LADY JUSTICE THIRLWALL: Good morning, everyone, I'm sorry for the slightly delayed start. There's been a slight rearrangement of the witness order, which I'll leave Mr De La Poer to tell you about.
MR DE LA POER: My Lady, thank you. Yes, in a change to what was published, our first witness today will be Dr Anna Milan, please.
DR ANNA MILAN (sworn)
LADY JUSTICE THIRLWALL: Do sit down, Anna Milan. Mr De La Poer.
MR DE LA POER: Please could you give us your full name.
MILAN: Anna Margaret Milan.
DE LA POER: And, Dr Milan, can you confirm for us, please, that on 15 May of this year you
provided the Inquiry with a witness statement?
MILAN: I did, yes.
DE LA POER: And are the contents of that witness statement true to the best of your knowledge and
belief?
MILAN: They are, yes.
DE LA POER: I start by introducing you. Following a period of university and formal training, did
you qualify as a clinical scientist in 2008?
MILAN: I did, yes.
DE LA POER: And did you take up the role of principal clinical scientist at that time?
MILAN: I took up the role of senior in 2008 and then principal in 2011.
DE LA POER: Thank you. Along the way to becoming the principal clinical scientist, did you obtain
membership of the Royal College of Pathologists in 2009?
MILAN: I did. It's in two parts, so I completed the full fellowship by 2011.
DE LA POER: Thank you. Then, as you've have told us, you took up the position of Principal
Clinical Scientist in 2011 and to bring us up to date, in 2017, did you get appointed to the role
of Consultant Clinical Scientist?
MILAN: I did, yes, at Liverpool.
DE LA POER: And all of these posts that we've discussed, were they at the Liverpool Clinical
Laboratories?
MILAN: They are, yes.
DE LA POER: And the Liverpool Clinical Laboratories form part of the Liverpool University
Hospital NHS Foundation Trust; is that correct?
MILAN: They do. They do.
DE LA POER: And so that we are clear, you are a doctor of biochemistry rather than a medical
doctor; is that right?
MILAN: That's correct, yes, via PhD.
DE LA POER: Now, in 2015/2016, as you've told us, you were a principal clinical scientist. Were
you one of three?
MILAN: I was, yes.
DE LA POER: Also within your team, did you have anybody above you?
MILAN: Yes, there was a Consultant above who's clinical lead.
DE LA POER: And below you?
MILAN: Yes, so previous bands similar to what I'd been, so there's more senior clinical scientists
below and then trainees.
DE LA POER: And together were you a team of 13?
MILAN: We were, yes.
DE LA POER: Now, I'd like to ask you, please, about [Child F], and we'll begin, please, by
bringing up on screen INQ0000861. That's a screenshot that you're familiar with, I believe.
MILAN: It is, yes.
DE LA POER: Let's just introduce some of the elements of this. Was it your role and that of your
colleagues at the Liverpool Clinical Laboratories to undertake testing
on blood from other hospitals?
MILAN: Yes. So we're a large referral centre, so we get -- we get all the Liverpool work but we
also take referral work in from all across the UK.
DE LA POER: And was there an agreement at the time with the Countess of Chester Hospital that
certain blood testing would be referred to you but for their benefit?
MILAN: Yes, so every hospital has the choice of where they want to refer work, but Chester chose
to send any tests that they didn't offer to Liverpool.
DE LA POER: Is it your understanding that a test identifying the level of insulin and C-peptide
was one of the tests that was referred to Liverpool?
MILAN: That's correct, yes.
DE LA POER: Just help us to understand that test. We don't need to go deep into the science here
but is there something particularly complex or time-consuming about that test that means that a
district hospital wouldn't be the obvious place to do it and a large centre like yours would
be?
MILAN: It's not a frequently requested test, so people tend to work with efficiency, so as a
referral centre we would offer the assay and then smaller laboratories would send the work into
ourselves. We don't get a large workload. We're largely an adult hospital. There is in Liverpool
Alder Hey, so they would offer paediatric service to the Liverpool region. So it was -- it's run
on a -- on an ad hoc basis, or it was.
DE LA POER: And in terms of a request to test both the insulin level and the C-peptide level in
the blood, which was the part of the request that Liverpool received, for [Child F], what would
you be expecting a clinician to want to learn from that test?
MILAN: So there's always -- any test that's requested there should always be a benefit to the
patient. So if -- as we know, this child was hypoglycaemia or hypoglycaemic they want to try and
investigate the cause of it, so performing a C-peptide and insulin is one of the differentials to
help understand the mechanism for that hypoglycaemia.
DE LA POER: So you would expect that that test would be requested when a child was
hypoglycaemic?
MILAN: Yes.
LADY JUSTICE THIRLWALL: Just can you explain what that means.
MILAN: Yes, sorry. So that's a low glucose, so glucose below the reference range.
MR DE LA POER: Sometimes referred to as low blood sugar --
MILAN: Yes.
DE LA POER: -- in ordinary life.
MILAN: In ordinary life.
DE LA POER: So you wouldn't expect that request to be made if a child or patient had high blood
sugar or was hyperglycaemic?
MILAN: Generally it's not in a child.
DE LA POER: And so the starting point is that you as the laboratory will be working on the
assumption that the patient is likely to have been hypoglycaemic at the time that the test was
requested and the blood taken?
MILAN: Yes, we would never assume. We would always try and hope that there's clinical details
provided with the test, and obviously with it being a referral test we'd hope that that would
cascade through the local laboratory to be passed through to us.
DE LA POER: Of course. Perhaps assumption but that would be your working hypothesis?
MILAN: Yes.
DE LA POER: Obviously requiring to be checked before any proper interpretation is made?
MILAN: Absolutely, yes.
DE LA POER: And here, if we look at this screenshot, we can see at the top that it was -- top
left-hand corner -- collected on 5 August 2017 at 17.56?
MILAN: Yes.
DE LA POER: And then we have some further dates, C-peptide at 6 August 16.15 and insulin at 6
August at 16.15. What are those dates references to, please?
MILAN: So those are when we receive that sample at Liverpool. So the sample would have been sent
from the Chester laboratory to ourselves and because it was collected probably at the end of the
day, they wouldn't have sent that over unless it was an urgent request until the next day. So we
received it on the 6th in the afternoon.
DE LA POER: So within approximately 24 hours of the sample being taken from the patient, it's in
your hands at the Liverpool laboratory?
MILAN: It is, yes.
DE LA POER: And is, therefore, available to be tested by you?
MILAN: Yes. I mean, we -- we -- at the time in Liverpool we ran these in batches, so this would
have been frozen until analysis unless it had been requested as an urgent.
DE LA POER: And having looked at the records, have you seen any evidence that this particular
sample was requested as urgent?
MILAN: It wasn't, no.
DE LA POER: So if we move to the detail of this, we can see that next to C-peptide there's a
value, and next to insulin there's a value?
MILAN: Yes.
DE LA POER: Can you just talk us through, please, what those two values signify?
MILAN: Yes. So for the C-peptide, the units haven't appeared on this screen but it was
undetectable, so the bottom of our measuring range, so the lowest we could accurately report, was
169, so this was below that and that's in picomoles per litre, that's the units for C-peptide. So
it could have been 165, it could have been zero. We could not quantitate below that level at that
time. For the insulin it's reported in two units, so the one that the arrow is pointing to is --
or the first arrow, sorry, is the milli-international units. And then the second one with the SI
is the picomoles per litre units. And it's the picomoles that's used with the C-peptide to look at
the ratio of appropriateness.
DE LA POER: So the --
MILAN: So it's a very high insulin -- sorry, I interrupted you there.
DE LA POER: Not at all, it's your evidence so tell us --
MILAN: Yes, so it's a very high insulin of 4,657 picomoles per litre and undetectable C-peptide.
DE LA POER: Now, if we have a look at another screenshot that we have, INQ0000862. We'll just speak to the other end of the process in
Liverpool.
MILAN: Yes.
DE LA POER: That -- that records the sample arriving and the times and the dates. Obviously it
records the results. Presumably they're populated into that screen once they become available?
MILAN: Yes.
DE LA POER: And do we know from this screenshot that we're looking at on screen that they became
available to the Liverpool laboratory on the 12th; is that right?
MILAN: That's correct, yes, so we didn't analyse them the day we received them. They were analysed
on 12 August.
DE LA POER: Just help us with the time frame there. Some people may be thinking that feels like
quite a long time for an important or potentially important blood result. Was that in accordance
with the agreement that you had at the time? Did this result take longer than you would have
expected? Was this fast for what you were doing at the time? Help us, please.
MILAN: Yes, so for a routine request this was appropriate. So we used to run these -- we used to
be
in an older building, it's now knocked down but -- so we used to run insulin and C-peptides twice
a week. So depending on where the weekend sat, depending on what time samples were received, they
would be prepared and run in a batch, and so this was within our appropriate time frame for a
routine request. If we get urgent requests we can expedite them and run them the day that we get
them if requested.
DE LA POER: And let's just have a look at some of the information that we can see recorded here.
Now, the first thing to say is that this wasn't you dealing with this particular entry that was a
colleague of yours.
MILAN: It was, yes.
DE LA POER: We know what the results were, we saw those on the previous screen, but the
advice/information, which is recorded at on 12 August 2015 at 16.40 "Low C-Peptide to insulin"
--
MILAN: Yes.
DE LA POER: -- and then "? Exogenous".
MILAN: (Nods).
DE LA POER: So now we just need to understand a little bit more about that ratio.
MILAN: Yes.
DE LA POER: And you're very much the expert in the room on this. So tell us, please, what the
significance or
potential significance is of having a very high level of insulin and an undetectable level of
C-peptide?
MILAN: So when insulin's formed in the body it's formed from a precursor, so it's a molecule that
contains insulin but it's got parts of it that stop it being reactive. So once it's cleaved in the
body you get one C-peptide and one insulin. So in health it's equamolarly produced, so equal
portions, and insulin has a very short half-life, whereas C-peptide has a longer half-life, so it
hangs around for longer. If the normal ratio in health should be that C-peptide to insulin has a
ratio of about 10 to 1, sometimes that can be 5 to 1, depending on metabolism. In this case it was
the other way round. So insulin is extremely high with an undetectable C-peptide. So that points
to the fact that this wasn't produced by the body and so the primary differential is exogenous
insulin administration.
DE LA POER: When you say primary differential, is that a -- can that be put another way, that
your first thought will be that it is likely to be?
MILAN: Yes, yes.
DE LA POER: So just to go back over that so it's absolutely clear, you would expect there to be
more
C-peptide than insulin if the body had produced it naturally?
MILAN: Absolutely, yes.
DE LA POER: And, as you've told us, this is the reverse. And, of course, as we've established,
the working hypothesis to be checked is that this result would only have been -- or only likely to
have been requested if the child had low blood sugar, was hypoglycaemic?
MILAN: Yes, and querying what the cause of that could be.
DE LA POER: And so if we just start to put all of this together in the minds of the informed lab
scientist, it is likely, although it needs to be checked, the child had low blood sugar --
MILAN: Yes.
DE LA POER: -- hypoglycaemic, and it is likely that they have been administered insulin.
MILAN: Yes.
DE LA POER: Now, insulin is given to patients who are hyperglycaemic; is that right?
MILAN: That's correct.
DE LA POER: And the purpose of it is to bring the blood sugar down.
MILAN: Yes.
DE LA POER: And so does it follow, then, that you would not ordinarily expect that a child would
be receiving insulin and be hypoglycaemic or have a low blood sugar?
MILAN: That would be the correct assumption, it shouldn't be in that situation. Not in an insulin
that level particularly.
DE LA POER: And so to the informed lab scientist, does that give rise to three -- one of three
likely scenarios, (1) that too much insulin has been administered, in other words that the child
was originally hyperglycaemic but they've been given such a lot of insulin that it has made them
hypoglycaemic?
MILAN: Yes.
DE LA POER: So potentially a medication error, too much insulin has been given?
MILAN: Yes.
DE LA POER: Or the child shouldn't have received insulin at all and someone has accidentally
given them insulin, in other words perhaps because they thought they were giving it to that baby
when they'd misidentified who needed it, so also a potential medical error; is that right?
MILAN: It could be, yes.
DE LA POER: Or the third scenario, that somebody has deliberately given insulin to a child who
they knew didn't need it?
MILAN: That could be the case as well, yes.
DE LA POER: Yes. But in terms of the likely explanations for this, are those the three that will
spring to mind?
MILAN: Yes. I mean, obviously you wouldn't always err on the side of suspicion, you would think
that it's been -- they've overshot by giving too much insulin.
DE LA POER: But that may still be a medical error?
MILAN: Yes.
DE LA POER: So whilst your mind might not -- within those three possibilities you might be
tending towards one just because that's your natural way of thinking about it --
MILAN: Yes.
DE LA POER: -- in the best case it's a potential medical error, and in the worst case it is
somebody has tried to harm or kill?
MILAN: Potentially, yes. Yes.
DE LA POER: And is that in fact really what a competent clinical scientist should be thinking
when they see results like that?
MILAN: So when you see results -- that's why it warranted a phone call to Chester because -- just
to expedite that information to the clinical team.
DE LA POER: Now, I just want to have a look at that telephone call. Within the lab you operate
under
guidance issued by the Royal College of Pathologists; is that right?
MILAN: We do, yes.
DE LA POER: And is it the position that that guidance at the time, and I think still now, but at
the time did not have a protocol for whether a phone call was needed in this sort of scenario?
MILAN: That's correct, yes, it's not in the guidelines.
DE LA POER: It's not in the guidance?
MILAN: No.
DE LA POER: But within your laboratory you're not slaves to the guidance, are you?
MILAN: You can't be.
DE LA POER: No. You are expected to exercise clinical judgment as well?
MILAN: That's what our training and role is, yes.
DE LA POER: And here what is quite apparent is that your colleague has exercised that clinical
judgment and rather than just putting the results in the post for them to arrive whenever they do
back at the Countess of Chester, they've picked up the phone and spoken to someone.
MILAN: They have, yes.
DE LA POER: And just help us with the way in which that
conversation would go. So obviously this is experienced and knowledgeable professional to
experienced and knowledgeable professional, so I'm sure they're not speaking in the terms that I
am to you, but how would you expect that conversation to go?
MILAN: Yes, so the -- the biochemist that rang this result through, if it had been myself would
have been done the same thing. We'd have, first of all, just double-checked that the glucose was
low at the time this sample was taken.
DE LA POER: Can I just stop you there. Did you have that information available to you?
MILAN: Not -- not when we actually authorised the result, but when we spoke to them we were told
they were hypoglycaemic at the time.
DE LA POER: Yes, thank you.
MILAN: So that -- that sort of cements the comment that's been put on there. So we would then say,
"Well, actually we are concerned about this result, there is a very high insulin with undetectable
C-peptide, it suggests there's exogenous insulin present, it's now for you guys to discuss it with
the clinical team at Chester." And by clinical team I mean the patient -- the doctors on the
wards.
DE LA POER: And, again, from the colleague who's receiving this information, who is, like you,
also an expert in it, would you expect that they would be thinking with that information the same
three possibilities that at best this may be a clinical error, at worst this is somebody trying to
harm a patient?
MILAN: Yeah. I mean, like I said, we always err on the side of unsuspicious, so it would have --
it would have just been that they think it's -- it's an error and it needs investigation.
DE LA POER: You say that you err on the side of not suspicious, but isn't the correct way to look
at this that there is a risk and that that risk needs to be addressed immediately?
MILAN: Yeah. I mean, the risk is to the child being still hypoglycaemic. Obviously this is quite a
few days later, so we would hope that they weren't. But it was really just to start investigating
the causes of how that had occurred.
DE LA POER: Well, quite. Because even if too much insulin had been administered and caused the
child to enter a hypoglycaemic state, you would still expect there to be a thorough investigation
of that because perhaps someone's written the wrong prescription for insulin or perhaps somebody
has picked up the wrong level, the wrong amount. So there are potentially systemic
problems that need to be addressed, even if the child is now well.
MILAN: Yeah, and that should be the response of a team to that result.
DE LA POER: Now, let's just be very clear about it. The team, who do you mean?
MILAN: Sorry, yes, the team that are looking after that child.
DE LA POER: So are you excluding from that the biochemist at Chester or are they part of the
team?
MILAN: So from the sort of biochemistry point of view obviously we've put an additional comment on
there about further investigations but it's more what is the current state of that patient and do
they need further investigations. That's where the role of the laboratory would aim, but most of
it is in dissemination of that to the clinical team looking after the patient so that they can
then decide the next coarse of action.
DE LA POER: Well, let's just address the further investigation that is proposed: "Suggest send
sample to Guildford for exogenous insulin. " Now, that is advice being given to the biochemist at
Chester; is that right?
MILAN: Yes, to pass on to the clinical team on the
wards.
DE LA POER: Why would it be for the clinical team to judge whether a further test is required at
Guildford as opposed to the biochemist?
MILAN: So generally if a test is going to be undertaken there has to be a benefit to the patient.
So we wouldn't know at the time of authorising this -- or the Chester team might -- what the
current clinical status was of that patient. So it's important that if you're going to undertake a
test it has an impact on the patient's management.
DE LA POER: And why Guildford?
MILAN: So Guildford is a specialist referral lab in the UK. It's the only one that does specialist
insulin testing. And even they don't test for different types of insulin. But as everybody in the
UK measures insulin, we all do it by a test called an immunoassay, and there's obviously been
issues suggested around that because it cannot distinguish between exogenous and endogenous.
However, with using a C-peptide that helps your differential, it gives you the robust nature of
your test to say that it's exogenous. But what we'd want to do is eliminate any other potential
interference if it didn't fit the clinical situation.
Now, if that baby hadn't been hypoglycaemic, then this wouldn't have fit, so it would have to have
been further investigated. But as it fitted clinically, whilst we put that comment on there, I
don't know of anybody that's actually referred for exogenous insulin testing. And actually
Guildford don't do it, they send to Germany. So nobody in UK offers a test which can say this is a
certain brand of insulin.
DE LA POER: So, in other words, looking at the molecule and determining whether it is synthetic
or naturally produced?
MILAN: Yes. Yeah.
DE LA POER: And so if this had been you making this call, would you have seen any benefit in
sending the sample to Guildford, or for the purpose the benefit of the patient did you have enough
information already?
MILAN: We had enough information already. So we knew the clinical state. We knew these results
provided the cause of the hypoglycaemia, which had resolved at the time that the result was
telephoned through. So additional testing wouldn't have made any difference to the clinical
management of that patient.
DE LA POER: And there was -- you have a quality assurance process within your laboratory, which
we don't need to go into the daily of, but the headline is this, Dr Milan, is this right that you
wouldn't -- your laboratory wouldn't have phoned through a result that they weren't satisfied was
accurate?
MILAN: We wouldn't have even measured the sample if we weren't sure that the analyser was
performing appropriately that day. And then with the results, we have to double-check that the --
it's a quality control procedure before we even release a result on to an electronic system to be
communicated.
DE LA POER: So let's just have a look at the other end just for your comment. So we're going to look and see how this is recorded on the ward. If we go to INQ0000859. We're going to go to page 334, please. Now, it may just be my eyesight but I suspect we need to crop into that a little.
LADY JUSTICE THIRLWALL: It's a bit of a challenge.
MR DE LA POER: So 334. That was what I was expecting. Thank you very much indeed. So, again, this
is something that you have had an opportunity to see in advance of today; is that right?
MILAN: Yeah, only just for this Inquiry. I haven't seen it before that.
DE LA POER: And, of course, it wouldn't be ordinary practice for you to see the ward notes in
Liverpool.
MILAN: No.
DE LA POER: And so far as you can tell, let's see if we can interpret these results. If we look
towards the bottom, we've got results telephoned by Con Lewe --
MILAN: Yes.
DE LA POER: -- at 16.49.
MILAN: Yes, so even though it wasn't recorded on the previous screen, my colleague must have
phoned it to Dr Emma Lewis who was working at Chester, and she's phoned through to the ward then.
DE LA POER: And if we consider the timings, that phone call is nine minutes after the phone call
from your lab to the laboratory at Chester?
MILAN: Correct.
DE LA POER: And just looking at what's recorded on there, are you satisfied that the results
obtained by your lab have been accurately captured on that document?
MILAN: Yes, I am, yes.
DE LA POER: I think the ratio is recorded as 0.0.
MILAN: Yes, it's an IT glitch unfortunately because the insulin -- sorry, because the C-peptide is
recorded as less than 169 it doesn't have a number to put into that ratio, so it can't calculate
it.
DE LA POER: So it defaults to zero?
MILAN: Yes.
DE LA POER: But there's nothing misleading about that, because anybody interpreting these results
can see what the insulin level is, what the C-peptide level is and the fact that it was at an
undetectable level --
MILAN: Yes.
DE LA POER: -- and so that's not going to lead to any confusion in an informed person, is it?
MILAN: No, and it's actually got an L by it, so it's indicating that it's low, and there is a
reference range there for that ratio. It's not come up very clear on this but it does say 5 to 10,
which is the ratio that we would expect.
DE LA POER: So, again, to an informed person this is a very low ratio --
MILAN: Yes.
DE LA POER: -- a long way outside of the normal range?
MILAN: (Nods).
DE LA POER: Now, we'll just, finally, look at what is recorded in the clinical notes, and
obviously this is two steps removed from your laboratory, but let's just check, from your point of
view, using your expertise, what's been recorded. The same INQ page 39, please. Again, the system
is just catching up.
MILAN: That's okay.
DE LA POER: Again, you will -- this will be very familiar
to you once it comes up on to screen. They're handwritten medical notes. That appears to be the
correct page but it's in fact lower down that we want to see, please. There we are. Thank you very
much indeed. So, again, just using your expertise, please, Dr Milan, the results that came from
your lab, are you satisfied that the person writing these notes has correctly identified the
relevant parts of the printout sheet that we just looked at?
MILAN: Yes, I am. They've used the correct form of the insulins, they've used the right SR units
value, which is the 4657. They've recorded that as high. The C-peptide, even though they've called
it insulin C-peptide it should be clear that's just C-peptide as low, and they've put the less
than sign in. And then the ratio they have got is zero. And I think that's a down arrow of
lowness, but it's missing half an arrow.
DE LA POER: And we've then got "Discussed with Dr ZA", so that's the person making the entry:
"Insulin high. C-peptide low. Unusual for hypoglycaemia." Again, a correct interpretation of the
results?
MILAN: Yes, and obviously they will know on the ward whether they've been given insulin or not. So
the fact that they've put "unusual for hypoglycaemia" would infer that they didn't give them
insulin.
DE LA POER: Thank you. We can take that down. We're going to just pause now and consider the
responsibility of everybody in this chain of events. Accepting entirely that the clinicians have a
very big responsibility in this situation, not least because they have access to the notes, they
were the ones who commissioned the test, and they are the ones who ultimately can check whether
insulin was prescribed, and if so whether the correct amount of insulin was prescribed.
MILAN: Yes.
DE LA POER: But if we take a step before that, looking at the role of the in-house laboratory,
your colleagues there will have a very high level of expertise in the interpretation of such
results, won't they?
MILAN: They should do, yes. I mean, they've done the same exams, which is as part of your
professional examination you look at all anolytes, even tests that you don't offer routinely.
DE LA POER: And, again, they will have their own protocols, and I'm sure you will feel a little
uncomfortable commenting upon what another organisation should do, but I'm here looking at the
professional
responsibility of someone like you.
MILAN: Yes.
DE LA POER: How important is it that the person who is speaking to the ward makes absolutely
clear that it is likely that there is some kind of medical problem here with these results?
MILAN: I mean, that's vital. I mean, the reason we rang it was to try and emphasise that, and so
the message has been translated because we can see that it's gone -- transcribed through to the
notes, so it's very important that that message is narrated to the clinical team via that liaison
with Chester.
DE LA POER: And this isn't a very common state of affairs, is it --
MILAN: No.
DE LA POER: -- that a hypoglycaemic child will have very high insulin and very low C-peptide?
MILAN: Very uncommon.
DE LA POER: And so from the point of view of alarm bells, red flags, whatever you want to -- that
should stick with the person as being, "I really need to make sure that this is communicated,
taken seriously and acted upon"?
MILAN: Yes.
DE LA POER: And you would agree that that is the
responsibility of the professional person in the in-house lab communicating to the ward?
MILAN: It's the whole chain. It's our responsibility to make sure Chester get that from ourselves
and then it's the closing the loop then back to the clinical team from the Chester laboratory.
DE LA POER: Because, do you agree, this is potentially a safeguarding issue?
MILAN: Safeguarding, yes, but obviously that's a very much a clinical decision because we don't
have the information available. For us it's a blood test, it's a clinical case, but for them they
have all the details. So if you were on the ward with those results that is -- that would be
considered a safeguarding issue, yes.
DE LA POER: While you say you don't have all the details, safeguarding, do you agree, is premised
on the idea that if there may be a risk, action is required?
MILAN: It is, but obviously we don't have all the information to determine that full risk, and
that risk does rest with the clinical team.
DE LA POER: Do you think back in 2015, when dealing with results of this nature, that because of
that safeguarding risk, there needed to be greater resilience built into this chain of
communication to make sure that action and investigation occurred?
MILAN: I think at the time, once we'd analysed the result, that chain was fast. We could have
measured it sooner, we could have been informed that it was urgent, and we could have closed that
front end of that, so that result actually may have directly impacted on patient care.
DE LA POER: But I'm talking about systemic resilience, obviously that's an important part, how
quickly it happens, but once you are seized with the knowledge --
MILAN: Yes.
DE LA POER: -- isn't it of vital importance that at every stage every person understands their
responsibility and that action does result at the end?
MILAN: Absolutely. That's why we have an audit trail.
DE LA POER: And for that -- I just want to invite you to consider something, it's again distant
from your position by at lowest one step, but do you think that results of that potential
significance need to be communicated to the Consultant as opposed to a junior doctor? Do you think
that level of resilience is required so that there is a in-person conversation between the person
with the greatest knowledge and expertise on the ward as opposed to potentially being passed via
junior doctors? Do you have a view on that?
MILAN: It's very difficult because we obviously telephone an awful lot of abnormal and critical
results routinely to wards. You'll find that the staff that are the most busy are unable to take
those calls because it might mean them leaving a situation where they're more required. So we
never have a requirement that we have to speak to the most senior person on the ward. It's just to
make sure that you have given that to somebody that clinically understands it.
DE LA POER: What about another way of building resilience in, which is that an email goes to the
Lead Clinician as well, that they can look at in slower time to make sure that they are checking
in with their colleagues to make sure that they haven't overlooked it, because, from what you've
told us, there's no two ways about it, this is a highly significant result?
MILAN: Yes. With emails I think there's always a degree of difficulty with that because you've got
no feedback on whether that's actually been acknowledged or read, so an email can sit unread in
somebody's inbox. So, again, that wouldn't be our primary route of communication.
DE LA POER: No, I wasn't suggesting it replaces the telephone call, it's just about -- we know,
and there's been a candid recognition of this, that the Consultant
who looked at it, I'm paraphrasing here, considered whether or not that had been deliberately
administered and dismissed it as being unthinkable.
MILAN: (Nods).
DE LA POER: An error, as she candidly accepted. But what we're looking here is at systemic issues
and whether we can build in a situation where that doesn't happen again, and really I'm just
seeking your views on --
MILAN: Yeah, I think now obviously IT has really supported laboratory medicine and patients
because we do have electronic patient records now. So we don't have paper notes, so it can be
recorded and it's always there as a memory so that you can click on results and see them. So I
would say that's the best mechanism that it's kept in electronic patient record.
DE LA POER: Have you yourself ever had to phone through a result like this?
MILAN: Not an insulin C-peptide, but obviously day in day out, as part of our role, we do phone
abnormal results to critical units.
DE LA POER: Do you think that it is sufficiently abnormal for somebody in your position that such
a telephone call would stick with you?
MILAN: Yes.
DE LA POER: [Child L], please. INQ0001175. So a familiar
screen here.
MILAN: Yes.
DE LA POER: We can interpret this relatively speedily. Collected on 9 April from [Child L],
received by your laboratory 11 April. So this time two days rather than one but --
MILAN: Yes.
DE LA POER: -- presumably that just depends on the post and --
MILAN: They're transported by vehicle, samples are to us, especially for an insulin C-peptide
because they have to be sent chilled. So it would have been stored and processed appropriately and
then sent when the next transport.
DE LA POER: Now, here, am I right, you tell me, we have a C-peptide level that is detectable?
MILAN: Yes. So it's 264 picomoles per litre. So it is above the bottom of that detectable limit.
DE LA POER: But is that a low C-peptide level?
MILAN: So it's always about whether it's appropriate for the insulin level. So on its own in
isolation in this case you wouldn't be able to interpret it, but in line with that insulin it's
inappropriately low again.
DE LA POER: Yes. And the insulin figure we're here focusing on is the lower one, the 1,099; is
that right?
MILAN: It is.
DE LA POER: And, again, you are expecting that top number to be 5 or 10 times bigger than that
bottom number?
MILAN: Absolutely, yes.
DE LA POER: So, I hope I get the maths right, 5,000 or 10,000?
MILAN: Yes.
DE LA POER: Now, we have a note at the bottom of this screen: "Difficult to interpret without
concurrent glucose." Is that simply because in your lab you didn't have the glucose?
MILAN: Yes. So we never undertake the glucose analysis. That would have been done -- and it could
have been done via various mechanisms. They use point of care glucose, which is where you do it on
a heel prick on the ward or a lab-based glucose, and we didn't have evidence of either of those
with this request.
DE LA POER: But just putting yourself in the minds of the clinicians and why they would ask for
such a test -- again, this is the working hypothesis --
MILAN: Yes.
DE LA POER: -- you would have expected them to have done that heel prick test, discovered the
child was hypoglycaemic and requested the test, that's the ordinary sequence of events?
MILAN: Yes, absolutely. I mean, the -- the only way to be able to interpret this is if it was
taken at the time of hypoglycaemia. But, again, we don't assume. We would like to see the result
to make that a definitive interpretation.
DE LA POER: And are you -- you're satisfied, then, that if the child was hypoglycaemic then the
results were inappropriate?
MILAN: Correct.
DE LA POER: And did you have any involvement in telephoning this result through?
MILAN: No, this was one of my colleagues again.
DE LA POER: But, again, this was a result that you've looked at the records and you're satisfied
that it was communicated the same day?
MILAN: Yes.
DE LA POER: So although the ratio is slightly different, this is, as before, stepping outside of
the ordinary protocol of just putting it in the post, sending it back saying, "This is
abnormal"?
MILAN: Yes.
DE LA POER: And would you expect a similar conversation to the one that you've told us about from
your colleague to
the biochemist at the Countess of Chester?
MILAN: Yes, I would.
DE LA POER: "Tell me what the -- the glucose level is"; right?
MILAN: Therefore -- yeah, "Therefore, this is our interpretation", and they would then communicate
that to the ward.
DE LA POER: Well, we're going to hear from the scientist who dealt with this call potentially
later today or next week. But just help us, if the child was slightly above the hypoglycaemic
range, would this result still be a cause for concern?
MILAN: Just because of the -- the reversal of that ratio, yes, it would.
DE LA POER: So it doesn't need to be bang within the hypoglycaemic range for you to look at those
numbers as a professional and say, as before, someone's -- may have given them too much, someone
may have given them insulin when they didn't need it, or someone may have deliberately
administered insulin to harm them?
MILAN: Yes, and the fact that there's a detectable C-peptide means at some stage that child has
made its own insulin because the C-peptide will be there for longer than insulin.
DE LA POER: So this is the residual half-life --
MILAN: Yes.
DE LA POER: -- for C-peptide, which you've told us is longer --
MILAN: Yes.
DE LA POER: -- and so you would expect there to be some C-peptide still in the system --
MILAN: Yes.
DE LA POER: -- even if not produced at the time of the test?
MILAN: Yes.
DE LA POER: Dr Milan, I just wanted to ask you about now, please, and the future. You tell us in
your witness statement that the new facilities are now giving you a real-time opportunity. Can you
just tell us what that -- what that means in ordinary language?
MILAN: Yes. So -- I mean, our old facilities we'd outgrown them, which is why some assays were
kept and run offline. But now we've got a purpose-built laboratory. Every sample is run in
real-time that comes in for tests, for example like insulin and C-peptide. So as soon as we get a
sample it will be through the lab that same day and a result available either at the end of that
day or the first thing the next morning. So we have improved process for turnaround time.
We have also brought in a process where Chester now send us the glucose result on the request so
that we can make sure that our interpretation is appropriate on any additional insulin C-peptide
requests.
DE LA POER: So when you say "on request", does that mean that they tell you what the result is
when they ask for the test or do you have to go back to them?
MILAN: They actually -- I mean it's old-fashioned but they write it on the request form for us. So
we actually enter that in our system, so we've got a full profile then to be able to interpret
that accordingly.
DE LA POER: Why do you think, given the potential significance of this, that that -- the old
system required you only to have two-thirds of the picture and then have to make a phone call to
know whether there was a problem?
MILAN: I guess sometimes it takes a situation for things to improve, and it's always about service
improvement, and that's what we're always striving for. And I think also, as far as pathology
goes, we're working as a network now. That had started. It was in its infancy in 2015/16 but we're
working as Cheshire and Merseyside now, so ultimately we're all going to be on one IT system in
the future. We say in the future, it could be four/five years off, so we will actually have full
record access across Cheshire and Merseyside, so it will again improve these processes to make
sure --
DE LA POER: Will that --
MILAN: -- interpretation is appropriate.
DE LA POER: Will that allow you to check the ward notes --
MILAN: Yes.
DE LA POER: -- to see whether or not insulin has been prescribed?
MILAN: Yes.
DE LA POER: And will your protocol mandate that once you have access to it if you get results
similar to this?
MILAN: As part of our training anybody, if they get results like that, will want to put an
appropriate comment, so we'll look for that and actually check the records before putting a
comment on that.
DE LA POER: You mentioned that it takes a situation like this to generate change. But we know
that a nurse in Stepping Hill used insulin to kill patients, and that was in 2011, tried and
sentenced in 2015, so just before. We know the notorious case of Beverley Allitt who used insulin.
Do you think that, in 2015, your lab should have been further ahead with its thinking about how to
deal with these results, given those cases?
MILAN: I think as a laboratory -- in laboratory
medicine you are one step back from the patient, so, you know, you don't have that -- that luxury
of being able to perhaps review all of the clinical situations on that. But also, again, I suppose
it comes back to suspicion. We have one -- we have 3,000 results a day but on that day we had one
that's potentially very suspicious, so it's putting in processes for one result out of 3,000. So
it's about adapting to a situation, so maybe. But, again, we don't -- we didn't have processes in
place for that.
DE LA POER: Was there any discussion within your lab about the Stepping Hill case?
MILAN: Not that I recall, no.
DE LA POER: And just looking back on it, bearing in mind that this is your subject area --
MILAN: Mm-hm.
DE LA POER: -- the potential, albeit extremely rare, use of drugs as a weapon, does that seem
surprising to you that there wasn't training and dissemination of that information given to you as
a laboratory saying, "Look, we've had a local" -- because it wasn't a million miles away from your
lab --
MILAN: No.
DE LA POER: -- "We've a local case of this. It's so
important that we detect this, you all need to be on your guard", does that seem surprising to you
now?
MILAN: I mean, hindsight's a wonderful thing and lessons learnt, but obviously we -- we routinely
have overdoses of many different anolytes, not just insulin and C-peptide. So we -- it's about
having appropriate processes in place, and, no, we didn't.
MR DE LA POER: Dr Milan, thank you very much. Indeed those are my questions, my Lady. There are no Rule 10 questions for Dr Milan.
LADY JUSTICE THIRLWALL: Thank you very much indeed, Mr De La Poer. Dr Milan, thank you very much
indeed for coming along this morning and for making so much of the science so much clearer for the
rest of us. That completes your evidence and you are free to go.
MILAN: Thank you very much.
MR DE LA POER: My Lady, our next witness should not take us too far past our ordinary break at about 11.30, so it may be convenient to deal with that witness now or my Lady could take a break.
LADY JUSTICE THIRLWALL: No, I think we will take the break now so that we can work out precisely what we are going to do, how we're going to order the witnesses for the rest of the day, so we will start again at quarter past 11.
(10.57 am) (A short break)
(11.16 am)
LADY JUSTICE THIRLWALL: Mr Bershadski.
MR BERSHADSKI: Good morning, my Lady.
LADY JUSTICE THIRLWALL: Would you like to come up to the desk, please, and take the oath.
KATHRYN ANN DE-BERGER (sworn)
LADY JUSTICE THIRLWALL: Do sit down.
DE BEGER: Thank you.
MR BERSHADSKI: Good morning.
DE BEGER: Good morning.
MR BERSHADSKI: Could you state your full name please?
DE BEGER: Kathryn Ann De-Beger.
MR BERSHADSKI: Is it right that you provided the Inquiry with a statement dated 30 May of this
year?
DE BEGER: That's correct.
MR BERSHADSKI: And are the contents of that statement true and accurate to the best of your
knowledge and belief?
DE BEGER: They are.
MR BERSHADSKI: Thank you. Is it right Ms De-Beger that you qualified as a nurse in 1985 and
started working as an occupational health nurse in 1995?
DE BEGER: That's correct.
MR BERSHADSKI: And I think you started working at the Countess of Chester Hospital in the
occupational health nursing field from 2001; is that right?
DE BEGER: I believe it was 2009.
MR BERSHADSKI: And were you the occupational health --
DE BEGER: 2009, yes.
MR BERSHADSKI: And were you the occupational health manager from 2010?
DE BEGER: I was.
MR BERSHADSKI: Could you just in a few words summarise for us what your role as an occupational
health nurse involved?
DE BEGER: Okay, so occupational health is all about the physical and mental well-being of all
employees in the workplace, so we're concerned with the individual and the effects on health. So
it's a unique speciality in that we don't have any patient contact. We are dealing with members of
staff that are employed by the Countess. So in essence the staff are our patients. The role
encompasses a variety of different roles, I suppose, but one of them is seeing staff that are
being managed under HR policies, management policies. So although occupational health is totally
independent and impartial, we do sit under HR but we don't have any influence on the application
or the decision-making of
any HR policies. We are there to support and give advice to members of staff going through those
policies in a very independent, impartial manner and non-judgmental.
