graph from the Office for National Statistics. Move through the document. They have their unit staffing levels finishing on page 7. Were you expecting that level of information back from Dr Jayaram having --
LADY JUSTICE THIRLWALL: Sorry, Ms Langdale, I think we might have gone backwards -- forwards and backwards, you said concluding on page 7 and that sounds like a different document.
MS LANGDALE: I think it may be. So if we could put up instead, please, INQ0102303, so that document can come down, that is the first document and then another document that you have exhibited for us, Mr Wenham, is a separate document then that was also attached I assume. INQ0102303, page 3. This as well was sent to you, the Inquiry has seen this before from Dr Brearey but it was the data pulling together information. Was that the level of information that you were expecting to get from Dr Jayaram at that time?
WENHAM: I'm not sure how detailed the information was going to be, but it was -- overall collectively the three documents were incredibly powerful and important in terms of how we moved forward.
LANGDALE: That can come down. Can we please have a different document on the screen, which relates to a meeting on 12 May. So that's INQ0102306, page 2. While that's coming up, Mr Wenham, so you have received that from Dr Jayaram and then you have a meeting on 12 May. You have had an internal meeting before that to the police and as you say, you are considering what you
are going to do and who you are going to interview or speak with, I should say. And there's a second meeting that takes place on 12 May with the Executives again. Do you know again why you had only the Executives at this meeting? I know what happened subsequently and you arrange a meeting with Dr Jayaram, but you only have Executives at this 12 May meeting.
WENHAM: I -- I can't recall why that was decision was made just to keep it at Executive level.
LANGDALE: So if we go to --
WENHAM: But -- sorry, but I think we had, I think we had the premeet and we had already had -- I think there was a plan already to meet with the paediatricians who had written the email and the letter so we had gone into that meeting with that plan.
LANGDALE: You seem to have responded on the emails we looked at earlier to Dr Jayaram to agree to meet but let's have a look at this meeting here, page 4. If we see "Situational review", you have shared presumably the information you have received from the doctors with them at this point, because Tony Chambers is commenting on that under this heading situation review and says: "TC stated there's nothing new in the email review from Dr Jayaram that has not already been shared with
the Royal College of Paediatrics and Child Health and all the inquiries that have gone on." Did you share the documents I have taken you through on screen, the ones that you exhibited to your statement, had they seen those before this meeting, because it appears that that's what's being commented upon here?
WENHAM: I don't think -- sorry, just let me read.
LANGDALE: Just read it.
WENHAM: I am sure I would remember some reference to it that the documents hadn't been shared by -- to Executive level?
LANGDALE: Yes.
WENHAM: Yes, I don't think they had been shared at that point.
LANGDALE: Well, what's he commenting on then because it looks like you are asking them their views and TC stated there's nothing new in the email review from Dr Jayaram that's already been shared?
WENHAM: Sorry, I might be misleading there. I -- I don't think they had been shared prior to the meeting, they were discussed in the meeting.
LANGDALE: Right --
WENHAM: So the contents of the email and the report would have been discussed in the meeting so they would
have got knowledge of it there but I can't remember if it was shared before.
LANGDALE: So it might not have been before but would you have taken them to the meeting because the email itself is very short, isn't it? The email simply refers you to the document, and then the documents are as you have attached for us, the reports relating to various babies on the indictment and other babies and also the graph. But it looks as though -- it's said here: "It reads in a fairly unbalanced way and it needs to be looked at in the context of all of the information that COCH can share with Cheshire Constabulary." Did you have any memory now what was being referred to, what material was being referred to there by Mr Chambers?
WENHAM: Is it the same highlighted section?
LANGDALE: Yes, yes.
WENHAM: So the question you are asking is?
LANGDALE: What did you think Mr Chambers had seen before he made that observation at the meeting, it reads in a fairly unbalanced way, what were you discussing with him?
WENHAM: I can't remember. I can't remember if the contents of the email that Dr Jayaram had provided to the Constabulary had been shared prior to the meeting or not.
LANGDALE: It looks like --
WENHAM: It looks like he's got reference to it so I would say he must have seen it.
LANGDALE: Further up it looks like it does say, doesn't it: "This document has now been shared with the COCH Executive Team."
WENHAM: Where's that?
LANGDALE: Just further up, if we can go three boxes up and you gave an overview, so on 10th of the 5th an email was sent: "Documents now have been shared with the Executive Team. NW gave an overview of the contents." Can we see, it is just three paragraphs down?
WENHAM: Yes, it says: "There was no personal information sent within the email and it was felt appropriate Executive Team were made aware of this."
LANGDALE: Mm-hm.
WENHAM: So it looks like the timeline is the email's come in, a discussion maybe taken place between myself and the ACC. And then it says: "This led to a further telephone conversation
between DM [which was the ACC] and SC Stephen Cross on 11th of the 5th to make him aware of [the] email." So it looks like the ACC has communicated with him the day before, so yes.
LANGDALE: Yes, so they have got it?
WENHAM: Yes.
LANGDALE: We see if we go down to the bottom of the page again it's expressed: "It is disappointing that it does feel that, as a group of clinicians, they have not moved on." If we go to page 5 of this note, please. We see in the second box, second paragraph: "[Mr Chambers] shared the same concerns [as DM] regarding putting the families through a process that feels unnecessary. [Mr Chambers] would be comfortable to pause at this point, but equally would be comfortable to see what level of enquiry could be done that would not necessitate an open transparent conversation with the families." And if we look further down the page, the last but one paragraph: "[Assistant constable] questioned if there is any scope for an external review". And Mr Chambers replies: "In the first instance the body would be the Royal
College of Paediatrics and Child Health. They would identify the [Terms of Reference] which were structured in a way that all concerns would have been in scope and any environment/behaviour concerns. RCPCH would constitute a review panel consisting of two experienced neonatologists, one senior nurse and a barrister." So they are relying, are they, in the meeting or referring to the RCPCH report being conducted by a number of professionals as described there. Do you remember that, them saying they had done that review?
WENHAM: Yes, I mean I can only say, I can only go by what's written in the minutes here in front of me -- I can't remember.
LANGDALE: Okay the next page, then, page 6, you may not remember this either, the third bullet point at the top: "QC -- purpose to involve was to help clinicians understand the difference between what they thought was criminal evidence and something that may not constitute as criminal evidence." So what was the tone -- do you remember anything now about the tone of this meeting and what the Executives were encouraging or thought should happen?
WENHAM: It's interesting now, sitting here looking back at the minutes as you have pointed out and identified and highlighted because when I was in the
middle of this, I genuinely -- my mindset was this was on a path to an investigation and there was a lot of external noise going on round here but I felt this was where it was going and that was where we would end up but when you read some of the comments now it's like indeed doors are trying to be shut, that is the way I feel as though it's presented, if that makes sense.
LANGDALE: It does. If you look at page 6, the last but one paragraph, this is an officer -- assistant chief constable clarifying: "... there was nothing new that had come out of the email that [Countess of Chester] were not already aware of, and nothing contained in email that makes specific allegation, which would cause COCH to believe that potential criminal offences have been committed. [Mr Chambers] and [Mr Harvey] both agreed there was nothing to suggest this and nothing new within email." If we go to page 7, and look at the last three paragraphs, please: "[Mr Chambers] stated it would become a wider GMC issue as there becomes a point where a group of clinicians who are not prepared to take the recommendation of the RCPCH are blocking the ability to move forward which creates a more difficult and dangerous environment for sick babies." Next, he says: "[He] added the Consultants have made their points and they have been seen and not judged as sufficient to warrant a police-led investigation, looking at how close it constitutes as a criminal act. There was a need to explore to ensure Countess of Chester have not missed anything but there is also a need to move on. It will become a GMC issue, likewise if the media are involved. This is for the Countess of Chester to manage appropriately. The Assistant Chief Constable replies: "If Countess of Chester's position is that they are satisfied where they are and there is nothing of anything that would cause to believe potentially criminal offences have been committed which may warrant a police investigation, then this needs to be placed in writing." So that's what the Assistant Chief Constable says, "it needs to be placed in writing". And over the page he asks that: "The [Countess of Chester] need to be clear what their expectations are of Cheshire Constabulary if a criminal investigation is required, and equally [the Assistant Chief Constable] needs to document back to the Countess of Chester what Cheshire Constabulary's
position is. This is to ensure a clear audit trail of what the information was, the decision-making and the grounds for those decisions, should anything arise in the future." You further down in the last five paragraphs say: "NW added an observation that Dr Jayaram has sent the email directly to the police and bypassed the Countess of Chester Executive Team. Cheshire Constabulary are duty-bound to respond to Dr Jayaram on behalf of the clinician team. It might be appropriate to have a conversation with Dr Jayaram around the content of the letter and gain a feel of anything else that they may wish to disclose, which would add some value to the contents of the letter." Again two paragraphs down, the assistant chief constable clarified what you are articulating: "That there could potentially be allegations of bullying, intimidation on the part of the Countess of Chester. It seems reasonable as they have written to have a conversation with Dr Jayaram to clarify there is nothing else sat behind the letter which has not been disclosed." When you were hearing reference to the GMC and the referrals, you are planning to meet Dr Jayaram anyway but had you already as police discussed that before,
that there potentially could be other allegations or was that something that emerged during this meeting?
WENHAM: It will have been something that's just emerged from that meeting.
LANGDALE: You agreed with your colleague that Cheshire Constabulary should speak to Dr Jayaram to give the clinicians an independent voice?
WENHAM: Yes.
LANGDALE: Mr Chambers clarified whether it's possible to have a conversation with the clinicians without involving the Families as the clinicians would value the conversation with a police officer. So recognition by Mr Chambers there that the clinicians might like to speak or would like to speak with a police officer?
WENHAM: Yes, I mean, I was quite clear that we needed to go and meet with those doctors and make sure that they were able to speak freely without any external influences and we had actually given them a voice so they were listened to.