MR BERSHADSKI: Thank you for that, Ms De-Beger. You say in your statement that you were first
asked to provide some support to Letby in July 2016; is that right?
DE BEGER: That's correct.
MR BERSHADSKI: Now, if I could ask for a document up on the screen, this is the referral, as I
understand it, which your department would have received, that's 0018046. Thank you. Do you recognise this document, Ms De-Beger?
DE BEGER: I do recognise that document.
MR BERSHADSKI: Now, can you just help us, would that document have come in directly to you or to
your department more generally?
DE BEGER: That would have come directly to the department.
MR BERSHADSKI: Would you have read it?
DE BEGER: I believe I did because I believe that's my writing at the top that says "Nurse
appointment".
MR BERSHADSKI: Thank you. We can see under "Reason for Referral" -- now, that presumably would
have been completed by the person mistaking the referral to you?
DE BEGER: (Nods).
MR BERSHADSKI: In this case that was Eirian Powell; is that right?
DE BEGER: I believe it was.
MR BERSHADSKI: Thank you. And I think it says there: "As I mentioned to you on the phone ..." So
would that have been a conversation between yourself on the phone with Eirian Powell or somebody
else?
DE BEGER: That reason for referral would have been written by Eirian.
MR BERSHADSKI: Yes. And it goes on to say: "I requested that Lucy come to the Occupational Health
Department for support especially in view of the proposed allegation that will evidently come to
light." Do you recall what was said to you about "the proposed allegation that will evidently come
to light" at this point?
DE BEGER: No, that would have been all the information we received that's written on this
referral. But this referral isn't the first time that I would have met Lucy Letby. I met her
earlier than when -- this referral.
MR BERSHADSKI: Right. So this referral we can see at the top is dated 30 June --
DE BEGER: Yes.
MR BERSHADSKI: -- 2 -- well, it says "2916", I think presumably that's 30 June 2016. When would
you have --
DE BEGER: So --
MR BERSHADSKI: -- met --
DE BEGER: So the appointment for this, as you can see, is Thursday, 21 July.
MR BERSHADSKI: Yes.
DE BEGER: But I saw Lucy Letby, I believe -- well, I can't remember without looking at my notes,
but I believe it was the week before.
MR BERSHADSKI: So the week before the appointment?
DE BEGER: Yes.
MR BERSHADSKI: So after you received this form, presumably?
DE BEGER: Yes, but I probably wouldn't have known about that form when I first saw Lucy Letby.
MR BERSHADSKI: Okay.
DE BEGER: Lucy Letby was brought to the department by her manager, and that was when I first saw
her.
MR BERSHADSKI: And do you think at that point you would have been given some information in
however broad terms about the proposed allegation that will evidently come to light?
DE BEGER: No, none whatsoever.
MR BERSHADSKI: So would you have known that there was a proposed allegation that will evidently
come to light?
DE BEGER: At the appointment I saw her about -- around about the 14th or 16th of July I was not
told -- I was not told what the allegations were, no.
MR BERSHADSKI: Okay. So you would have known that there was some sort of allegation but not what
it was?
DE BEGER: No, I only knew that there was an investigation on the neonatal unit and Lucy was on
restricted practice and so that's why they brought her down to me.
MR BERSHADSKI: Okay. If I could, please, turn up another document on the screen, this is 0003174. If we can go to page 30 -- sorry, to page 29 of that, please. You
can see an email here, on page 29, of 8 July 2016. And if we just go over a couple of pages to
page 31, towards the bottom there, can you see where it says "Sue Hodkinson", can you just tell
the Inquiry who that was?
DE BEGER: Sue Hodkinson was the Executive Director of HR and my direct line manager.
MR BERSHADSKI: Yes. And so it says there: "Sue Hodkinson updated at 1.40 pm Kathryn De-Beger and
Katie Holstrum have visited the NNU at 12.15 pm today. Team spoken with. Shift leader spoken with.
No immediate support put in place but team feel
vulnerable." Do you recall visiting the neonatal unit on or around 8 July 2016?
DE BEGER: I have no direct recollection of visiting on this particular day, but Occupational
Health did visit various wards and departments throughout the hospital on a regular planned basis.
MR BERSHADSKI: Well, do you recall visiting the neonatal unit if not on that specific date then
around that time of the summer of 2016?
DE BEGER: Yes, I do.
MR BERSHADSKI: And what was the purpose of your visit to the neonatal unit then?
DE BEGER: So, as I said at the beginning, our role was about the health and well-being of staff,
so we would have gone to do a welfare visit to see how the staff were managing and coping.
MR BERSHADSKI: And what was your understanding of why you were going to see the neonatal unit
around that time to see how the staff were coping?
DE BEGER: Because there was an increase in deaths on the unit and that was under investigation.
MR BERSHADSKI: Right. So is it fair to say that in around July 2016, you would have known both
that there was an increase in neonatal deaths on the neonatal unit and
that Lucy Letby had been redeployed away from the neonatal unit?
DE BEGER: That's correct.
MR BERSHADSKI: So would it be fair to say that around July 2016 you would have known that the
substance of the allegation against Lucy Letby was that she was -- somehow may have been related
to those deaths?
DE BEGER: No. The reason I -- I would think that she was moved to a non-clinical role was because
there -- she was having to redo her competencies and there was the investigation, but no more
about accusations around her being involved, no.
MR BERSHADSKI: So did you make any connection in your mind between the fact that you were
visiting the neonatal unit because of deaths and Letby being somebody that you were supporting in
particular?
DE BEGER: Sorry, can you repeat the question?
MR BERSHADSKI: Did you make any connection in your mind at that time between the fact that the
neonatal unit needed support because of increased deaths and that Letby had been redeployed away
from that unit?
DE BEGER: I would have made the connection that Lucy Letby would have been part of the
investigation that they were looking at, yes.
MR BERSHADSKI: Yes. I'm just picking this up because I think
in your statement you suggest at paragraph 10 that it was at some point later after you started
providing Letby with support, that you were made aware that the investigation was to do with
deaths on the neonatal unit, but I think you're now saying that you would have been aware closer
to July 2016, that that was the case?
DE BEGER: I'm saying that on the very first time I met Lucy Letby on the 14th or 16th of July I
was not aware of any connection or that there was an increase in deaths on the unit. But
subsequently, later, in my other meetings with her, I was, but I can't pinpoint the time when that
might have been.
MR BERSHADSKI: Okay. And is it right that you started from July 2016 visiting the neonatal unit
on a weekly basis to provide the staff there with support in light of the increase in deaths?
DE BEGER: I don't believe it was a weekly basis but it would have been a regular basis, yes.
MR BERSHADSKI: Well, just so -- just so that you have it, can I ask for document 0014604, page 24. Yes, just the previous page. Do you recall speaking to
investigators from the Royal College of Paediatrics, the RCPCH team?
DE BEGER: I didn't recall until I was provided with this evidence for the Inquiry.
MR BERSHADSKI: I think these are typed notes of an interview with you that they held on 1
September. Again, we've got a slightly odd date there, 1 September 2016, and you can see it just
says, three lines up from the bottom: "Dropped in to see how staff are. Was two to three times
years ..." Presumably that means was two to three times a year: "... after the problems weekly
basis."
DE BEGER: Yeah, that could have been correct at that time but it wouldn't have been correct for a
prolonged period of time. There's no way we could have visited the neonatal unit on a weekly basis
for the period of time we're talking about.
MR BERSHADSKI: So you would have been visiting the NNU on a weekly basis, what, from July 2016
until at least September 2016; is that right?
DE BEGER: I haven't got any evidence of that but that could be correct.
MR BERSHADSKI: And did you discuss the increase in deaths of babies on the NNU with staff when
you conducted these regular visits?
DE BEGER: No, I didn't.
MR BERSHADSKI: So what were you discussing with them?
DE BEGER: We were discussing their health and well-being
because that's what occupational health is all about.
MR BERSHADSKI: Thank you. If I could just take you to another document, please, 0101342. We've got an extract of some of the text messages that you
exchanged with Lucy Letby there. Would it be fair to say that there was a significant amount of
text message and WhatsApp messaging between you and Letby for the period that you were providing
her with support?
DE BEGER: That would be correct.
MR BERSHADSKI: Now, I don't know, I'm sure you haven't counted them up, but I've estimated around
750 messages may have gone between you over the period of around 15 months. Does that sound about
right?
DE BEGER: That could be right, including all the group messages as well, yes.
MR BERSHADSKI: And that was a WhatsApp group you're referring to, which I think you were a member
of along with Karen Rees, Hayley Cooper and Lucy Letby; is that right?
DE BEGER: That's correct.
MR BERSHADSKI: Now, I think you've said in your statement that being part of a WhatsApp group to
provide support for a member of staff was not a usual thing for you to do as part of your role; is
that right?
DE BEGER: That's right.
MR BERSHADSKI: Now, would -- would -- this high amount of direct messaging over texts, would that
be a normal part of the kind of support you would provide to a staff member?
DE BEGER: No, it would not.
MR BERSHADSKI: If we look at some of the messages, for example if we start from page 18 of that
document that's on screen, please. Towards the top there, there's a discussion of going out
shopping in Liverpool. Over the page, on page 19, I think we can see some continued discussions
about shopping, about family matters, an upcoming wedding. And over the page, on page 20, some
discussion about cooking. Would it be usual for you to be having these sorts of discussions about
personal extraneous matters with a member of staff that you were supporting that was going through
an HR process of some sort?
DE BEGER: No, it wouldn't be normal at all. As I say, I've not been in contact in a WhatsApp group
with any other member of staff, but I've not been supporting staff in this situation ever before
and I felt at the time that I was the only support that Lucy Letby had. I was given that role by
the Trust to support her, to support her mental health, to support her well-being
going through what I thought at the time was a very distressing situation, and it was given to me
to support her the best that I could and keep her in work, to maintain her mental health during
that period, and I felt that fell just on me. So in order to do that, I did that to the best of my
ability, and that was why there were so many messages to try and make sure that she was okay. And
all the messages can't be about mindfulness and coping strategies to keep her grounded and to keep
her in moment, it was about normally events as well.
MR BERSHADSKI: If we go to page 24, please, of those messages. You say to her -- and I think the
green message will be one from you; is that right?
DE BEGER: It will be but, I can't read it on the screen.
LADY JUSTICE THIRLWALL: Neither can I.
MR BERSHADSKI: The screens aren't always the best quality. I'll read out the relevant bit.
DE BEGER: Thank you.
MR BERSHADSKI: You say to her: "We are supporting all the staff. I was on the unit yesterday and
will go again Monday but you are my priority." Why was Letby your priority if you were also tasked
with supporting all the members of staff on the neonatal unit?
DE BEGER: Because I was the only person that Lucy Letby was seeing. I did have other members of
the team that were able to do ward and neonatal unit visits.
MR BERSHADSKI: You did mention before that you were part of a support group along with Karen Rees
and Hayley Cooper on WhatsApp. So would it be fair to say that there were -- you weren't the only
member of staff who was supporting Letby at this time; is that fair?
DE BEGER: That is fair, but in the role that I did I had a very different role to them. So, as you
are aware, Hayley Cooper is her Union rep, so she would have advised her on Union matters. Karen
Rees was a very senior member of staff who would advise her on other matters, clinical matters
maybe. I was the only person, in my view, that was supporting her well-being at that time.
MR BERSHADSKI: You would have, presumably most of the time, been seeing Letby as part of regular
one-to-one Occupational Health support meetings?
DE BEGER: (Nods).
MR BERSHADSKI: And they would be -- you would document them in a formal way as part of your work;
is that right?
DE BEGER: That's correct.
MR BERSHADSKI: Why did you also need, in addition to
providing that regular support documented, to have this extensive informal channel of
communication with her, do you think?
DE BEGER: Because that then enabled Lucy Letby to contact me when she needed to, even if that was
outside of my work hours.
MR BERSHADSKI: You said at the start of your evidence that part of your role as Occupational
Health nurse and Occupational Health manager is to provide a completely independent service in
effect to a member of staff. Do you think on reflection and with the benefit of hindsight that
having such a significant degree of informal personal contact with a member of staff that you are
supporting that that might tend to detract from that independence which you are required to
maintain?
DE BEGER: When I say independence, I mean independence from HR, independence from any policies and
procedures. We are just concentrating on that individual member of staff. So in doing this I felt
I was going above and beyond my job role, and my job role was given to me by the Trust to support
her through this investigation.
MR BERSHADSKI: I think you've said towards the end of your witness statement that you think it
would be useful for there to be -- to have been a bit more guidance for somebody in your role
about how to act in that role when
a serious allegation has been made against a member of staff; is that right?
DE BEGER: That is correct.
MR BERSHADSKI: With the benefit of hindsight, what do you think -- and as a senior Occupational
Health nurse, what do you think the substance of that guidance should have been for how to manage
a member of staff in this situation?
DE BEGER: I do feel there should be guidance on the -- as you're putting it, the amount of time
and contact that you have with somebody that's going through this. But at the time, I didn't feel
there was any other alternative. There was nobody else to share this with. I had no clinical
supervision to talk to this -- with anybody. So I was working to the best of my ability, but there
is some learning that could be taken from this, definitely.
MR BERSHADSKI: I think it's right that you attended one meeting with Letby and her parents where
there was an argument between Letby and her parents about how to deal with the process that she
was under; is that right?
DE BEGER: That's correct.
MR BERSHADSKI: Do you think, again with the benefit of hindsight, that such guidance should
prevent you from getting involved with that sort of intra-familial
dispute?
DE BEGER: So anybody attending an Occupational Health appointment can bring somebody with them. So
they can bring their partner and they can bring their Union rep, they can bring their manager. So
anybody attending can bring somebody with them for support. So that's not unusual. Now -- and in
this case, Lucy Letby rang me from home asking to see me and ask whether she could bring her
mother with her. So I agreed because that is my standard practice.
MR BERSHADSKI: Is it right that you also had contact on the phone directly with Letby's
father?
DE BEGER: I do not recall any telephone calls with Letby's father.
MR BERSHADSKI: I think you may have seen that there's a witness who suggests that there was
pressure being put on you that you were in effect being harassed by Letby's father. Is that
incorrect, then; is that what you're saying?
DE BEGER: I have no recollection of any telephone calls. I have no recollection of being harassed.
MR BERSHADSKI: Thank you. Could I ask you to please turn up or to put up on the screen document
0017911 and page 7 of that document, please. Ms De-Beger, this is an extract
from a witness statement that you gave to the police as part of the criminal proceedings. I just
want to ask you about one passage of that. You see in the middle of the page it says: "Lucy did
ask for meetings with me on anniversaries of some of the babies' deaths as she was particularly
distressed." How many times, approximately, did Letby ask you for meetings on anniversaries of the
deaths of babies?
DE BEGER: To my recollection, it was only once.
MR BERSHADSKI: Did any of the other members of staff that you were supporting on the neonatal
unit, nurses in particular, did they ask you for meetings around the anniversaries of the deaths
of babies?
DE BEGER: No.
MR BERSHADSKI: Is it right, therefore, that Letby's distress around anniversaries of babies was
unusual compared to other nurses that you were supporting at the time?
DE BEGER: I can only take it on that at the meeting that I had with Lucy Letby she spoke about
being particularly distressed that week because it was, as she recalled, an anniversary of one of
the baby's deaths. But we then would have a meeting that was just about her managing her feelings,
her symptoms and talking about coping
strategies.
MR BERSHADSKI: And so this meeting that she asked for was in July 2017 I think you've said in
your police statement?
DE BEGER: (Nods).
MR BERSHADSKI: So by that point, would you have known that some of the allegations against Letby
was that she had deliberately killed babies on the neonatal unit?
DE BEGER: That is likely. So I see members of staff who are under an investigation for all sorts
of reasons, it could be that they've allegedly committed theft, fraud, been racist, whatever it
is, and I offer the staff support, coping strategies, onward referrals throughout the whole of
that investigation and until it reaches the conclusion. Now, the conclusion can be that the
person's given a written warning, they're dismissed, or they're actually returned to work. Now,
that does not influence what I do in my practice during that investigation with that member of
staff because, as I said to you, it's independent, it's impartial and it's non-judgmental. So I
would look after staff during that investigation without knowing any of the detail or that detail
impacting on what I do.
MR BERSHADSKI: I think you've said earlier that you've been supporting members of staff since
2010 at the
Countess --
DE BEGER: Correct.
MR BERSHADSKI: -- in this role. In that period of time, so from when you started in 2010 until
July 2017, how many times had you come across a situation where a member of staff was displaying
this kind of distress around the anniversary of the death of a patient, is that at all a normal
situation for you to confront?
DE BEGER: I can't recall another situation, no.
MR BERSHADSKI: Given that you knew at this time that the allegation was that Letby had
deliberately killed babies on the neonatal unit, did it give you any cause for concern that she
was displaying this distress at the anniversary of a baby death?
DE BEGER: No, not at all, because she -- it was in the context of she said that she was feeling
particularly distressed but how much more distressed would the parents be at the loss of their
baby, that's how she framed it, and -- but we had no other conversation about that.
MR BERSHADSKI: And if I could just ask one more document to be put up on the screen. This is 0063777. If we go to page 2, so we can follow this chain of emails. You will
see at the bottom Letby emails you on 25 April asking if you'll be around saying that she's
not having a good week and that she's going to Alder Hey the following day, and she's asking you
whether you've read some amended minutes of a document. And you respond on the same day saying: "I
think going to Alder Hey is a good idea. It will be something positive. How was Saturday? Did you
go to an event there? I think you should go to Alder Hey regularly, it will give you a little
break from the stress here." Would you have known at this point, so April 2017, that the
allegation against Letby is that she killed babies on the neonatal unit?
DE BEGER: I'm presuming I would have known by then, yes.
MR BERSHADSKI: Why did you think, in that case, with that knowledge, that Lucy going to Alder Hey
would be a good idea and something positive?
DE BEGER: Because I would of assumed that that was in place and agreed by senior managers, and --
and if it was agreed, which I assumed it was, then to be away from the stress of the Countess
would have been a good idea for her health and well-being.
MR BERSHADSKI: Do you think it fair to say that at this point you would have personally not
agreed with the allegation against Letby, that's why you thought it would be a good idea for her
to go?
DE BEGER: Say that again, sorry.
MR BERSHADSKI: Well, is it fair to say that you, at this point, had taken a view that it was safe
for her to go to Alder Hey?
DE BEGER: That's not my remit at all.
MR BERSHADSKI: If we go back up the page to follow the chain to page 1. You say to her in your --
in the email at 3.55, just below the middle of the page: "I understand why you are feeling like
you are but you have all the reassurances that the execs and us support you returning to the NNU
and that is where you belong." Why did you feel, at this point, that the Executives were
supporting Letby returning to the NNU?
DE BEGER: Because that's all the information that was -- well, that was the information that was
always given to Lucy Letby at our meetings. So at the meetings with Sue Hodkinson, Alison Kelly,
Karen Rees, Hayley Cooper and myself the meetings were all about how we could work to returning
her to the NNU.
MR BERSHADSKI: I think you had known by this point that she had been given a management
instruction that she wasn't even allowed to visit the NNU; is that right?
DE BEGER: I don't know whether it was by this time. I haven't got a timeline, but --
MR BERSHADSKI: Okay. And you reply -- well, she replies to you -- sorry, just up the page -- at
4.07 she says: "I feel as though this must be my fault and maybe I have done something wrong to
the babies and blame myself -- do you think that's normal?" Do you see that?
DE BEGER: Yes, I do.
MR BERSHADSKI: Given you say you knew by this point that the allegation against Letby was that
she deliberately killed babies on the neonatal unit, did it give you any cause for concern when
you received that email from Letby saying, "I feel as though this must be my fault", et
cetera?
DE BEGER: No, I didn't, because at that time, in April 17, I believe that mediation between the
clinicians and Lucy Letby had broken down and she was very distressed about that. Her -- she was
-- it was a plan to return her to the neonatal unit at the beginning of April and that had been
paused, so she was very upset about that, and this -- I do remember this time being that she was
very, very distressed, very confused about why she couldn't go back, why it had been paused when
it had been planned that she was going back and she'd been visiting the unit. So I felt that that
was an explanation of all those mixed emotions, and
that's what I reply to her on her confusion about what was -- what was happening.
MR BERSHADSKI: I think you address in your statement that you're aware of safeguarding principles
and that if you come into possession of any information that might cause you to think there's a
risk to somebody, that you would deal appropriately with that and pass it on; is that fair?
DE BEGER: That's fair.
MR BERSHADSKI: And I think you say in your statement that you didn't come across any such
information when you were dealing with Letby, hence you didn't initiate any of the safeguarding
routes that you were aware of. With the benefit of hindsight now, knowing that Letby was accused
and has been convicted of killing babies on the neonatal unit, do you think that this email from
her could have been enough for you to mention it to somebody?
DE BEGER: No, I don't, because she says "maybe I have done something", she doesn't say she has,
and I know that she was very distressed and stressed at that particular time, and all the
conversations that we've had previous to this she has always told me that she'd done nothing
wrong, why did -- why were people doing this to her? And why did the Consultants hate her so
much? And I heard that many times.
MR BERSHADSKI: I think you'd said in your statement that you didn't tend to have discussions with
Letby about the actual allegations.
DE BEGER: (Nods).
MR BERSHADSKI: So is it fair to say you must have had some discussions about the substance of the
allegations because you say she was telling you she'd done nothing wrong?
DE BEGER: So she would tell me she has done nothing wrong and how that made her feel --
MR BERSHADSKI: Yes.
DE BEGER: -- but nothing about the babies or deaths.
MR BERSHADSKI: Just going back to the point you made earlier that you -- it's your wish that
there had been some more -- some clearer guidelines about how to provide Occupational Health
support to members of staff accused of misconduct, do you think that if there had been such
guidance in place you might have acted differently upon receipt of such a message from Letby?
DE BEGER: I think if I'd had some clinical supervision it might have been something that I would
have spoken to them about, yes.
LADY JUSTICE THIRLWALL: Clinical supervision, that's where someone's responsibility is to you and
so you can offload. I know it's called "supervision" but is that what you mean --
DE BEGER: Yes.
LADY JUSTICE THIRLWALL: -- someone was there for you?
DE BEGER: Yes, it's like a mentorship or a clinical supervision where you might want to discuss
particular cases that you've got and you would -- with somebody that was equally qualified that
you would be helped on the way forward with that particular case, yes.
LADY JUSTICE THIRLWALL: I follow, thank you.
MR BERSHADSKI: Thank you, my Lady, those are my questions for Ms De-Beger.
LADY JUSTICE THIRLWALL: Thank you, Mr Bershadski. Ms De-Beger, I've got no more questions for
you. Thank you very much for coming and giving your evidence to us today. You are free to go.
DE BEGER: Thank you.
LADY JUSTICE THIRLWALL: I think the next witness is going to be ready at 1 o'clock, so I suggest that we take the lunch break now and we will start again at 1 o'clock.
(11.54 am) (The luncheon adjournment) (12.59 pm)
LADY JUSTICE THIRLWALL: Mr De La Poer.
MR DE LA POER: My Lady, our final live witness for today is Dr Shirley Bowles, and I wonder if she might come forward to the witness box, please.
LADY JUSTICE THIRLWALL: Yes, Dr Bowles, do come forward.
DR SHIRLEY BOWLES (affirmed)
LADY JUSTICE THIRLWALL: Thank you very much indeed, Dr Bowles, do sit down.
BOWLES: Thank you.
MR DE LA POER: Please could you give us your full name.
BOWLES: Dr Shirley Anne Bowles.
DE LA POER: Dr Bowles, can you confirm, please, that you provided to Inquiry a witness statement
dated 24 May of this year?
BOWLES: Yes, I did.
DE LA POER: And are the contents of that witness statement true to the best of your knowledge and
belief?
BOWLES: Yes, they are.
DE LA POER: I'll just deal with your background first, if we may. You qualified as a medical
doctor in 1996; is that right?
BOWLES: No, '81.
DE LA POER: '81, I beg your pardon. And you became a member of the Royal College of Pathologists
in 1996?
BOWLES: That's correct, yes.
DE LA POER: And a fellow in 2004?
BOWLES: Yes, that's right.
DE LA POER: You are a chartered -- a registered chartered scientist?
BOWLES: Yes.
DE LA POER: And a member of the Association for Laboratory Medicine?
BOWLES: Yes, that's correct.
DE LA POER: And you have been on the GMC specialist register for chemical pathology since 17
April 1997?
BOWLES: Yes, that's correct.
DE LA POER: And you are currently a Consultant chemical pathologist at the Countess of Chester
Hospital; is that right?
BOWLES: Yes, that's right.
DE LA POER: And did you hold that position in 2015/2016?
BOWLES: Yes, I've been in that position since 1996.
DE LA POER: Dr Bowles, I would like to begin the substance of your evidence by considering your
department in 2016. So that department, firstly, is the blood science department; is that
right?
BOWLES: Yes, that's right.
DE LA POER: And in 2016, where did you sit within the hierarchy of that department?
BOWLES: I was director of blood sciences.
DE LA POER: So at the very top?
BOWLES: Well, it's sort of -- yes, I mean, it's a -- I suppose it's where the buck stops with
respect to sort of problems in the department, but there are other managers who also are
responsible for running the day-to-day.
DE LA POER: And were you the sole Consultant chemical pathologist at that time?
BOWLES: Yes, I was the only chemical pathologist but there was also a Consultant clinical
scientist working alongside me.
DE LA POER: And between the two of you, did you share the duty biochemist role?
BOWLES: We did, yes.
DE LA POER: Just tell us, please, in a nutshell what the duty biochemist role was in 2016?
BOWLES: Well, it was on a rota basis, you do a day at a time, and there was a variety of things
that would fall under that umbrella, things like reviewing the "send away" lists because when
samples were sent away we would review them to see if they all seemed appropriate in terms of what
was being sent and why, but the main bulk of it was to do with looking through the various reports
of results. So there would be two main groups of results. There would be some that had been filed
after analysis for us to look at, so they would be some of the more complex tests like hormones,
two more markers, et cetera, where it was felt they weren't required for the immediate management
of the patient, so they could actually be held back for a -- you know, until the duty biochemist
was able to review them, and it could be helpful for comments, et cetera, to be. And then there
was another group of results which we called the exception report, which I instigated, which was
results that had already been authorised but we felt should -- would benefit from another review.
So there were often results that were extremely abnormal and fell on to our telephone list, and we
would then review them and see -- make sure that they had been telephoned, if that was
appropriate, check that if there was any additional investigations could be added because
sometimes, for example, if there was a very high calcium we might add a parathyroid hormone to see
if we could help determine the cause of that high calcium. And sometimes I would check to see
whether the clinical team
had acted on the results. So, for example, if someone had a very high potassium I would look up
the patient again and see whether it had been repeated or whether there was anything saying that
they'd actually done something about it. So it was a sort of second check of results that had
already gone out. We would also field any phone calls to the lab about anything, any queries about
how to investigate patients, et cetera.
DE LA POER: In that duty biochemist role, would you be the person being asked for if another
laboratory had urgent or abnormal results that they wanted to speak to somebody about in your
department?
BOWLES: Usually. Occasionally there were relationships perhaps with, for example, some of the
clinical scientists a different lab might know Dr Lewis well and they might decide they might have
a phone number of and just call her directly, but other times they would just ask to speak to the
duty biochemist and then they would be put through to whoever was doing that duty at the time.
DE LA POER: In terms of how your department was functioning in 2016, was it able to cope with the
demands which were being placed on it, or was it under strain?
BOWLES: Oh, it's difficult to say because you always feel you're -- you're stretched. I think
we've always felt that they were on the lean side of the staffing spectrum. In terms of the sort
of clinical team there were only two of us, so if -- and, for example, on that particular week Dr
Lewis was actually on annual leave so I was actually on my own all week, so we would be doing duty
biochemist five days as well as doing clinic. So there were times when it did feel a bit pressured
but I think there is a feeling in the NHS that you just sort of get on with it really and -- and
manage.
DE LA POER: I appreciate others have spoken about that attitude in terms of just making do and
carrying on, but the week that we're going to be focused upon you've described your colleague
being away leaving --
BOWLES: Yes.
DE LA POER: -- you to do five straight days as duty biochemist on top of your other duties.
BOWLES: Yes.
DE LA POER: I mean, being realistic about it, was that too much for one person to be doing well
or would you say that you, that week, were able to do every aspect of your job well?
BOWLES: I would hope I would. I mean, I've got experience to prioritise and I would hope that I
would
know what were the important things to do and what were the things that could be left. But, yes,
you would feel busy -- very busy. But, as I say, it was a situation I'd always been in, because in
fact when I started at Countess of Chester I didn't even have a clinical scientist, so I was
actually on my own. So it's -- it wasn't something that I sort of saw as unusual, and I don't
think it's unusual in the NHS. I mean, for sort of the hospitals the size the Countess it would
have been quite common to only have a Consultant scientist and the chemical pathologists in that
department, so I don't think I saw it as exceptional. It was busy, I hoped that I managed it well.
DE LA POER: Part of your role as duty biochemist, as we understand it, would be to contact the
ward or particular departments in the event that certain results justified it.
BOWLES: Yes.
DE LA POER: Focusing upon the paediatric ward and more specifically the neonatal unit, what was
your experience at that time of being able to get hold of a doctor to speak to of sufficient
knowledge, authority and experience to talk about results?
BOWLES: I have to admit that I don't actually think that I'd actually had to call the neonatal
unit very often because most of the results that were phoned through would have been done by the
-- by medical scientists. Most of the sort of every day results like bilirubins or potassiums, et
cetera, they would have been done by the people actually analysing the specimens. We had a
protocol for telephoning results, and those results that came straight through off the machines
would have been phoned by the biomedical scientist. So the need for myself or Dr Lewis to
intervene was probably very infrequent. But, in general, if I had to get hold of people on the
wards it was variable as to how successful I would be.
DE LA POER: In that the telephone wasn't always answered or that it was answered but the person
you wanted to speak to wasn't available or a combination of the two?
BOWLES: A combination of the two. It wasn't unusual, particularly at busy times of the day, which
would include sort of in the morning, that nobody would answer the phone and you'd have to try
again later, or you would answer the phone -- and I usually, if I was ringing, I would want to
speak to a doctor rather than -- I mean, when the biomedical scientists ring results, they
generally just give it to whoever answers
the phone. I mean, there's a protocol for, you know, asking them to repeat the results back, et
cetera, but they would just give them to whoever answered the phone. Usually when I was phoning
results I was wanting to know a little bit more information, so I would normally ask to speak to
the doctor, and sometimes there would -- the doctor would not be on the ward or they may be on the
ward but weren't available to speak to either because they were doing a procedure or they were on
a ward round, in which case I would either ask them to call me back or I would take a bleep number
and try again later.
DE LA POER: So in terms of what sort of occasions when you needed to be involved, it required a
doctor at the other end?
BOWLES: Well, usually, because I normally wanted to know a little bit more about the patient, and
usually the doctor would have a better indication of the sort of things I was talking about. I
have spoken to nurses who were particularly in the more specialised units where they were more
intensive one to one and, therefore, would know a lot about the patient, but usually I would want
to speak to a doctor.
DE LA POER: When you say doctor, are you just asking for any doctor on the ward at that time or
the patient's
doctor or the Consultant in charge of the patient, what sort of request would you be making when
the phone is answered?
BOWLES: I would usually be looking for the doctor who was looking after that patient, so it could
be -- it wouldn't normally be the Consultant because they wouldn't usually be on the ward. It
would be unusual unless I had to hit a ward round. So it would usually be one of the doctors who
was directly involved in that patient's care.
DE LA POER: Let's just walk through the process. We've heard from your colleague, Dr Milan, this
morning, something about the Liverpool end of the process, but your understanding is that -- and
I'm just summarising your witness statement here for you to agree or disagree -- that blood would
be taken on the ward, it would arrive at your lab first with the request on it.
BOWLES: Yes.
DE LA POER: That if it was a test that your lab did your lab would undertake that test. If it
wasn't a test for your lab but it was a test for Liverpool, that you would prepare the sample for
transport and ensure it was correctly pack and arrange for the transport to Liverpool --
BOWLES: Yes --
DE LA POER: -- have I got that right?
BOWLES: -- it would be -- I mean, depending on the type of requests, sometimes the samples needed
to be frozen, sometimes they could just be stored in the refrigerator, so each -- I mean, we have
quite a lot of documentation around what's required for each particular type of test. So -- I
mean, obviously I'm not directly involved in that, but the staff in the laboratory would -- when
they get the request in, they would take whichever sample -- if there was a sample specifically
for a referral laboratory or if they just would take a part of one of the samples they had, which,
as I say, they would either put to one side in the fridge or store it frozen until they were able
to send it on the next transport, which would usually be the next working day. For Liverpool in
particular we had transport every day -- well, Monday to Friday so that they would -- it would go
on the next day's transport.
DE LA POER: And in terms of the particular test that we're focused upon, the insulin C-peptide
and the ratio between the two, we understand that that wasn't a test that the Countess was doing
in-house at that time.
BOWLES: No.
DE LA POER: Can you just help us to understand why that wasn't an in-house test and why you
needed to outsource that?
BOWLES: Well, in -- very few laboratories would do insulin. They're specialist tests, they're not
asked for -- when you make a decision about whether to have a test in a lab or send it elsewhere
it's usually a decision based on how quickly the results are required. Anything that we think
needs to be required within four hours for a patient's immediate management we would do in-house.
But more esoteric tests need to be done in specialised laboratories because it's not feasible for
every laboratory to set up this -- the instrumentation, the expertise that's required to do these
assays, and if you are only doing a few, then you would not have that expertise inevitably because
people wouldn't have the familiarity with the test. So I think, as far as my understanding is,
Liverpool does the insulin and C-peptides for the whole area. I could be wrong, but that's my
understanding. So they would have all the hospitals from the Cheshire/Merseyside region sending
their samples there, which allows them to -- there's also an economy of scale as well but it
allows them to develop the assay and have the expertise in performing those assays.
DE LA POER: And just help us with a little further understanding about the thought process you
would expect
for somebody asking for that test. If a clinician has a child who is hypoglycaemic, so low blood
glucose, and they said they wanted an insulin and C-peptide test, what would you expect the
clinical reasoning for that request to be?
BOWLES: Well, they would be looking for a reason for the blood glucose to be low. I mean, it's not
uncommon for neonates to have low blood glucose, especially if they are premature or small. But --
and a lot of the time they may not go through the full investigation because it may be a very
transient thing which is easily managed. If it's proving a little more difficult to manage, they
might want to try and understand what the cause is. And insulin is the main hormone that reduces
glucose levels so, you know, too much insulin can be a cause of a low glucose, so that would be
the rationale behind asking for that particular test.
DE LA POER: And so under that clinical reasoning, the clinician doesn't know the explanation but
is thinking to themselves, "This baby might be producing too much insulin causing him or herself
to become hypoglycaemic, and the test, the insulin and C-peptide, may confirm that."
BOWLES: Yes.
DE LA POER: And, therefore, the clinician, if that was going to be the outcome, would be
expecting to see both a high level of insulin and a high level of C-peptide; is that right?
BOWLES: Well, it depends what the cause was because they can also be the opposite. You can have a
lack of the other hormones that increase glucose that can also be a cause of hypoglycaemia. So the
three hormones that they do look at commonly are the glucose -- insulin, cortisol, and growth
hormone, and they're the sort of three main hormones that keep glucose within relatively close
limits in healthy individuals. So if you have an imbalance of any of those that would give an
explanation.
DE LA POER: Absolutely, but one part of that triangle of drugs is the insulin --
BOWLES: Yes.
DE LA POER: -- and so the reason why you ask for the insulin level is because that might provide
the explanation for why the child is --
BOWLES: Yes.
DE LA POER: -- hypoglycaemic?
BOWLES: Yes. You would be looking to see whether it was low or high in the context of the glucose,
yes.
DE LA POER: And, of course, the additional piece of
information in the request is for the C-peptide because --
BOWLES: Yes.
DE LA POER: -- if that C-peptide is high, then the clinician can say to themselves, "This child
is producing a lot of insulin, we need it think about how we manage that"?
BOWLES: Yes. So there is a relative relationship between the two, yes.
DE LA POER: Yes. So that's what's in the clinician's mind when they ask for the insulin and for
the C-peptide?
BOWLES: I assume so, yes, they're looking for that cause.
DE LA POER: That's what you would expect?
BOWLES: Yes.
DE LA POER: So let's just look, please, at the circumstances relating to [Child L] with those
factors in mind, and we can begin by having a look at INQ0001169 at page 216, please. So here we're looking at a record from the
Countess of Chester. This is a record I think you're familiar with, is that right, Dr Bowles?
BOWLES: Yes.
DE LA POER: And just draw our attention, please, to a few items. I think we can see towards the
top left, about a third the way down, the date 9 April 2016 at 15.45. Do you see that?
BOWLES: Yes.
DE LA POER: In fact it's a little lower than that?
BOWLES: I can't see the 15.45 -- oh, yes, I can, yes.
DE LA POER: Lower than where it's being highlighted --
BOWLES: Yes, I can see that now, yes.
DE LA POER: You can see that? Thank you very much indeed. And would you -- what would you
understand that entry to correspond with?
BOWLES: That would have been probably the time that the request was made for the blood test, so
that would have been made on the unit for -- for the actual request.
DE LA POER: So the chain of events in terms of the record starts with that, with somebody on the
unit saying, "I would like the following tests undertaken"?
BOWLES: Yes.
DE LA POER: So we can take that down, please. You would then have expected the sample to reach
your laboratory --
BOWLES: Yes.
DE LA POER: -- is that right? You just looked at the screen there, was there -- was there a
record on there that might help you with that question?
BOWLES: Yes, it was received --
DE LA POER: Can we bring that back up again?