LANGDALE: You then -- or it is documented, rather, on page 9 of the bullet points under: "DM reiterated what has been agreed ..." Crucially a meeting will be held on 15 May with Dr Jayaram. That document can go down now. You in fact invite
Dr Jayaram to bring a couple of people with him if he would like to and I think it's Dr Holt and Dr Brearey who attend?
WENHAM: (Nods)
LANGDALE: You tell us at paragraph 90 of your statement, Mr Wenham: "This meeting was in my view the most critical and important event following the CDOP meeting on 24 March 2017." You say: "I can still recall how these clinicians presented. They were completely professional in their presentation and they were knowledgeable and passion in that about their work with the neonatal unit. There was some degree of frustration in where they felt this situation had reached and I felt that they were relieved that they could speak to the police about their concerns. "Following this meeting, my own personal assessment was that this further reinforced my view that this was now going to progress to a criminal investigation. It was my responsibility to communicate this to the chief officer level ... to inform future decisions." So if we could go, please, to the notes of that meeting, INQ0102309, page 2, and we see at page 3 at the top, Dr Jayaram in that second paragraph, specifically mentions forensic review and the fact is these babies would not be the ones you would have expected at the point they collapsed and they did not respond physiologically to the treatment as expected. Dr Brearey says: "Of those nine we reviewed six out of nine collapsed between midnight and 4 which was highly unusual." Dr Jayaram further down: "At the point of the collapse the nurse was present at that time in close proximity. This has not happened to other staff." A bit further down he says: "There is perception that we are on campaign. This is not the case. Other Consultants and junior doctors had come to the same view. It got to the point that when the nurse was on duty we feared something would happen." Over the page, page 4, six paragraphs up: "Concern we have is could something being done deliberately to harm them. "We don't know. I don't know if this is something we just have to live with. We would rather there was some explanation. Our concern is to have enough questions being asked. Can we be satisfied we have done
all we can to confirm if there is something more going on." He says: "Nobody's talked to junior doctors who have been involved. We appreciate that a lot of time has passed since these" events, presumably. "We at the end of the day are responsible for patient safety on the ward, the buck stops with us." Of course when the investigation did take place all of the junior doctors were spoken to, weren't they, and the evidence was collated?
WENHAM: Yes.
LANGDALE: We see at page 5: "Survival rate for babies over 32 is nearly 100%. For six of our babies to have died who are over 32 weeks to die is not right." Reference to the Thematic Review. Over the page at page 6, Dr Brearey repeating at the top, "most babies were at gestation would not expect these sorts of things happening". Dr Jayaram: "these babies simply did not respond as expected." Then in the closing comments on page 7, the highlight, the death of two Triplets: "there was no explanation, she was the named nurse". "Duty Exec was happy for nurse to remain on duty at
that time. When expressed our concerns we don't think the Executives have understood our concerns." Further down, Dr Jayaram: "I don't want the obvious fractious relationship between us and the Executive, this is not why we want you here. We are not sure of the process, reports have asked the right questions." I mean: "We are not sure whether the process, reports has asked the right questions, We want to exclude is there anyone who is deliberately harming these babies?" And: "Speaking for myself, we are not comfortable as worried about safety of our patients." You may not have been aware, Mr Wenham, but at this point, certainly back at the end of March there was discussion about Letby coming back on to the wards to work with babies. You say these doctors impressed you as professional in that meeting. Why was that? How was that that they impressed you?
WENHAM: The meeting was -- I can't describe how powerful it was. They were knowledgeable, they spoke from the points of view whereby they were dealing with these things real-time and the -- they have had -- they
have had -- they have lived and are breathed these events for the last several years and I just felt for those professionals there, they had an opportunity now to just speak to someone and be listened to and believed what they were saying. And it felt as though that we weren't just going to push them away like they had been in the past or threatened or intimidated, which is what the perception is they had. They were just very powerful in what they were saying and committed and, you know, I think we all owe them a great deal for coming forward and speaking out the way they did.
LANGDALE: That document can come down now. At paragraph 94 of your statement, you say on 15 May, telephone meeting with the Executive Team. You had made the decision to launch the criminal investigation, a telephone meeting arranged with the Executives from the Countess of Chester and Cheshire Police. We know at paragraph 95, you recall a discussion regarding a strategy to support the Families and issues regarding the impending Inquest. At paragraph 96 you say: "The initial plan was to visit and provide one-to-one briefings to all of the families and it was finalised during the evening of 15 May and the visits to the families started early the following day, 16 May." Do you know sitting there now what information the Families were provided with at that time?
WENHAM: I can't remember, it was subject to a -- we have a tiered approach to family liaison so you have a co-ordinator and then you have family liaison officers so we would have put a strategy in place but it would have been directed by the senior investigating officer, but it would have been very factual, it would have been concise and it would have been probably fairly narrow at that point because we didn't really know -- so it would have been very specific to those individuals, those Families and to give them some reassurance and a contact within the Constabulary.
LANGDALE: At that stage when you are just beginning an investigation, are you able to say that you have suspicions or concerns about an individual or what? I mean, what's the balance between giving information and protecting the investigation and not prejudicing any trial when you get there in terms of how you share information?