BOWLES: It was received in laboratory at 18.26.
DE LA POER: Thank you. Could we bring that up again. Thank you. That's my mistake. So where
should we be --
BOWLES: That's -- at the top, there's -- next to the specimen number there's -- the next column
along there's three --
DE LA POER: I see so we've got, "Ordered for COLL received"?
BOWLES: Yes, the received would be when the sample barcode was read by the specimen reception, so
they would wand the barcode, and that was what's called "receiving specimen into the laboratory".
DE LA POER: Now, in fact there's a matter I overlooked to ask you about -- in fact two. We can
see hypoglycaemia is marked in the very centre.
BOWLES: Yes.
DE LA POER: So would that be information provided from the ward as a result of a heel prick test
that they'd done or would you actually see --
BOWLES: Yes. I mean, they would generally monitor the baby's blood sugars using the heel prick
tests and glucose meters on the unit because they're supposed to
collect these specimens when the baby is hypoglycaemic, but we usually do a check of the blood
sugar in the laboratory because that's considered more reliable than the -- the glucose meters. So
they would -- you need -- in order to interpret the results, you do need the glucose to be low, so
they would -- they would collect those results at a time when the baby was recorded as being
hypoglycaemic.
DE LA POER: So that hypoglycaemia entry there against the words "relevant clinical details", is
that what your laboratory has been told by the ward or is that as a result of your laboratory's
check?
BOWLES: No, that's -- that's what they would have told that -- that was what they would have told
the ward. From the ward, yes.
DE LA POER: But to be checked and to be calibrated accurately by your --
BOWLES: Yes, to be checked, yes.
DE LA POER: Yes. Obviously we can also see -- and this is the other matter I omitted to ask you
about -- that on the 11th of the 4th, just below where it's highlighted, we've got "closed", and I
think by you. I think that's -- that would be a reference to your name; is that right?
BOWLES: Yes, that was -- I think that was related to
the cortisol and growth hormone results.
DE LA POER: Yes. So those are the results that you can do in-house.
BOWLES: Yes.
DE LA POER: And so you can close those ones off within two days of receiving them --
BOWLES: Yeah, well, those -- that would have -- because this was a Saturday the 9th --
DE LA POER: Yes.
BOWLES: -- and the 11th was the Monday, so that -- I would have been duty biochemist on that day,
so that would have been one of the results that I looked through on that particular day.
DE LA POER: So in-house dealt with within two days first --
BOWLES: Yes.
DE LA POER: -- day of the week. But, of course, we've got part of the sample going off to
Liverpool for the testing for the C-peptide --
BOWLES: Yes.
DE LA POER: -- and insulin.
BOWLES: That would have been transported on the Monday with the Liverpool transport.
DE LA POER: Thank you. So we can --
LADY JUSTICE THIRLWALL: Sorry, just before you --
MR DE LA POER: My Lady, of course.
LADY JUSTICE THIRLWALL: -- I just want to check my note at the top when we've got the three
timings, or rather unknown, unknown, and then what time was it received in your --
BOWLES: I think it is 18.26, is it not?
LADY JUSTICE THIRLWALL: Well, that was my question. I couldn't see whether it was 15, 16 or
18.
BOWLES: I think it must be 18 because the entry was only made at 15.49, so I think it was 18.26.
LADY JUSTICE THIRLWALL: So 18.26 on the basis that it must have been that -- there would have
been that much time between it being taken and then received?
BOWLES: Yes, and then the timings that are below which are the sort of series, there's an 18.29,
that would have been when the sample was put on the track to have the in-house samples done. So we
have a robotic track and that reads the barcode as well and that was at 18.29.
MR DE LA POER: That in the bottom half --
BOWLES: Yes.
DE LA POER: -- that series of columns --
BOWLES: Yes, that is right.
DE LA POER: -- there we can see --
LADY JUSTICE THIRLWALL: So 18.26 followed by 18.29. Thank you very much.
MR DE LA POER: So in terms of the in-house results, what -- before you received the final part of
the puzzle from Liverpool, what conclusions if any could be reached from those in-house tests?
BOWLES: I think from what I can remember, all the results were relatively normal. The glucose was
low, it was 2.8, not quite within the definition of hypoglycaemia, but certainly low. The growth
hormone was relatively high, which is what you would expect in a hypoglycaemic patient because
glucose -- growth hormone and cortisol tend to raise cortisol levels -- glucose levels, so you
would expect the normal reaction would be for them to be increased. The cortisol doesn't look
raised but the reference range that's given on the -- on the -- the report is based on a 9 am
cortisol, which is -- cortisol has what we call a diurnal rhythm, so it tends to be high --
highest in the morning and lowest at midnight, so a result that's -- looks like it's within the
reference range but is -- later in the day could be considered to be higher than you might expect
if the patient wasn't stressed by having hypoglycaemia.
DE LA POER: So we can take that down. So does it come to this that, in terms of the
in-house tests that you'd done, there was no obvious explanation for the very near
hypoglycaemia?
BOWLES: No, they were what would be expected in that situation. I mean, obviously if there was a
deficiency of hormonal -- of growth hormone or cortisol you might -- that might be picked up in
that situation because they could perhaps be the cause of a hypoglycaemia, but those look like
perfectly normal responses in that situation.
DE LA POER: And so -- I'm not suggesting this happened but anybody looking at just those results
and knowing that another result was due would be expecting a high level of insulin to come back,
would that be the hypothesis that you would have waiting to be confirmed, because that would then
explain why the blood sugar was very low?
BOWLES: Yes. I mean, there may be other non-hormonal explanations but that's probably a reasonable
supposition, yes.
DE LA POER: And so we come to the 14 April, and you were the duty biochemist, as you've told us,
that day. And we understand from the evidence from the Liverpool end that a telephone call was
made. And whether you answered it or whether someone answered it and put it through to you, you
ended up in conversation with
somebody --
BOWLES: Yes.
DE LA POER: -- from Liverpool; is that right?
BOWLES: Well, I -- yes. I mean, I have to emphasise that I don't actually remember this -- any of
this had actually happened. It's -- I'm purely reliant on the records that I've been presented
with and also the usual practices -- procedures in the lab and practices at the time. It was many
years afterwards before I was -- this was highlighted to me. So I have to say that I'm basing this
on supposition as to what I would have done in that situation, apart from the ones where I
actually have documentary evidence of my actions.
DE LA POER: Well, we'll come to all of that in a moment. Let's just build the picture. INQ0001176. Now, this is the Liverpool end, this is an entry on their
system, and we can see that that person has recorded on the system that the advice is: "Difficult
to interpret without concurrent glucose but may be inappropriate if patient was hypoglycaemic at
the time of collection." And your full name is indicated about three lines above.
BOWLES: Yes.
DE LA POER: And we've got the time there in terms of their system record of 9.38 and 23
seconds.
BOWLES: Yes. I mean, I would not have actually seen that comment.
DE LA POER: No, I'm not suggesting for a moment --
BOWLES: But I assume that's the thrust of the conversation that I had.
DE LA POER: Well, exactly so. So this is what that person has recorded their advice as being in
that situation and --
BOWLES: Yes.
DE LA POER: -- if we just take yourself out of the situation for a moment, just think about these
results, that's good advice, is it?
BOWLES: Yes. I mean, on the basis of results, yes, that seems a reasonable decision.
DE LA POER: So you would have -- you would have expected somebody with those results in Liverpool
to be saying something like that?
BOWLES: Yes.
DE LA POER: But, of course, the missing piece of the puzzle for them, a piece of information that
you had, was the glucose level.
BOWLES: Yes, that's right.
DE LA POER: So let's now have a look at the other side, the note at Chester, INQ0001169 at page 217, please.
Now, regrettably, there are aspects of this that are harder to make out, but I think that the
relevant details are just appearing on the bottom of our screen there. We can see there the
insulin result of 1,099. Is that the number that we should be looking at?
BOWLES: Yes.
DE LA POER: And we can see under that interpretation of insulin level depends on glucose, so that
appears to precisely match --
BOWLES: Yes, that --
DE LA POER: -- what the record of advice from Liverpool.
BOWLES: That goes on automatically I think on every insulin.
DE LA POER: That's a warning to everybody, don't assume, double-check?
BOWLES: Yes.
DE LA POER: I understand. So it looks like the advice at Liverpool was in line with your
automated warning. And then we've got the insulin C-pep at 264. Is that the right number that we
should be looking at?
BOWLES: I think so, yes.
DE LA POER: Now, let's just consider these circumstances. Firstly, will you have manually input
those entries into this -- into a pro forma on a screen that produces
this printout?
BOWLES: Yes. I mean, that's what made me realise I had obviously -- probably had had a phone call,
even though I didn't remember it, because I wouldn't normally enter the results of tests myself.
They would normally have been done by one of the biomedical scientists and then we would check
them as a second check. So the fact that I entered them was a clue to me that I probably had a
phone call or else alternatively that the -- sometimes the post does come addressed to me and I
would open it, and then I might see a result and think, "Oh, I should do something with this." But
I think -- obviously now I know it was a phone call that prompted me to act on them. Because our
normal process is the results go to a box upstairs and the biomedical scientists work their way
through them, and because there are so many pieces of paper it actually can take quite a long time
for them to work their way through, so with a result like this obviously I would want to make sure
there's no delay I've made the decision to enter it myself.
DE LA POER: And in fact we can see just directly below, about an inch on my screen, 9.38 is the
entry time. So if you just go straight down the screen about four lines, we should see a 9.38 next
to the date with your
name. I wonder if we can just highlight that so that -- so four lines down. There we are. And, of
course, we know that the Liverpool record is timed at exactly the same time, which, again putting
the pieces together, demonstrates, doesn't it, that this was a telephone call from Liverpool
--
BOWLES: Yes.
DE LA POER: -- to you and you are at the same time, one in Liverpool, you in Chester, making
entries on your system about that call?
BOWLES: Well, I don't know whether I would have made the entries directly at that time. I usually
write them down and then read them back, but certainly I put them in very shortly after the phone
call or around the time of the phone call.
DE LA POER: So we're going to come to, further along that row in a moment, the verified. But I
just -- before we get to verified, let's just talk about the context of this. What were the
circumstances in which you would expect Liverpool to be telephoning through a result for what was
otherwise a non-urgent testing request?
BOWLES: They would ring through results that they felt needed someone to look at and possibly act
upon, bearing in mind that they might not have all the information that they required.
DE LA POER: Is it -- bearing in mind that they could otherwise just put it in the post and it
could turn up a couple of days later, be sorted through and so on, does it in fact indicate that
this is urgent --
BOWLES: It indicates --
DE LA POER: -- if they're telephoning --
BOWLES: -- that it's either urgent or unexpected or unusual, yes.
DE LA POER: So that's the fact of the telephone call. Let's look at the results themselves. We've
heard from Dr Milan that in the event that this was insulin secreted by the body, one would expect
the C-peptide level to be five or ten times higher than the insulin level.
BOWLES: Yes, that's what the ratio indicates, yes.
DE LA POER: And so that number 264 should have been, if this was naturally occurring insulin,
between 5 and 10,000.
BOWLES: Yes, yes.
DE LA POER: And it is -- and I won't attempt to say how many factors, but many factors less than
that, isn't it?
BOWLES: Yes.
DE LA POER: And from the point of view of you as
a scientist understanding how the human body works and what the ratios should be, is your
interpretation of that result it's at least highly likely that that child has received insulin by
way of medication as in externally?
BOWLES: Yes. I mean, obviously I'm sort of looking back and interpreting them trying not to think
about what I know now compared to what I knew then but, yes, this certainly would have been a
puzzling result in a patient on the neonatal unit.
DE LA POER: We're going to look -- because you use the "puzzling" in your statement we're going
to have a look at that in a moment. But from your point of view, understanding how the ratio of
insulin and C-peptide should work, that is the obvious conclusion, isn't it?
BOWLES: Yes, it seemed to be -- seems to be a conclusion that it looks like there is external
administration of insulin.
DE LA POER: And, of course, you had access to the glucose level.
BOWLES: Yes.
DE LA POER: And you had that prompt that you ought to check it --
BOWLES: (Nods).
DE LA POER: -- and checking the glucose level would
indicate that the child was very nearly within the hypoglycaemic range; is that right?
BOWLES: Yes.
DE LA POER: And working on the hypothesis that this is externally administered insulin, doesn't
that only leave three possibilities? Let me tell you what they are and you can see if you agree or
disagree. Either that child had been legitimately given insulin but they had been given so much in
a hyperglycaemic state that it had almost taken them to state of hypoglycaemia. That's possibility
1. Possibility 2 -- that they have accidentally been given insulin, in other words it wasn't
indicated for them at all but by reason of some kind of medication confusion they've received it.
Or option number 3, somebody has deliberately given insulin when it was not clinically indicated,
which would obviously be the most serious possible implication. So those are the three
possibilities for your conclusion. Do you agree or disagree with that?
BOWLES: Yes. I mean, I have been -- highlighted another case that did have similar results and was
diagnosed as congenital hyperinsulinism, but I was a bit dubious about the likelihood of that
diagnosis. But
the -- in my mind, at that time, yes, the three --
DE LA POER: Yes --
BOWLES: -- were probably the most likely.
DE LA POER: -- exactly so. I mean, we're not talking about extremities, whether they do or do not
legitimately exist. As a doctor as a pathologist interpreting these are going to start with the
most obvious explanations, aren't you --
BOWLES: Yes.
DE LA POER: -- and exclude those? But those three are the obvious explanation for the -- this
result?
BOWLES: Yes, yes, I would agree.
DE LA POER: And it being one of those three, do you agree at best it's likely that there has been
a medication error?
BOWLES: Yes. I mean, I -- I can't say whether I thought through that clearly at that time about
the possible scenarios. I possibly just thought this is something I need to convey and find out a
bit more about. So I may not have -- in the -- you know, at the time I may not have actually gone
through that process, I might have just thought, "I need to speak to someone about these results."
DE LA POER: That poses this question: why wouldn't you have thought in that structured way about
these results?
BOWLES: I don't know. I mean, sometimes you just get results that are puzzling, and I guess the
obvious thing to do is to try and find out a bit more information about them. Rather than to sit
and sort of wonder actually to try and find some facts out about it.
DE LA POER: I suppose the reason you would do your own analysis is that you would then be able to
decide what level of priority to give your efforts that followed. Do you follow the reasoning of
that, that if you had sat there and thought, "At best someone's has made a medication error, I
really need it make sure that I speak to somebody about this and have a proper discussion about
them", that would be a valuable use of your time analysing what these results might mean; is that
fair?
BOWLES: That's fair but, as I say, I can't remember what my process of thoughts -- thought
processes were at that time. All I know is that I obviously felt the need to ensure the results
were communicated rapidly.
DE LA POER: Now, do you in the lab have access to the patient medical records, the electronic
ones?
BOWLES: At that time, we had very limited access because most of the clinical notes were
paper-based. The only notes that were available on the computer system were the nurse care --
nurse care notes --
patient care notes. The doctors' notes were all paper and then they would be scanned on to what we
call Evolve, usually quite some time later, so we wouldn't have access to all the information
about the patient at that time.
DE LA POER: Would the nursing notes, if you looked at them, that you did have access, to tell you
whether or not a patient had been prescribed insulin or had received insulin?
BOWLES: They were very variable as to what detail was in them. A lot of it was things like details
about their feeds, et cetera, and so it would vary from one baby to another or one patient to
another what detail was in those particular notes, so it wouldn't necessarily say what medication
they were given.
DE LA POER: But it might?
BOWLES: It might, but it wouldn't always.
DE LA POER: So let's look at that verifying, because you mention that second timing in your
witness statement, so if we look back towards the bottom where we were looking at 9.38 we can see
the VER and then the time 9.40.
BOWLES: Yes.
DE LA POER: So just tell us, what is the significance of the verification step of the
procedure?
BOWLES: Well, if you're actually verifying after you
have entered a result and you just -- you're not -- there's nothing untoward about result, it's an
instantaneous process, so basically you just press A and return, so it would be instantaneous. So
the fact there was this two-minute gap was what made me think that that would be my usual practice
would -- that I tried to telephone someone at that stage.
DE LA POER: You have said two minutes, in fact they verified that's being highlighted here is
against a time I think of 9.36 to the left.
BOWLES: Entered 9.36. Oh, well, I --
DE LA POER: And then the line below --
BOWLES: Oh, it's there. So there's -- yes, so there's -- right okay. Well, yes, the 9.36 that's
possibly -- that's a bit -- I don't quite understand that. Is it 9.36? I assume they were all 9.38
actually because --
DE LA POER: Well, it may be that that's my eyesight and bad reproduction.
LADY JUSTICE THIRLWALL: It's 9.36.
BOWLES: I can't understand why there would be two different times actually. I assumed it was 9.38.
DE LA POER: At all events, there's at least a two-minute gap --
BOWLES: Yes.
DE LA POER: -- for at least most of these results --
BOWLES: Yes.
DE LA POER: -- as against the verification, and so just looking back at your practice at the
time, what might be an explanation for the fact that you haven't just pressed "Enter" to verify
the results?
BOWLES: That I tried to contact someone with the results. And I would -- I would hold back the
verification because if you do manage to speak to someone then you can put a comment -- electronic
comment to that effect on the -- on the report before it's verified.
DE LA POER: Does it follow from that answer that if have -- once you verified it you can't then
add a comment?
BOWLES: It's not very straightforward, you have to go back to a process to edit and everything, so
it's much more straightforward to wait until you've actually spoken to someone and then put -- you
could just put P, phoned, and there's a little box came up to say what time you'd phoned it, et
cetera. So you would tend to hold back until you'd actually phoned the result through. So the fact
that there was no comment there but there was that gap makes me think I had tried to phone but
hadn't actually been successful in speaking to anyone at that stage.
DE LA POER: A combination of the delay to verify but the lack of a comment put together in your
mind means, "I did call, but nobody answered"?
BOWLES: Well, it could be I called and somebody answered but I wasn't able to speak to the person
I needed to speak to. As I said before, what can sometimes happen -- I mean, it may be there was
no answer but it could be that someone answered, I asked to speak to the doctor looking after this
baby, and the -- whoever it was had told me that they were either not on the unit or they might
have been doing a procedure, they might have been on a ward round and, therefore, they weren't
available to come to the phone. So I would have then made a note of that with the view to try and
speak to them later. But I -- especially if I did think they were on the ward round, then
verifying the result would be sensible because they may then see that result while they were on
the ward round.
DE LA POER: Having verified it, is it then posted to the electronic records?
BOWLES: Yes, it goes directly to the clinical notes then so they can see it.
DE LA POER: Now, I would like to going back to the word that you used earlier about it being a
puzzle or you were experiencing some puzzlement with this. Just explain to us, please, in your own
words, why you think that this result is "puzzling" as opposed to perhaps "worrying" or "of
concern" or "ringing alarm bells", why do you choose the word "puzzling"?
BOWLES: I suppose I was probably influenced, perhaps falsely, as it turns out, by the fact that
this was a baby that had been on the neonatal unit since birth and, therefore, I guess the idea
that anyone was trying to deliberately harm babies would have been, you know, a very, I suppose,
unthinkable or at least so horrifying as to not really want to go there. I think it was -- I think
probably was -- that would be my process of thought that surely not.
DE LA POER: Can I just ask you about --
BOWLES: And I didn't -- as I say, I had no knowledge of any problems on the neonatal unit at that
stage, so I -- I wasn't working within the context of, you know, there having been unexpected
problems on there.
DE LA POER: You've talked us through your thought process about how you couldn't really conceive
of how somebody could be doing harm deliberately. But I think we'd -- correct me if I'm wrong, but
we'd already established
that this is one of three possibilities and you don't have to jump straight to that. Before you
get there, this could have been a serious medication error. Again, just your word "puzzled", if
you're recognising the possibility it might be a serious medication error as the best case, surely
you would be concerned or worried?
BOWLES: Well, I think both. I mean, obviously, yes, I would be -- "puzzled" I suppose is not sure
of what the possible explanation is and concerned enough to want to phone and make sure that it's
seen by the staff. Yes, obviously I would be concerned. But I -- puzzled I suppose was because I
was faced with a set of results that didn't -- there didn't seem to be a reasonable explanation
for and, as you say, the explanations that could be would be disturbing.
DE LA POER: Medication errors are well-recognised problem, isn't it?
BOWLES: Yes.
DE LA POER: It does happen. And if it had happened, it would be absolutely imperative, do you
agree, that everybody on the ward knew about it so that they could make sure no harm was done,
make sure the patient is okay, make sure that the systems are robust, make sure it doesn't happen
again. Isn't that the reaction that
you would expect from someone flagging a medication error?
BOWLES: Yes.
DE LA POER: And so I just -- it's my last question really about the -- your use of the word
"puzzle" and "puzzlement". It's just as you've used that word both in your witness statement and
in your oral evidence, looking back on it, do you think you will have seen this as more of
something that is intriguing and confusing as opposed to a serious cause for concern? Do you think
your choice of language just reflects that that is likely to have been your mental state back in
2016?
BOWLES: Well, at the time obviously -- as I say, I don't remember that date or any of the events
around this from actual memory. I think I would have just looked at these results as being
something that required explanation and I would look for further -- further information in order
to try and explain them. I can't remember what my thought processes were at the time.
DE LA POER: Had you heard of the case of Beverley Allitt?
BOWLES: I was -- I was vaguely -- yeah, I mean, I have heard of heard that name, yes.
DE LA POER: And that -- were you aware that she used insulin?
BOWLES: Possibly. I'm not sure whether I was aware at 2016. But, I mean, I am now, yes.
DE LA POER: I mean, we also know of a case relatively locally to the Countess in 2011 when a
nurse used insulin to kill two patients. Were you aware of that case in Stepping Hill?
BOWLES: Probably, yes.
DE LA POER: And so although it was a difficult thing to conceive of it wasn't impossible to
imagine because it had happened in reality, do you agree with that?
BOWLES: Yes, but I suppose you always tend to think those as being one-offs and you don't expect
them to be in your own institution, I suppose. It's something you -- I mean, if I -- I had been
aware that there had been problems with babies on the unit, then obviously this would have been a
huge red flag, but at that stage I had absolutely no knowledge of any problems on the unit. So it
was like having a piece of a jigsaw but I didn't actually know there was a jigsaw. So, you know,
it was standing alone as an isolated result, and obviously looking at it now it's very obvious
what it was saying, but at that time I -- I guess I just didn't -- it didn't fire that suspicion.
DE LA POER: Do you think it should have? Not with the
benefit of hindsight, but just knowing about Stepping Hill, seeing those results, knowing that the
child was almost hypoglycaemic, do you think it should have at the time caused you to recognise
that there was potentially a very serious problem here?
BOWLES: Yes. I mean, I don't know that I didn't recognise there was a problem, but I probably
didn't have that deliberate harm at the top of my list. I think -- I suppose I was hoping that
there would be some sort of explanation that was less sinister than that.
DE LA POER: Had you ever before in your career come across that combination of hormonal profile,
so where there was no explanation from the in-house tests for the hypoglycaemia or virtual
hypoglycaemia and you had a C-peptide and insulin level like that?
BOWLES: Probably not. But I don't look at a lot of these results. I mean, we did a search of 10
years of C-peptide and insulins recently and there were over 300, but only 23 of them were from
neonates, so that's only a few a year, and obviously I would have seen a -- a proportion of those
but not meant -- not all of them, so it wasn't a set of results that I was used to looking at
frequently.
DE LA POER: And as you've told us, you had no -- no memory
of the telephone call that you received and you don't have a positive memory of having spoken to
anybody on the ward about this.
BOWLES: No.
DE LA POER: I would just like to examine that, acknowledging -- and we'll come back to your notes
and the fact that they'd been destroyed -- but if you had had the sort of thought process that
we've been discussing, in other words at best this is a medication error which really urgently
needs to be addressed, in the context of results that you had never previously seen before, do you
think you would have remembered a conversation with a doctor about those results?
BOWLES: I don't know.
DE LA POER: Just on an ordinary human level, and you tell us about your experience, but human
beings tend to remember exceptional, alarming, concerning events ahead of ordinary run-of-the-mill
events, and I'm just inviting you to consider whether -- if you had thought in those terms whether
you would have had a memory of having phoned it through, spoken to somebody, told them, "Look,
there's a problem here, you really need to look closely at this"?
BOWLES: I mean, I've racked my brains, you know, to try and think about what I can remember of
this case,
and the trouble is the more you think about it the more you can come up with snippets of
conversation that you think may be -- may be related, but I couldn't reliably say that anything I
remember is either real or is related to this case in particular. I mean, we do get unusual
results that we discuss with doctors quite regularly. I mean, as duty biochemists you look at 2 or
300 sets of results a day, so it's not unusual to see results that are difficult to explain or --
or, you know, unusual you might want to talk to someone about. So in that context, you know, I
don't remember. And, you know, I genuinely can't say that I have memories of that -- of any
conversation.
DE LA POER: If we just think about how that conversation would have worked. You would have said,
"These are the results." Presumably you would have said, "This indicates the child has been
injected with insulin or given insulin in some way and it's caused them to become hypoglycaemic."
Is that the sort of thing that you would be saying?
BOWLES: Well, yes, along those lines that this was a result that -- yes, that tended to indicate
insulin administration and that was -- you know, we'd try to understand how that could have
happened.
DE LA POER: Yes, and what they had at the ward level that you may have had access to but you may
not have is absolute confirmation about whether that child was prescribed insulin, and so
presumably you would have said, "I think you need to go and check whether that child was
prescribed insulin because if they were, they might have been given too much, and if they weren't,
we've got a really big problem." Is that the sort of thing that you'd be saying to the doctor?
BOWLES: I think what I probably would have said is that this, "These results suggest it the child
has been given insulin and I don't really understand how that could have happened in these
circumstances and obviously that needs looking into." I mean, whether that was something the
doctor would know offhand or whether they would have to go and check, I don't know. I mean, we do
tend to find that if results are registered as being unexpected and they're often set aside as
unusual, a quirk, laboratory error, especially in a situation where -- which was the situation
here that the patient was no longer hypoglycaemic, so it's not unusual for us to ring results
through and then for people to say or not even to say, to just go away and actually just note that
there doesn't seem to be anything to explain it but
we'll just put it to one side.
DE LA POER: There was no question of any error with the test here, though, was there?
BOWLES: No, but that doesn't stop the clinician sometimes believing that that might be an
explanation.
DE LA POER: But isn't that where your role comes in to say "I've no reason to think this is
wrong", with all your expertise in the lab, it's come from Liverpool, they've got excellent
quality assurance process, "I'm satisfied, as far as I can be, that this is right, you can't
dismiss this, you need to look into it", isn't that part of your role speaking to the doctor?
BOWLES: Yes, but the decision about whether they actually say that it's -- if they went away and
then found it had a result that was -- didn't fit in with what they expected and the baby was
quite well, they might have just noted that it was unusual but not -- not actually taken any
further action, which I think was the case with another child in the -- in the --
DE LA POER: There is a note for [Child F]. By contrast there isn't -- and I think you've
satisfied yourself of this, there is no corresponding note for [Child L]. Again, putting these
things together, is that what -- would you expect that if you'd spoken to a doctor and
communicated to them that there was
a concern about these results, that the doctor then wouldn't write it down? I appreciate
ultimately it will be down to the doctor, but is that what you would expect to happen?
BOWLES: No, it's not what I expect. But, again, it would depend on where the doctor was when I
spoke to them. You know, it's all speculation really about, you know, what -- I know they did have
the results and they did comment on them in the notes. They did say the C-peptide insulin ratio
was low, so they did comment on it. But, you know, I can't say what happened beyond that.
DE LA POER: That comment you're referring to is the following day on the ward round.
BOWLES: Yes.
DE LA POER: So not in the context of any conversation with you.
BOWLES: No.
DE LA POER: Did you have access to the Datix system?
BOWLES: Yes.
DE LA POER: Do you think that these results merited a Datix report from you?
BOWLES: Well, they may have merited a Datix. I suppose the question would be who would have the
information to complete that Datix.
DE LA POER: But did you have enough information here to complete a Datix so that a further
investigation could take place?
BOWLES: I suppose in retrospect I may well have done. But, yes, I didn't -- I didn't do that. As I
say, I probably felt I didn't have the complete picture at that stage.
DE LA POER: You say with retrospect, in fact with the information you had at the time, do you
think you did have information to do a Datix or that you had insufficient?
BOWLES: I think it would have been necessary to have a bit more information about the patient
before completing it. So it could have been after a conversation, I suppose, or it may have been
reasonable depending on what the conclusion about the results was for the doctors on the unit to
have done it.
DE LA POER: Does the fact that you didn't complete a Datix tend to suggest you didn't speak to a
doctor or do you regard that as a neutral factor?
BOWLES: No, I don't think I would necessarily have completed a Datix on the basis -- on regardless
of whether or not I had spoken to the doctor.
DE LA POER: I mean, did you see yourself as under an obligation to complete a Datix when there
were potential clinical issues that needed further investigation?
BOWLES: Yes, I suppose I did. But, again, at the laboratory side of things we do have a limited
amount of information available and so where there are patients involved we do often rely on the
clinicians actually doing a lot of the investigation because they have more information. But, yes,
in retrospect it may have been a reasonable thing to do.
DE LA POER: Your notes which have been destroyed and, therefore, you can't refer to them to say
definitively one way or the other whether you had such a telephone call, just help us to
understand why your notes would have been destroyed?
BOWLES: Well, my practice is to use a diary each year and I have -- at the end of each day I write
down my tasks for the following day and then if anything comes up that I need to do, I add to it.
So that's the sort of place I would have written down any phone calls I needed to make. I don't
keep those diaries for more than a couple of years because generally we have relied on the audit
trails on the laboratory computers. I think most of my colleagues have had paper-based telephone
logs and they don't tend to keep them for long periods either, so it's
not particularly unusual. Obviously in retrospect it would have been helpful to have had that
diary.
DE LA POER: So if you had a conversation with a doctor in which you conveyed important
information about the patient, would you write that in your diary as opposed to on any record
accessible to anybody else?
BOWLES: Well, usually I would put something in the -- on the -- may have put something on the
comment, but obviously the difficulty is you have to be a little bit careful about what you put in
comments because if they are speculative, they are obviously visible to a lot of people. So I
would probably put a -- usually put some sort of comment on -- on the result if there was a
conversation. But the records of the conversations generally I probably would have anticipated if
they were relevant to the case, the doctor themselves would perhaps note them down. I didn't have
anywhere other than my own log to write them down. I didn't have access to the patient notes to
write anything.
DE LA POER: But you could write a comment on -- on the system.
BOWLES: I could write a comment -- well, if I hadn't edited it I could have written a comment on
the result but you would be a little reluctant to put something
speculative on there because, you know, for example, if you said this could be a case of, you
know, insulin administration, it -- it wouldn't necessarily be something you -- if you then are
proved wrong that you would want on that record forever. So like the comment that Dr Davies put,
it's -- they tend to be rather than anodyne comments that sort of highlight something but they
don't give the full picture.
DE LA POER: It would be entirely my question -- I'm talking about in the event that you had a
conversation with the clinician, that wouldn't be speculative at all, that would -- you recording
the key points that you had conveyed.
BOWLES: Yes, but there wasn't anywhere formal for me to put that in terms of -- other than walking
out to the ward and writing something in the notes.
DE LA POER: Do you think that was a failing in the system that was being operated, that you don't
seem to have had a place on the patient record that everybody could see about potentially
important advice that you have given to a doctor on the ward?
BOWLES: Yes. But that -- that was the system. There was no access for us to actually write. As I
say, we would have had to walk to the unit and write it in the
clinical notes at that point. There was nowhere else for us to document it.
DE LA POER: And who had overall responsibility for that system?
BOWLES: The --
DE LA POER: The system that meant that you couldn't write on the patient records what advice
you'd given to --
BOWLES: Well, it was the --
DE LA POER: -- a doctor?
BOWLES: Well, it was the hospital computer system, so that was the way it was configured. I don't
know -- I mean, obviously that's just the way the system was. The current system we have now would
allow us to do that but that system didn't, so we --
DE LA POER: Do you --
BOWLES: -- didn't have access -- we didn't have a place in the system to do that.
DE LA POER: Given your leadership role, do you think that was something that you should have
identified to the hospital to say, "When I impart important information about a patient to a
doctor on the ward there needs to be somewhere where I can record that that can be checked in the
future"?
BOWLES: Yeah. I mean, there was a lot of functionality issues about Meditech that we didn't
necessarily find useful. For example, there was supposed to be, when it was introduced, an
endorsement function where it could be seen that clinicians had actually reviewed the result and
it could be shown that they had actually reviewed it. That never -- that functionality was never
realised. So I think there were a lot of limitations within that system. I suppose it was
relatively old. 2002 it was introduced. But I have to say, I never really thought about having
that functionality and I don't know whether we would have been able to introduce it or not.
DE LA POER: Finally on the destruction of your records, just to understand, we know that in June
of 2017, so just over a year after any record that you would have written in your diary, that one
of the doctors on the ward drew attention to a potential anomalous insulin result that they could
recall, that was in June of 2017, very shortly after the police were contacted for the first time.
What was your awareness of whether there was any investigation going on by the police into events
on the neonatal unit? Did you know in 2017?
BOWLES: No. I think the first thing I knew about it was in 2018 when -- I mean, obviously I knew
that -- I knew -- I think it was during 2018 I realised there
were problems on the unit. My understanding is that the first approach to the laboratory for
insulin results was in October 2018. I think someone spoke -- at that stage spoke to my colleague,
Dr Lewis.
DE LA POER: And was it by that date that you had -- or before that date that you had destroyed
your diary for 2016?
BOWLES: No, I probably hadn't because I didn't appreciate my connection with this case until
later, because it was only when I got all the printouts from the laboratory that I realised that
I'd had any involvement with that particular case. So it was probably later than that. I would
usually keep them a year or two and then dispose of them in the confidential waste.
DE LA POER: Do you think that once you realised that the police were investigating matters that
touched upon your laboratory's operation that you should have kept your records then?
BOWLES: Well, as I say, it was towards the end of 2018, so I don't -- I don't know that I would
have -- it would have occurred to me at that stage that that was something that was required.
DE LA POER: Now, you deal in your statement, Dr Bowles, with a number of changes that have
occurred since, and
I'm just going to headline them for you. You describe those changes as "fundamental". Is that a
fair description of the extent of them?
BOWLES: I thought I'd said that the -- fundamentally things hadn't changed but we'd made some --
DE LA POER: Forgive me -- well, it is important that you correct me if I get it wrong.
BOWLES: Well, what I think I said was the fundamental processes of how the laboratory works in
terms of the analytical validation, et cetera, hadn't changed but there were differences to how we
-- we recorded the duty biochemist role and telephone, et cetera.
DE LA POER: Then that is entirely my misremembering. There is now an electronic transfer between
labs.
BOWLES: No, there isn't?
DE LA POER: There isn't?
BOWLES: Well, we aspire to it, and we've aspired to it for probably well over a decade, but we
haven't been able to implement it. There is a system called Empex which we've been trying to
instigate for many, many years. We never managed it. We are Meditech system. We'd hoped when our
newer one, Cerner, came in it would work, and now we've been told we had to wait until the Cerner
upgrade, which happened last month, so it's a piece of work that
we have been waiting for for many, many years but it hasn't -- it hasn't been realised yet.
DE LA POER: What about the number of duty biochemists, are there the same number --
BOWLES: Yeah, we have --
DE LA POER: -- or are there more?
BOWLES: We have more staff now. We have -- there's myself and the Consultant scientist who
replaced Dr Lewis, and then there are -- there's another Consultant chemical pathologist who's 50%
Chester and 50% Wirral, Arrowe Park Hospital, and there's also a scientist -- a band 8A scientist
who splits between the two sites as well. And then we also at the moment have a specialist
Registrar, quite a senior specialist Registrar who is attached to the department. So there's now
five of us that we are now able to share the duty biochemist rota.
DE LA POER: In terms of the particular issue of insulin and C-peptide, what is the level of
understanding within the lab about the potential significance of such a result?
BOWLES: Well, I think we are all very attuned to the possibilities. As I say, we -- we've tried to
instigate a regular review of the insulin C-peptide results. I mean, very few of them are
neonates. As I say, we only get -- probably get an average of two or three a year, neonates but we
obviously are scrutinising them more carefully.
DE LA POER: How about the approach to the telephone log, is that the same or different?
BOWLES: No, we have a shared electronic telephone log now, which was introduced, and this means
all the people who are duty biochemists use it to record telephone conversations, either the ones
they've received or ones they have telephoned out, so it's there as a permanent document. We also
have on that document an instruction to follow up any phone calls with an email confirmation of
the conversation, particularly if it's -- if it's resolved. And we also have another note to say
that if we've been phoned by a referral laboratory we must phone that result through.
DE LA POER: And what about the glucose result and Liverpool, which historically they were not
provided with and needed to contact --
BOWLES: No, we do --
DE LA POER: -- you about?
BOWLES: We do -- it's not -- it's still not the perfect system, we do try to make sure those
results are -- are sent. I think we haven't quite got it right yet sometimes. It basically
involves us writing the
result on the form that goes off to the Liverpool. I had hoped that maybe one thing we could do is
actually send them the glucose sample and they could analyse it themselves. But then, of course,
we need to analyse it probably too to make sure it's worth sending the samples, because if the
child is not hypoglycaemia, then it's probably not going to be helpful. So there are still some
quirks -- slight flaws in the system but we are working to try and improve it.
DE LA POER: And finally this, are there any other changes that, in your view, need to be made
that haven't yet been made or aren't in train to be made?
BOWLES: Well, as I say, the electronic transmission of requests and results would obviously be
very helpful. I mean, I think one of the things that came out of this for me is that the
paediatricians perhaps didn't share their concerns. I mean, I know it's a -- it was a sensitive
issue and it's difficult, but if we had known that there were problems on the unit, then these
results would have been so much more significant to us and we could have been very helpful. So
there is a sort of, you know, is it reasonable for them to think about, if there are concerns,
possibility of blood results being important? We do tend to be sidelined a little in the
laboratory medicine side.