WENHAM: At that point there wouldn't have been any public comment or statements regarding any individual because the investigation from the outset would have
been approached with a very open mind. So it would have been a case of going out, gathering information, bringing that information into the system and then making assessments from there. But clearly the investigating team couldn't avoid the fact, you know, the nurse had been mentioned and was a significant individual involved in these events. But you would have had a very open mind in terms of the investigation from the outset.
MS LANGDALE: Thank you those are my questions, Mr Wenham. I think both Mr Baker and Mr Skelton have some questions, my Lady.
MR SKELTON: Mr Wenham, I ask questions on behalf of one of the Family groups. Can I ask you first of all, just a bit of a recap about your service in Cheshire Police. I think you spent 30 years in the Constabulary, so your entire career?
WENHAM: 30 years, yes.
SKELTON: You started in uniform and went on to become a DC fairly early on, a detective constable; is that right?
WENHAM: Yes, I was a detective sort of most of my career, yes.
SKELTON: Retired at the rank of detective chief superintendent?
WENHAM: That's correct.
SKELTON: So you spent most of your career in CID?
WENHAM: CID is a specific area of business, criminal investigation, also the area of safeguarding and public protection which is another specialist area of investigation and also homicide and murder investigations as well.
SKELTON: You were a homicide SIO, senior investigating officer; is that right?
WENHAM: Yes, between 2009/10 and 13.
SKELTON: Would that have been at the rank of a detective inspector?
WENHAM: Detective inspector, yes.
SKELTON: While you were in Cheshire Police, did you come across Stephen Cross?
WENHAM: No, I think he was a little bit possibly before my time or because we are geographically based I think he may have worked at the West and I never really worked in the West as a geographical area personally until that meeting, I don't think I have ever met him.
SKELTON: Were you aware that he was a senior or had been a senior officer?
WENHAM: I may have been told at some point but it may -- probably after that meeting because he attended that meeting and I didn't know who he was, I didn't know who Ian Harvey was. Obviously I knew the positions they held, but I didn't know who they were.
SKELTON: Did you subsequently find out what rank he had been?
WENHAM: I'm not sure.
SKELTON: Dr Brearey yesterday mentioned the fact that he thought that he had been demoted from a fairly senior rank to being a constable again. Do you know anything about that?
WENHAM: I can say I have got no direct knowledge of that.
SKELTON: Ms Langdale asked you about SUDiC. Was it your expectation that all deaths that occurred -- child deaths that occurred in hospital would result in the SUDiC process?
WENHAM: If you take that term in its broadest terms, yes, if you are following the procedure as in -- it's outlined but in the broadest terms of the hospital setting. Generally it, it's interpreted, I think now reflecting back, as in an A&E or someone's being from an A&E into a ward. I think there was possibly -- well, there was a lack of understanding in terms of the compliance with the policy and in a neonatal unit.
SKELTON: Do you think you appreciated that lack of understanding when you were in post at the time in CDOP?
WENHAM: Did I appreciate it or understand it?
SKELTON: That difference between types of death of children? In the community, sudden death would inevitably be SUDiC; coming into A&E I think you are saying then transferred to a ward and dying, that might be SUDiC. But being admitted, say, for several weeks wouldn't necessarily be SUDiC; is that the difference?
WENHAM: Yes, certainly from my experience and you have outlined my background, I have never had any knowledge of being notified of a death within a neonatal unit from a police perspective.
SKELTON: So far as the CDOP is concerned, as I understand your evidence from your statement, you on CDOP were completely unaware of the neonatal increase in deaths in 2015 and following until very late on in the process?
WENHAM: From a personal perspective?
SKELTON: Yes.
WENHAM: I wasn't aware until 24 March but I understand the CDOP had references to it before then as a group or in minutes.
SKELTON: If someone had come to a CDOP meeting in 2015 or 2016 and said: we have had what we perceive to be a significant increase in the number of deaths, how would you have thought CDOP should respond?
WENHAM: It depends on the circumstances. I think it's a really difficult or impossible question to answer. Because it could well be that I am thinking from just from a police perspective, "is there something criminal going on here", as opposed to a CDOP perspective around that multi-agency work and is there something criminal and I would probably pick it up and run with it like I did with this to understand what's going on. But I can't answer that because obviously it's so -- it's difficult to answer because that scenario just didn't happen.
SKELTON: Can I put a bit more flesh on the information. So if someone had come to CDOP and said: The number of deaths has increased to an unusual degree, the deaths appear to be unexpected in that we weren't expecting the children to die and we can't find a clinical explanation for team that's obvious, the cause of death is uncertain for a number of the babies, the babies didn't seem to respond as we would expect when we tried to resuscitate them after their collapses. We have identified that one member of staff appears to have been present during each
of the collapses and deaths and our investigations that we have conducted haven't yet revealed a medical cause or any other cause that links the deaths... Presented with that information, what would you have been thinking?
WENHAM: In effect, you've just outlined where we were on 15 May.
SKELTON: I have.
WENHAM: So we know what happened at 15 May. We launched a criminal investigation. So -- but clearly I just can't relate that back to a different time and a different space because I don't know and also, in terms of the timeline of the events at what point were -- would these concerns have been raised? So --
SKELTON: Well, is there any --
WENHAM: Does that make -- do you understand what I'm saying?
SKELTON: Indeed. But is there any reason to think -- the number of deaths would obviously have been fewer the further we go back. But is there any reason to think that if the Consultants or a person, a clinician, had brought you that information in 2015 and 2016 that the same kind of response wouldn't have occurred?
WENHAM: From -- individually or CDOP?
SKELTON: CDOP.
WENHAM: If it had been a little bit more specific around the points you've just raised, then I would expect CDOP as a group and the chair to raise some questions and ask some questions around that, that scenario you have presented. Now, how that -- how they would go about that as a group would have to be assessed at that time. You know, it might well be that sometimes -- it doesn't, this doesn't sound right -- but the CDOP would maybe set up like a little task and finish group to go and look at something. So it could well be some -- you know, it could be a case of three or four individuals just go and gather more information and then go and make an assessment. But I can't really answer that. It's too broad a question.
SKELTON: If a clinician, or any member of staff, had said to you in the formal meeting or outside the formal meeting: I'm concerned we have got a number of unexpected deaths and I suspect a member of staff may be harming children, what would you have done?
WENHAM: I would have -- I would've clearly listened to them and took some steps to gather some further information, whether it's just through that individual or by speaking to other individuals within the organisation, bring in more information into -- and knowledge into my -- into my domain so we can make a decision.
SKELTON: Would you have recognised if the individual that was the subject of the suspicion was still working that there was a degree of urgency required?
WENHAM: If that information had been provided, clearly, yes.
SKELTON: Can I ask you about recommendations and whether you have any views on some of the issues that this Inquiry is looking at. Obviously there is the issue of SUDiC and CDOP and its application, but that's a general national policy issue, which is probably outside of your remit as it were, but just in terms of -- for healthcare staff understanding what to do if they suspect their fellow members of staff, do you think more guidance is needed about what to do from a safeguarding perspective?
WENHAM: From a -- from a safeguarding perspective the -- the guidance is fairly clear. If someone's got any concerns regarding any safeguarding issues, then they should speak out and speak up. But individuals did that in that case, but weren't listened to and that, that creates a problem in itself because we're in at an Executive level. If that starts
to get shut down, that creates a problem. So individuals should have confidence and trust within their organisation that they can speak out and be listened to. So that, that in itself is challenging if the culture within that organisation doesn't allow that.
SKELTON: What about the question of reporting externally. Obviously you have rightly said you would expect -- implicitly said you would expect people to raise things internally within their safeguarding team or via the other processes CDOP, SUDiC and so on. But what about external communication? Do you think there is a case for there being some guidance on healthcare staff being able to contact the police for example, directly without fear of unleashing awful consequences upon themselves or others?
WENHAM: I mean, individuals can do that now. They, they can contact an organisation the police, and, and speak in confidence around any issues or concerns they have got. The police, I mean I've been out of policing for six years, but as an organisation we would always listen to people, we will treat that information with confidence and respond accordingly as to what we are told. But you'd have to make an assessment of what that information is. If there are any immediate safeguarding
issues we would have to address that, whether it's safeguarding in relation to an individual or to do with children or a family we would respond and address that.
SKELTON: So could a doctor have called the police in 2015 and not given their name and not given any details but alerted the police to the possibility that somebody was murdering children?
WENHAM: Well, clearly the answer to that would be yes and we would -- someone would have responded to that and made an assessment of that piece of information. I was asked to comment in my statement whether, you know, the police should have been notified at an earlier stage and clearly with hindsight and looking back the obvious answer to that is yes. You know, we should have been notified and engaged with earlier. I think looking at the scenario and the events as we know a lot of those doctors involved did raise the concerns repeatedly and continued to raise those concerns and they were shut down, sadly.
MR SKELTON: Thank you, Mr Wenham. Thank you, my Lady.
LADY JUSTICE THIRLWALL: Thank you, Mr Skelton. Mr Jamieson.
MR JAMIESON: My Lady, through you, may I make the enquiry of the shorthand writer whether she is content to continue. I have 10 minutes.
LADY JUSTICE THIRLWALL: Yes. Thank you, Mr Jamieson.
MR JAMIESON: Yes, I have 10 minutes but lawyers' time estimates have not always been accurate.
MR JAMIESON: Mr Wenham, I ask you questions also on behalf of The Families. Most of the topics I would have covered have already been and so please excuse me if this is a little staccato.
WENHAM: Okay.
JAMIESON: Can we start with CDOP, please, and may we have a document on the screen that I don't think we have looked at yet. It's the protocol that you provided us with, so it's INQ0102288 and may we start at page 2, please. So this was the governing protocol for the Pan Cheshire CDOP. The date of the document that we can see that it was in force is at the bottom of the page 2014 and you have provided in your statement that this was the one in force in 2017?
WENHAM: It says July -- oh, yes, yes.
JAMIESON: Yes. So it was supposed to be reviewed in '15, that doesn't always happen, does it, it was the one that was being used in 2017?
WENHAM: I understand this was the one because obviously I was asked to provide a statement and I have gone back retrospectively to try and confirm which protocol was the relevant one.