I mean, we -- we are sort of thinking about the sort of results that we could scrutinise and see
whether there's any likelihood of safeguarding issues. It's quite difficult, though, because
without the sort of clinicians' prompting we don't have often samples that are very clear-cut. I
mean, obviously insulin and C-peptide have been highlighted as one. We've -- we have had urine
samples, toxicology screens from a child recently where there was cocaine in it. So that was
obviously a flag. But the GP was aware of that, that's why they'd sent the sample. So, you know,
us just looking at the samples in isolation is -- there are some that are obvious but a lot of
them would not be obvious because the results would be not really specific to anything in
particular. But certainly better communication in terms of the sort of things they are concerned
about would be helpful.
MR DE LA POER: Dr Bowles, those are all my questions.
LADY JUSTICE THIRLWALL: Thank you, Mr De La Poer. Dr Bowles, just can I pick up on something you
were just describing, which is that some results are not obvious and some aren't clear-cut, but I
think you accept that the insulin C-peptide result was very
clear-cut.
BOWLES: In looking at it now it was certainly very supportive of, you know, the scenario that --
that was of concern.
LADY JUSTICE THIRLWALL: Yes. I mean, irrespective of a scenario, it was still a very clear-cut
result and what it meant, I'm not going to ask you about again, you have been through that. Can I
then turn to something else you mentioned, which was about the sort of records and the
availability of the records, and you said there was no way you can make a record on the patient
notes, and you said, "I could have walked over to the ward." I appreciate that's not something you
did on this occasion -- I'm assuming it's not something you did on this occasion?
BOWLES: No.
LADY JUSTICE THIRLWALL: Has there ever been a situation when you would have done that? I'm not
suggesting there should have been, I would just like to know --
BOWLES: I have occasionally actually gone to the wards with a problem. I mean, with -- you know,
where -- particularly if the wards that were close to the laboratory, or I might have nipped on to
the ward and just sort of had a word with them. In that case I might have scribbled in the notes
to say, you know, this is what I thought. But, generally, we don't tend to write in the notes.
But, as I say, with the new system we could raise a clinical note and actually write something
now, but there wasn't a place for us to do that at that time.
LADY JUSTICE THIRLWALL: And just what you just said, "But we don't tend to write in the notes",
so I would just like to understand what difference it makes that you can now write in the notes.
Do you actually write in the notes?
BOWLES: I haven't had -- I mean, I do write in the notes for my own patients that I see.
LADY JUSTICE THIRLWALL: Sure. Yes.
BOWLES: I haven't really had cause to do so that I can think of for any other patient as yet, but
that functionality is -- does exist.
LADY JUSTICE THIRLWALL: Thank you. Anything else.
MR DE LA POER: No, thank you, my Lady.
LADY JUSTICE THIRLWALL: Dr Bowles, thank you very much for coming this afternoon. I know that was
a change from the arrangements that had been made --
BOWLES: Yes.
LADY JUSTICE THIRLWALL: -- but we're grateful to
you for coming and you're free to go now.
BOWLES: Thank you.
LADY JUSTICE THIRLWALL: Ms Brown.
MS BROWN: Yes, if we could call Mrs Peacock, please.
LADY JUSTICE THIRLWALL: Mrs Peacock, if you would like to come up to the desk, please.
MRS DEBBIE PEACOCK (affirmed)
LADY JUSTICE THIRLWALL: Do sit down.
MS BROWN: Could you please give your full name?
PEACOCK: Debbie Peacock.
BROWN: You provided a statement to the Inquiry dated 5 June 2024 and I think there's a matter
that you wish to correct at paragraph 127?
PEACOCK: Yes. In reference to the risk registers, they also went through to the divisional board
meetings as well as QSPEC.
BROWN: So that paragraph says that the risk registers will be at QSPEC and the addition is that
you are now adding that they would have been also been discussed at the divisional board?
PEACOCK: Yes.
BROWN: Taking into account that correction, is that statement true to the best of your knowledge
and belief?
PEACOCK: As far as I am aware, yes.
BROWN: I think there is something you wish to say at the start of your evidence?
PEACOCK: Yes, I would just like to extend my sincere condolences and sympathies to the Families
and parents involved in these events.
BROWN: Thank you. Turning to your qualifications, you qualified as a Registered General Nurse and
a Registered Sick Children's Nurse in 1985 and a midwife in 1987; is that correct?
PEACOCK: It is, yes.
BROWN: You then went on to obtain a law degree in 2001. Is it correct that you then went on to
qualify as a solicitor?
PEACOCK: I did, yes.
BROWN: When did you qualify as a solicitor?
PEACOCK: Oh, I think it was 2010.
BROWN: You also hold a National General Certificate in Occupational Health and Safety that was
awarded in 2015?
PEACOCK: Yes.
BROWN: Turning to your career, Mrs Peacock, you worked as a qualified nurse from 1985 and also as
a midwife. Over what period did you work as a nurse or
midwife within the NHS?
PEACOCK: I was working as a nurse and midwife either under contract or on the bank up until
probably 2013.
BROWN: So over 30 years?
PEACOCK: Yes.
BROWN: Was that mainly as a nurse or mainly as a midwife?
PEACOCK: Mainly as a midwife and a neonatal nurse.
BROWN: Coming to your period as a neonatal nurse, how long did you work as a neonatal nurse on a
neonatal unit?
PEACOCK: There were different periods. I really couldn't quantify that at the moment off the top
of my head, sorry.
BROWN: Just approximately, was it a number of years?
PEACOCK: A number of years, yes.
BROWN: Roughly what period, obviously you span from 1985, quite a long period over 30 years?
PEACOCK: Yes. So when I actually went to do my legal training I was working as a transitional care
midwife which is a midwife on the wards looking after babies that needed a little bit of extra
support. So that was still under the neonatal hat. But I probably left the neonatal unit in
probably 2008 I think maybe.
BROWN: So a period of five years you worked on
a neonatal unit or are we talking less than that?
PEACOCK: Probably a little bit more over the years.
BROWN: Where was the neonatal unit that you worked on?
PEACOCK: So I worked at Fazakerley Hospital, which is now Aintree, as a neonatal nurse, I worked
at Warrington General as a neonatal nurse and I worked at Liverpool Women's.
BROWN: And as a neonatal nurse that included working with babies in intensive care, did it?
PEACOCK: I generally didn't do intensive care, I tended to stay in the HDUs and the nursery.
BROWN: So you were working with special care babies rather than those in intensive care?
PEACOCK: Yes.
BROWN: What band nurse were you on the neonatal ward?
PEACOCK: When I worked at Fazakerley I would have been a Band E and then they changed the -- the
gradings. So as a midwife I was a Band 6 when I worked on the neonatal unit at Liverpool Women's.
BROWN: In terms of the Countess of Chester, did you work at any time as a midwife or a nurse at
the Countess of Chester Hospital?
PEACOCK: No, I never worked clinically.
BROWN: Looking at your legal career, you say that you worked from 2008 to June 2012 as a
paralegal then a trainee and then as a solicitor. How long did you work as a qualified solicitor
in clinical negligence?
PEACOCK: Probably just less than two years.
BROWN: Why did you leave your role as a solicitor?
PEACOCK: There was a Clinical Risk Manager job came up that I thought suited me better.
BROWN: Turning to that, when you moved to work in Risk and Patient Safety in 2012, from June 2012
to December 2013 you worked as a clinical risk manager in Southport & Ormskirk Hospital, so
about an 18-month period?
PEACOCK: Yes.
BROWN: Very briefly, what did your role involve there?
PEACOCK: My role there covered the whole hospital so it wasn't confined to one particular
specialty. And it was just quality improvement and monitoring patient safety via Datix and
investigations, obviously sharing lessons learned.
BROWN: Then turning to when you started employment at the Countess of Chester, you started there
in December 2013 and what was the title of your role when you started at the Countess of
Chester?
PEACOCK: So it was Quality Improvement Facilitator when
I started and that later changed to Risk and Patient Safety Lead for Women's and Children's.
BROWN: That was specifically related to -- well, what was initially the Women's and Children's
Department but then you went on to remain working within that area albeit then you had split?
PEACOCK: It was, it was split from before I started there into different divisions. So it never
changed while I was there.
BROWN: Did you take over from someone in that role or was it a new post?
PEACOCK: I took over from somebody in that role who I don't think they were in post for a long
time, I'm not sure.
BROWN: You have explained that your job title changed to Risk and Patient Safety Lead. But other
than the change in title, was there any change to what the job involved?
PEACOCK: No, it was still the same job description; that never changed.
BROWN: We have seen from documents that you were present at a meeting on 15 February 2016 and it
appears that was your last day or near to your last day?
PEACOCK: Yes, I think so.
BROWN: That date would fit with your recollection
that you left prior to the CQC visit which commenced on 16 February?
PEACOCK: I definitely left prior to the CQC visit.
BROWN: So you were at the Countess of Chester as a Risk and Patient Safety Lead for just over two
years?
PEACOCK: Yes.
BROWN: When you left there, I think you took up a post in the Royal Liverpool & Broadgreen
University Hospitals. Was that a promotion?
PEACOCK: It was, yes.
BROWN: What was the role that you went to?
PEACOCK: Very similar to what I had been doing, but I was -- for scheduled care so it was a larger
remit.
BROWN: In what sense then was it a promotion, what were the additional responsibilities?
PEACOCK: It was a higher band, more responsibility.
BROWN: And you stayed there I think for just under four years until January 2020?
PEACOCK: Yes.
BROWN: So summarising your career and looking focusing on your Risk and Patient Safety roles, you
worked in the NHS across three hospitals for approximately seven and a half years in this
field?
PEACOCK: Yes.
BROWN: How did your background in nursing and
midwifery assist you in your role in Risk and Patient Safety?
PEACOCK: I think because I had such a varied nursing background, it was useful, it was applicable
to all the areas that I worked within.
BROWN: What about your training and experience as a solicitor, how did that assist you?
PEACOCK: I think it probably enabled a bit more critical thinking. Certainly it probably gave me
more awareness of the things that can go wrong and do go wrong so I wasn't so tunnel-visioned and
protective of the NHS. I suppose I was a little bit more cynical.
BROWN: In your role as Risk and Safety Lead, you covered both the neonatal unit and
midwifery?
PEACOCK: Yes, and gynaecology.
BROWN: Yes, and also general paediatrics?
PEACOCK: Yes.
BROWN: So whilst we have heard and you confirmed that even from when you started, the maternity
unit was within the Planned Care Division and the neonatal unit in the Urgent Care Division, in
terms of Risk and Patient Safety you looked across both units?
PEACOCK: I did, yes.
BROWN: And from a risk and safety perspective, why was that important?
PEACOCK: It gave me a better overarching view of what was going on across the units, I think. So
obviously any issues in obstetrics could feed into problems with babies who then subsequently went
to the neonatal unit.
BROWN: So you were able to follow through from antenatal the birth and then if the child was
treated on the neonatal unit?
PEACOCK: Yes.
BROWN: So you could see the picture and you would look at the patient safety across that?
PEACOCK: Yes.
BROWN: Who did you report to?
PEACOCK: I reported to the head of risk and governance which was Ruth Millward for most the time.
Sally Goode was originally in post but she left soon after I started.
BROWN: So for most of this period, certainly from June 2015, you were reporting to Ruth
Millward?
PEACOCK: Yes.
BROWN: She in turn I think reported to Sian Williams, the Deputy Director of Nursing?
PEACOCK: As far as I am aware, yes.
BROWN: Were there other Risk and Patient Safety Leads for the other departments? You were
covering, as you explained, the neonatal unit, midwifery, paediatrics
obstetrics and gynaecology. What about other Risk and Patient Safety Leads?
PEACOCK: So there was a Risk and Patient Safety Lead for each division as well and I can't
remember how, what specialties fell into which division, I am sorry.
BROWN: So can you just give an indication approximately of how many Risk and Patient Safety Leads
there were other than you?
PEACOCK: I think there were probably four of five others.
BROWN: Can you give an indication of how many people worked within the Risk and Patient Safety
Team, so obviously yourself the other Risk and Patient Leads, Ruth Millward, supervising. Were
there other individuals that worked within the Risk and Patient Safety?
PEACOCK: We had somebody who was part of clinical audit, we had somebody who managed the Datix
system for us and there was a PA, a personal assistant, secretary, that worked for Ruth Millward
and Sian Williams.
BROWN: So we are looking at a team of about 12, something like that?
PEACOCK: Probably, yes.
BROWN: Physically in the hospital, did you work as one unit together or were you embedded, so to
speak, in
the different divisions?
PEACOCK: No, we were in a separate building away from our divisions.
BROWN: And you say "in a separate building". To what extent would you have any day-to-day contact
with those working in the neonatal unit?
PEACOCK: I had a lot of contact, I made sure I was quite visible on all the units.
BROWN: What does that mean in practical terms, you made sure you were visible?
PEACOCK: So I would probably be there at least once a day depending what meetings I had and the
reason I had for going on to the different units.
BROWN: So obviously we are focusing on the neonatal unit. Would you go to the neonatal unit once
a day?
PEACOCK: Possibly. There might have been some days when I didn't go but if I had gone through to
delivery suite or the ward for any reason or paediatrics sometimes I would pop in and say: any
concerns, anything you want to discuss?
BROWN: So when you went there, what was your purpose of going to the neonatal unit?
PEACOCK: Quite often there had been an incident or we were having one of our regular Neonatal
Incident Review Groups and sometimes it would just be in passing to see
if everything is okay.
BROWN: When you say "everything okay", who would you be asking that of who would you be speaking
to when you got there?
PEACOCK: Usually it was either Dr Steve Brearey or Eirian or Yvonne Griffiths or Yvonne Farmer.
BROWN: Would you talk to the doctors working there or the nurses working or would you just speak
to the Consultants and the managers?
PEACOCK: It would usually be just the Consultants and the managers.
BROWN: Did you think it was important to, in terms of patient safety, also speak to the doctors
and nurses or was that not something that would have been a useful conversation?
PEACOCK: I certainly passed the time of day with them. But generally speaking they were busy doing
their work and from an infection control point of view, I wouldn't go into rooms unnecessarily
with the babies in there.
BROWN: At paragraph 7 of your statement, you say in terms of your role that it was to ensure that
identified risk was managed via appropriate investigation reporting and action planning. Can you
just break that down and explain in very practical terms what your role as Risk and Patient Safety
Lead involved?
PEACOCK: So I would manage the Datix incidents in real-time when they came through. I would --
BROWN: Just stopping with Datix there for a moment. Were you looking at seeing if those reports
were consistent, properly filled out, was that part of your role?
PEACOCK: We weren't particularly worried about the content at that stage because that was
something that we would go and pick up on, we would review. So that would be the start of
preliminary enquiries really to see whether there was anything that needed to be reported,
escalated up for investigation.
BROWN: So the first thing would be to if there was anything urgent and then at a later stage you
would look at those Datixes to see if they had been properly filled in, for example?
PEACOCK: Yes. Yes.
BROWN: Yes, sorry, I have interrupted you, that was Datix, you were carrying on with your
role?
PEACOCK: So the majority of the Datixes were things that people had reported as a general concern
and they hadn't actually caused harm so they would be managed at local level. I took an
overarching view of that and did do some
trending analysis with the individual managers and Consultants if there was anything of concern
that seemed to be recurring.
BROWN: So just on that trending analysis. So you would be -- what does that mean, if you got a
similar incident, so if you had, for example, a series of neonatal deaths, what would you do in
terms of trending analysis then?
PEACOCK: So the trending analysis, obviously when they were reported initially they would be
classed as moderate or severe harm, so they were always picked up as soon as. I would go along
just to find out the facts, I would rely on Steve Brearey's clinical assessment to tell me whether
there were any concerns. From his response I would copy and paste his assessment and put that on
to an SBAR. The SBAR would be then escalated to the Serious Incident, the SI Panel.
BROWN: Just stopping you there, just explain what an SBAR is, please?
PEACOCK: So the SBAR is basically a communication tool to put as much information --
LADY JUSTICE THIRLWALL: What does it stand for?
PEACOCK: Sorry it is an information tool that stands
for Situation Background Assessment and Recommendation. So we would -- say a Datix has come in,
that would be the situation, the background would be for instance 28 week gestation baby had been
born in poor condition. The assessment would be the clinician's view of it and the recommendation
would be to send it through to the Serious Incident Review Panel.
MS BROWN: And that recommendation aspect, that would be where your expertise would come in, would
it, as to whether --
PEACOCK: No, the SBARS were always escalated to the SI Panel. That was just -- they all said that.
BROWN: Yes, carry on. So was there also a recording function and collating of incidents?
PEACOCK: Yes. So I would pull reports for the individual areas and also an overarching report. So
that the report -- I think I pulled the report quarterly that went to the Women's & Children's
Governance Board. But I also pulled reports to -- on a monthly basis to discuss with the ward
managers in the different areas to look at their trends.
BROWN: In terms of following up incidents, what was your role in relation to that?
PEACOCK: So it depended on what the incident was and what the next steps were. So if they were at
local
level then it was usually the ward manager or the lead Consultant that dealt with them. If it was
escalated further, it would depend on what the recommendations of the Serious Incident Review
Panel were. So if it was recommended that there was a Level 2 investigation, then the panel would
appoint a chair to investigate and I would support the chair with that investigation.
BROWN: So drawing that all together, the purpose of your role was to improve patient safety?
PEACOCK: Basically, yes.
BROWN: Part of the reason for having a dedicated role for risk and patient was, as you explained,
to spot trends and ensure problems were carried out -- actions carried out?
PEACOCK: Yes.
BROWN: That would be fair, would it, as a summary?
PEACOCK: Yes.
BROWN: Just looking at the Women's & Children's Care Governance Board. If we could call up INQ0015325, which I hope is the Terms of Reference. This is tab 27, my Lady,
of your bundle. We see there the Terms of Reference, this is a document we have looked at before
in the Inquiry and we see there the membership and the membership here consists of people from
Planned Care, so we have got the Consultant obstetrician gynaecologist Mr McCormack, who is the
chair, the Head of Midwifery Ms Fogarty then under Urgent Care we have got Dr Brearey and Dr
Jayaram and we see there at the bottom that you were there as part of the membership as the Risk
and Patient Safety Lead?
PEACOCK: Yes.
BROWN: If we just could turn over to page 2. In addition to the membership, there were a few
individuals who we can see there who would attend when requested, the people with asterisks?
PEACOCK: Yes.
BROWN: Just looking down in terms of the duties and responsibilities, just picking out two of
those, the second bullet point down, one of the Terms of Reference was to provide assurance to the
board lead Executive of effective risk management?
PEACOCK: Yes.
BROWN: So the minutes from this I think you understood certainly went to Alison Kelly, so what
was reported here went up to the Executive?
PEACOCK: Yes.
BROWN: The third bullet point from the bottom: "Ensuring that clinical performance quality
monitoring reporting mechanisms are working effectively"?
PEACOCK: Yes.
BROWN: So whilst you as Risk and Patient Safety Lead yourself brought together, gave that
overview, looked at trends, this was the committee where you would bring concerns to and then they
in turn would take concerns up to the Executive?
PEACOCK: Yes. I think given that we were only allowed an hour and a half for this meeting, and it
covers a large breadth -- obviously it covered all the departments, I think a lot of the documents
would be sent out prior to the meeting for people to read and comment on and they would bring any
queries to this meeting. But generally, I think things were just noted at this meeting and then
escalated from that point of view.
BROWN: So it was a meeting where you would focus on the most important matters?
PEACOCK: Yes.
BROWN: Baby deaths amongst those would be one of the most important matters, if that was a trend
that would be something that you would see as important for this meeting in principle?
PEACOCK: Yes. On the face of it. If the baby deaths had been due to natural causes then that
wouldn't cause any concern enough to escalate.
But that would have been picked up at the end of year report that I would have pulled together for
the -- the meeting, yes.
BROWN: But an unexpected or an unexplained death or concerns about a trend in that respect this
would have been the forum to raise that?
PEACOCK: This one and the perinatal mortality meetings, the M&M meetings that the
paediatricians held. So I would expect them to be discussed there and then escalated to this
meeting.
BROWN: You in your role, any death would have been reported to you as the Risk and Patient Safety
Lead, any neonatal death?
PEACOCK: Yes.
BROWN: You say in your statement that you worked closely with Mr McCormack who was the Consultant
obstetrician and gynaecologist and the chair of the Women's & Children's Care Governance Board
to produce the agenda. Did you have a good working relationship with Mr McCormack?
PEACOCK: Yes.
BROWN: So if you suggested an item for the agenda, he would be amenable to that?
PEACOCK: That never actually occurred but yes, I am sure he would. Yes.
BROWN: That clearly was one way of raising concerns through the medium of governance boards. If
you had a concern that you felt needed more senior consideration another route would have been
referring matters to Ruth Millward?
PEACOCK: Yes.
BROWN: How would you describe your relationship with her?
PEACOCK: Excellent, I had no problem at all.
BROWN: I think you say in your statement she had an open-door policy, so I take that to mean that
you felt very able to walk in and raise any concerns you had with her?
PEACOCK: Yes.
BROWN: You say in your statement this is paragraph 18, that you worked with senior nurses and
midwives. You of course were yourself a qualified nurse and a midwife and you have told us that
you made frequent daily or thereabouts visits to the neonatal ward. Would you also be visiting the
obstetric -- the delivery ward as well?
PEACOCK: Yes.
BROWN: So were you able to or did you observe relationships between nurses and midwives?
PEACOCK: Not particularly because the midwives would have been in the delivery rooms. So I didn't
see any interaction between the neonatal staff when they were coming to the delivery suite for
babies that were problematic.
BROWN: Because the Inquiry has heard some accounts of there being tensions between midwives and
nurses, was that something that you observed of or were aware of?
PEACOCK: I was aware of some comments here and there, nothing specific and I think it boiled down
to personalities rather than anything else.
BROWN: Would that tension be something that would be of some concern to you in your Patient and
Safety Risk, because lack of communication can lead to concerns?
PEACOCK: If there was a lack of communication, then yes. But if there were problems with a baby
not being transferred appropriately, then, yes, I would pick up on that. But generally speaking,
they were professionals and whilst they might not like each other personally, I think they dealt
with each other professionally very well.
BROWN: Did you -- you said what you would have done. Did you in fact ever get involved in
speaking about difficulties between nurses and midwives in your Risk and Patient Safety role, was
that something you were
ever involved in discussing or?
PEACOCK: No, it would usually be the result of an incident if there had been a delay in a baby
being reviewed for whatever reason.
BROWN: You worked, you explain in your statement, across obstetrics, gynaecology, paediatrics,
neonates, so you had interactions with quite a number of Consultants?
PEACOCK: Yes.
BROWN: How were those interactions with Consultants?
PEACOCK: Again, as with everyday life, you don't make friends with everybody but everybody worked
very well together as far as I could see at the time I was there.
BROWN: Specifically, did you feel your views were listened to, that you were treated
appropriately with appropriate respect for your role?
PEACOCK: I think so. I can't think of any particular time when I had a problem.
BROWN: In particular, we are focusing on the neonatal ward, the neonatal unit, so in particular
Dr Brearey, how would you describe your relationship with him?
PEACOCK: Professionally we got on fine.
BROWN: Again because you are in a position of giving an overview visiting these wards, on a
regular basis, we have heard some references to difficulties in
relationships between Consultants and nurses. Was that something that you observed?
PEACOCK: Sometimes I picked up on a bit of tension between Steve Brearey and Eirian Powell. But I
didn't delve into that, that was -- it didn't affect the working relationship.
BROWN: You can't give any details?
PEACOCK: No, it's just a -- sorry.
BROWN: Mrs Peacock, when you were working within Risk and Patient Safety at the Countess of
Chester Hospital, were you aware of the case of Beverley Allitt?
PEACOCK: I was, yes.
BROWN: And Recommendation 13 of the Clothier Inquiry into Beverley Allitt was that Beverley
Allitt's 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. Now, you may not
have been aware of the exact wording or indeed the number of the Recommendation, but were you
aware of the principle that as Risk and Patient Safety Lead you should be aware of the possibility
of deliberate harm as a cause of unexplained clinical events?
PEACOCK: I was and it was something that we considered with every review that we did, whether
there was a harm
event, whether there was an action or omission during the care that would have caused or
contributed to harm. So that was at the back of our -- our mind whichever review we did.
BROWN: So you were -- I think you are saying very explicitly that you were open to deliberate
harm as a possible cause?
PEACOCK: Yes, and we also -- as a tool in risk and governance we had something called the Decision
Incident Tree. So if a member of staff was thought to have caused harm we would use the Incident
Decision Tree which was an algorithm for us to follow to determine what the best course of action
was.
BROWN: I don't think we have heard about that at all before. Was that something that was ever
used in the period that you worked at the Countess of Chester?
PEACOCK: So it was something that I don't think I ever took along to any of the review meetings
but it was certainly at the back of my mind and I had a copy in my desk to refer back to if ever I
needed it.
BROWN: You never considered using it once you became aware -- we will move to that, but you never
considered using that once you became aware of the correlation between Letby's presence and the
deaths of babies?
PEACOCK: So when we looked at the specific case reviews that we did, there was no suspicion there,
there was no thought there that there was an act or omission from the evidence that we had that
had caused harm. So no, it wouldn't have been used then.
BROWN: But presumably the tool you had was there not when there was certainty that someone had
been harming, but the very purpose of the tool was to assist in identifying if that might be the
case?
PEACOCK: You needed probably something to prompt that thought. So the -- there would have been
whether it was, you know, not following procedure, whether there was an action that had caused
harm. But as far as I can remember, there was nothing that actually along those lines was picked
up from the reviews.
BROWN: And this, you say you had it on your desk. Can you just explain a bit more what it was you
had on your desk, was it a flowchart?
PEACOCK: Yes, it is an algorithm flowchart, yes.
BROWN: Would that have been on the desk of everybody working within Risk and Patient Safety?
PEACOCK: I don't know.
BROWN: Would this be something that Ruth Millward would be aware of?
PEACOCK: I would have thought so, if she -- the National Patient Safety Agency training on root
cause
analysis introduced the decision tree. So anybody that had done that training would know about it.
BROWN: How did you come to have that on your desk, why did you have that on your desk?
PEACOCK: Because I had done the three-day NPSA training.
BROWN: So, Mrs Peacock, we have heard clinicians saying that to them, from a clinician's point of
view, someone harming -- a healthcare professional harming a child was unthinkable that wasn't
your perspective from your risk and patient -- that was something that very much you did think and
was a possibility that you were open to?
PEACOCK: Given my clinical negligence background, yes, very open to it.
BROWN: In relation to Datix you say at paragraph 27 that baby deaths were reported on Datix and
that would have been the case for all baby deaths on the maternity ward or the neonatal ward?
PEACOCK: Yes.
BROWN: When a Datix form was completed as I understand it that would trigger an automatic email
notification to you so it wasn't reliant on someone remembering to forward it to you, you would be
through the system notified?
PEACOCK: It would come to me and other relevant people. But they -- the neonatal unit and delivery
suite were very good at picking the phone up as soon as something like that happened.
BROWN: Yes, you refer to this in your statement and I was going to ask who was it who would
actually pick up the phone to you, who would you speak to?
PEACOCK: I think generally speaking it would have been Eirian Powell, the unit manager but it
could have been anyone. I don't know whether other people did, my recollection isn't that good I'm
afraid, sorry.
BROWN: What information would be given to you over the phone?
PEACOCK: That there had been a baby death. So obviously then I would usually go over to the unit,
we would have a look through the medical records and sit down with Steve Brearey, who was
obviously the clinician, to review the notes and see whether there was -- we thought there was any
concern. Even if it was a natural death, natural cause of death, we would still go through the
notes anyway just to make sure that all policies and procedures had been followed correctly.
BROWN: So just breaking that down. You would get a call and if the death had occurred during the
night that call would be first thing in the morning?
PEACOCK: Usually yes.
BROWN: Then your procedure would be to visit the unit to look at the clinical -- look at the
notes, speak to Dr Brearey if he was there and speak to Eirian Powell, is that a fair summary of
what you would do?
PEACOCK: Yes. Yes.
BROWN: What was your understanding of the Datix reporting position where a baby collapsed
unexpectedly requiring resuscitation, but survived. Would you have expected that to have been
reported on Datix?
PEACOCK: They generally weren't unless there was an actual issue with a piece of equipment or
somebody had competency issues. So something -- it's dreadful to term a collapse as normal but
something out of the ordinary had happened, then they would Datix it but generally speaking
collapses weren't Datixed.
BROWN: So obviously an unexpected -- particularly if it was an unexpected collapse requiring
resuscitation would be a concerning clinical event. From what I understand it, there would be no
way under the Datix system that that would be brought to your attention in Risk and Patient
Safety, so whereas if the baby died you would be aware, you would go through these processes you
have explained. If the baby survived you wouldn't even be aware of that; is that correct?
PEACOCK: That's correct. But I think small babies do collapse, it's not unusual.
BROWN: Well, just leaving aside that for a moment. Was that not a flaw in the system, that it was
only those babies that died that were reported and therefore you didn't have a complete picture
because babies who collapsed but survived, that was never raised as an issue?
PEACOCK: I think it was certainly a flaw in the system. However, if they reported every collapse
on Datix, it would be its own industry, I think. However, in this situation, I would have thought
it was relevant for us to be notified of the collapses, which we weren't.
BROWN: So taking that answer that in this situation, once you became aware and we are going to go
through that, once you became aware that there were a number, a trend, a cluster of neonatal
deaths, it would at that point have been relevant to know whether there were collapses where the
baby survived?
PEACOCK: It certainly would have been relevant to know, yes, at that time. I think the difficulty
was from my perspective that they were seen as natural causes, the deaths. Obviously we had the
postmortems that gave natural causes. So at that stage we weren't thinking that they were
particularly -- there was a cluster, an
unexplained cluster, which we needed to review but we hadn't thought anything further than that at
the time.
BROWN: Well, we will come back in a moment to the individual deaths. But in terms of you say
that, with your legal career, analysis was one of the things that brought to your role, you had
identified that it would have been helpful to know if there were collapses where the babies
survived, what action did you take in response to that? Did you raise that with Mrs Millward and
say: this is something we need to be following, this is a trend we need to look at?
PEACOCK: No, I didn't at the time.
BROWN: Why do you think that was?
PEACOCK: Because I thought if there were any collapses that I needed to know about that they would
have been escalated.
BROWN: Well, you have explained they wouldn't have been on Datix, how would they have been
escalated to you?
PEACOCK: So we had numerous meetings about the unexpected rise in mortality, so I would have
expected either Steve Brearey or Eirian to let me know about those collapses.
BROWN: Did you ever ask the question?
PEACOCK: I didn't, no.
BROWN: Can we just go through some of the Datixes now. If I could have INQ000016 and this is tab 2, my Lady, in the bundle. This I hope will be a
Datix relating to [Child A]. You will see there, Mrs Peacock if we just work through it we see
that it relates to [Child A] and then we have got "reported date" and "opened date". Can you just
explain why we have got a difference of date, what's the difference between reported and open and
why do we have two different dates?
PEACOCK: So the reported date is as it suggests, it is the date that the incident was reported.
And the opened day was when the Datix was actually accessed by somebody either in the risk -- risk
department or on the wards.
BROWN: So that would be opened by you, would it, if it came straight to you as this was a
neonatal?
PEACOCK: I would have thought so but I was actually on annual leave when [Child A] died.
BROWN: Yes, so it would be the person, if not you, when you were there or the person covering for
you when you were away?
PEACOCK: Yes.
BROWN: We see "handler", a Ms Kenny, what was the handler?
PEACOCK: I don't know, I don't know who Ms Kenny is.
BROWN: And did you not ask that when you looked at these when you came to review these Datix, who
is the handler?
PEACOCK: I don't know whether that was on there, it must have been on there at the time, I wasn't
aware of it, to be honest.
LADY JUSTICE THIRLWALL: I am sorry, Ms Brown. I appreciate you don't know who Ms Kenny is but do
you not know what the handler was meant to be?
PEACOCK: No, I don't, sorry.
LADY JUSTICE THIRLWALL: I see, thank you.
MS BROWN: You are then listed as the manager. What does that mean "manager"? I think you said in
your statement you certainly weren't a manager of anyone. But what does "manager" mean in that
context?
PEACOCK: I managed the actual Datix from opening it and then following up on any information that
we needed to gather for the SBAR if that was necessary, obviously in this case it was.
BROWN: Then if we come down, we see subcategory and "Expected and Unexpected Death". Now, we know
that [Child A] was an unexpected death. Why does it say "Expected and Unexpected Death"?
PEACOCK: We didn't have anything to do with the -- the titles. I don't know why, whether they were
titles that came with the Datix, I don't understand the technological side of it, but to me it
didn't matter whether it was expected or unexpected at this stage because we would be looking into
it anyway. We just needed to be notified that there had been a death.
BROWN: Because was that a drop down list?
PEACOCK: It was as far as I am aware, yes.
BROWN: You say you didn't understand the technology of it, but if it was your role to review the
Datix, wasn't it quite important to understand how these forms were filled in and what the items
on the forms meant?
PEACOCK: As I say, it was reporting a death and that was what was important to me. At that stage,
I wouldn't expect anybody to be commenting on whether it was expected or unexpected depending who
was reporting the Datix.
BROWN: In relation then, well, picking up on that. Surely in terms of a patient and risk safety
whether it was either expected or unexpected was something that was of great significance in terms
of what alarm bells it would ring to you?
PEACOCK: It was greatly significant once we undertook the assessment of the medical records and
any subsequent investigation. The Datix forms were quite subjective depending who
completed them and really the -- the information that was on there was only guidance for us to
look further into it or -- or not depending on the incident that had been reported.
BROWN: If we can just look down we have then got under the risk grading potential for harm and
what's filled in there is high potential harm. Why high? What was the -- who made that risk
grading and why was it high potential harm chosen?
PEACOCK: So the risk grading would have been entered by the person reporting the Datix.
BROWN: That would be something that you would review, would it?
PEACOCK: We would review that, yes, with the clinicians and as I say they were quite subjective so
people could -- obviously this is a child death, it wouldn't be the case. But some Datix forms --
BROWN: Just let's focus on child deaths because that is what we are interested in. So would high
potential harm be what you would be expecting to see for what we can see further down was a sudden
and unexpected deterioration, would you expect high to be what should have been filled in
there?
PEACOCK: As I say, that was the person submitting the form and regardless of what they put there
we would do
our own assessment with the clinician to determine whether that was indeed correct or not.
BROWN: But did you review and see whether that had been correctly filled out, whether high
potential harm was the correct -- or did you take -- did you take no view on what had been filled
out in terms of potential for harm?
PEACOCK: So we would obviously look at what the reporter had put on there. But as I say, we didn't
take that as gospel. We would then follow up and look into it further.
BROWN: If we could just go over the page to page 2. We have got then -- we can see at the bottom
the incident reporter here is Miss Lappalainen, who was one of the neonatal nurses. Would it have
been -- would your understanding have been it was her that would have filled in who the employees
involved were?
PEACOCK: No, I think that probably would have been done at a later date but I am really not sure
about that.
BROWN: What should have been filled in under "employees involved", who should have featured in
employees involved in a neonatal death?
PEACOCK: So any of the team that were around at the time.
BROWN: So the team that were involved in the resuscitation, in this case sadly the failed
resuscitation?
PEACOCK: Usually, yes.
BROWN: Because we see there indeed doctors and the names of nurses that were working on the
neonatal unit. We don't see the name of Dr Jayaram who was the doctor that was called in in this
case. Was there any reason why the Consultant wouldn't be included?
PEACOCK: I really can't comment on that, sorry, I don't know.
BROWN: What was the purpose on a Datix of having a list of the employees involved?
PEACOCK: So you would look at people who were cropping up regularly that they may have competency
issues that needed to be addressed. Any other concerns, there could be somebody if there had been
medication errors, they had had several medication errors that -- so we needed to look into
supporting that person.
BROWN: So just looking at where you said you would see if someone whose name was coming up and
competency issues. So given that you were looking at trends it was quite important, was it, that
the employees involved listed were that that was completed properly?
PEACOCK: Yes.
BROWN: If we could just go to 0000111 and this is tab 4, my Lady, in your bundle and I hope we
will come up there with the Datix for [Child C]. We see very similar, we have got the name of the
child, you as the -- Ms Kenny's name appears. Your name as the manager, the specialty we have got
"Neonatology", again we have got "Expected and unexpected death". This time under "risk grading"
we have got low potential harm. Do you have any explanation as to why this would be low whereas
[Child A] was high? We see under the description that we have got sudden deterioration of an
infant following full resuscitation. So a sudden death again. Why would this have been low whereas
the other one was high?
PEACOCK: Again, subjective opinion of the reporter at the time. So maybe they thought that well, I
am presuming that they thought no harm had been caused.
BROWN: If we could go over to page 2, please. We have got there we have got the incident reporter
we can see that was Yvonne Griffiths who we are aware worked on the neonatal ward. But the
employees involved here named, we are not familiar with, because they are not people who worked on
the neonatal ward.
We have got we can see Mr McCormack, David Semple. So we have got Consultant obstetricians there.
So we have got the Consultants featuring but we have got the midwifery and the Consultants. So we
have got the -- although this is a neonatology Datix, looking at a death that happened on the
neonatal ward, the employees involved, here we have got a list of people who were involved in the
obstetric care. So why would that have been?
PEACOCK: I really can't comment. I don't know. This again was -- I was on annual leave for this
death.
BROWN: Well, we will look in a moment but we know you came to look at these three deaths at a
meeting together. But that would be concerning wouldn't it, Mrs Peacock?
PEACOCK: Sorry, what was the actual incident again?
BROWN: This is the -- this is the death of [Child C]?
PEACOCK: What was the actual incident that was reported, is it the death that was reported? Sorry,
can I see the first page of the Datix?
BROWN: Sorry. Yes, go back to the first page. So the category we have been given is "Expected and
unexpected death"?