JAMIESON: Okay. Well, if anything turns on it we will hear about it, but I doubt it frankly. Can we go forward to page 5, please, which is the introduction to this document and what I just wanted to draw out is if we could crop in on the bottom half of the page, please. So under "Introduction", this is the first guidance that's given to the readers of this document. It's really that underlined text that's put there in the first paragraph: "As highlighted in the guidance it is vitally important that local safeguarding children boards establish mechanisms for appropriately informing and involving parents and other family members in both Child Death Overview and the Rapid Response process." And there "Rapid Response process", is that a type of SUDiC, is that what that's talking about?
WENHAM: Yes, the Rapid Response process a stage in the SUDiC protocol.
JAMIESON: Yes, so it's the initial stage.
WENHAM: It's an initial meeting -- well, the initial
meeting would take place within the first few hours. But a Rapid Response Meeting would generally take place within 72 hours --
JAMIESON: Yes.
WENHAM: -- or up to five days maximum from the events.
JAMIESON: And what this guidance is telling you, and everybody else on the CDOP right at the start, is that it is vitally important that families are both informed and involved in the process?
WENHAM: Yes.
JAMIESON: When you sat on the CDOP meetings and considered the cases, did families ever attend? Were they ever invited to attend?
WENHAM: I'm -- I'm not aware of that. That was part of the process of the group for third parties to attend, families or external.
JAMIESON: I mean, if we just go, sorry to jump around, but if we go to page 13 of this document, just how that is supposed to be achieved I think is identified for us. Can you see there 4.6, "Involvement of parents and family members." So having highlighted at the start that it's important, this is how it's supposed to happen and what it comes to -- please do take a moment to read the paragraphs if it's helpful -- but essentially they get a letter that tells them about the process and it
will be hand-delivered to them by a co-ordinator who will be in a position to answer their questions, but that's it?
WENHAM: Yes. What -- what that's referring to is the process around the rapid response meeting. So the rapid response meeting would normally be chaired, if it was for example a death of an infant or a child in the community and went to A&E, then a detective inspector from the police would attend and within the time period of 72 hours a professional meeting would be held. That's the rapid response meeting. And one of the things covered in that rapid response meeting is communication and engagement with the family.
JAMIESON: Okay.
WENHAM: So that would involve who is -- who's in contact with the family, who is the liaison and covering the CDOP aspect of that to make them aware of the CDOP process.
JAMIESON: Okay.
WENHAM: That's my understanding of where that sits.
JAMIESON: Okay. So because I suppose what could be said is delivering a letter that might deal with informing, but it's not going to involve --
WENHAM: No.
JAMIESON: -- a parent. But if a police officer is going
to go talk to them and start that dialogue --
WENHAM: Yes.
JAMIESON: -- that might be how that occurs?
WENHAM: Yes, and delivering a letter there it sounds quite clinical.
JAMIESON: It does.
WENHAM: -- and very transactional.
JAMIESON: It does.
WENHAM: -- whereas it's actually more of a -- it's a process where the family is engaged by either the best person who's working with that family. Because bearing in mind a lot of investigations we decide at that meeting: is it criminal, or is it safeguarding or is it none, none of those two things or is it one or the other.
JAMIESON: Yes.
WENHAM: So for example if it wasn't criminal, then it might well just be who's the lead professional. So who's the best -- who's already working with that family and that person may already be the link and do the CDOP process.
JAMIESON: But in that circumstance that you are talking about, where you are having that discussion, is that one of those cases where there has been a rapid review, ie we are on the SUDiC route rather than the CDOP Form A and Form B route?
WENHAM: Well, they both -- they both run tandem with each other. So this is the SUDiC process in which you have a rapid response meeting within 72 hours of the death or the event.
JAMIESON: Yes.
WENHAM: And part of that then the CDOP process runs off that because the professionals have to complete the relevant documentation and notifications to CDOP.
JAMIESON: Yes.
WENHAM: Does that make sense?
JAMIESON: It does.
WENHAM: Yes.
JAMIESON: And I think what I'll say to you is that's how it is supposed to work.
WENHAM: Yes. And also invariably in the community setting or in an A&E, that would work. What we know now is within a neonatal setting it hasn't worked effectively.
JAMIESON: May I just pick up something with you while I'm here. Can you see just at the very bottom of this page, it says "Bereavement Support Services" and it says: "The role of the Pan Cheshire CDOP is to question whether bereavement services were offered to the parents
MITTAL: the time of the child's death and if not to establish the reasons for this." Now, one of the recurring features for The Families in this case is that they did not receive adequate bereavement services. Now, I know not all of them came to the CDOP, but, how was that assured? What was your process for making sure that families had received bereavement support?
WENHAM: Yes, I think you have got to detach the two things here. I think if you put CDOP over to, over this side --
JAMIESON: Yes.
WENHAM: -- as like a -- it's a stage that kicks in here in notifications. But the actual activity sort of takes place some time down the line.
JAMIESON: Right.
WENHAM: Well, the bereavement issues with families need to be dealt with here.
JAMIESON: Of course they do.