PEACOCK: Mm-hm. Yes, I can't explain that at all, sorry.
BROWN: Because that would be quite concerning, wouldn't it, because if part of your answer before
was that part of the reason for listing the employees was to see if there was any commonality, any
competencies that might be raised, well, that's not going to be followed through if the employees
involved there are not the employees who were involved in the resuscitation and involved in the
care just prior to the baby's death?
PEACOCK: As far as I am -- my opinion is that when I did any of the updating on these, well
certainly when we investigated, well, when we reviewed the notes, that wasn't the investigation,
but we would certainly take note of the people who had been involved in the actual incident
itself. So I can't explain why the obstetric team is there instead of the neonatal team.
BROWN: Can we now go to 0000766 and this is tab 6, my Lady. This I hope should be the Datix of
[Child D]. We see there again [Child D], your name as manager. Again the subcategory expected and
unexpected death. Again we have got low potential harm, this time. I think your evidence is you
can't -- you don't know why that was filled in?
PEACOCK: As I say, it would have been the reporter of the Datix.
BROWN: And we see there under "Action Taken", at the
bottom, the second -- the last two sentences there, a review was completed by the neonatal lead
Consultant and they managed to ascertain if there are any commonalities or poor standards of care,
there were none found. That I think is a reference to the fact that [Child D]'s case was
considered alongside [Child A] and [Child C]?
PEACOCK: Yes.
BROWN: We don't have any details but there is just a highlighter that that was done?
PEACOCK: Yes.
BROWN: If we turn over to page 2, we have got another variant here in terms of employees
involved. So we have got the incident reporter of Caroline Oakley, who we know was a neonatal
nurse, senior neonatal nurse. But the employees involved here, whereas A, we didn't have the
Consultant, here we have got a paediatric Consultant but we only have the name of the Consultant,
not of the names of anybody else who was involved in the resuscitation and we know that there
clearly were nurses and others involved in that resuscitation. Again, can you explain that?
PEACOCK: I can't, sorry. No.
BROWN: Then if we can go to 0002658, and this is tab 5, going back one tab. Now, this is a
slightly different Datix because this is the Datix for Mother D so the mother of [Child D] who
died, and we can see there as you would expect the specialty is obstetrics because this is looking
at her care. But if we could go over to page 2 in this Datix, we have got a long entry and I think
this is -- we will see this later, but this is in fact copy pasted from an email from Dr Brearey
and that's setting out if you look at the beginning, just confirm that I have met and that is
referring to Dr Brearey has met with Eirian reviewed the case notes of [Child D] and then if you
scan down, you can see it's referring to [Child A] and [Child C]. So that's a discussion about the
care or discussion of the consideration of the cases of [Child A], [Child C] and [Child D] and yet
that's appearing in the Datix for the mother of [Child D]. It wasn't -- I am not going to go back
to it but it wasn't in the Datix of [Child D] and it's not in the Datixes of [Child A] or [Child
C]. So someone coming to that Datix wouldn't have the advantage of seeing that, they would find it
only after the mother's Datix, doesn't that suggest that this is a system that wasn't working,
that wasn't creating an accurate record?
PEACOCK: No. We actually merged -- if there were several incidents about one particular patient,
or that they were connected, we would merge the incidents so that could see it on all the incident
forms. It wouldn't have been on A and C Datixes at this stage until we decided what we were doing,
investigation-wise, and I think Steve Brearey had said that he didn't think there was a connection
between Baby D [Child D] and the other two.
BROWN: Yes, I think the point, Mrs Peacock, is that that information about the review of [Child
A], [Child C] and [Child D] is not appearing on the Datixes of [Child C] or [Child D] or indeed
[Child A]?
PEACOCK: Yes. That's correct.
BROWN: You can't explain that?
PEACOCK: No, no.
BROWN: Just finally, if we could look at 000194, I might have said one two few zeros there, 0000194 and this is the Datix concerning the death of [Child E]. And it's
tab 7 for my Lady. Again, we can go very briefly. It is [Child E] again you are the manager,
"Expected and unexpected death". Here we have gone back to high potential harm and we see under
the details "Unexpected death, full resuscitation unsuccessful". If we could go over to page 2,
here the incident
reporter was Letby and under the employees involved it simply hasn't been filled in. There are no
employees involved. Would that -- ought that to have been a highlighter? I think we are going to
look at your holiday period but E was a period where you were working?
PEACOCK: Yes.
BROWN: When you received a Datix where it said "no employees" under employees involved, would
that not have been something that you would have wanted to investigate?
PEACOCK: Sorry, can you just go to the first page again?
BROWN: Yes, go back to page 1.
PEACOCK: So the risk grading here, the result the actual harm was no harm caused.
BROWN: Understood?
PEACOCK: The actual harm, which is what we looked at, so obviously we considered the potential for
harm as well for if we needed to put processes in place to stop it reoccurring, whatever had
happened. But the -- it was the actual harm that we looked at and staff were generally not very
good at determining actual harm when they completed the Datix. So as I started saying earlier,
they could be used as if
somebody had their own agenda, if they wanted -- for instance, if there was poor staffing on one
shift the person reporting the poor staffing could put that there was high actual harm but when we
looked into it there was no incident had been caused as a result of that staffing. So, as I say,
it could be very subjective, that grading. So if this was taken as a no harm when we assessed with
Steve Brearey, then we probably wouldn't have looked at the staff at that stage that were involved
in the incident.
BROWN: But Mrs Peacock, surely where a baby has died, and you have got what's described as an
unexpected death, and you have got a form that allows for the employees involved as you have said
that would be important to see if there were any issues of competencies, was it not a concern that
this report filled in by Letby where it says "employees involved" there are none, was that not
something that as a matter of course, as a matter of your overarching role as Risk and Patient
Lead, you should have picked up on, asked the questions, there must have been employees involved,
who were they?
PEACOCK: I think if we had reviewed the case and Steve Brearey said there were no concerns then
possibly that wouldn't have been our priority.
BROWN: What did you, what was your view at the time of the Datix system of reporting of incidents
and how effective it was as a means of identifying trends?
PEACOCK: As a means for flagging up incidents it was obviously dependent on having a good
reporting culture. So if it was used effectively, as it's meant to be, then it was -- I thought it
was a good tool to use. Obviously it wasn't perfect, there were things that could have been
improved, but basically it did the job it was meant to do, just alerted us to incidents to dive a
bit deeper, really.
BROWN: If we can turn now to when you returned from holiday. You say in your statement that you
were away for the first three weeks of June 2015 and you returned to work on Monday, June 22. That
was the day that [Child D] died. [Child D] had died in the early hours of the morning of 22 June.
You have explained that where a death occurred out of working hours normally you would be called
first thing in the morning. Do you recall receiving a call on that first day back to work?
PEACOCK: No. Sorry, no recollection at all.
BROWN: Over the three weeks that you had been away, two other babies had died. We have looked at
the
Datixes of those already, [Child A] and [Child C]. How would you have been informed of those
deaths?
PEACOCK: I am not really sure, I can't remember, to be honest, how I would have been informed. I
would expect whoever had been covering for me would let me know. I am sure when I came back to
work that Eirian Powell and Steve Brearey would have let me know. But I can't remember how it
actually happened.
BROWN: Because it would have been quite a shocking return to work, wouldn't it, Mrs Peacock? You
return to work and you receive a call that a baby has died and you find that two other babies had
died in a two-week period? That would be the same total as the total number of deaths in 2014. Is
that not something that would have stuck in your mind as particularly unusual, particularly
concerning in fact?
PEACOCK: It was unusual and concerning but no, I don't recall it, I am sorry.
BROWN: What -- you say you can't recall it, but what would you have done in that, in that
circumstance? You say you would have gone to the -- your practice would have been to are gone to
the neonatal unit in the case of a death. Can we take it that that is what it is likely you did on
the 22nd?
PEACOCK: Yes.
BROWN: What questions would you have asked then when you went to the neonatal unit?
PEACOCK: Well, first I would have wanted to know how it had -- whether the SBAR had been completed
and what was the result of the SBAR going to the Serious Incident Review Panel and what their
determination was and what should be done next. I would have asked if there were any particular
concerns which, as far as I can recall, there were no -- obviously there were concerns that there
was an increase in mortality and that there was a cluster of deaths, but there were no suspicions
at that time.
BROWN: We have heard from Dr Lambie that at around this time she recalls seeing nurses who were
looking to see whether anybody had been on duty for all of the deaths. When you visited the
neonatal ward were you aware of any of that sort of discussion, who was on duty?
PEACOCK: Not at all, no.
BROWN: The Inquiry has also heard evidence that junior doctors and Consultants were discussing
these deaths. One of the issues they were discussing was the existence of a concerning rash. Did
you pick up on any of those discussions?
PEACOCK: I wasn't included in any of the email trail that was going on at this time.
BROWN: I'm not asking about the email trail, I am just asking about when you visited on this
morning, where we have got a third baby die in a very short period, were you aware of those
concerns doctors speaking about those?
PEACOCK: I don't recall -- I don't recall anybody mentioning concerns no, as a rash.
LADY JUSTICE THIRLWALL: Do you remember them mentioning the deaths at all?
PEACOCK: Unfortunately nine years ago I really can't remember that far back. There would have been
general discussions and obviously I would have spoken to Steve but what the content of those
discussions was, I really don't recall.
MS BROWN: And you say that your general course would have been to report matters to Ruth
Millward. Would you have reported not only the death of [Child D] but would you have gone to Ruth
Millward about the fact that there had now been three deaths within a very short period; is that
something you would have taken to Ruth Millward?
PEACOCK: I would have thought so and I think Ruth actually completed one the SBARs so she was
certainly aware of at least one of the deaths. Whether she would have been aware what the normal
acceptable death rate was for the unit, I don't know. But she -- yes, I certainly would have
escalated that there had been a cluster.
BROWN: We are going to come on to a meeting in due course but just on a few other matters. In
relation to Child Death Overview Panels and Sudden Death in Infancy Panels you say in your
statement that was not a matter that you were involved in and not trained in. Is that the case?
Did the Risk and Safety Department have any involvement in when deaths should be reported to an
external?
PEACOCK: No.
BROWN: That was not -- neither you nor Ruth Millward, that was something that the Risk and Safety
Patient Department didn't deal with?
PEACOCK: No.
BROWN: In relation to Coroners, is that the same situation?
PEACOCK: Yes, it was the legal department and bereavement that dealt with Coroner referrals.
BROWN: You say in terms of the management and your unit that Ruth Millward introduced daily
huddles within the risk team.
Do you think the fact of three deaths occurring in such short succession would be something that
you would have raised at that huddle? You are the risk team as I take it to be an informal
meeting, is that the sort of thing you would have shared then?
PEACOCK: I am not really sure to be honest. I think I would have shared that with Ruth outside of
the huddle. The huddle was mainly to catch up on what your plans were for the day, who would be in
the office, cascading any information that we needed.
MS BROWN: My Lady, I don't know if that would be a convenient moment. I am going to turn now to going through some documents in quite some detail so that might be an appropriate moment?
LADY JUSTICE THIRLWALL: Very well. So we will take a break now and we will come back at 20 past 11.
(11.06 am) (A short break)
(11.20 am)
MS BROWN: If we could go to INQ0003110, please, at page 6. So, Mrs Peacock, this is the email that was
sent on the evening of 22 June so on the Monday evening after you had returned to work so
presumably you would have received it on the Tuesday when you came into work. It's from Dr Brearey
and it's sent to Dr Jayaram
with you copied in. We can see your name on the copy list there: "Just to confirm that I have met
with Eirian and reviewed the case notes of [Child D] who died in the early hours of this morning.
We have discussed whether there are any other issues in view of the two other recent sudden deaths
on the NNU." So at that point, you were clearly being copied in and made aware of the fact that
there had been these three deaths and then Dr Brearey says: "All deaths occurred in Room 1 in
different cot spaces. All microbiology results have been negative. The initial postmortem did not
identify a definite cause of death in relation to [Child A]. The other two postmortems are in
progress. [Child D] was not on TPN [Total Parental Nutrition] ... died ..." The number of days has
been redacted. Nosocomial infection, so no hospital acquired infection, or that's unlikely. They
say that is very unlikely. Then it goes on to say: "There does not seem to be any staff, medical
or nursing members present at all three episodes other than one nurse who was not the nurse
responsible for [Child D] on that shift".
Then if we go on, if we could go to page 7, it says there at the bottom of the paragraph just
before the numbers: "I would be very surprised if [Child D]'s death is linked in any way to the
previous recent deaths of [Child A] and [Child C]. We have agreed an action plan however ..." And
then the action plan is set out, to review [Child A] and [Child C] in detail, review [Child A]'s
postmortem, discuss microbiology. Eirian to check the thermometers, the incubator the antibiotics
prescribed and Dr Brearey is going to speak to Jo Davies, so the obstetrician involved, in
relation to [Child D]. So it seems there what Dr Brearey is saying is that they are going to look
at or he is initiating looking at these deaths together and presumably that would have been
something that you would have wanted from a patient risk and patient safety perspective too?
PEACOCK: Yes.
BROWN: In terms of the action plan, considering whether there are points in, you know, potential
themes, potential things that might link the deaths?
PEACOCK: Yes.
BROWN: We see if we go then to page 4, that Eirian Powell on the 25th responds at the top that
all three babies were nursed in different incubators, the thermometers have been checked,
antibiotics prescribed were given as prescribed. So we are -- in terms of the common -- possible
common themes, they have been checked out and proved to be negative?
PEACOCK: Yes.
BROWN: If we just go to page 1 of that document, that email trail, we see that you responded you
had actually responded prior to Eirian Powell, you had responded on 23 June: "Hi Steve, who spoke
with the Coroner regarding recent deaths? Do you know if the Coroner has raised any specific
concerns". You have said that you weren't involved in the Coroner's proceedings, what was the
reason for that email?
PEACOCK: Obviously I would have liked to have known in response to the Coroner referrals whether
the Coroner had any confirmed --any concerns, if things had been discussed with him, whether there
were there was anything suggested by the Coroner.
BROWN: One of the things of course that Stephen Brearey -- Eirian Powell has checked on the
thermometers and the incubators. One of the other
things Stephen Brearey had raised was the commonality of one nurse. Was that something that you
felt as Risk and Patient Safety Lead you should look into at that point?
PEACOCK: No. My understanding at that point was that there were a couple of nurses and a couple of
doctors that were -- had a commonality with the babies.
BROWN: How did you find that out?
PEACOCK: I really don't know. I think it was discussions rather than something that was written
down.
BROWN: Who would the discussions have been with?
PEACOCK: It would have been with Stephen Brearey and Eirian, I would presume, because they would
have been the only two people I was talking to in relation to this.
BROWN: So what was the context, you were discussing which nurses were in common, because it seems
that Stephen Brearey had already identified that, he had identified that there was just one nurse
in common?
PEACOCK: As I say, I don't know where I got the understanding from but I understood that there
were two nurses and two doctors, that there was a commonality.
LADY JUSTICE THIRLWALL: Are you sure that was at this stage and not later?
PEACOCK: I really don't know, I am sorry. It was just
my general understanding.
LADY JUSTICE THIRLWALL: So you don't know whether it was at this stage --
PEACOCK: No, I don't.
LADY JUSTICE THIRLWALL: -- or not. Thank you.
MS BROWN: Can we just look briefly at what else was going on at this point. If we could just go
now to INQ0025767 [not found] and this is tab 13. So one of the other things that was going on is
that there were meetings -- sorry, meetings being held of the Neonatal Incident Review Group and
we see there that is an email from you sent on the 24th to a number of recipients attaching the
incidents for review. We don't need to go to that document now but the document was a list of the
various incidents and we see on that that certainly [Child A] and [Child D], it doesn't appear
that [Child C], but certainly [Child A] and [Child D]'s deaths are referred to in that. Do you
recall that discussion that was held on 24 June?
PEACOCK: So these were regular meetings that we held. We tried to have them fortnightly depending
on availability of Eirian and Steve Brearey. So we pulled up all the incidents to review them all
and this is where we were doing the trending.
But certainly if the baby deaths had have come up at these, I think they would have been reviewed
and discussed at a separate meeting.
BROWN: At that meeting, what would your role be, who first of all would be have been at that
meeting?
PEACOCK: So there was -- you can see the recipients of the email. So generally there was Stephen
Brearey, Eirian Powell, quite often Eirian's deputy, depending on her workload, we had the
pharmacist for the neonatal unit and it was also used as a teaching experience as well for members
of staff could come in if they were available just to see how the process worked. We would sit
down and have the notes for the babies. I think Steve would get the prescription charts and
suchlike up on the computer and we would go through them and it would be Steve that would
determine the level of harm, if any, was caused and what the follow-up was from that.
BROWN: Would you in terms of Risk and Patient Safety Lead and knowing at this point that there
had been three deaths in a short period, would you have raised this as a concern at that meeting
would that have been a topic of discussion?
PEACOCK: I really don't know, I am sorry, I can't remember. I would have hoped that I would have
done. I would have been surprised if I hadn't.
BROWN: If we can look then now at the meeting of 2 July. If we could go to tab INQ0008302. This is tab 15, my Lady, in your bundle. This is an email from
Stephen Brearey: "Hi Debbie, thanks for your help today. I have attached my summary and data for
tomorrow's meeting." So this is the meeting on 2 July whereas prefaced in the email we looked at
before, there is going to be consideration of [Child A], [Child C] and [Child D]'s death
together?
PEACOCK: Yes.
BROWN: If we could go to 0003191, these are the notes that Dr Brearey attached to that email and we
see that he produces a short summary, he refers to [Child A] who died on 8 June and underneath
[Child A] refers to Twin 1 and that's [Child B] who had a respiratory arrest 24 hours later but
responded to resuscitation. So we have got a death and a near death, a resuscitation incident.
Then we have got [Child C] six days later on 14 June, bottom of the page [Child D], and noting and
in fact as is the case for all of them "awaiting postmortem". Then there is a heading "Learning
from these cases". If we could go on to the next page, page 3, we see
Dr Brearey has also set out the mortality data and we see that in 2013 there were two neonatal
deaths according to this chart in 2014 -- according to this chart, there were three. So that
rather highlights, Mrs Peacock, that this was a very unusual string of events having three deaths
--
PEACOCK: Yes.
BROWN: -- within a two-week period?
PEACOCK: Mm-hm.
BROWN: At that meeting, we know at the meeting on 2 July, Alison Kelly, the Director of Nursing
attended, Eirian Powell, Ruth Millward, so your boss, Stephen Brearey, you, and Sian Williams, how
common would it be for you to be at a meeting where Alison Kelly was also present?
PEACOCK: Not very common but I had been at meetings when she was present.
BROWN: We see the meeting, in fact the meeting is -- we don't need to go to it, it is in
paragraph 88 of your statement. But the meeting is referred to in fact within a review of [Child
D] but it's described as an Executive Serious Incident Panel on 2 July, there had been three
neonatal deaths in a short period of time and the circumstances were discussed to identify if
there
was any commonality which linked the deaths. Is that a meeting you recall, Mrs Peacock?
PEACOCK: I don't, sorry, no.
BROWN: Given that it was such an unusual -- first of all an unusual string of events to have
three deaths in such a short period and personally unusual for you to be at a meeting with Mrs
Kelly, so with the most senior nurse in the organisation, the Director of Nursing, you have no
recollection of the meeting at all, is that your evidence?
PEACOCK: Sorry, no, until I saw the email sending the summary around, I didn't think I had
actually been there.
BROWN: So in the absence of an actual recollection in terms of best practice, bearing in mind
this meeting was looking at the potential commonality between three deaths, would you have had an
agenda, would you have gone through the areas of commonality to see if there was anything that
linked the deaths together?
PEACOCK: As I say, I really don't know what we discussed at the meeting. I don't know the format
of the meeting. Sorry.
BROWN: Would you have been concerned that the same nurse was identified as being present on
those, you have heard that you were one of the people who was alert to
the fact that, whilst rare, harm inflicted by a healthcare professional was a possibility. Do you
think that's something you would have raised at that meeting as something that they needed to be
sure of because if that was the case, this would be an extremely serious situation?
PEACOCK: I think at this stage Steve Brearey had quite clearly said that he didn't think there was
a link between D and A and C and he said that the nurse wasn't actually looking after Baby D
[Child D] at the time. So that connection wasn't there for me.
BROWN: In relation to that, as you have explained, you provided an overview, is that something
that you would have looked into to check whether Letby was involved in the care of [Child D]
because in fact Letby was working in Nursery 1?
PEACOCK: Right.
BROWN: Not as the designated nurse, but is that something you would have checked?
PEACOCK: Not if Steve Brearey had told me definitively no.
BROWN: Well, he didn't say -- he didn't get into the detail of the nursery, he was the clinician,
you were Risk and Patient Safety. Was that not something that you felt was something that was
within your remit to check, to be -- so that you could be sure in your mind?
PEACOCK: It wasn't for me to personally go and check to see who was on where. I would have had
those discussions to ascertain for my own peace of mind but as I say, timeline wise, I'm not sure
whether at this stage I knew that there was another nurse and two doctors that had -- were in
common with some of these deaths, I really don't know.
BROWN: You address this in paragraph 74 and 75 of your statement and you say that: "... a
particular nurse referred to was employed full time but also worked extra shifts to provide cover
for the short staffing." So it would appear from your statement that prior to this meeting you had
discussed the commonality of the nurse with Eirian Powell. Would that be right, is that what you
were likely to have done, is that what you say in your statement?
PEACOCK: Yes, yes.
BROWN: So you were aware that Letby was the nurse?
PEACOCK: I don't know whether I would have been aware that's who it was. I didn't know Lucy Letby
at all, so it wouldn't have had any relevance them giving a name to me.
BROWN: It seems to be from your statement that you
are accepting what Eirian Powell said, that it was unlikely to be an issue that it was the same
nurse because Letby worked a lot of shifts and Letby was not the designated nurse for [Child
D]?
PEACOCK: As I say, timeline wise, I don't know what I knew at that time. I was just aware that she
did cover a lot of shifts because she was working extras, that particular nurse. So it wasn't
deemed to be unusual for her to be on duty when there was an incident and I understood obviously
further down the line that there were some deaths that she wasn't on duty for. So ...
BROWN: In terms of the number of deaths that she was there, we have seen from Dr Brearey's notes
that he highlights [Child B]'s collapse. Would you have thought it was relevant to see, well, was
Letby on duty or was the nurse the common nurse on duty for [Child B]'s collapse, that would have
been relevant in order to assess the commonality?
PEACOCK: At that stage I probably wouldn't, I really don't know. Sorry. As I say, I don't recall
being aware of any collapses but that was obviously in the document. So it was never highlighted
as an issue.
BROWN: Well, you were the Risk and Patient Safety Lead for neonatal care?
PEACOCK: Yes.
BROWN: Dr Brearey had said that there was one nurse who was on duty at the three deaths and he's
referred in his note there was also a collapse of [Child B] and it appears that you had discussed
the issue of staffing with Eirian Powell. Now surely, as the Risk and Safety Lead, the person
who's drawing together the issues of risk and safety, and within your mind as you have said, the
possibility that you had to always be alert to, that harm could be caused, why were you not
raising that at that meeting? Was that not your role as Risk and Safety Lead at that meeting, to
look into that because if there was a common factor of a nurse involved in the three deaths, but
possibly in the one collapse that had been present, that is something that warranted a serious
investigation, didn't it?
PEACOCK: It wasn't for me to determine whether it warranted a serious investigation. I think at
the time I had been led to believe that there were no suspicions, no suspicious circumstances
surrounding the deaths, that they were natural causes. So concerns were raised about the increased
mortality rate but --
BROWN: Why -- why do you say, Mrs Peacock, that these were natural causes? Where are you getting
that from?
We have looked at the Datixes which talk to "unexpected deaths"?
PEACOCK: So that was the impression.
BROWN: "Postmortems are awaited".
PEACOCK: That was the impression I was given by Steve Brearey that we had a presumed natural cause
for each of the deaths, we hadn't identified anything in the care that would suggest otherwise and
I don't know, just overall. So yes, it was a consideration. How much emphasis we put on that at
the time, I really can't say.
BROWN: There were no postmortems at this stage for any of those children, so a conclusion on the
cause of death had not been made, that is the case isn't it?
PEACOCK: No, there had been cause of deaths suggested at that stage.
BROWN: And --
PEACOCK: Proposed.
BROWN: Who -- who do you say had informed you that these were natural deaths?
PEACOCK: From the proposed causes that we were given, it didn't suggest that they were unnatural.
BROWN: Given -- given by whom?
PEACOCK: It was on one of the emails I think that Steve sent round with a presumed cause of death
on them.
BROWN: Well, maybe we can return to that if we need to. But looking at the conclusion of that
meeting, the meeting concluded that no further investigation was warranted at this stage. Was that
a conclusion that you agreed with?
PEACOCK: On the information that we had that Steve had presented, then yes.
BROWN: What did you take it to mean at this stage?
PEACOCK: We were waiting for the postmortem to come back on Baby D [Child D], I think.
BROWN: Would another aspect of at this stage be that if there were further deaths and the same
nurse was found to be on duty, that that would also be a reason for reconsidering further
investigation?
PEACOCK: I don't think we had considered that at that stage that there would be more deaths.
BROWN: But that's something that should have been considered, wasn't it, Mrs Peacock, because you
have already alerted the fact that in terms of three deaths it was the same nurse. You were aware
that in unexpected circumstances, and these -- we have looked at the Datixes -- were all
unexpected deaths, that harm by a health professional has to at least be considered. Was that not
something that you were noting, if not at this stage, for future
reference?
PEACOCK: I think I was noting it. But Steve had also said that that nurse wasn't looking after
Baby D [Child D] at the time.
BROWN: Do you accept that you didn't look to see to find out any further details about that,
whether Letby was in fact on Nursery 1, did you undertake any investigations?
PEACOCK: No.
BROWN: Ruth Millward in her statement to the Inquiry says it would have been appropriate for the
hospital to have reported the overall increase in neonatal deaths that occurred in June as a
Serious Incident and this would have then triggered a comprehensive investigation into the
increased mortality at an earlier stage. Do you agree with Ruth Millward's view?
PEACOCK: Sorry?
BROWN: Should there have been at that stage in June, after the deaths in June, a comprehensive
investigation of the increased mortality?
PEACOCK: I really can't say. That wasn't my decision to make.
BROWN: In terms of safeguarding, you say -- and I think you are relying on the fact that you say
that you didn't consider there was a connection between the
nurse and the baby deaths, that's correct, is it, you at that point didn't see a connection
between the nurse and the baby deaths?
PEACOCK: That's correct.
BROWN: On the possibility that you were wrong, did you consider that there was a safeguarding
risk here, did you ever see this in terms of safeguarding, that if there was a risk that harm was
being caused to a baby that was something that you should be reporting?
PEACOCK: I am not aware of having that conscious thought, but yes.
BROWN: Looking back now, can you think why you didn't see this as a safeguarding, where there was
harm caused to a baby and a possibility that someone was involved and that should be raised
through safeguarding channels, can you explain why that didn't occur to you?
PEACOCK: So this was after the third death?
BROWN: Yes. Or indeed at any point, did you consider safeguarding at any point we are going to go
on and look at subsequently?
PEACOCK: I don't know whether safeguarding actually crystallised as a thought. I certainly would
have reported if I -- I had any suspicions. But at that stage, although there were concerns, there
were no suspicions that somebody had actually caused harm and
I was aware that there were conversations with the Coroner at the time and I would have thought
the doctors would have raised any concerns, certainly with the Coroner referrals and then
obviously the postmortems when we had got them back, they gave natural causes as well. So I
suppose my thought processes never moved forward to that stage.
BROWN: Moving forward a little in terms of what happened then after that meeting, so the meeting
concluded that there was no further investigation at that stage. We then see that in fact what was
decided at that meeting was that there should be a full review of Baby D [Child D]'s death and if
we can see INQ0004520, this is tab 10. This is -- I will get it on screen in a moment
-- this shows there was a report, a fuller report into death of [Child D] and we can see there in
the investigation team of obstetrics, you feature in the investigation team for the secondary
review obstetric and indeed in the Neonatal Review Team and that reflects your role, doesn't it,
that you were looking both from an obstetric and from a neonatal perspective?
PEACOCK: Yes. Mmm mm.
BROWN: Why is it that this was done for Baby D [Child D] a fuller report, but not for A and C? Do
you recall why that decision was made?
PEACOCK: I don't, sorry.
BROWN: How was this report produced was there actually a meeting or was this a paper
exercise?
PEACOCK: So this was a paper exercise. The obstetric secondary report had already been done as had
the neonatal review. So this paper was just combining the two, the narrative from the two reports.
BROWN: That was something you did, you physically brought these together, did you, was this a
document that you produced?
PEACOCK: It's a document that I produced which was copy and pasting so it -- it's -- the authors
would be the obstetric team and the neonatal, or Steve Brearey, it would have been.
BROWN: There was then subsequently a round table meeting after the postmortem was obtained in the
case of [Child D] and at that time, I think there was an actual meeting. Do you recall that
meeting when Dr Davies, Dr Newby, Ms Fogarty, Eirian Powell and yourself met to consider the
postmortem results of Baby D [Child D]?
PEACOCK: I am sorry, I don't recall it, no.
BROWN: Because by that stage that was held on 12 October -- considering Baby D [Child D] -- by
that stage Baby E
had died as well in August. Did you consider that now we have got an additional baby death that
you needed to review the position and consider whether to look first of all to see whether this
same nurse was present at that death?
PEACOCK: I really don't recall, I am sorry.
BROWN: Is that something that you should have been doing as patient and safety where you have got
an additional death, it's been identified the same nurse is present at A, C and D, you have then
got a very short period afterwards another unexpected death? As Risk and Patient Safety Lead, you
have said that your role was patient safety. What were you proactively doing to -- to investigate
at this point, to take steps for patient safety?
PEACOCK: So I would like to think that I did have that thought. I can't say whether I did or not.
I would be surprised if I didn't but that would have been a discussion with Steve Brearey and
Eirian. Other than that, I can't say any more, sorry, because I have no recollection of it.
BROWN: If we can move forward again now. So Baby E [Child E] has died, you say you don't recall
that death?
PEACOCK: Sorry.
BROWN: Is that your evidence, you don't recall the
death of Baby E [Child E]?
PEACOCK: I don't no.
BROWN: So moving forward now to 23 October. That was the day that [Child I] died and if we could
go to INQ0005609 and this is tab 21, my Lady. So we have got an email here from
Eirian Powell that you are copied into and it says: "Hi Steve, just to say that I have discussed
the above with Anne Murphy and on reflection it was decided to leave this until Monday. Alison
Kelly was not in the hospital and Sian had just left. I have devised a document to reflect the
information clearly ... it is unfortunate that she was on." That is a reference to Letby being on
duty?
PEACOCK: Mm-hm.
BROWN: It ends: "I will discuss further with Debbie on Monday." Attached to that was a chart that
listed eight deaths, the first of which was back in March. But all the deaths from June onwards,
and that included [Child A], [Child C], [Child D], [Child E] and [Child I], on each of those
occasions Eirian Powell has noted that Lucy Letby was on duty and she had highlighted her name in
red. What did you think when you received that document?
PEACOCK: I really don't know what my thoughts were at
the time, sorry.
BROWN: Well, you were Risk and Patient Safety Lead. That must have caused concern, mustn't it,
that we have now got the initial three but two additional deaths that we are concerned at, but
indeed other deaths as well, all of which Lucy Letby was present at and her name's being
highlighted in red and that's been prompted, it appears, by the clinical -- the neonatal lead Dr
Brearey, contacting the ward manager. That has to be a very serious patient safety concern,
doesn't it?
PEACOCK: It would be looking at it, but I also understood that she wasn't looking after all the
babies that she died that had died.
LADY JUSTICE THIRLWALL: So where do you understand that from?
PEACOCK: It is on the chart.
LADY JUSTICE THIRLWALL: I see, so you do remember that?
PEACOCK: I -- I remember -- I don't remember the chart I've seen it on the chart in the documents
that were provided to me.
LADY JUSTICE THIRLWALL: I see, and that is something you would have taken account of, is it?
PEACOCK: I would hope so, yes.
MS BROWN: So by that you mean that whilst Letby was staff on duty, she wasn't necessarily
allocated to the baby, is that the point you are making?
PEACOCK: Yes.
BROWN: Why did you think that Eirian Powell had highlighted Lucy Letby's name in red and what did
you understand to be Dr Brearey's concern?
PEACOCK: Dr Brearey never discussed any concerns with me. He certainly never discussed any
suspicions about any member of staff. Obviously this -- we looked at all the staff that were on.
BROWN: But what did you understand to be -- Eirian Powell had drawn up this statement. What did
you understand to be Dr Brearey's concern that had led to the creation of this chart?
PEACOCK: Other than noting that she had been on for a lot of the deaths he never voiced a concern
and I didn't know what his concern was.
BROWN: Well, why did you think that Stephen Brearey had asked Eirian Powell to draw up a chart
stating who was on duty and why Eirian Powell had highlighted Letby in red?
PEACOCK: He obviously had some concern about her being on duty.
BROWN: So that was obvious, wasn't it, that was
obvious from the fact he asked for this and a chart was produced with her name in red that he had
concerns?
PEACOCK: I -- I suppose at the time I believed that he had any concerns, any suspicions, they
would have been reported to the Coroner or the police.
BROWN: Well, let's just look at what was being reported to you. At the stage of that email being
sent on 23rd, it appears that the view of Eirian Powell was that it was going to be raised with
Alison Kelly. What discussion did you then have with Eirian Powell about this, about the chart and
your views on this?
PEACOCK: As I say, I don't recall the discussion.
BROWN: Can we just turn to INQ0003107. So that's an email from Eirian Powell to Steve: "I have spoken
at length with Debbie this morning in relation to the mortality rate." So do you have any
recollection of that conversation that was at length about the mortality rate?
PEACOCK: I have a vague recollection of discussing with Eirian that we should look at all the
staff that were present, not just highlighting one particular member of staff.
BROWN: Why was that? Why did you think it was
relevant to look at other members of staff?
PEACOCK: To see whether there were any competency issues, if it was a recurrent theme with one
member of staff.
BROWN: So you were clear that what this chart was doing was looking to see a connection between
someone being on duty and the death of the baby whether there was a connection to be made?
PEACOCK: Yes.
BROWN: And the connection what had been made was with Letby, that is why she was in red.
PEACOCK: As I say, on that table, yes, I had been led to understand that there was another nurse
that was a commonality and two doctors.
BROWN: Well, you were then saying that doctors should be highlighted as well?
PEACOCK: Yes.
BROWN: That was to see if there was any commonality --
PEACOCK: Yes.
BROWN: -- in terms of doctors? It then goes, this email says: "Debbie was of the same opinion
that we did not think there was a connection." So you are referring there, are you, Mrs Peacock,
to a connection between Letby and the deaths, that is the connection you are talking about, is it?
If you just look at the email?
PEACOCK: No, I was talking about a connection with all the deaths, with all the variables, not
just Letby, I -- I would imagine.
BROWN: Well, let's just look at the sequence because you have, at this point, the chart you are
-- you have in front of you was a chart that lists a number of baby deaths against each of those,
barring the death that was much earlier in the year, but all of the deaths from Baby A [Child A]
onwards until October 23, which was [Child I]'s death, against each of those Letby was shown to be
on duty and her name was highlighted in red and then you are responding after a lengthy meeting
saying that you were of the "opinion we did not think there was a connection". Now the obvious
meaning of that is, isn't it, Mrs Peacock, is that there wasn't a connection between Letby and the
deaths; that's what you were saying, was it?
PEACOCK: As I say I can't comment because I don't remember the conversation.
BROWN: Because what could have been your basis for concluding that there wasn't a connection
between Letby and the deaths, what would you have seen that could have led you to that
conclusion?
PEACOCK: I am presuming because she wasn't the nurse caring for the -- some of the babies that
died at the time of their death.
BROWN: Can you recall what information you had in front of you to inform you of who was of that
information?
PEACOCK: Only this chart that's been produced and the documents.
BROWN: So that wouldn't have told you whether she had attended that baby through looking at the
medical records, for example?
PEACOCK: It wouldn't have told me whether she had attended the baby but it was the nurse assigned
to that baby and these were ill babies so the nurses stay with the babies a lot of -- most of the
time.
BROWN: So whereas Stephen Brearey was raising that as a concern, hence the production of the
chart, you were saying there wasn't a connection. Did you feel in a position to say that?
PEACOCK: No, I wasn't in a position to say that at all.
BROWN: The consequences it appears of that discussion was that this wasn't then raised with the
Executive team and Alison Kelly at that point so this was a very --
there were very serious consequences to this discussion because at that point this matter it would
appear then did not go to Alison Kelly?
PEACOCK: From what I know now after seeing the documents I think Steve was escalating this outside
of meetings with risk and governance to Alison Kelly.
BROWN: And at this stage, so we have moved on now, you have said that you visited the neonatal
ward I think on an almost daily basis. Were you aware of rumours by this stage that now we have
got more deaths and we have also got the death of [Child E], the death of [Child I], were you
aware of rumours or concerns on the neonatal ward when you visited, that there was an undue number
of deaths, that they were unexpected and that there may be a staff member involved?
PEACOCK: No, I wasn't aware of any of the rumblings behind the scenes.
BROWN: Not aware of concern at the increased mortality?
PEACOCK: No, I didn't really speak to the nurses, as I say, they were in the rooms with their
babies and I tended not to go in the rooms unless it was necessary.
BROWN: But you were -- you said you spoke to Dr Brearey and you were aware of his concerns?
PEACOCK: I was aware of his concerns at the rise in the mortality rate but I wasn't aware of any
suspicions that he had or concerns in relation to a particular member of staff.
BROWN: If we could go now to INQ0003222, that is tab 25. So this is a review of neonatal deaths. We see
"Review of neonatal deaths and stillbirths at the Countess of Chester" and you were part, you can
see, of the review team. Can you recall being part of this review team?
PEACOCK: I actually wasn't part of the review team, I sat in to observe this meeting which is why
I didn't organise it, I didn't take minutes from the meeting.
BROWN: What was your purpose as an observer there, presumably it was you observing from the point
of view of Risk and Patient Safety?
PEACOCK: As I say my -- my recollection of this meeting is quite sketchy. I did think that there
were paediatricians present at this meeting but patently there weren't.
BROWN: We will see that the heading of that report is review of neonatal deaths and stillbirths
at the Countess of Chester. In fact, this was just looking at the obstetric care, wasn't it?
PEACOCK: It was looking at the early neonatal deaths as well, the babies that had been born in
poor condition and died on delivery suite.
BROWN: But it was just looking at it from the obstetric point of view?
PEACOCK: Yes.
BROWN: It wasn't looking at it from the neonatal aspect?
PEACOCK: That's correct.
BROWN: So that heading was actually misleading, wasn't it?
PEACOCK: As I say, the obstetricians would have referred to early neonatal deaths for babies that
died on delivery suite from their way of thinking, yes, it is misleading. But probably not
intentional.
BROWN: If we just look then at tab 27 -- sorry, tab 28, if we could look at INQ0004371. So this is then -- so we have that review in November, and that
review, the obstetric review, didn't identify any themes or concerns; that is the case, isn't
it?
PEACOCK: Sorry, what is the question?
BROWN: The obstetric review didn't reveal any themes or concerns about the maternity care?
PEACOCK: I don't think so looking at the documents, no.
BROWN: Then the Women's and Children's Care and Governance Board meeting on 18 December, and that
was one that you sat on, this was the committee, the board, that you sat on?
PEACOCK: Yes.
BROWN: We will see if we could go to page 2 of that, we see there at point 9: "Stillbirth and
early neonatal death review and action plan." And it says there: "No themes identified." Did you
think at that point from a risk and safety point of view, you should have been alerting the
meeting knowing that these minutes went on to Alison Kelly alerting the meeting that this was only
the obstetric clean bill of health and that there were concerns in terms of neonatal, the neonatal
care and in fact you were aware certainly of Stephen Brearey's concerns about the commonality of
the nurse because that appears to suggest that there were no themes identified but that is purely
from an obstetric point of view?
PEACOCK: It is, yes. But it does say "Stillbirth and early neonatal death" and it comes to
assuming people have similar knowledge to yourself. So I would have thought seeing who the authors
were and what the report was that people would have realised that it was deaths
on the delivery suite and stillbirths.
BROWN: But you didn't highlight at any point, Mrs Peacock, in the Women's and Children's Care
Governance Board or indeed the other meetings that went ahead the various reviews you had, that
there was a concern about the deaths on the neonatal unit?
PEACOCK: No. I would have escalated it had one of the paediatricians raised it, then that would
have been something that I would have escalated.
BROWN: But you were employed to give risk and to look specifically at Risk and Patient Safety.
Given that Stephen Brearey had raised the commonality of a nurse you had seen that document with
the deaths and her name highlighted in red, did you not think that at that point this is something
that needs to be highlighted, this needs the Executives need to be aware, this needs to be
discussed at this meeting? Why -- from a risk and safety point of view, why weren't you bringing
that to these meetings? That is what we need to understand.
PEACOCK: I think I was aware at this stage that Steve was escalating to Ian Harvey and Alison
Kelly.
BROWN: If we could just look at 0015141. So this is an Incident Trend Analysis Report that I
think you authored, do you recall that?
PEACOCK: Yes.
BROWN: If we could just go to page 6 where you deal with neonatology. We don't have to work
through that in detail but there's nothing in that report that draws attention to the increased
mortality or concerns about the number of unexpected deaths. Was that not something that was
headed "Trend Analysis Report" should have been referred to?
PEACOCK: So this was just the pure data from Datix that I pulled looking at the highest category
of reported incidents and explaining what they were. If there had been investigations and they
were raised as a separate agenda item at the Women's and Children's, I think the end of year
report when we had the yearly figures in, that would have been something that I would raise then.
BROWN: Can we just turn now to INQ0005643. So this is in January. So we have had the -- you have looked at
the obstetric review, that has happened in November, we have seen back in October you saw and
discussed the chart identifying Letby's name next to child deaths and then we come to January and
we see at the bottom of that page there is an email from Eirian Powell to Stephen Brearey and if
one goes over the page, you can see what she is saying is: "I have amended the last list ..." That
is the list where Letby's name was in red:
"... to ensure that we have included all the babies that have died on the unit within the
timeframe." Because in fact two further babies had died where Letby had been on duty. If we just
go back then to page 1 because the emails are in the wrong order, so to speak. So we have got the
reply from Stephen Brearey on 22 January and you are copied in to this reply. He says: "I have
discussed our increased mortality with Nim." That is Dr Subhedar from Liverpool. Why did you
understand that Dr Brearey was wanting to bring in an outsider, a specialist from outside the
Trust?
PEACOCK: I would presume because he was concerned about the raise in mortality rates and he wanted
an independent person to come and review the notes to see whether anything had been missed.
BROWN: Were you concerned about the mortality rates?
PEACOCK: Yes, sorry, I thought I had already said that earlier. Yes, I did have a concern.
BROWN: You were concerned and -- and this is Stephen Brearey's initiative, were you taking any
initiative from a patient safety -- from your Risk and Patient Safety?
PEACOCK: I was relying on Steve.
BROWN: He goes on to say they are going to review the cases and set up a meeting and that meeting
in fact happened we know on 8 February and if we could look at INQ0003217. This is the meeting that did then take place with Dr Subhedar,
we see him, Liverpool Women's Hospital Consultant, as attending. We see your name appearing there
and the other attendees listed. Is that a meeting that you recall?
PEACOCK: Not in any detail, no. I certainly wouldn't have known who attended other than Steve and
Nim.
BROWN: Most significantly this -- this has been prompted by the -- or it appears it has been
prompted by the chart where Letby's name had been highlighted in red. Do you recall whether the
issue of Letby harming babies was discussed at that meeting?
PEACOCK: I really don't know, sorry.
BROWN: If it wasn't raised from a patient and safety point of view, would it not have been your
responsibility to raise that and say: this is something we need to discuss?
PEACOCK: I really don't know, to be honest. Yes. If those concerns hadn't been discussed already,
I think, I think Steve said he did actually discuss it at this
meeting in some of the documents I have seen.
BROWN: Can I just take you back to your statement, Mrs Peacock, paragraph 72. You say in that
statement: "it is sadly not unusual to have an unexplained cluster of deaths on an NNU ..." It was
unusual though, wasn't it, Mrs Peacock? You had never seen a series of deaths like this before
where you had a number -- a significant number of unexplained deaths, had you ever come across
that before?
PEACOCK: Not at the Countess of Chester. Probably at Liverpool Women's and Fazakerley I had.
BROWN: Sorry, where you are you saying you had seen this?
PEACOCK: My first -- it wouldn't have been my first job, when I worked at Fazakerley, which is now
Aintree hospital.
LADY JUSTICE THIRLWALL: When was that?
PEACOCK: Oh gosh, probably in the 90s. And then at Liverpool Women's.
BROWN: Liverpool Women's was slightly different, wasn't it, because that was a tertiary unit,
that was seen as a slightly different set of babies?
PEACOCK: Yes.
BROWN: But the evidence that this Inquiry has received is that it was indeed very unusual to have
a series of unexplained deaths on the neonatal unit within a short period?
PEACOCK: So a series of unexplained deaths yes. However, I was aware that we had postmortem
results back that gave us an explanation for those deaths.
BROWN: If I could just then turn you to your reflections at paragraph 154, you say: "I cannot
think of any steps that could have been taken to identify earlier that Letby was harming babies on
the NNU or steps that could be taken now on NNUs to prevent a similar situation." Is that still
your position?
PEACOCK: Obviously with the information that we have now, and the postmortem results that gave us
cause of death are now in question, aren't they, so I didn't have that at the time. So being given
the same set of information at the time, then yes. However, with the information we have now
obviously things are different. So, yes, had potentially the Coroner been informed sooner, that
would have, you know, stopped things in its tracks. Yes.
MS BROWN: Yes. Those are my questions but there will be some questions from Mr Baker and Mr Skelton.
LADY JUSTICE THIRLWALL: Thank you.
MR SKELTON: Mrs Peacock, I ask questions on behalf of one of the Family groups. Can I just start
with some basics about the policies that were in place that governed what staff were meant to be
doing in respect of reporting. May I have on screen INQ0006466. Do you recognise this document?
PEACOCK: I can't recall the document now.
SKELTON: You can't remember it?
PEACOCK: No, no.
SKELTON: So as I understand it, if we go just to page 9 first of all, if you see -- if you could
highlight right at the bottom, please, that very small print in the footer of the page, very
bottom of the page on page 9, I think it's about to be put on screen, hopefully. Can that be made
legible? There we go. Author: Sally Goode. Who's she?
PEACOCK: When I first took up post at the Countess of Chester she was the head of risk and
governance.
SKELTON: When you were in post, she was -- what relation with her did you have?
PEACOCK: Sorry?
SKELTON: What relationship with her did you have when you took up your post?
PEACOCK: So she would have been my line manager when I first starred.
SKELTON: Okay. So this is a document she has produced?
PEACOCK: Yes.
SKELTON: It's printed on 19 July 2016. Can we infer from that that it was the working document
that was in post when you were there?
PEACOCK: I don't know sorry I left at the beginning of 16 -- 2016.
SKELTON: Okay. Is it really the case that you don't remember this document at all as the policy
that governed reporting incidents?
PEACOCK: I don't. I have had other risk in governance jobs since and I wouldn't remember which
policies applied to which hospital at a given time.
SKELTON: If we go back to page 2 and have page 2 on the screen, please. Thank you. So this is
about the duties on who should report incidents and you can see that there is a section -- there
are three sections there, "All staff", "Managers" and then the Risk and Patient Safety team. So
just to clarify. Was it your understanding that all staff were obliged to report incidents and
near misses?
PEACOCK: Yes.
SKELTON: Likewise we can see it also says:
"All staff have a duty to raise concerns regarding care or other activities using the Speak Out
Safely policy"?
PEACOCK: Yes.
SKELTON: You were familiar with that policy?
PEACOCK: As I say, I don't remember the policy but if that was in place, then yes.
SKELTON: From your perspective, would a concern about a nurse being connected with some deaths,
leaving aside deliberate harm, be -- fall within that Speak Out Safely duty?
PEACOCK: So somebody just being connected with deaths, no.
SKELTON: What about concerns regarding care being substandard by that nurse?
PEACOCK: Certainly if the care was substandard, yes.
SKELTON: By definition, if the nurse was harming patients as well?
PEACOCK: Yes.
SKELTON: The duties on the managers: "All managers are responsible for engaging all staff in the
reporting and management of incidents." If we think of the NNU, the neonatal unit, is that does
that mean Eirian Powell is responsible for reporting on that unit ultimately or by "managers" does
this mean the managers of the two teams, as it were, of healthcare staff, the doctors and the
nurses?
PEACOCK: I think it fell to everyone, to be honest, to promote a good reporting culture.
SKELTON: So Steve Brearey, for example, would fall into this category, would he?
PEACOCK: Certainly, yes.
SKELTON: Eirian Powell would fall into that category?
PEACOCK: Yes.
SKELTON: And are you aware of what training staff had on reporting incidents?
PEACOCK: I don't think they were given any formal training on completing Datix forms and
submitting them. I think that was done locally. But certainly as a Trust induction they were given
a talk on risk and safety and how it's everybody's responsibility to report and not assume
somebody else had.
SKELTON: One of the duties is on managers is to ensure they have proper training, so again that
would be a question perhaps to ask Dr Brearey in respect of doctors or senior nurses in respect of
nurses?
PEACOCK: To be honest I think it was probably Eirian would certainly oversee junior doctors if
they were submitting a Datix. As I say, it was done locally, probably, you know, as new doctors or
new nurses came in
and a situation arose then they would be supported through submitting a Datix.
SKELTON: Lastly, just briefly, the Risk and Patient Safety Team in which you sat: "Ensure
managers are alerted to all significant incidents or trends in their areas in a timely manner." So
you are the collating body in the Trust when it comes to incidents?
PEACOCK: Yes.
SKELTON: You feed back out to those that need to know if you have spotted a trend from their
reporting?
PEACOCK: Yes.
SKELTON: The idea being obviously it is a virtuous circle of learning?
PEACOCK: I had regular meetings with all the ward managers to look at their incidents and to
discuss any concerns and issues with them in their area.
SKELTON: Thank you. Can I go to the next page, please. Would it be possible just to highlight the
second half "What should be reported as an incident" or make it a bit bigger? I am going to ask
you about this paragraph because it's quite important but it may be felt that the wording is
unclear or unfortunate. It looks a little bit like a lawyer's sentence rather than a healthcare
professional sentence. Do you know -- would your predecessor -- sorry, your manager have drafted
that, or would it have been a lawyer who attempted to draft it?
PEACOCK: I would imagine it was my line manager.
SKELTON: So can we just try and understand what it means: "An event or circumstance which could
have resulted or did result in unnecessary damage, loss or harm to patients, staff, visitors or
members of the public." So an event or circumstance which could have resulted or did result in
unnecessary damage. So "event or circumstance" is just something that happened, is it,
anything?
PEACOCK: It's any concern; we encouraged staff to report anything.
SKELTON: What does the word "unnecessary" mean?
PEACOCK: I really don't know.
SKELTON: Is there an implication in this that there needs to have been something untoward,
something that the staff have done or not done which they should have done?
PEACOCK: Not necessarily. Staff, as I say, could report anything that was of concern to them. I
think the unnecessary damage is probably looking at the -- the
buildings and equipment.
SKELTON: Well, it's unnecessary damage, loss or harm to patients. I just want to know, what's
unnecessary harm as opposed to harm?
PEACOCK: Well, it's unnecessary damage, loss or harm, isn't it? So it's not unnecessary harm.
SKELTON: I see. So you think the adjective actually just applies to damage and not just loss or
harm?
PEACOCK: I really don't know because this is the first time I have read it so I don't know what it
means --
SKELTON: You are responsible in this department for understanding incidents?
PEACOCK: Yes.
SKELTON: I am asking you what your understanding was of what incidents needed to be or were
mandated to be reported?
PEACOCK: So my understanding and certainly what I was encouraging was for any and every harm
incident to be reported but also for any concerns whatsoever that they had that they felt that
they needed to raise. So it didn't necessarily need to result in harm for them to report
something.
SKELTON: It seems that this consistent reporting of the deaths, so all deaths, would that apply
not just to neonates and children across the hospital, would be
reported as incidents?
PEACOCK: I can't comment on the rest of the hospital. I didn't see their incidents, sorry, but
yes, I would imagine that all deaths.
SKELTON: All deaths for children as far as you are concerned would be reported?
PEACOCK: Yes.
SKELTON: Eirian Powell said that all collapses requiring resuscitation were also or should also
have been reported on Datix. Is that your understanding?
PEACOCK: No, I don't think unless there was something untoward happened during the resuscitation,
I don't think they were all reported.
SKELTON: What's "untoward" mean?
PEACOCK: So it could be an equipment failure, or a member of staff not following correct
procedure. So not necessarily resulting in harm, but has caused a concern to somebody.
SKELTON: So a child can die from nothing untoward and it would have to be reported?
PEACOCK: Yes.
SKELTON: But a child could collapse and nearly die but survive from nothing untoward, but that
would not be reported insofar as you are concerned?
PEACOCK: It's very difficult because if a small ET tube
blocks and some of these ET tubes that ventilated patients had a diameter of 2 mm, 2.5 mm, so
could easily get blocked with secretions, if that happened, the child collapsed as in the
saturations dropped and obviously the child couldn't breathe. So that could have necessitated just
suction to the tube to clear the blockage but quite often it resulted in the tube being changed so
that would be classed as a collapse with intervention.
SKELTON: But if a collapse is unexpected, then isn't it the case that you need to report it to
find out what caused it?
PEACOCK: I would argue a lot of collapses can't be expected because you can't anticipate that
things like an ET tube is going to block. It happens.
SKELTON: Well, the evidence almost uniformly from the Consultants who have given evidence is that
the unexpected collapse of a child leading to resuscitation or death is something that needs
looking at because by definition there isn't an obvious medical cause?
PEACOCK: Leading to resuscitation and death?
SKELTON: Leading to resuscitation which would otherwise have caused death, or leading to death
and, I mean, the difference between life and death in those situations can often be very
slight?
PEACOCK: Yes, yes.
SKELTON: For obvious reasons I am trying to understand why you make a -- in terms of learning,
why there is a differentiation from your perspective?
PEACOCK: As I say, the -- the -- I think if there were lessons to be learned then they would be
reported. They would be discussed at some level. That's the only answer I can give, I am sorry.
SKELTON: Briefly before I move on, and it might be said one of the reasons to report the
unexpected collapse where a child has nearly died and required full resuscitation is to set in
motion an investigative process which might not otherwise occur and to make sure that patterns --
a series of children were collapsing requiring full resuscitation is by definition worrying?
PEACOCK: Yes.
SKELTON: The whole purpose of your job was to identify such trends so that they could be
addressed --
PEACOCK: Mm-hm.
SKELTON: -- and remedied; do you accept that as logical?
PEACOCK: Yes, yes.
SKELTON: In this document I don't think it's fully defined what a Serious Incident is. What's the
difference between an incident and a Serious Incident as
far as you are concerned?
PEACOCK: So a Serious Incident would usually be resulting in some level of harm. However, it could
also be -- a Serious Incident could be a thematic review picking up on trends that could cause
potential harm.
SKELTON: There is a framework, I won't take you to it because it is a national framework?
PEACOCK: There is, yes.
SKELTON: Were you aware of that the NHS framework for serious harm --
PEACOCK: Yes.
SKELTON: -- that was in place at the time as a document, publicly available from March 2015?
PEACOCK: Yes.
SKELTON: Which I think is still in use? Is that the document which you would use as the sort of
source for what defines a Serious Incident as far as the NHS is concerned nationally?
PEACOCK: Yes, it is. However, that wasn't my decision. So, as I said earlier, we would complete an
SBAR, escalate that to the Serious Incident Review Panel and it would be their determination
whether something was classed as a Serious Incident.
SKELTON: Do you think, stepping back now, and having listened to your own answers, both to my
questions and
from Ms Brown, that the degree of ambiguity about what should or shouldn't be reported is a
problem that needs to be thought about?
PEACOCK: It certainly needs thinking about, yes. Yes.
SKELTON: Because if Eirian Powell thinks you should report resuscitations that nearly cause
death, you don't think you should report them, the wording --
PEACOCK: I am not saying we shouldn't report them, no. I am telling you what actually happened. I
think -- I think there should be some sort of local review of collapses to pick up on trends and
I'm not sure that that wasn't happening. But they -- at the time, they weren't reported on Datix
unless there was something unusual.
SKELTON: Without going into all the details, there does appear to be quite -- there is an
inconsistent pattern between the children, all of whom suffered collapses and many of whom died,
in terms of exactly what incidents or what investigations were prompted by the incident
reporting?
PEACOCK: (Nods)
SKELTON: One of the causes for that may be that there was a lack of understanding about what
should or shouldn't be done in response each time. So should a Datix be completed, should a
Serious Incident
investigation be initiated? That clearly needs to be thought about, doesn't it, to make sure that
--
PEACOCK: I think so, yes yes.
SKELTON: It's important for those on the ground involved in the incident they know exactly, or as
close as possible to exactly, what they need to do when a child collapses or dies: I need to do a
Datix?
PEACOCK: Yes.
SKELTON: Dr Brearey or his or her equivalent needs to initiate a certain type of
investigation?
PEACOCK: Yes.
SKELTON: That is clearly important?
PEACOCK: Mm-hm.
SKELTON: Can I ask you about [Child A]. [Child A] as you know died, he was the first death, as
you know he was murdered by Lucy Letby. There was a Datix in respect of his death. It is at INQ0000016. Ms Brown has already asked you a bit about this I just want to
ask you a little bit more. I will try not to cover the same ground. So this is the Datix admin
form for [Child A]. Would you expect extra details about a child's collapse and death from the
medical notes to find their way into the Datix?
PEACOCK: Not in detail, no. So this was just an alert to us that there had been a death. And then
we would make preliminary enquiries whereas I say Steve Brearey would review the death, the care.
And that would be escalated. So no, at this stage, probably not.
SKELTON: So it's the responsibility of the clinician who's following up on the initial report to
garner the information about the child's death, Steve Brearey in that case?
PEACOCK: Steve Brearey would do the review of the child's death, yes.
SKELTON: Okay. So information -- you may have heard about [Child A] had a rash as did his sister
that was unusual that was spotted at the time. Would you expect during the Datix investigation
process or associated processes that that kind of information would be captured?
PEACOCK: Not on Datix no.
SKELTON: Not in Datix?
PEACOCK: No.
SKELTON: Well, we will come on to the other things that are mentioned within the Datix because
Datix, this form at least reports other investigations or considerations, doesn't it, like the
Coroners' process, for example?
PEACOCK: Mmm mm I don't think the Datix forms didn't
inform the Coroner referrals.
SKELTON: You don't think what, sorry?
PEACOCK: The Datix forms didn't inform the Coroner referrals as far as I am aware.
SKELTON: No, but it is the other way round, I think isn't it. This document includes material
from the Inquest process?
PEACOCK: Not in the initial stages, no. That's only added to later on.
SKELTON: Absolutely.
PEACOCK: Yes.
SKELTON: Along the way updates are put in?
PEACOCK: Yes.
SKELTON: Perhaps we will come on to it and you can explain what's happening. Can we go to 5,
please. You were asked about this previously. So there is the SBAR. This is the SBAR section.
PEACOCK: Yes.
SKELTON: You can see that there is an assessment bit there where the mother's background, ie her
medical background, is considered, that has been removed for privacy reasons. It's then in the
next paragraph it says: "At present there is no explanation for the sudden cardiorespiratory
collapse. Twin 1 was stable until
then receiving the usual type of support in keeping with his prematurity, ie on CPAP and receiving
IV fluids and antibiotics. Initial PM findings did not give any answers, however we are awaiting
the results of pathology slide examination. However, if it was due to a cardiac arrhythmia this
would not show on this examination." There is a query about the mother's background there which we
see elsewhere on the form. But the reality is here that there is no explanation for the child's
death been found on the PM or identified by whoever has filled this assessment in?
PEACOCK: Mm-hm.
SKELTON: You have said repeatedly in your evidence today that you understood that the children
had died from natural causes?
PEACOCK: Yes.
SKELTON: In respect of [Child A] that was wrong, wasn't it, there wasn't an identified natural
cause for his death?
PEACOCK: This wasn't my SBAR and I -- I don't know, well, it's worded the way it is, obviously. So
it's the initial PM findings didn't give any answers and I understand that there wasn't a cause
identified in the final report.
SKELTON: No.
PEACOCK: Sorry, what was the question again?
SKELTON: I am trying to understand how you came to the view that this child died of natural
causes?
PEACOCK: I think I am going from what cause of death the doctors proposed and the fact that Steve
Brearey didn't find anything to suggest otherwise on his review.
SKELTON: But he -- there was some speculation that the mother's condition may have related to the
child's but that was never turned into anything positive?
PEACOCK: I don't remember, I am sorry.
SKELTON: Can I ask you about just a little bit further on, as we go down on to the SI Panel
meeting, this is another section. You can see Alison Kelly there, if we go overleaf, please.
Again, we do see as I mentioned before midway through that first section may be related to
maternal disease but again there's nothing in there that actually identifies the cause of the
child's death. Can you see that?
PEACOCK: Yes.
SKELTON: You are listed there I think as investigating officer. So at some point you were
aware?
PEACOCK: No, I was never an investigating officer. I don't know why my name has been put under
that title.
SKELTON: Well, who will have put you down?
PEACOCK: I really don't know.
SKELTON: And M&M is mortality and morbidity?
PEACOCK: Morbidity, yes.
SKELTON: So did you have no role in the type of investigation that went on as the named
investigating officer?
PEACOCK: So if there was a maternal concern then there was an obstetric secondary review and I was
part of that. If there was a neonatal concern there was Steve Brearey's review and Eirian, that I
was generally included in somewhere along the way. But I wasn't an investigating officer.
SKELTON: How -- how do you think it's happened that you were?
PEACOCK: Sorry?
SKELTON: Why do you think this is there?
PEACOCK: I really don't know. Sometimes these titles are preset and people just put names in where
they think appropriate.
SKELTON: And when it says "level of investigation", can you explain where M&M sits in the
hierarchy of seriousness?
PEACOCK: I can't. I would have thought that it had
been discussed at the Morbidity and Mortality Meeting and any concerns would have been escalated,
which I would have sent forward to the SI Panel on an SBAR.
SKELTON: Okay. The NHS Framework for Serious Incidents requires a root cause analysis to be
done.
PEACOCK: Yes.
SKELTON: Does [Child A]'s death qualify as a Serious Incident in the sense that he died
unexpectedly without explanation within an NHS setting?
PEACOCK: So as I say the review that Steve Brearey did and I wasn't, I was in America at the time
of this death, Steve Brearey's assessment, and obviously we have had an obstetric secondary review
here, I would have expected them to go to the Serious Incident Review Panel. So I didn't set the
level of investigation. It was set at the Serious Incident Review Panel that I was not part of.
SKELTON: Well, I understand that. What I am trying to ask you is looking at the facts of [Child
A]'s death, he is a premature baby, but he's in stable condition, he unexpectedly collapses and he
dies and there is no medical explanation identified on investigation. On the face of it that looks
like a Serious Incident?
PEACOCK: I would have thought it was a Coroner referral in the first instance.
SKELTON: It was a Coroner referral --
PEACOCK: So --
SKELTON: But does that call off a Serious Incident investigation if that happens?
PEACOCK: No, but the Coroner could direct us to undertake a Serious Incident Review. And I think
on one of the cases I know when we had the neonatal review on 8 February, there had been a request
come through from the Coroner for us to undertake a Serious Incident Review for long lines and
catheter insertion.
SKELTON: So there is a request in fact for this child repeatedly?
PEACOCK: Right, so I had seen that, yes. So ...
SKELTON: So just to understand. If -- if a Coroner referral is made by someone like in Dr
Brearey's position, the Serious Investigation will cease unless the Coroner asks for it to be
done?
PEACOCK: I really don't know, to be honest. Quite often the -- they are done in tandem I think
because quite often the Coroner will ask if there has been a Serious Incident Review. But
obviously the Coroner referral timeline-wise is almost immediately after the death. So it could be
that we have started
a Serious Incident in the meantime but I don't know whether it would actually put the brakes on a
Serious Incident Review.
SKELTON: Difficult to say, certainly in my own experience it can run in parallel and the Coroner
asks for the report and it becomes part of the Inquest but that's maybe local practice.
PEACOCK: Yes. As I say, I don't know what happened in this situation.
SKELTON: You I think left in February; is that right?
PEACOCK: Yes.
SKELTON: So the communications that went on with the Coroner are completely outside of your
knowledge when it comes to February onwards?
PEACOCK: Yes.
SKELTON: The Coroner does appear through their officer to have requested repeatedly for an SI
--
PEACOCK: Sorry, I can't hear you.
SKELTON: The Coroner's officer repeatedly requested for an SI or chased up if one had been done
but it was never done?
PEACOCK: Oh, right.
SKELTON: Are you able to explain why that decision might have come about at least in
principle?
PEACOCK: I noticed in my document bundle that there was an email from the legal department titled
"Urgent" from -- well, it had obviously come from the Coroners's officer to the legal department
asking for that SI to be undertaken. I unfortunately didn't get the email until the day after we
had done the neonatal review because it was only sent to me on 8 February, although the initial
email was at the end of January, so I don't know.
SKELTON: On the 28th.
PEACOCK: I don't know what that delay was caused by. Obviously I was on the point of leaving, so I
escalated that to my line manager, Ruth, and in my response to the legal department in the
hospital, I think I had put that Ruth had determined that it wasn't -- I think she -- I can't
remember the wording. It was to wait and see the outcome of some meeting or review. But obviously
that was -- I presume I had left by that stage.
SKELTON: Well, I appreciate you are doing the best you can. This may be a question for Ms
Millward; is that right?
PEACOCK: Why there was no follow-up, yes, definitely.
SKELTON: Okay. When it comes to this Datix document, if I am calling it, is this called a Datix
document?
PEACOCK: It is just called a Datix.
SKELTON: Just called the Datix?
PEACOCK: Yes.
SKELTON: It records the Inquest results?
PEACOCK: Mm-hm.
SKELTON: The Inquest result is that the death is unascertained and there the story ends when it
comes to investigation of the child's death within the hospital?
PEACOCK: Mm-hm.
SKELTON: Is that an appropriate response, the Coroner's investigation has proceeded, the
Coroner's investigation has not found an answer. But the other routes that could find answers, the
SI route, et cetera, the root cause analysis, have not been undertaken and never do get
undertaken?
PEACOCK: I think if we had postmortem results and the Coroner had been involved I'm not sure what
else we would find out at a Serious Incident Review.
SKELTON: Well, in this case of course you know what you might have found out: the child was
murdered.
PEACOCK: Yes, in retrospect we have that knowledge now but we didn't at the time. There were no
suspicions at the time and with this being the first baby death.
SKELTON: Again I have to take issue with that to some extent and it may be outside your knowledge
but you mentioned the rash that the child had had. As you
probably know, the rashes that the children had became a thing of significance because it led Dr
Jayaram to think these children may have been injected with air, so there was information within
the hospital that could have been captured?
PEACOCK: There was, yes.
SKELTON: By an internal investigation potentially?
PEACOCK: Yes.
SKELTON: I can't say it would have been.
PEACOCK: And I am surprised it wasn't picked up on Dr Brearey's review, to be -- to be honest, the
same with the insulin results that we had.
SKELTON: Precisely.
PEACOCK: They seem to have all been overlooked and I think having a Serious Incident Review --
well, we will never know now whether it would have identified those at the time.
SKELTON: But do you accept in principle the hospital were in possession of some information in
respect of this child and indeed in other children that could have led internally to the
recognition earlier on of an untoward event?
PEACOCK: Potentially. But as I say on those initial results, those things weren't picked up then.
SKELTON: On the question of insulin, is overdose of
insulin or giving children a child insulin that isn't medically required, is that a Never Event,
or do Never Events -- gross errors of administration?
PEACOCK: I'm not sure whether it falls within a Never Event. Insulin is mentioned somewhere, but I
would have to have the document in front of me, sorry. The list of Never Events.
SKELTON: It is mentioned but I think it's probably too much of a digression to take you to the
wording of it. Can I just put it this way perhaps: giving a child a large dose of insulin that
they don't require lead to go their collapse must be a Serious Incident requiring
investigation?
PEACOCK: I don't think anybody would dispute that.
SKELTON: Just involvement of the parents. The parents are mentioned a number of times in here
being spoken to and the Datix documents and there's mention of a duty of candour. To what extent
did you feel that there is an obligation to keep the parents updated about the investigation
process?
PEACOCK: I think there is an obligation there to keep them updated, yes.
SKELTON: So if, for example, a Serious Incident Investigation proceeds, would you expect the
parents to be notified of that?
PEACOCK: Yes, I would.
SKELTON: Who by?
PEACOCK: So that would usually be the clinical staff who have been dealing with the parents and
explaining things as they have gone along. I think -- at the time I was due to leave I think we
were looking at having a key person in the risk team to be a point of contact for parents. But I
-- that's just a vague memory, I don't know whether that actually happened.
SKELTON: The risk team?
PEACOCK: Just having somebody as a point of contact if they had any questions, not to actually
deliver the duty of candour that was felt it should be a clinical person doing that, so they could
explain, you know, the report what we had looked at, the significance of the findings.
SKELTON: Would you expect the person contacting the family to not simply try and deal with their
questions and update them about what's going on but trying to see if they have any information
that may be of value to the investigation itself?
PEACOCK: Yes, and that's certainly with the introduction of the medical examiner service, they put
the emphasis on the bereaved in that service and they would particularly ask the bereaved for any
information
that they have that might be relevant.
SKELTON: So in Mother A and B's case, she could have said, for example: I remember this rash on
my child, have you investigated it? And that may have fed back into the investigation team?
PEACOCK: I -- yes, yes. That is as it ought to be.
MR SKELTON: Thank you. Thank you.
LADY JUSTICE THIRLWALL: Thank you, Mr Skelton. I saw Mr Baker wasn't here, and I'm afraid I inferred that there were no questions.
MR JAMIESON: I'm afraid you have the understudy my Lady.
LADY JUSTICE THIRLWALL: You are very welcome.
MR JAMIESON: What I was going to do before I started was just to remark that this witness had
been giving evidence for quite a long time but it is also quite close to 1 o'clock so through you,
my Lady, if I may, as to enquire whether she would like to go on a bit longer and finish?
PEACOCK: I would sooner finish, if it's okay.
LADY JUSTICE THIRLWALL: I thought you might but thank you very much for raising that.
MR JAMIESON: Thank you, Mrs Peacock, I also ask you questions on behalf of the Family groups,
okay? My
name is Jamieson. Really what I would like, please, is your perspective on the importance of
critical challenge in the management of risk because what you have told us about your background
is that you had a unique perspective to bring through your long experience in the NHS and indeed
your training as a lawyer. My questions are going to centre on that meeting when you came back
from your annual leave in the July of 2015 and the information that was available to that meeting
and the actions that came out of it. Now, I acknowledge, as you have said, that in relation to
that meeting on 2 July, 2015 you, as you sit there, have no memory of that meeting?
PEACOCK: No, sorry.
JAMIESON: But just to put the pieces together as best we can, this was a Serious Incident
meeting?
PEACOCK: My understanding was that it was a Serious Incident Review Panel meeting --
JAMIESON: Right.
PEACOCK: -- to determine whether it was going to be a Serious Incident. I think they determined
that they wanted the obstetric secondary review and the neonatal review brought together on a
Level 2 template.
JAMIESON: That is the output of the meeting, isn't it?
PEACOCK: Yes.
JAMIESON: We will look at that later.
PEACOCK: So it wasn't.
JAMIESON: Really what I am interested in is that type of meeting. Was that one that you would
typically go to or was this unusual for you?
PEACOCK: It was unusual, yes.
JAMIESON: Yes, and the attendance at the panel, was that also unusual? For your memory, what we
have are Alison Kelly and Sian Williams who were the director and deputy Director of Nursing. We
had got Ruth Millward who was the head of risk and your boss, and Julie Fogarty, the Head of
Midwifery Stephen Brearey and yourself, so a high powered group of individuals, is that a fair
summary?
PEACOCK: Yes.
JAMIESON: Yes. Now, your role at that sort of meeting I know you have no memory, but would it
have been to ensure that the relevant information was there for everybody to consider, would that
have been part of your role?
PEACOCK: So I didn't usually attend these meetings.
JAMIESON: No.
PEACOCK: So I didn't know the format of them. I think Steve Brearey supplied the information and
from a neonatal perspective and Julie Fogarty was the head of midwifery provided the obstetric
overview. So no, I didn't contribute at that meeting.
JAMIESON: Really what I am particularly interested in respect the Datixes if that is the plural
for each of these children that we have had a bit of a look at, we will look at again in a moment,
were those available at the meeting, had the attendees read them ahead of time, what was your
expectation?
PEACOCK: I don't know, sorry.
JAMIESON: You don't know?
PEACOCK: I would presume that they -- they were not available, but I can't be certain about that.
JAMIESON: Maybe just look at something that may help. It's a document, I am sorry, we have looked
at a couple of times, but we will do it quickly. It is Datix for [Child A], it is INQ0000016. Now, we have looked at this lots of times. I'm not going to take
you through what you have been through already but what we have on this first page are the initial
details of what is reported. If we go on to page 5, please, we have the SBAR which you have told
us is the then subsequent investigation that takes place upon the reporting of a Datix, but then
it's really just at the bottom of this
page. Can you see that this is a section that's headed "SI Panel meeting", it has the date of that
meeting that took place, 2 July, and then thank you very much, if we could just go on to the next
page, so page 6, it is the follow-on. That appears to be a minute or a note of what was discussed
on that meeting, 2 July. My question is, would that have been one of your tasks, the inputting of
this information into this document to take away from that meeting?
PEACOCK: I didn't normally update Datix with -- as I say, I didn't go to the SI Panel meetings.
JAMIESON: I understand that. But in relation to this meeting --
PEACOCK: I really don't know, I'm sorry.
JAMIESON: In relation to this meeting you are there, you are, and I say this respectfully, but I
think you are the most junior --
PEACOCK: Yes.
JAMIESON: -- of the attendees?
PEACOCK: Yes, I accept that.
JAMIESON: So we can see although you are clear that you would not have been the investigating
officer, the name that has been attached to the bottom of this segment is yours, Debbie Peacock.
Is this or if I were to suggest to you that this looks like a minute of that meeting, can you help
me?
PEACOCK: As I say, I really don't remember. I don't recall at all.
JAMIESON: All right.
PEACOCK: I was used to the Datix forms having the person's name and time if they made an amendment
to the form.
JAMIESON: Sorry, say that --
PEACOCK: I was used to the Datix forms actually logging who had made any amendments.
JAMIESON: Yes.
PEACOCK: The date and time that those amendments had been made. So without seeing that on here, I
wouldn't know whether it was my work or not.
JAMIESON: I think we are going to see an example of that in a moment and you're right that there
isn't one here. But what I can see, just looking at this page, is that under "SI tracker",
somebody called Janet McMahon has stated as at 10 August '15 that this report is complete. Can you
see that?
PEACOCK: I can, yes.
JAMIESON: And if we went on to page 8 of this document, thank you very much, we would see right
at the bottom the closed date, this document is being marked as
completed on 10 August 2015.
PEACOCK: Mm-hm.
JAMIESON: So it doesn't look like any entries or any substantive entries after that point in
time. Now, Mr Skelton has just asked you questions about what you had said about thinking natural
causes for the death and in fact when you looked at the contents of what was here, there was
nothing that proved natural causes?