WENHAM: Not down there. So --
JAMIESON: May I be clear. I'm not saying you could make sure that that happened at the time.
WENHAM: So in terms of the bereavement issues, if they --
JAMIESON: How did you check it's happened --
WENHAM: From my experience when a child has died, normally as I say you'll end up in an A&E situation or a home environment. The bereavement issues would always be picked up by the health professionals within the hospital setting and I am not aware of any issues really where it fails because it's a natural process for them health professionals to follow up on. But the Rapid Response Meeting is a process to check that that's been done and is it being managed?
JAMIESON: Yes. But isn't the best way to check as to whether it's happened to ask The Families?
WENHAM: For -- for those individuals who are working with that family, the families at that time, yes.
JAMIESON: And if CDOP have a role to assure whether or not that is happening, shouldn't they be making that enquiry of the families?
WENHAM: Yes. But I mean I would certainly go back to the point where this is a CDOP sort of a process further down the line, sort of at the end, whereas the questions need to be asked earlier on in the process.
JAMIESON: Okay, I've asked the question.
WENHAM: Okay.
JAMIESON: That's your perspective. May we just go back in this guidance, please, to page 5 where the objectives for CDOP are set out. I am so sorry, I think it's the
internal page 5, so page 6 in the pdf. No, that is -- can we try one more page, please. So at page 7, there we are. "Objectives". Sorry for the reference. There are a series of objectives under the bullet point. If we just go over the page, please, to pdf page 8, towards the bottom of the list, one of the -- in fact the final bullet, "Objectives of CDOP: " "Where patterns and trends are identified CDOP will ensure that LSCBs respond with appropriate campaigns and activities." So from the context of public health presumably, but where patterns and trends are identified CDOP's objective is to report that back so something can be done about it. One of the things you told us in your witness statement, for your reference, I am not saying we need to put it up but it's in paragraph 33, which is something we have looked at already, you were reflecting on the shortcomings of CDOP, delay you have told us about, geographic boundaries was another problem. But the other sentence that you have put in there is that CDOP tended to look at cases individually rather than comparing a number of similar cases. My question to you is: if CDOP is going to look at cases individually, isn't it inevitable that patterns are going to be very hard to detect?
WENHAM: When the cases are scheduled and listed then all the professionals involved in the CDOP go away and research their systems and provide the relevant agency information into the system. So, for example, if the Constabulary were provided with, which they will be provided with, the agenda for the next CDOP and it's got 15 cases on it we would research all those cases. Now, from that research we may identify that that family's already been open to service. Occasionally you might identify that there's been a previous death within the family or at that address or an issue and that would be part of the report that we would prepare to take to the CDOP. Other professionals would do the same. So if we are talking about patterns in terms of geography you may, you may identify through addresses or locations. If we are talking about patterns in terms of like modifiable factors, then that's part of the group to identify for example issues around smoking being a relevant factor or cots.
JAMIESON: Well, may I give you a factor that comes really directly from these facts. We know that we have got -- the witness before you had had all of these deaths reported to him on the relevant forms across the
12 months that we are concerned with, but at CDOP level no system, no process that could join those together and to allow you as the member to be aware that there was this continuing increase and pattern of fatalities. Wasn't that a shortcoming? Shouldn't there be a process that doesn't rely on the individual members to highlight commonalities amongst cases?
WENHAM: I -- I wouldn't disagree with you and certainly when we look at the neonatal deaths and the numbers involved and the fact that CDOP wasn't sighted on the majority of those then there's definitely gaps in the system. I mean it's six years, seven years since I've been involved.
JAMIESON: I know.
WENHAM: So systems will have changed since then anyway. But certainly looking back then yes, there was gaps in the system in terms of CDOP's ability to identify repeats.
JAMIESON: Thank you. That document can come down, thank you very much. I wanted to move on just briefly to deal with the journey, as you have called it, from the notification, your first notification in March of '17 to the decision of the Constabulary as to whether or not there would be
a police investigation. Just in relation to that March meeting, as you told Ms Langdale King's Counsel effectively all of the information, all of the documents that was presented to you and your colleagues at that meeting was the Royal College review, and the redacted version of that at that, and a short tracker of actions in relation to it. Those were the only documents. But from your perspective that material was obviously significant and enough that it engaged your police officer's instincts that more was required here, is that right?
WENHAM: It caused me concern, yes.
JAMIESON: Yes. And so anybody who's listening to your evidence, anybody who is following this Inquiry should understand that that is the sort of information that should be reported to the police if it is available?
WENHAM: Yes.
JAMIESON: Thank you. You have dealt with the chronology as it goes along, but there was just one more document that I wanted to look at, please. So just to orientate ourselves there is the meeting on 24 March when the Executives come to CDOP, there is then a meeting a month or so later on 27 April, where you go to the Countess of Chester with Hayley Frame and
talk to the Executives and the doctors and then on that day, you deal with it in your statement -- I don't suggest that we turn it up -- you go back to the police station, you speak to your ACC and you send an email to the Executives and effectively what you are asking for in that email is an official letter that they send to you to invite you to consider the problem; okay?