PEACOCK: No, we had no conclusion.
JAMIESON: The question was still open.
PEACOCK: Mm-hm.
JAMIESON: Right. So with that in mind, can we go all the way back to page 1, please. The risk
grading of this form at the point that it is closed looks very much like it is graded as: no harm.
Can we see that?
PEACOCK: Yes.
JAMIESON: The potential for harm is there and it has been properly noted, but the decision at the
point of closure of this form when the postmortem and the Coroner's investigation is not going to
be completed for another year, I believe, is that there is no harm and no actual harm. And those
gradings really mattered for your system, didn't they?
PEACOCK: They mattered for pulling the Datix data together, yes.
JAMIESON: Yes.
PEACOCK: Yes.
JAMIESON: Perhaps we can just illustrate that point now before we look at another Datix. That
will be the end of that document, thank you very much. If we go to the trend report that again we
have looked at briefly, so that's INQ0015141. Now I make -- we can see from the date of it it's not dealing
with this cluster of deaths, it's not that time period but it would have captured at least one
other death during this period --
PEACOCK: Yes.
JAMIESON: -- and some collapses. But we can see that if we go on to page 3, please, we can see
the overall incident table that you have pulled together, as I understand it, for presentation at
one of the governance boards. They are graded by department and if we go on to page 6 we can see
the particular table for the NNU and we can see just looking at that top table the way in which
these risks are brought to the attention of the governance board is in order of their harm: none,
low and moderate. And if I just look under that table, I can see that the text underneath; no harm
incidents do not have
a further description, but where there is some harm there will be a short explanation. So I looked
at the low harm incidents. I can see three health and safety incidents, two inoculation charts
injuries and: "A falling window blind hit a member of staff on the hand and a baby's
identification band marked the skin even though it was not tight (skin remained intact)." And then
there is a description underneath that of the moderate harm of a member of staff who scalded her
hand as a result of not following the standard operating procedure for a particular item. So if I
looked at that table and I am on that board, the understanding I am going to take is that there
have only been a few incidents that have caused harm and they are of the nature of what I have
read about in that text, aren't they? There's not going to be anything in there that tells me
about sudden and unexpected baby deaths?
PEACOCK: So if you look at the report that was pulled together on the SI template, I think it was
regraded as severe harm.
JAMIESON: Which one, sorry?
PEACOCK: The -- the combination of the obstetric
secondary review and the neonatal review on to the one document.
JAMIESON: When are you talking about? Are you talking about into 2016?
PEACOCK: No. I had left by then. I am talking about the one after the July meeting that I was
asked to pull together.
JAMIESON: Right, okay.
PEACOCK: So it was regraded as severe harm. Because that was viewed as a Serious Incident, a Level
2, that would have been mentioned further down in my report because I would generally put --
JAMIESON: Okay.
PEACOCK: -- RTAs --
JAMIESON: Okay --
PEACOCK: -- or whatever. So it would be included in this report and it would go to the board as a
report with an action plan for us to follow up at board. So it was very clearly it would be on
that.
JAMIESON: So I believe what you are referring to is the report that was put together in relation
to [Child D]?
PEACOCK: Yes.
JAMIESON: Is that the one you mean?
PEACOCK: Yes.
JAMIESON: So what you are telling me is because of those
two things were put together in that particular case, there was a special report --
PEACOCK: Yes.
JAMIESON: -- which would have highlighted its import?
PEACOCK: Yes.
JAMIESON: Fine. Thank you. That's important evidence and I am glad you have given it. But just in
relation to the point that I am making with you, the grading of the harm in those Datixes really
matters because unless there are one of those stage 2 reports, which brings the risk to the
attention of the board in another way, all they are going to get is this?
PEACOCK: But if it had been deemed that there was no harm, there wouldn't be anything to report at
that stage --
JAMIESON: Yes.
PEACOCK: -- apart from the rise in mortality.
JAMIESON: But that's the point I am making --
PEACOCK: And the rise in mortality would have come at the end of the year in my report then when
we had the full year to look at and we could break it down further from there.
JAMIESON: I think with an eye on the time, I am going to really compress this right down and just
look -- since you raised [Child D], may we just look at [Child D]. Could we look at the Datix INQ0002658. Now, again we have looked at this one already we are going to
look at it in a bit more detail now. This unusually is the Datix, as I understand it, that related
to the mother, not the child?
PEACOCK: Yes.
JAMIESON: But as we are going to see much of the content of it actually does relate to the
child?
PEACOCK: Mm-hm.
JAMIESON: But I give that clarification at the start because when we look at risk grading, which
is put at actual harm, result: actual harm, actual harm, moderate, potential for harm, low
potential harm; in fairness, we should probably be looking at it through the lens of the mother
rather than the baby. But in relation to the details we have them there. If we could just go on to
page 2, please. If we just crop in on the top half of that page. Do you remember that you said to
me your experience of this system was that when an amendment was made to it there would be a date
stamp?
PEACOCK: Yes.
JAMIESON: As I look at that first paragraph, there are three date stamps. So I say first
paragraph, can you
see three entries on the left-hand side?
PEACOCK: Yes.
JAMIESON: At the bottom of that, as I look over to the right-hand side, there are a number of
date stamps. The earliest in time is 24 June 15 at 10.45 in the morning, Debbie Peacock. Can you
see that?
PEACOCK: Sorry, 24 June?
JAMIESON: Yes. So of the three Mr Bennett, Mr Dean Bennett entries --
PEACOCK: Yes.
JAMIESON: -- the bottom one, if you look over to the big Registrar on the right --
PEACOCK: Yes.
JAMIESON: -- there are then three date stamps at the top of that paragraph.
PEACOCK: Oh, yes.
JAMIESON: And it's the one that's just been highlighted for you. Thank you very much, Mrs
Killingback. 24 June 15 at 10.45 "Debbie Peacock" and then what follows, as has been discussed is
the email from Stephen Brearey that has been sent to you?
PEACOCK: Yes.
JAMIESON: And you, it looks like, have copied and pasted this into this document at this
time?
PEACOCK: Yes.
JAMIESON: So can we take it that from that date and that time, this information was available to
anybody who looked at this date Datix?
PEACOCK: I presume so, yes, who had access to the Datix.
JAMIESON: Okay. Did you read what you copied and pasted into it?
PEACOCK: Sorry, I don't remember.
JAMIESON: What was your practice? Would you have just copied and pasted it without reading it
given that your job --
PEACOCK: No, I would usually have read it to see whether there was any pushback that I needed, any
challenge on what Steve or clarification from what Steve had found.
JAMIESON: Right. So we know that as at 24 June, a week or so before you go to that meeting on 2
July, you have received this email, you have put it into this Datix and we have got the familiar
analysis of any common issues in that second paragraph underneath. There don't seem to be any
common items of infection or equipment or location. But there is a common member of staff. The
final document, please, that I would ask us to look at is the Level 2 report, as you have called
it,
the which is INQ0014204. I think this is the document that you were --
PEACOCK: Yes.
JAMIESON: -- talking about in answer to my earlier question. If we go to page 2, please. Can you
see under "Detection of incident", the fourth paragraph under that looks like a description, a
minute of that meeting of 2 July 15. Can you see that?
PEACOCK: Yes.
JAMIESON: The incident was escalated to the Medical Director. Now, did you write that
paragraph?
PEACOCK: I really don't know.
JAMIESON: Okay. Because what it records there is that it records the meeting, it tells us that in
addition to the Director of Nursing and quality, that's Alison Kelly, this matter had also been
escalated to the Medical Director at that time, but there had been three neonatal deaths in a
short period of time and the circumstances were discussed to identify if there was any commonality
which linked the deaths. And that section of that email that you had put into that Datix were
circumstances which potentially related to commonality of the deaths, didn't it?
PEACOCK: Yes.
JAMIESON: Yes. So you have no memory as to what was discussed?
PEACOCK: No, sorry.
JAMIESON: But this record, close to the time, tells us that those are the sort of features that
were being discussed. What it goes on to say is that two of the babies had medical conditions
which could be clearly seen to have contributed to their deaths. Now, just pausing there. Mr
Skelton did the exercise with you with [Child A]. Actually when you looked at that Datix, it
didn't tell you that there was something in the background that caused the death: maybe, maybe
not; the question was not answered. If we looked, if we had the time to look at the Datix for
[Child C], we would do a similar exercise. I am not going to do it with you now but I am just
going to note it. But what it goes on to say is this: "The third baby appeared to be an
unexplained death and at this time the baby's cause of death was unknown. It was agreed that no
further investigation was warranted at this stage as there were no concerns highlighting any
obstetric or neonatal views. However, the SI panel were of the opinion that the obstetric
secondary review findings and the neonatal findings
should be put into this one report." That's sort of set out even more starkly if we go, please, to
page 8. Care and service delivery problems are set out. They are of the nature that they are.
Underneath there: alleged contributory factors: none. So nothing here that can have contributed to
the death. Root causes: no root cause has been identified. But yet no further analysis is going to
be undertaken at this time. That's really what I would like your reflection on, your understanding
on. You have -- The Families would say to you that all of the information in relation to [Child A]
and [Child C] was there to see that these were unexplained deaths at the time. But putting that to
one side, in relation to [Child D], that is your conclusion. This is a sudden death, it's an
unexpected death, it's an unexplained death. Why was there not more consideration?
PEACOCK: So this wasn't my conclusion. I have obviously -- I don't know where I have taken this
from. This report would have been circulated to the staff at the meeting before it was finalised.
So I don't know whether it's been tweaked along the way. I don't know where I have got this
information. I thought I had copied and pasted it looking at it. I really don't
know, I'm sorry.
JAMIESON: But this, you are telling us in clear terms, this is the outcome, this is the decision
of that meeting of 2 July '15, which had the membership that I set out with you at the start.
PEACOCK: So my understanding is that they were going to reconvene when we had the postmortem
results --
JAMIESON: Right.
PEACOCK: -- to determine then if there were further actions required. That was my understanding
reading the document.
JAMIESON: And in fairness to you that postmortem I think, or at least the Coroner's
investigation, completed after you had left the Trust?
PEACOCK: Right. MR JAMIESON: There it is. My Lady, thank you very much. I apologise if I have
trespassed into the lunch.
LADY JUSTICE THIRLWALL: Not at all. Thank you very much, Mr Jamieson.
MR JAMIESON: So sorry, there is another page that we are asked to put to the witness. (Pause) I'm sure we can put that right at a different time. Thank you very much.
LADY JUSTICE THIRLWALL: Very well. Thank you very
much, Mr Jamieson and Mr Kennedy. Mrs Peacock, I have just got two brief matters to ask you about.
I asked you a question earlier, where I had obviously not listened carefully to what you had said
in the first place. It was in relation to the chart that we have looked at -- well, we have, you
haven't looked at -- many times with the name of the various nurses who were on shift when babies
collapsed. And you said, quite rightly, that what you had said was that she hadn't been looking
after the babies and I asked you why you were saying that, and you rightly say it's in the chart
which of course we all know well. I had a note of what you said earlier and I want to check that I
have got this correct and if not, you just tell me. Much earlier in your evidence, when you were
being asked about the fact that it looked as though there was a nurse who was present for number
of the deaths, I have noted you as saying -- and I have not been able to check it on the
transcript -- she wasn't on duty for other deaths. Now, did you mean she wasn't on duty for other
deaths or did you mean she wasn't always the allocated nurse?
PEACOCK: So my understanding was that there were other deaths -- where they fell, I don't know in
the timetable of, of -- that we have here --
LADY JUSTICE THIRLWALL: So sorry --
PEACOCK: -- that she wasn't actually present on the unit for.
LADY JUSTICE THIRLWALL: Thank you. So my note is correct. She wasn't on duty for other deaths. I
don't suppose you are able to help us as to which ones?
PEACOCK: I'm sorry, I wasn't involved in the trial at all, so I don't know the indictment babies
or the others.
LADY JUSTICE THIRLWALL: No, all right. Thank you. Then one last question, if I may. You were
asked very early in your evidence about the Clothier report in relation to Beverley Allitt and one
of the recommendations being that there needs to be a heightened awareness of malevolent intent
and you referred us to an algorithm --
PEACOCK: Yes.
LADY JUSTICE THIRLWALL: -- which you had. But just so I understand it correctly. The algorithm
doesn't anywhere direct you to consider malevolent action, does it?
PEACOCK: Yes, it does.
LADY JUSTICE THIRLWALL: Oh, it does?
PEACOCK: It starts off: did they do it? Was the
outcome intended? And it takes you through. But the actions for "yes", if it was intended is
consider the police.
LADY JUSTICE THIRLWALL: Thank you. But you never referred to it when considering this case
because ...?
PEACOCK: There was no act or omission at that stage for us to consider it in relation to any
person.
LADY JUSTICE THIRLWALL: Does it mean, therefore, and I just want to understand because you
mentioned that you had always at the back of your mind the possibility of malevolent intent, or
whatever phrase you might use, but that never came to the front of your mind?
PEACOCK: On the information that I had, no, unfortunately.
LADY JUSTICE THIRLWALL: All right. Thank you very much indeed, Mrs Peacock. You are now free to
go.
PEACOCK: Thank you.
LADY JUSTICE THIRLWALL: Ms Brown, are you able to help about the timetable for the afternoon? I know we have got Ms McMahon.
MS BROWN: Yes. We have two witnesses that are being called this afternoon.
LADY JUSTICE THIRLWALL: Yes. Are we going to complete their evidence this afternoon?
MS BROWN: I'm just looking behind me.
LADY JUSTICE THIRLWALL: Yes, I can see there's someone who knows better than you.
MS BROWN: Yes, yes, I am told we will.
LADY JUSTICE THIRLWALL: Good. I think Ms McMahon has probably been waiting all morning, but I'm afraid we will start again at quarter past 2.
(1.12 pm) (The luncheon adjournment)
(2.15 pm)
LADY JUSTICE THIRLWALL: Mr De La Poer.
MR DE LA POER: My Lady, the first of our two witnesses for the afternoon is Janet McMahon and I wonder if she might come forward, please.
LADY JUSTICE THIRLWALL: Yes, do come forward, Ms McMahon.
MRS JANET MCMAHON (Sworn)
LADY JUSTICE THIRLWALL: Do sit down.
MCMAHON: Thank you.
MR DE LA POER: Please can you state your full name?
MCMAHON: Mrs Janet Lesley McMahon.
DE LA POER: Mrs McMahon, is it correct that you have provided to the Inquiry two witness
statements, one dated 13 June of this year and one dated 3 October of
this year?
MCMAHON: That's correct.
DE LA POER: Are the contents of those two witness statements true to the best of your knowledge
and belief?
MCMAHON: Yes, they are.
DE LA POER: We will begin with your background. Did you qualify as a Registered Nurse in
1985?
MCMAHON: Yes, I did.
DE LA POER: And then in 1987 as a midwife?
MCMAHON: Yes.
DE LA POER: At that stage, did you start work at the Countess of Chester Hospital?
MCMAHON: Yes.
DE LA POER: If we move forward in time to 1998, from that date forward, did you work
predominantly as a midwife on the labour suite?
MCMAHON: Yes, I think so, I wouldn't be sure of the dates, but I think so.
DE LA POER: Around that time at least?
MCMAHON: Uh-huh.
DE LA POER: Moving forward approximately a decade. You tell us in your witness statement that you
became a governance facilitator in 2007 --
MCMAHON: Yes.
DE LA POER: -- is that right?
MCMAHON: Yes.
DE LA POER: Which department did the governance facilitator role work from?
MCMAHON: At that time I worked for therapies, pharmacy, radiology.
DE LA POER: At what stage did you join the Risk and Safety Department?
MCMAHON: That was the Risk and Safety Department. It just -- we just changed names.
DE LA POER: So to all intents and purposes it was the same department, just differently
branded?
MCMAHON: Yes.
DE LA POER: In terms of the role of governance facilitator as it started out, in summary what
were you expected to do?
MCMAHON: Look at incidents daily for the areas that I covered and look into any concerns that were
raised.
DE LA POER: In the early stages in terms of the areas that you covered, did that include
obstetrics?
MCMAHON: Not initially.
DE LA POER: Did there come a point in time where it included obstetrics?
MCMAHON: Yes. So I worked for the therapies division for probably a couple of years and then moved
back to
Women's and Children's.
DE LA POER: Once you moved back to Women's and Children's, did your role include looking at
neonatal incidents?
MCMAHON: Yes.
DE LA POER: In terms of your background, experience and training, did you have adequate knowledge
as someone who had practiced as a midwife to do your role so far as neonatal medicine was
concerned?
MCMAHON: I believe so.
DE LA POER: What level of knowledge did you need, practically speaking, to be able to do that
role when looking at an area that you hadn't practiced in?
MCMAHON: To be aware of potential risks and when to escalate them for other people who had more
neonatal knowledge than I did.
DE LA POER: Now, we know from Ruth Millward's statement that initially on an interim basis but
that was then confirmed into a full role, she was the head of the Risk and Safety Department from
about 2013. Does that accord with your recollection?
MCMAHON: Probably. I wouldn't know the dates but I think so, sounds --
DE LA POER: That sounds about right?
MCMAHON: That sounds about right.
DE LA POER: To put it another way, by the time we get to
2015, Ruth Millward was well-established as the head of that department; is that right?
MCMAHON: Yes.
DE LA POER: And you, who had been there even longer in that department, were also
well-established; is that fair?
MCMAHON: No, Ruth was in the department when I joined. She was a governance facilitator at the
same time that I was but I joined later.
DE LA POER: Forgive me, I should have been clearer in my question. She was well-established as
the head of the department --
MCMAHON: Yes.
DE LA POER: -- by the time we get to 2015?
MCMAHON: Yes.
DE LA POER: But in terms of her experience of the department overall, obviously that stretched
back before she took that role?
MCMAHON: (Nods)
DE LA POER: Just continuing with your history. We know that Debbie Peacock who the Inquiry heard
from this morning, and I think you were present in the room when she gave at least some of her
evidence, left the Countess of Chester in February of 2016?
MCMAHON: (Nods)
DE LA POER: At which point her role became effectively vacant. The Inquiry has information to
suggest that you may have undertaken her role for a period of time on an interim basis; is that
correct?
MCMAHON: Yes, at the same time as doing my other role. So I was covering -- it was a dual role,
but yes, for the three months before Annemarie joined, yes.
DE LA POER: Absolutely. And when by the time we get to May 2016 Annemarie Lawrence then took over
the role that Debbie Peacock had previously undertaken and which you had filled in for?
MCMAHON: Mm-hm.
DE LA POER: In terms of that period February 2016 to May 2016, you have described it as a dual
role. Were you given any more hours or pay or anything to reflect the fact that you were expected
to do more than you had previously?
MCMAHON: I don't believe so. I don't recollect.
DE LA POER: How well placed do you consider you were, at the time, to take over that role from
Debbie Peacock for a period of time?
MCMAHON: With my background of midwifery and previously having covered the obstetrics and gynae
departments, I felt able to do that, from an experience point of view. But obviously time-wise
there was a conflict.
DE LA POER: So no difficulty in terms of your qualification for the role in your mind, tell me
about the time conflict as you have characterised it, what do you mean by that?
MCMAHON: Because if you are doing two people's jobs, you can't do them both the same as if you are
only doing your own.
DE LA POER: Were you effectively performing two full-time roles or did you have any support for
the two roles that you were undertaking?
MCMAHON: I don't really remember. But I imagine that you would prioritise differently given the
two workloads.
DE LA POER: Just looking back on it and being as reflective as you can, do you think that you
gave sufficient time in that conflict situation as you have described it, to the Risk Midwife role
or do you think that you were compromised in that?
MCMAHON: I think I probably did the best I could. It's quite often that situation happens, where a
member of staff leaves and they are not replaced for some time afterwards so it's a recurrent
happening in the NHS that roles aren't covered immediately. So that work has to be covered by
somebody else in the interim.
DE LA POER: The role of Risk Midwife which you were
covering, is that an important role within the hospital, do you think?
MCMAHON: Absolutely.
DE LA POER: Did you receive any additional training for undertaking that role or were you just
one minute doing one role and presumably after a short period of consultation then doing both?
MCMAHON: I had done the role before. And I had been in the team quite a number of years by then,
so I felt qualified and experienced enough.
DE LA POER: But in terms of things move on in the NHS, computer systems change, practices change,
policy changes. Did you feel you needed any additional support to undertake that role?
MCMAHON: I was doing the same role but for different areas. So I was used to the -- the electronic
systems, the policies.
DE LA POER: What had been your role title at the point that you took over the Risk Midwife role
on an interim basis as well?
MCMAHON: Project Lead.
DE LA POER: Was that the same role, Project Lead, as you had had as a governance facilitator or
were there differences to it?
MCMAHON: No, there were differences to it.
DE LA POER: What were those main differences, please?
MCMAHON: So as Project Lead I focused on certain areas, for example I think at the time I was
looking at falls in the Trust, it was a high safety incident so we looked at falls and how we
could manage them and reduce harm.
DE LA POER: So we have the period of time when you are doing both the Project Lead role and the
Risk Midwife role and I think it was in May of 2016 that you were seconded to the role of Patient
Experience Lead; is that right?
MCMAHON: That's correct.
DE LA POER: Was that also within the Risk and Safety Department or was that in a different
department?
MCMAHON: Initially, before I took up the post, it was a different department managed by a
different manager and then three teams were merged into one at the same time as I took up that
post.
DE LA POER: So was that in May 2016?
MCMAHON: Yes.
DE LA POER: Who was your line manager once those departments were merged?
MCMAHON: Ruth Millward.
DE LA POER: So in terms of line management it remained the same, but you were working with what
was had previously been a separate part of the hospital?
MCMAHON: Yes.
DE LA POER: Did you hold that role for 18 months?
MCMAHON: Just over 18 months.
DE LA POER: Having undertaken that role for 18 months, did you then come back to a risk role?
MCMAHON: Yes.
DE LA POER: You tell us that at that time it was described as the Risk and Safety Lead?
MCMAHON: Yes.
DE LA POER: Again the Risk and Safety Lead, is that different from the Project Lead or is it the
same job, just differently titled?
MCMAHON: Similar job, I was just aligned to an area rather than focused on different projects. As
a Project Lead I didn't have a certain area to work whereas a Risk Lead, you had certain areas.
DE LA POER: Finally to complete your history in the NHS, did you retire in 2020?
MCMAHON: I did.
DE LA POER: So we are just going to move to consider in a little bit more detail the culture in
the Risk and Safety Department. Your line manager throughout the period that we are focused upon
was Ruth Millward, what was your working relationship with her like?
MCMAHON: I had a very good working relationship with Ruth for a long time until the merger of the
three services, while I was in secondment post and the relationship deteriorated quite
significantly.
DE LA POER: That was the subject matter of your second witness statement; is that right?
MCMAHON: (Nods)
DE LA POER: If we just deal with that in summary. Once you were seconded to that post, did you
find yourself in a position where you felt unsupported and effectively out on a limb?
MCMAHON: Yes.
DE LA POER: And experiencing a very high degree of pressure upon you to deliver?
MCMAHON: Yes.
DE LA POER: So before May 2016, the Inquiry can proceed on the basis that your working
relationship with Ruth Millward was a good one?
MCMAHON: Yes.
DE LA POER: What was she like as a manager, what was her managerial style?
MCMAHON: She had an open-door policy, she was usually very supportive and welcomed challenge,
escalating and she usually made very good judgments.
DE LA POER: And in terms of the pressure the department
was under, let's take it in stages, up until the point that you undertook the interim Risk Midwife
role, so up to the point of February 2016, what was the working environment in the department like
in terms of how busy it was, how much pressure you were under?
MCMAHON: It was always very busy. Always a lot of pressure, it's quite a high pressure job looking
at incidents, things that could be going wrong. So it was always very busy, quite stressful.
DE LA POER: Once you were undertaking the dual role that you were for the three-month period
before your secondment, obviously you were much busier, as you have told us, but how about the
department generally, was it under any greater pressure during that period or was it the same or
were you simply focused upon what you were trying to achieve?
MCMAHON: I think the pressure was the same for everybody, it has a knock-on effect because whilst
I was covering two roles, some of the work I should have been doing would have gone to somebody
else. So the pressures is sort of shared throughout the team.
DE LA POER: Now, I am given to understand that you have considerable experience of the operation
of the Datix system; is that right?
MCMAHON: I do.
DE LA POER: And that you can help us by starting by providing a summary with the origin of the
Datix system at the Countess of Chester, we don't need precise dates or anything like that, but
how it was first adopted and for what purpose and then how it developed over time?
MCMAHON: So I can't remember the date it started but quite some time before I went into the risk
team. It was an electronic system to monitor incident reporting initially, that is all we did on
it by way of being able to pull reports, recognise trends, themes, do data analysis. Then the
system grew to include complaints and claims, the complaints side of things didn't go in there
until I was actually in the patient experience post, but it was a growing system that was changing
very, very frequently.
DE LA POER: In terms of who effectively had ownership of that system within the hospital, did
that sit with your department?
MCMAHON: Yes. I can't remember exactly when but we employed a Datix compliance manager and so she
initially managed the incidents and then later on it was another person who came in and that's
when the development started of the programme.
DE LA POER: But was that person in the Risk and Safety
Department?
MCMAHON: Yes.
DE LA POER: So they were part of that umbrella?
MCMAHON: Yes, yes.
DE LA POER: Therefore if it was effectively owned within the hospital by that department as being
the place that people would turn to if they needed help, does that mean that that same department
had responsibility for ensuring that everybody else in the hospital understood what their
responsibilities were?
MCMAHON: Yes. And we provided training on mandatory training days, we did a risk talk which
included Datix, Datix reporting and the purpose of the system.
DE LA POER: In terms of the reach of that training, I mean in the beginning of 2015, to take a
moment in time, would it be your expectation that everybody who had worked in the hospital over
the previous 12 months would have all received Datix training in that time?
MCMAHON: They should have done and also there was a statement at the top of the report to say that
if you required help that you could contact us and we often assisted people reporting incidents so
the support was there but it wasn't always taken but it was always there on offer.
DE LA POER: Of course that offer of support requires a person to understand that they need the
support, they need to understand their own deficiency or shortcoming or uncertainty before they
can reach out; is that fair?
MCMAHON: Mm-hm.
DE LA POER: That is not in any way critical of the offer that's made. The Inquiry has seen an
example which we will look at with Ruth Millward about how over time definitions can sometimes
change or new national policy comes out that expects a different way of working or an improved way
of working, was it your experience within the NHS that there were updates to how people were
expected to interact with the Datix system or Serious Incident reporting?
MCMAHON: I'm not sure so much that there were updates. But we had a very, very high reporting
culture nationally. So that kind of indicates that people did know when and how to report. Any
updates to the system might go out to that department that's being updated or by a generic email
if it affects the whole Trust.
DE LA POER: So from your point of view, just sitting at the place that people can reach out to,
what was your overall impression of -- across the hospital of the understanding of what was
expected of every single person in terms of Datix?
MCMAHON: I believe that most staff knew that they
should report a Datix incident as soon as possible. Often you would -- when you would read an
incident it wouldn't be reported as you would report it because sometimes it's subjective. For
example, when things are reported as "no harm" or "severe harm" it might -- be that is their
perception at the time and when we do the investigation or review the incident that is when we
will change to the realistic categories.
DE LA POER: But of course the important thing is that someone has filled in a Datix so that the
incident can start its paper life, it enters the process at that point and then can be reviewed to
be improved, updated, corrected, that sort of thing?
MCMAHON: Mm-hm.
DE LA POER: But the fundamental point is that none of that happens unless somebody completes a
Datix?
MCMAHON: No, because as part of the process anybody who recognises an incident should also phone,
alert their manager or the risk lead. So completing the Datix is not the be-all and end-all, it is
important, but the important thing is to escalate whatever concern you have picked up by either
phoning the risk team or your ward manager wherever the incident happened.
DE LA POER: In just a moment we are going to look specifically at your perception of the neonatal
unit but
before we get to that, can we just stay with how Datix works in principle. Is it right to say that
there were effectively three important roles at the early stage of a Datix and I will tell you
which roles, I mean, you can comment on them. You have the role of the reporter, the role of the
handler and the role of the manager?
MCMAHON: (Nods)
DE LA POER: Each an important role. So can you just-- I mean, the first one I am sure is
perfectly obvious, but let's deal with all three. The role of the reporter?
MCMAHON: So the reporter has identified an incident and they report it on the Datix system. The
Datix will then be accessed within the next working day by the handler who will look through the
incident and allocate it accordingly, so, for example, if it was a neonatal incident, it would
have gone to Debbie Peacock, if it was a radiology incident at one time it would have gone to me
as the manager.
DE LA POER: So if you just pause there. So the handler is a person within the risk department who
has effectively as part of their portfolio the department that it's come from?
MCMAHON: So they open up Datix in the morning to -- to
open and approve all the Datix that have been reported since the last working day.
DE LA POER: So as far as you were concerned when you took over the Risk Midwife for a period of
three months, would you have been the handler for any Datix coming from the neonatal unit?
MCMAHON: I would have been the manager.
DE LA POER: You would be the manager. Now you mentioned that Debbie Peacock in the context of
being the handler, she was the Risk Midwife?
MCMAHON: No, the handler is the person who first opens, so the handler every morning will open up
the entire Datix system and access all the Datix reports that have been made since the last
working day and they allocate to the manager.
DE LA POER: They allocate to the manager and so you and Debbie Peacock sit at the manager
level?
MCMAHON: Yes.
DE LA POER: So the handler, are they somebody junior to you or in the roles that you had within
the Risk and Safety Department?
MCMAHON: Junior. When I first started in the role we -- the risk leads, then governance
facilitators, used to open and access the Datix. But as time went on, we had administrative staff
to do that.
DE LA POER: All they are doing is really -- I hope I am not underselling it here, saying this has
come from, for example, the neonatal unit, Debbie Peacock is the risk lead for the neonatal unit,
I need to put it on -- across her desk?
MCMAHON: (Nods)
DE LA POER: Now, we will come back to how the manager can change over time and look at some
examples, but was it the manager's role to write what is termed an SBAR?
MCMAHON: If it was a serious -- if it was a patient safety harm incident and required an SBAR. Not
all incidents would require an SBARS, it would only be incidents of concern.
DE LA POER: SBAR of course --
MCMAHON: Sorry, and yes, the manager would do that, would investigate it, get it an initial
picture, write the SBAR which would go to the Execs.
DE LA POER: Situation Background Assessment Recommendation is what that acronym stands for?
MCMAHON: Yes.
DE LA POER: Presumably that provides a format for the way in which such a report should be
written?
MCMAHON: That's right, it is a communication tool.
DE LA POER: And so the manager looks at the Datix, makes a decision about whether or not it
justifies an SBAR
having made the enquiries they want to. If yes, then the SBAR is created and it's sent on to the
Execs?
MCMAHON: It might be discussed with Ruth Millward before an SBAR is undertaken.
DE LA POER: Once an SBAR is written is the expectation that there will be a Serious Incident
Review Panel convened?
MCMAHON: So the Serious Incident Review Panel happened weekly. So any SBARS would go to that
panel.
DE LA POER: So not convened for that SBAR; because it is happening --
MCMAHON: Unless it was something of particular concern.
DE LA POER: Is it at that review panel meeting that a decision is made about whether or not the
event is going to be classified as a Serious Incident so far as the NHS England criteria is
concerned?
MCMAHON: Yes.
DE LA POER: Are there two levels of investigation at that stage?
MCMAHON: There is MPSA Level 1, MPSA Level 2 and MPSA Level 3.
DE LA POER: Three. So tell us please what the difference so far as you can recall between the
different levels are and who's deciding that?
MCMAHON: So it was the National Patient Safety Agency
that decided on the levels of investigation. Level 1 is a lower level, less concerns, Level 2
would be more serious where there may have been serious harm, for example, and every event where
something shouldn't have happened. And Level 3 is more about deaths but I think it's homicide it's
actually classed as in the -- in the literature.
DE LA POER: In terms of?
MCMAHON: Sorry, external investigations they are normally, so like the police.
DE LA POER: External investigations therefore for police. So within the system, had somebody been
saying in the clearest possible terms all the way up the chain "We think that Letby has killed
this baby", quite aside from whether anyone is immediately going to pick up the phone and call the
police and whether that should happen, the system allows for that position to be arrived at in any
event?
MCMAHON: Yes.
DE LA POER: What is the level of certainty required in terms of how one classifies Level 1, Level
2 or Level 3 and by that I mean do you simply have to suspect that it is a homicide to reach Level
3 or do you need to have some form of evidence or more likely than not standards. What's -- at
that stage what's the test?
MCMAHON: You would have to have some sort of evidence to warrant that, the same as you would have
to have some sort of severity to warrant a Level 2 investigation.
DE LA POER: Now, Datix was a live system; is that right?
MCMAHON: Yes.
DE LA POER: By that, so I define what I mean, is that it was constantly running and constantly
capable of being accessed and constantly capable of being updated?
MCMAHON: Mm-hm.
DE LA POER: From an audit perspective, just for the ordinary user screen, was it sometimes
difficult to tell when an update was applied?
MCMAHON: No. We usually knew if there had been an update because the system would go down for a
period of time, so we would have been informed that that was going to happen.
DE LA POER: I don't mean software update.
MCMAHON: Sorry.
DE LA POER: I mean updated information. So if you were going to change a field within the Datix
system, to change a name or something like that -- well, let's have a look at an example, I will
make myself clearer I am sure in this way. INQ0040506. This is the Datix form for [Child I]. We will just pick out one
or two details on it. We can see the reported date is 23 October and the submitted time is
9.05?
MCMAHON: (Nods)
DE LA POER: Although presumably the time this incident is created on Datix, we don't need to
worry about who the handler is, you have told us they have an administrative function and we can
see that at the time that this form was -- this moment in time whenever that was from this form,
you are identified as the manager?
MCMAHON: (Nods) Yes.
DE LA POER: We don't need to worry too much about the moment of time because we are going to just
lay this alongside another form. But if we just go over the page, just so that we can satisfy
ourselves because obviously multiple people can create Datix entries for the same event. We can
see that the reporter at the bottom is Caroline Oakley?
MCMAHON: Yes.
DE LA POER: So we know that this is an event in respect of [Child I] reported by Caroline Oakley
at 9.05 on 23 October. Let's bring it down and let's please bring up INQ0000457. Again we see this is [Child I], we see the time is 9.05 but here
we can see that the manager who had
previously been you is now identified as Mrs Anne-Marie Lawrence.
MCMAHON: (Nods)
DE LA POER: If we go over the page just to satisfy ourselves it is the same event, in fact I
think we might need to go one more to get to our incident reporter. Just towards the top we can
see Caroline Oakley, so this is the same event by the same person, but a field has been updated
--
MCMAHON: (Nods)
DE LA POER: -- to reflect that at the moment in time that we are looking at, it's Lawrence who is
the manager, not you; is that right?
MCMAHON: Yes.
DE LA POER: My point really about updates and audits was that just on the face of this document
it isn't immediately apparent when that change was made?
MCMAHON: No and both the documents are quite different and the only way to see when the change has
been made is to get the audit trail so you can print out a copy that shows every date and time a
change has been made.
DE LA POER: Absolutely, I am sure that sits in the background of it but just looking at the form,
you wouldn't actually be able to tell from that. Obviously you can see that if you lay them side
by side some will
have later dates in time, but that was really the point I was making. So can we go back to page 2
just to have a look at the succession management of this event, because we can see under the
incident investigation, this is obviously [Child I] who was murdered on 23 October 2015, Debbie
Peacock is the first entry there on 17 December. We can see the 25 January, Debbie Peacock is
still identified, unsurprising given that her role was Risk Midwife until February 2016. Then on 1
March, you have sent an email according to the entry for an update on the incident review. The
following day, you got a response from the Consultant paediatrician: "Case has been reviewed
internally in a tabletop meeting in AHCH ..." AHCH?
MCMAHON: Alder Hey Children's Hospital.
DE LA POER: "... and awaiting PM results, will forward draft minutes of thematic review when
complete." You have sent a chaser on 15 April: "Further email sent requesting update on review."
Is that a request for the thematic review that you are asking for?
MCMAHON: I'm not sure.
DE LA POER: I mean, the word "review" appears twice in the preceding entry, one that it's been
reviewed internally and secondly, the thematic review when complete.
MCMAHON: I don't know this is the review that had been done at Alder Hey Children's Hospital.
DE LA POER: The tabletop meeting?
MCMAHON: Yes.
DE LA POER: Then we can see again an entry 27 April still with you because Ms Lawrence hasn't
taken over by this point: "Still awaiting feedback from review." Presumably those entries you have
managed to take from the medical records just to pick out some details because [Child I] as we
know was transferred between a number of hospitals over a period of time, so you have done a
little digging to try and get to the bottom of that and put that in and then we can see because we
know that Ms Lawrence takes over in May, that she's now the manager and she's got the postmortem
report and she is recorded as sending an email to the Consultant paediatrician requesting update
on 1 June and a further entry 22nd of the 6th, Ms Lawrence entering some data in -- we can ask her
about that. But in terms of just an example, is this the sort of thing that we can see across all
the Datix forms that at various points people have the opportunity to add data, and that managers
can change as people move roles?
MCMAHON: Yes.
DE LA POER: Thank you very much indeed. We can take that down. That's all that I am going to ask
you about the theory of Datix. We are going to have a look shortly potentially at another one, but
let's see how we get on. I would like to just ask you some questions about the Women's &
Children's Care Governance Board. Was that a committee that you attended?
MCMAHON: I believe I attended between Debbie Peacock leaving and Annemarie starting.
DE LA POER: So do we infer from that that you would have attended in your capacity as Risk
Midwife?
MCMAHON: Yes.