WENHAM: (Nods)
JAMIESON: And it's just that letter that I would like to look at. It is INQ0102319. So if we could go to the second page, please, we will find it. So this is a letter we can see that's dated 2 May 17, it's from Tony Chambers the Chief Executive of the Countess of Chester, it's to your Chief Constable Byrne and it comes out of the email that you have sent in the chronology and it is an invitation to the police to commence what's called in the final paragraph a forensic investigation into the circumstances. But can I just invite your attention to that final paragraph and what I am going to ask you a question about are the words that come after. What you are being -- in fact I am going to read it out loud: "I am writing formally requesting that Cheshire Police conduct a forensic investigation into the circumstances surrounding the deaths ..." And then these words: "... with a view to excluding any unnatural causes." What I would like your reflection on, please, as a police officer, with all of that experience that you have told us about, when you begin an investigation, do you know where you are going to end up?
WENHAM: No, absolutely not. I wouldn't use that language.
JAMIESON: No, not at all. Those final words have no place in this letter, do they?
WENHAM: They do not, no.
JAMIESON: You told us that your impression or your reflections of the conduct of the Executives in these meetings in this chronology was of attempting to shut doors of the investigation as it was being considered. Is this an example of that?
WENHAM: It looks that way. I would interpret it that way. It's trying to maybe direct a mindset.
JAMIESON: Yes. Finally, officer -- thank you that can come down -- I just wanted to touch upon something you have told us already, which was when the decision was made to launch this investigation on 15 May 17, one of the initial priorities, one of the key priorities was
family liaison, talking to the families involved and you have told us about that first 36 hours. Can I just deal with this. We have heard from another witness, a clinician, that he had concerns about telling families the true picture or his concerns about what was happening in the hospital for fear of prejudicing a criminal investigation or a potential police investigation. Can I suggest to you that if a clinician has those sorts of concerns what needs to happen is that they telephone the police and the police will be able to advise them about what can be said and what can't?
WENHAM: Sorry, can you just clarify and repeat that again? Sorry to ask you.
JAMIESON: Well, in this case we end up with a position where we have got doctors that are having conversations with patients where their patients want to know how their children have died and the doctor has a suspicion that the answer as to how their children have died may be the presence and activities of a nurse, but in his mind he feels he cannot say that, he cannot be candid because he's concerned about prejudicing a police investigation. I hope I have summarised that fairly.
WENHAM: Okay. I think I understand now. I'm not -- at the beginning in the early stages of
the investigation there was an agreement or some communication between the Constabulary and the Countess at an Executive level as to how they would manage and communicate with their staff --
JAMIESON: Yes.
WENHAM: -- and how they should respond to any requests or media or any other type of activity. So there was an expectation that that would be managed if I remember at those early stages. How it progressed in the investigation, I'm not -- I couldn't comment on.
JAMIESON: But really the point I am asking you to comment on is the way that that clinician works that out, the way that he gets guidance is to speak to the police because they will be best placed to say what can safely be said and what can't?
WENHAM: Yes. Well, that, that would be the answer. Yes, speak to the police and I would imagine that at that point through the Inquiry team there would have been a liaison into the Countess.
MR JAMIESON: Yes, thank you very much. Those are all of my questions, my Lady.
LADY JUSTICE THIRLWALL: Thank you, Mr Jamieson. Mr Wenham, just before you go, would you mind going
back to 27 April. I know you probably feel we've spent rather a lot of time on that and the reference is INQ102292 [INQ0102292]. It's the note of Stephen Cross. Thank you, and could we look at page 7, please. It is just really for me to look at something which I hadn't picked up before. At the top: "IH to protect nurse." And then: "Hayley, what is nurse doing now?" And then a little bit later. "IH: grievance, HR process. Recommendation of mediation. Behavioural issues." Which Ms Langdale took you to. "No previous [perhaps concern] nurse skills or abilities, then criticised for what we did to be reintroduced." So that sounded as though -- it looks as though the nurse is to be reintroduced and Hayley says: "Not wise for her to return." Can you remember anything about that?
WENHAM: I -- we mentioned this before. There was some discussion around the nurse clearly in that meeting.
LADY JUSTICE THIRLWALL: Yes.
WENHAM: I can't remember that specific point.
LADY JUSTICE THIRLWALL: It was not attributed to you, it is just I noticed it afterwards and I want to ask you about it.
WENHAM: I can't remember the specific point but, I mean, if there would have been a timeline on that or a date suggested for that nurse to be returned that would have caused me some concerns clearly. But I can't comment any further.
LADY JUSTICE THIRLWALL: No. All right. Thank, you that was my only question.
WENHAM: Thank you.
LADY JUSTICE THIRLWALL: Thank you very much indeed for coming this afternoon. You are now free to go.
WENHAM: Thank you.
MS LANGDALE: 10 o'clock.
LADY JUSTICE THIRLWALL: 4.15 feels like an early finish, doesn't it? Enjoy your extra 15 minutes. See you in the morning at 10 o'clock.
(4.16 pm) (The Inquiry adjourned until 10.00 am, on Thursday, 21 November 2024)