DE LA POER: Well, helpfully we have some Terms of Reference which are dated the period that you
began attending that, so we can see what it says about itself. Ms Peacock looked at these earlier
in the day but just a couple of things to pick out, INQ0015325. I'm not going to duplicate what Ms Brown asked about this
morning, so we can go over to page 2 because we have the membership well in mind. I just wanted to
ask you about number 3 on the list
or the third on the list. We have: "Review and monitor the risk registers, escalate risks to the
divisional and organisational risk registers." Now, we heard from Mrs Murphy about how the risk
interacted at the local level and she described for us a situation in which once there is -- an
incident is identified at a local level, there will be input from the risk department about that
and that by the time the incident is escalated to the Women's & Children's Care Governance
Board, a decision has already been made effectively about the level of risk around this incident
and how it should be treated. Is that your experience of it or was the risk input at this board
level?
MCMAHON: It depended on the level of risk which risk register it sat on, you would have a local
risk register, a divisional risk register and a board assurance framework so it would depend on
the level of risk, where it was reviewed and how it was scored. And then the scoring would then
dictate which level of risk register it sat on.
DE LA POER: Would that all be decided before you get to the Women's & Children's Care
Governance Board?
MCMAHON: Yes. Usually, unless it needed discussion by
some areas rather than just a single area.
DE LA POER: Did this governance board, as far as you understood it, have a function to consider
that particular case if somebody wanted to raise something about it and reflect upon whether it
was being managed correctly?
MCMAHON: Yes.
DE LA POER: That is rather what governance means, would you agree?
MCMAHON: (Nods)
DE LA POER: Similarly, if there was a report that looked at a number of events, again would that
be something for this board to consider?
MCMAHON: (Nods)
DE LA POER: So as to reflect upon whether the conclusions are right, ask questions, challenge and
really just establish whether or not it was being managed properly?
MCMAHON: Yes, usually, yes.
DE LA POER: The only other question to ask you about is the next one down says: "Review and
monitor staffing levels for obstetrics and anaesthetists and midwifery staff." My question really
was this: this is February 2016, which we can see from the next page, but I am sure you have seen
it before, you can take that from me, there
doesn't appear to be a similar function in relation to paediatrics or neonatology in terms of
their staffing levels?
MCMAHON: (Nods)
DE LA POER: Now, obviously you only joined this committee in February on an interim basis but I
was just wondering whether you can help us with that, because -- I'll explain why. We know that in
December of 2015, there were repeated complaints to the senior management about the staffing
levels within the paediatric department generally and yet when we get to February and the Terms of
Reference appear to be settled once again, we see only a focus upon the obstetrics side. So can
you shed any light on to that?
MCMAHON: Well, first of all it is a draft document, so it may have been updated to include
neonatal staff.
DE LA POER: Can I just pause you there?
MCMAHON: Yes.
DE LA POER: Obviously that is a theoretical possibility. Do you know whether or not that happened
or?
MCMAHON: No.
DE LA POER: You are just allowing for the possibility because it's got "draft" written on it?
MCMAHON: No, I don't know.
DE LA POER: Thank you. Please continue.
MCMAHON: The other thing is it could be that staffing in obstetrics and anaesthetists and
midwifery staff might have been highlighted as an issue and if that were the case, it would
indicate that the neonatal staffing wasn't an issue but I don't know the answer.
DE LA POER: Well, certainly --
MCMAHON: I don't know why the omission.
DE LA POER: Well, you can take it from me, although you probably can't comment, that certainly
there is very clear evidence that by the end of 2015, from both the nursing and a medical side,
the managers were being told there is a problem on the paediatric unit?
MCMAHON: (Nods)
DE LA POER: There we are, that is all that you can tell us about that. Thank you very much indeed
for your help on that. I would just like to ask you about the neonatal unit and your experience of
the neonatal unit's attitude towards the Risk Department, and that is something you mention in
your witness statement. I would just like you to just tell us what your perception was?
MCMAHON: At that time, I didn't actually have -- so from 2015 to 2016 I didn't have any time spent
with the unit, the staff. Obviously the short time where I was
covering that role I will have had some interaction with them. I didn't pick up anything that
concerned me in any behaviours.
DE LA POER: You didn't pick up anything. What you suggest in your statement is that -- it's
paragraph 5 if you want to look at it: "Governance has historically not always been welcomed
and/or understood by some clinicians, which at times could lead to difficulty with some
professional relationships and maintenance of robust governance policies. I would not be able to
pinpoint anything in particular between the years 2015 and 2016 or that specifically affected the
neonatal department at that time." So are we to take it that that comment is across the hospital,
rather than intended to be -- because the preceding paragraph is talking about the NNU I was just
trying to understand whether or not the clinicians you are referring to were paediatric clinicians
who worked on the neonatal department or whether it wasn't specific?
MCMAHON: It wasn't specific. I think that was a more general observation.
DE LA POER: The second question about the neonatal unit is to the best that you are able to help
us it's important
for an understanding about when people became aware of particular things. It's now very
well-established that there was an increase in the mortality rate on the neonatal unit. When do
you think you first became aware of the increase in the mortality rate?
MCMAHON: I can't recall becoming aware of the increase in the mortality rate. The first time I
knew of a link a potential link with Lucy Letby was --
DE LA POER: Can I just, I have --
MCMAHON: I have gone too far.
DE LA POER: You have moved to my second question --
MCMAHON: Sorry.
DE LA POER: -- which will be when a member of staff might be resolved in it. I am just talking
about the fact that there were more deaths on the neonatal unit than people were expecting. When
do you think your first awareness of that was?
MCMAHON: I really couldn't pinpoint when I was -- when I first became aware and I think now my
memory is very muddled by things that I have read and heard since, so it's hard to pinpoint any
particular time. I -- I don't believe I was aware before May 16 that there was.
DE LA POER: Before May 16. If I can give you some moments
in time, we have got the period before February 2016 when you took over the Risk Midwife role, we
have got the period that that ended May 2016 and we have got the end of June 2016 when Letby was
taken off the department, although that wasn't confirmed until her return and there was a period
where that was in doubt and then she started in the risk department in July. So thinking about
those dates, are you able to help us with when you might become aware of the increase in
mortality?
MCMAHON: I really don't remember any specific dates. I don't know whether it was something I just
knew or I don't even know if I was aware of it at the time.
DE LA POER: Bearing in mind your role as risk midwife during the period February to May 2016, was
that something that you should have known during that period?
MCMAHON: Yes.
DE LA POER: Sitting there now, do you think that is something that you did know at the time or
that you didn't know, or can you not say?
MCMAHON: I -- I don't think I did know because of what happened next, otherwise I think I would
have been a lot more concerned.
DE LA POER: There are you referring to the discussion you had once Annemarie Lawrence came?
MCMAHON: (Nods)
DE LA POER: So we will come to that. How about the second part of my question, which is: when you
first became aware that there was a concern that a particular member of staff may be somehow
connected to the increase in mortality?
MCMAHON: When did I become aware?
DE LA POER: Yes.
MCMAHON: In I think late May/early June soon after Annemarie had started in post.
DE LA POER: Well, we will come to that in a moment. Let's just deal with the thematic review that
we know took place on 8 February. Debbie Peacock was in the role that you took over at that time,
it was right towards the end of her time and she attended that meeting, we know that from records
and you may have heard that this morning?
MCMAHON: (Nods)
DE LA POER: When she handed over to you, did she tell you anything about a meeting that she had
been to on the neonatal unit, was there any such handover?
MCMAHON: Not that I remember, no.
DE LA POER: Again looking back on things, is that something that should have been the subject of
a handover?
MCMAHON: Yes.
DE LA POER: Now, I would just like to look a little bit further at what information you had.
Please -- you were asked to have a look at an email today, something that I asked to have drawn to
your attention. It's INQ0014226. This is an email dated 2 March 2016 and it's an email that Dr
Brearey sends to a number of people and he attaches the final version of the neonatal thematic
review. And if we look on the cc list, both you and Ruth Millward are recorded as recipients of
that email. There's some text about it in the body of the email but it's the report that's
attached that's important. Now, you have told us that you don't have any recollection of having
seen that report before speaking to Ms Lawrence in late May and looking at this email, can you see
that it appears to have been sent to you?
MCMAHON: Yes, I can.
DE LA POER: And you have told us you were doing two roles at that time. But the reason you would
be on copy for this would be as your as the Risk Midwife role, not as your Project Lead role; is
that right?
MCMAHON: Yes.
DE LA POER: So this is your second job having taken over from Debbie Peacock.
If we just remember that date, 2 March 2016 and go back to INQ0000457. We go to page 2 and we just slot that into the chronology that
we looked at earlier. We can see that the day before, so 1 March, you emailed for an update. On
the day that that email was sent and it was sent at 14:57, so at 10.09 you made an entry that you
received a response from the Consultant paediatrician, the case had been reviewed internally. We
know that because it was reviewed on 8 February and at tabletop meeting in AHCC, 25th of the 3rd
16. Just pausing there. In terms of that 25th of the 3rd 16, that appears to be a date in the
future. Might that be a typo?
MCMAHON: Yes, I would imagine so.
DE LA POER: Because as you have written it, it appears to be talking about the past, doesn't
it?
MCMAHON: Yes.
DE LA POER: And: "Awaiting PM results. Will forward draft minutes of thematic review when
complete." And: "Consultant paediatrician likely to be Dr Brearey", are you able to recall now who
that was?
MCMAHON: (Shakes head)
DE LA POER: Let's assume for a moment it was -- Dr Brearey
was the person running the thematic review and later that day, about four hours later, it appears
that he sent you the thematic review, you were on copy together with your boss?
MCMAHON: Mm-hm.
DE LA POER: We can then see that on 15 April, you have sent an email requesting an update on
review. Now, you have told us you are not sure whether that's the Alder Hey review or whether
that's the thematic review. But if it was the thematic review you were referring to, it would tend
to suggest that you hadn't realised that you had received it by this date, do you agree?
MCMAHON: Yes. And maybe -- I don't know but maybe the Alder Hey Children's meeting was -- was to
be held in the future, the case has been reviewed internally?
DE LA POER: And at a tabletop meeting in Alder Hey?
MCMAHON: Mm-hm. I mean I have absolutely no recollection. I am sorry.
DE LA POER: And again you appear to have chased it again whatever it is the feedback from review
on 27 April and then we get to the end of your tenure and Ms Lawrence takes over?
MCMAHON: Within Datix all the emails sent and received should be saved, so without looking, if I
was able to look at them, I might be able to piece that story together but without that, I just
can't recall. I'm sorry.
DE LA POER: Absolutely, and I am sure that's something that we can look into. If we just take
that down and just look at this from another perspective. The thematic review, which I know that
you have recently had a chance to see, and which reaches the conclusion that no theme has been
identified and that there are sudden and unexpected deteriorations, some of which have no
explanation, was that the sort of report that should have been considered by the Women's &
Children's Care Governance Board?
MCMAHON: It should have been received there.
DE LA POER: You as part of your preparation I think have had a chance to consider the board
meetings for both April and May and we can bring them up if you want, but I am sure you will be
able to agree with me that in fact although you are recorded as present at both of those meetings,
the thematic review was not tabled at either of them?
MCMAHON: I don't recollect, sorry.
DE LA POER: Is that something that would help you to have a look at if you don't have it in
mind?
MCMAHON: Yes, please. Each month looks at the month before, so I would have expected if it had
been
completed, but looking at that the email and the Datix, if I was chasing the incident review in
April, then I wouldn't -- I hadn't -- I wouldn't have had it for the May report, if that makes
sense.
DE LA POER: But if you were sent the thematic review on 2 March, then as we have seen from the
email, then it would be available to you and others to table it from that date?
MCMAHON: I just wonder why I have written that I have chased it again in April.
DE LA POER: One explanation is that you haven't realised it being an email you are copied into
that you have it?
MCMAHON: Have I then written that I have received it later on? No.
DE LA POER: No, because in fact as we will get to, it seemed like a fresh document to you when
your colleague Annemarie Lawrence showed it to you in May and so I am just -- if we triangulate
these pieces of information, we have got the fact you appear on one interpretation to be chasing
it, we have got the fact that on the records it hasn't been tabled by you in April or May?
MCMAHON: (Nods)
DE LA POER: And we have got the fact that it appeared to you to be a brand new document when your
colleague was showing it to you in May.
So if you take three pieces of information, an interpretation for your comment is that you just
didn't notice that you had been put on copy or didn't realise that you had it on 2 May -- 2 March,
when of course you were performing those two roles?
MCMAHON: I really don't remember either. I -- I would be guessing.
DE LA POER: Well, let's just come then to deal with the events involving your colleague Ms
Lawrence. We know that she started at some point in May of 2016, in fact she's recorded as
attending the 19 May Women's & Children's Care Governance Board. Shortly after she joined your
department, I think she came and had a conversation with you?
MCMAHON: (Nods)
DE LA POER: And I would just like you, please, to help us with exactly what happened.
MCMAHON: Annemarie approached me I think one morning quite early and asked me to have a look at
this, and it was a table of the children -- the babies with Lucy Letby identified as present in
some capacity for each of the deaths or collapses.
DE LA POER: If we just bring up what you were looking at so there can be no misunderstanding
about this INQ0003251, page 9. You can have a look at this and see
whether I have identified the document that you were talking about. Forgive me, I don't think that
is the document that I was intending to come up. By all means consider that but I don't think that
that meets the description that you have previously given. Just bear with me a moment. INQ0003217. I'm sorry if I read that out incorrectly. This is the appendix 1
Neonatal Mortality 2015 January to 2016. Obviously we have applied some ciphers but we can see the
"Staff allocated", "Staff on duty" columns. Is that the document that to the best you can
recollect that Ms Lawrence brought to you or was it a different one?
MCMAHON: I can't be 100% certain. I just know that what I looked at had a column where Lucy Letby
was identified as being present on duty.
DE LA POER: Well, this is not the best page to start on because the first entry doesn't appear
like that, but if we look at [Child A] we can see in the "staff allocated" column, if we go over
the page because that first entry is the exception, we can see that for [Child C], she is in the
right-hand column, we can see for [Child D], she is in the right-hand column, if we go over the
page just to satisfy you, [Child E], she is staff allocated, for the next child, she's right-hand
column. Does that help you with the sort of pattern that you were looking at?
MCMAHON: Yes.
DE LA POER: So Ms Lawrence came to see you, brought a document and what did she say to you?
MCMAHON: She just asked me to look at it and what did I think the fact that Lucy Letby was on duty
when each baby either died or collapsed?
DE LA POER: Did you do that?
MCMAHON: Yes.
DE LA POER: And what did you say once you had had a chance to consider the document?
MCMAHON: I said that Annemarie needed to go and speak to Ruth about it.
DE LA POER: Why did you say that?
MCMAHON: Because it is quite a significant trend to have the same member of duty on staff for all
those occurrences.
DE LA POER: Now, other witnesses have drawn a distinction between the staff allocated and the
staff on duty and have used the fact that Letby is not always staff allocated as being somehow
significant in the interpretation of this chart. That doesn't seem to have been the approach that
you were taking; is that fair?
MCMAHON: Sorry, can you say that again?
DE LA POER: Absolutely. Was it sufficient for you that she was either on duty or allocated to the
baby?
MCMAHON: Yes, because just because she wasn't allocated to a baby doesn't mean she wouldn't have
been involved in some care, if she was covering a meal break. It's still a trend that she's on
duty all of those times but it could be for any other number of reasons and it needed more
investigation.
DE LA POER: So you told Ms Lawrence to go and see Ruth Millward?
MCMAHON: Mmm mm.
DE LA POER: At the time did either of you describe your thoughts about this trend in terms of its
potential significance or otherwise?
MCMAHON: I don't think so, not that I recollect.
DE LA POER: What was your view about the potential significance of the trend that had been shown
to you and that you had seen for yourself?
MCMAHON: I didn't really have a view, it was just one piece of information that was quite a
significant trend. It could be for a number of reasons so I didn't know any other background
information.
DE LA POER: And you tell us in your witness statement that you thought that the theme identified
could be
a significant finding and should be discussed with Ruth Millward?
MCMAHON: (Nods)
DE LA POER: So did Annemarie Lawrence tell you that is what she was going to do?
MCMAHON: I know that she went and did it virtually straight away.
DE LA POER: Yes, and did she speak to you immediately afterwards or after some time?
MCMAHON: Fairly soon afterwards, I don't know exactly. But she did say.
DE LA POER: What did Ms Lawrence tell you had been said between her and Ruth Millward?
MCMAHON: That Ruth had dismissed her and told her that she shouldn't be saying or implying things
like that and it needed more investigation.
DE LA POER: What did you understand her to mean by "implying things like that"?
MCMAHON: That with -- that it was a deliberate harm or that it could be a deliberate harm.
DE LA POER: I mean, is that something that crossed your mind when you looked at the trend as a
possibility?
MCMAHON: Not at all.
DE LA POER: So when you looked at it that hadn't crossed your mind?
MCMAHON: It would be more of a competency issue would be your first thoughts if something
recurrent is happening with a member of staff.
DE LA POER: But then Anne-Marie Lawrence comes back to you, says that her concern has been
dismissed and then is talking in terms that you understood might imply that deliberate harm had
been caused or was being alleged?
MCMAHON: Sorry, say that again?
DE LA POER: Not at all. When Annemarie Lawrence came back to you and said that she shouldn't be
implying things like that, correct me if I am wrong, but it sounds like the idea or the
implication that deliberate harm might be being caused was suddenly in the room, so to speak?
MCMAHON: Yes, yes.
DE LA POER: When that was said to you, what were your thoughts about whether that was at least a
possibility based upon what you had seen?
MCMAHON: I agreed with what Ruth alleged to have said in that it needed more investigation.
DE LA POER: But Ruth--
MCMAHON: Ruth had said to Annemarie.
DE LA POER: That it needed more investigation?
MCMAHON: Yes.
DE LA POER: I thought you had said that her concern had been dismissed and that she shouldn't be
implying things like that?
MCMAHON: But also that it needed more investigation.
DE LA POER: Who did you understand from Ms Lawrence was going to carry out that
investigation?
MCMAHON: Well, Annemarie and Ruth, that side of the team.
DE LA POER: So did you think that it was staying with Ms Lawrence to investigate?
MCMAHON: Yes. But also it could have been if -- if there were any concerns about a certain member
of staff it would often be a HR investigation rather than a clinical incident investigation and I
think this probably crossed borders.
DE LA POER: What about it being a safeguarding issue?
MCMAHON: Yes. But that would come as part of an incident investigation that would be included in
that.
DE LA POER: Obviously investigations take time. If there is a safeguarding issue, do you agree
that it needs to be acted upon immediately?
MCMAHON: Mm-hm.
DE LA POER: So did you have any discussion with Ms Lawrence about whether or not immediate action
needed to be taken to safeguard babies?
MCMAHON: No.
DE LA POER: Looking back on it, why do you think that you
didn't raise that or discuss that in those terms?
MCMAHON: Because I didn't think of any -- any thing that deliberate.
DE LA POER: Well, you have told us that the idea that it might be deliberate harm was inherent in
what was being fed back to you.
MCMAHON: It's a bit difficult really to remember exactly with the length of time. I just knew it
needed more investigation to -- to find out exactly what was happening.
DE LA POER: Did you ever follow up with Ms Lawrence or Ms Millward about whether or not that
investigation was progressing?
MCMAHON: No. I had my own role to do and I trusted both Ruth and Annemarie to undertake those
further investigations and nothing ever came to me afterwards to suggest that that wasn't
happening.
DE LA POER: But if nothing was happening, then nothing would necessarily come back to you?
MCMAHON: But I didn't become aware of any other concerns from anyone.
DE LA POER: In your role over the years in the Risk and Patient Safety Department, I am not
asking you to name the incident, but had you ever come across a situation where it was even
suggested that a member of staff might
be harming patients?
MCMAHON: Not deliberately, no.
DE LA POER: So this is the one and only time in your experience that that has been, as I have
previously termed it and you have agreed in the room, so inherent in the conversation that you are
having?
MCMAHON: (Nods)
DE LA POER: Looking back on it, do you think you should have done more to make sure that the
matter was being progressed or do you think your response was reasonable?
MCMAHON: If I had had any more concerns, I would have escalated them but I didn't have any
concerns and I didn't -- with the knowledge I had it wasn't enough to escalate any further with
that one piece of information I had and so I am sure in that situation again, without the benefit
of hindsight, I would probably do the same again. It wasn't my role to undertake any investigation
and I knew that there were people who did have that responsibility and trusted them to be doing
that and I had no reason to think that they weren't.
DE LA POER: The last thing I would like to ask you about is a reflection that you added at the
end of your witness statement. I will just read out to you what you said:
"I think that the concerns raised by the paediatricians were not acknowledged or taken seriously
enough or soon enough by the Executive team." I just wanted you to help us with whether that was
as a result of things that you saw happening or whether that is an impression that you formed
having read newspapers and so on. So if you just help us with what that reflection is based
upon?
MCMAHON: So it is the latter, it's what -- what I now know following the investigations and the
criminal trial. Because I wasn't aware at the time what was happening.
MR DE LA POER: Mrs McMahon, thank you very much indeed.
MCMAHON: Thank you.
MR DE LA POER: I don't have any more questions for you. There are no Rule 10s.
LADY JUSTICE THIRLWALL: Thank you very much indeed, Ms McMahon I have got no questions for
you.
MCMAHON: Thank you.
LADY JUSTICE THIRLWALL: Thank you for waiting all morning and you are free to go now.
MR DE LA POER: My Lady if I just check, no thank you very much indeed, it occurred to me I needed to make a check -- I have now made that check, I'm sorry to interrupt.
LADY JUSTICE THIRLWALL: That is all right. Are we ready for the next witness?
MR DE LA POER: Yes, we are. Annemarie Lawrence, please.
MRS ANNEMARIE LAWRENCE (sworn)
LADY JUSTICE THIRLWALL: Do sit down. Mr De La Poer.
MR DE LA POER: Please can you give us your full name?
LAWRENCE: Mrs Annemarie Lawrence.
DE LA POER: Mrs Lawrence, is it correct that on 8 July of this year you provided to the Inquiry a
witness statement?
LAWRENCE: I did, yes.
DE LA POER: And are the contents of that witness statement true to the best of your knowledge and
belief?
LAWRENCE: They are.
DE LA POER: Did you qualify as a midwife in 2006?
LAWRENCE: I did.
DE LA POER: And did you start in the role of midwife at the Countess of Chester in 2014?
LAWRENCE: I did, yes.
DE LA POER: And in May of 2016, as we have just heard from Ms McMahon, did you take up the role
of Risk Midwife?
LAWRENCE: I did.
DE LA POER: And just to summarise how you came by that role, did you see the job advertised
within the hospital buildings?
LAWRENCE: Yes, it was on one of the staff forums within the central labour suite as expressions of
interest to apply via the NHS Jobs Trac system.
DE LA POER: I am terribly sorry and I don't mean this in any way critically, can I just ask you
to keep your voice up a little or move slightly closer to the microphones. That would be really
kind. Thank you very much?
LAWRENCE: Yes, of course.
DE LA POER: So you saw the job advertised and did you consider that you meat the criteria that
they were identifying?
LAWRENCE: I did, I went to speak to my current manager, after she had asked me to have a look at
it on the board, she felt I had the necessary knowledge and skills and she thought I would be a
good fit for the role. So I did apply.
DE LA POER: The application involved you making a presentation to Ruth Millward and Julie
Fogarty; is
that right?
LAWRENCE: That's correct.
DE LA POER: You were then appointed to the role effectively taking over from Debbie Peacock as
the full-time occupant but in practice taking over from Janet McMahon who had been doing the job
for about three months?
LAWRENCE: That's correct.
DE LA POER: What you tell us that the role that you undertook required -- well, let's put it a
different way: tell us what you thought the role of Risk Midwife involved?
LAWRENCE: I thought the role would be regarding the day-to-day incident management, the governance
facilitation guidelines, governance board, et cetera. It was very multi-faceted but it would be
involving midwifery and the neonates as well.
DE LA POER: So on the subject of neonates, you were, before this role, a midwife by background
and training?
LAWRENCE: That's right.
DE LA POER: Did you consider that you were able to provide a risk role for a department that you
weren't trained to work in?
LAWRENCE: Yes, because we don't undertake this role as sole practitioners. We work as part of
a multi-disciplinary team, so I would always be within the capacity of neonatal nurses,
neonatologists or paediatricians. So if there was anything that needed any expert guidance per se,
I would go to the expert for that relevant area.
DE LA POER: And bearing in mind your role involved looking after the neonatal department, or
unit, as much as it did the midwifery obstetric side of things, did you ever ask why you were the
Risk Midwife as opposed to a broader term that included neonates?
LAWRENCE: I think certainly over the last few years leading up to maybe 2018, when there was some
national guidance published, neonates was very much added on to maternity as an addition.
Maternity is very much nationally driven by various drivers, et cetera, and the workload and
incidences is significant compared to other areas and therefore it takes up a large proportion of
time that isn't the same within neonates, gynaecology or children's and that has changed over the
last few years with the publication of MBRRACE and PMRT, et cetera. But certainly at that time, it
wouldn't have warranted a full time officer for that area.
DE LA POER: In terms of where your focus lay, and the hours that you were spending, do we infer
from your previous answer that most of your work was involved looking at the midwifery obstetrics
side?
LAWRENCE: It was, yes.
DE LA POER: Just to complete the picture as far as you are concerned, in 2019 did you take up the
role of governance matron for the Women and Children's Hospital at the Wirral University Teaching
Hospital?
LAWRENCE: I did, yes.
DE LA POER: And in 2020, were you promoted to clinical service lead for obstetrics and
gynaecology?
LAWRENCE: I was.
DE LA POER: When you were training as a midwife, and then practising, did you receive any
safeguarding training specifically in relation to what you should do in the event that you were
concerned that a member of staff was harming patients?
LAWRENCE: Not specifically for a member of staff, no. I think that is a gap within our national
safeguarding training because certainly, when I have looked back retrospectively at the various
trusts I have worked in across the north-west and when I did my training, it wasn't covered in any
shape or form within safeguarding training specifically for harm by a staff member or service
user.
DE LA POER: Now, you have described it as a gap. Obviously we are going to get to a moment in
time where you were presented with some particular information and you reached some particular
conclusions about it. Would it have helped you navigate that situation if you had had such
training?
LAWRENCE: I think so and that is an area of reflection for myself over several years now. If I'd
have had the knowledge I have now back in 2016, then I do believe I would have escalated further.
It may be that I would have continued not to be listened to, but at least I would have tried
harder than I did at the time.
DE LA POER: Now, you went from practical on-the-ward midwifery into a non-patient-facing role in
the Risk Department as Risk Midwife?
LAWRENCE: Yes.
DE LA POER: Did that involve you having a greater degree of interaction with the Datix
system?
LAWRENCE: Yes. I worked significantly with the Datix system.
DE LA POER: So presumably you had some prior knowledge of it from the point of view of a
clinician on the ward putting -- making entries?
LAWRENCE: Yes.
DE LA POER: Did you receive any additional training when
you joined the Risk Department in terms of how its other functions worked and what your role was
with that?
LAWRENCE: Yes. We had a Datix compliance manager, or administrator he was at the time, who talked
me through the back office functions, and then we also had the office PA, Joanna Donnelly, who
filled in for the Datix administrator who knew the system inside and out. So if there was anything
you needed and you were unsure of, she would always be on hand to help navigate or help a
workaround if you were unsure.
DE LA POER: Now, we are just going to spend a short period of time looking at when a Datix is
required. Was it an important part of your role as Risk Midwife to have a clear understanding of
when a Datix was required?
LAWRENCE: Absolutely. Because a large part of my role was as educator as well, with some of the
visits to the clinical areas, sometimes you hear things, sometimes you see things, and sometimes
you know when -- once something should be submitted. So it's really important to have a very clear
understanding of both the obstetric and the neonatal pick list, as we called it, which is a
selection of incidents that would automatically normally generate a Datix being submitted. It's
important to have that knowledge on the tip of your tongue so that you can use it in action when
you
are in those clinical areas.
DE LA POER: And of course you have this unique perspective, as far as Inquiry witnesses are
concerned, is that you practised on the labour suite, no doubt --
LAWRENCE: Yes.
DE LA POER: -- filling in Datixes yourself up until May of 2016, at which point you effectively
went behind the curtain and were able to see what happened to them after that. Did your knowledge
and understanding about the importance of ward level Datix completion change once you joined the
Risk Department?
LAWRENCE: It really did, yes. It was very much an eye-opener because I got to see -- if you don't
fill in a certain box, I got to see the ramifications of that in the background. So how difficult
it is if you don't include the staff involved in an incident at the time you submit the Datix. It
can be really difficult to go back at a moment in time, especially if the incident reporter is on
annual leave for a period of two weeks. Sometimes you are coming back several weeks later and
people's memories are not what they were, and you may miss an opportunity to identify somebody or
something that was important at the time.
DE LA POER: Now, we are going to look at some policies in a moment, and this isn't by any means a
test or vie of you but we have heard the term "Serious Incident" and we have heard the term
"Incident" and you use both in your witness statement.
LAWRENCE: Yes.
DE LA POER: Can you just help us to understand what you understand to be the difference between
an Incident and a Serious Incident?
LAWRENCE: Yes, absolutely. So an Incident is -- certainly in midwifery and more so in neonatology
over the last few years, we submit an incident report for things where there is a deviation from
normal. And, as I say, in midwifery certainly we use an incident Datix submission for a data
collection as well. So we will collect data on the number of third degree tears whether or not
they have been caused or have occurred, and I will give an example of that, if I may. So a lady
could deliver at home without a midwife present and could experience a third degree tear. We
wouldn't have caused that harm by an individual but it is still a harm that has occurred to the
woman and should be reported. So that would be an incident. And then a Serious Incident is where
there has been an act or omission of care that has contributed, or may have contributed, and, as
we move into PSIRF, which is the
Patient Safety Incident Response Framework, which it wasn't in place in 2016 so I don't want it
blur lines or things, but it's really important that we look at harm suffered versus harm caused
as well because the experience of a neonatal death, for example, in an expected death -- so a baby
that is incompatible with life -- we used to grade those incidents as "no harm" because there is
no act or omission that would have prevented that baby's demise. However, when you look at it from
the point of view of the patient and the family, for them to see that incident graded as "no harm"
was quite detrimental to them because it's not no harm to them, which is why we have moved over
into the Patient Safety Incident Response Framework so we are a bit more empathetic as to the
impact on our women and families.
DE LA POER: Now, we are going to look at this in more detail with Ruth Millward but it may have
been on your radar at the time, it may not. But we know that in June of 2015, so whilst you were
still working as a midwife, she sent an email which was to this effect: that child death, so
outside your area of work, is no longer included as a Serious Incident by definition in the SI
framework or on STEIS. However, it may be reported as a Serious Incident under another category.
So, in other words, it would appear that a policy change has resulted in how events should be
categorised. You don't need to comment upon that, particularly if you don't know about it, but was
it your experience that there were evolutions in what was expected and how things were defined
over time?
LAWRENCE: Yes, I think -- and in some ways it shows a good link to the latest available evidence.
It's really important as clinicians we stay as current as we can and we maintain our clinical
credibility. So being aware of the latest guidance and updates I think is really important. I
won't share my personal view on that if you don't mind but ...
DE LA POER: Now, you comment in your witness statement about the approach, as you perceived it to
be, to Datix on the neonatal unit. I will just read out what you have said: "The neonatal unit
staff did not approach the Datix reporting system in an open and transparent way. They would often
only report an incident if they felt it was avoidable or there had been an obvious omission in
care."
LAWRENCE: Okay.
DE LA POER: So a number of things to ask about that.
LAWRENCE: Yes.
DE LA POER: The first thing is when you say "neonatal unit staff", are you talking all staff or
are you talking doctors or nurses or Consultants, or managers? Who do you mean by "staff" when you
say that?
LAWRENCE: I mean every person who works within the neonatal unit umbrella.
DE LA POER: Obviously you frame that in the past tense "did not". So we just need to understand
what our date parameters are. Presumably, that wasn't an opinion you held before May 2016 because
you didn't have access?
LAWRENCE: Absolutely.
DE LA POER: So this is from May 2016?
LAWRENCE: Yes.
DE LA POER: And over what period from May 2016 did that apply?
LAWRENCE: I am not certain of the dates with any certainty. But there was a change in leadership
from the Neonatal Risk Department and there was a Dr Dangerfield who was appointed into that risk
role. And after her appointment, the department seemed to be much more amenable because she -- she
got risk. That is the only way I can describe it really. She understood the impact of acts or
omissions and that risk isn't just about managing the incident that's happened, it's about
learning from acts or omissions and preventing the next incident from happening. There was
certainly an improvement after the Royal College review as well. So kind of after the Royal
College, maybe September, October time, and then up until the point where Jo Dangerfield, Dr
Dangerfield, took over things definitely improved after then.
DE LA POER: Can you give us a year when Dr Dangerfield took over?
LAWRENCE: '18. Definitely she was there by '18.
DE LA POER: Now, you have chosen to use the words "Did not approach Datix reporting system in an
open and transparent way". And what you go on to say might be thought to imply that you thought
that this was deliberate or in some way calculated as opposed to born of confusion or ignorance.
Can you help us with whether that is what you are implying, that you thought that they knew they
had to fill out Datixes for certain situations and they made a cynical decision not to fill them
in, or whether it might be a misunderstanding, a cultural misunderstanding, about the importance?
So can you help us with what you are meaning to imply?
LAWRENCE: I think there is an element of both situations that you have described. I think there
were definitely some staff who, certainly new to department, may not
have understood the need to report certain things. But there was also a number of other staff who
I would say purposely didn't report things until they had discussed it with managers or
Consultants to agree that something should be reported. They certainly didn't do it freely in the
same way that the maternity service did.
DE LA POER: Well, I'm afraid can you help us please with who?
LAWRENCE: Band 5 nurses, Band 6 nurses, some shift leaders, although I wasn't sure of their
grading at the time, and certainly some managers as well.
DE LA POER: And is that all on the nursing side or are there any doctors involved in this?
LAWRENCE: I suppose there would be some Registrars involved in that, although I definitely
couldn't give you names of that. But what they would do is they would come along to the Incident
Review Group or they would come along to an MDT forum, they would discuss it and they would be in
agreement in that meeting that, yes, it should be reported and then an incident form would be
submitted.
DE LA POER: And from the point of view of your impression of the Consultants in this issue -- and
we will get to your relationship with Dr Brearey -- but speaking about
the Consultant body, was this a concern that you had about the Consultants, that they were
cynically and deliberately not filling in Datix until effectively they had no choice?
LAWRENCE: Yes.
DE LA POER: And which Consultants are you referring to?
LAWRENCE: I think I would say the body of Consultants. What you -- what I found certainly in
neonatology was they all stuck together. If -- they wouldn't go against one another. So even if
they thought somebody had made a clinical omission, rather than report it, they would have a
conversation first Consultant to Consultant. So I would say, yes.
DE LA POER: Just to understand that. I am not here as an apologist for the Consultants but, based
on what you have just described, a reason for doing that may be to check that in fact an error has
been made by getting a second opinion by someone who's perhaps a bit more objective about it, a
little less introspective about it. I mean, is that a legitimate way to approach the Datix system
or the moment you think you may have created -- done something in error, are you obligated to
immediately declare it without further reflection?
LAWRENCE: Well, it has to be safe to undertake that submission. So if you are involved in a
clinical
incident and you are still working clinically, it wouldn't be appropriate to step away to submit
an incident form. But any individual can submit an incident form. Even if you don't have time on
your clinical shift, you can hand it over to the next person. But generally we say as close to the
time of the event as possible, that is when you should submit the form because your memory is as
fresh as it can be.
DE LA POER: And it's not appropriate to take a colleague aside before you do that and say, "Look,
this has just happened. I just want to check whether you think anything has gone wrong here"?
LAWRENCE: I wouldn't say that it's not appropriate because there may be situations where the
situation, for example, that conversation has just manifested itself, there was an opportunity and
the clinician has taken it. So I wouldn't say there were times when it was never appropriate to do
that. But Datix should be used to learn lessons. It is an open and transparent way of improving
the safety and culture of a hospital. So my view to it is that it should be done regardless.
DE LA POER: One of the matters of interest to the Inquiry, and which is commented upon in
relation to the immediate internal investigation of July 2016, was whether or not there was
adequate completion of Datix and, from the Inquiry's point of view, children who suddenly and
unexpectedly collapsed but who did not die is an area of interest. So I just want to gauge your
opinion as someone who worked in the Risk Department. If a baby suddenly and unexpectedly
deteriorated but was successfully resuscitated and no error in care was identified at that time,
was a Datix form required in 2015/2016?
LAWRENCE: So are you asking me whether I think it was required?
DE LA POER: Yes, as in mandated by the hospital policy at the time.
LAWRENCE: I don't think it was mandated per se because I don't think it was in the pick list at
the time and that was some of the challenges that I faced as a newcomer to the organisation, that
the Risk Department was that, trying to amend the pick list to have the appropriate things in
there. There were some things that were out of date and some things that, on the information that
I had been researching, I felt should be included but wasn't and when put that to the clinicians
the view wasn't reciprocated. So if you wanted to add something like that,
there'd have to be a consensus and an agreement among the clinicians to have the pick list
changed. It was quite difficult to do.
DE LA POER: Well, let's just have a look at the policy and it was put on screen earlier today. INQ0010022. Were you sitting in when your former colleague Ms Peacock was
being asked questions about this?
LAWRENCE: I was, yes.
DE LA POER: Well, that is extremely helpful to know. If we go over the page, we can see there the
duties applied to all staff and there is a sort of reflection expected of the Risk and Patient
Safety team which is once it comes to them, they should be making sure it goes back to the local
level so that managers are aware. So we have seen all of that. We don't need to go over that
again. Let's look at that definition that was considered this morning, page 3: "What should be
reported? An event or circumstance which could have resulted or did result in unnecessary damage,
loss or harm to patients, staff, visitors or members of the public." And then some examples are
given: "Clinical affecting a patient eg, investigation, diagnosis, treatment, medical equipment
malfunction, misuse, decontamination issues, medicine management,
confidentiality, consent." So a list of examples. Now, Ms Peacock read the word "unnecessary" as
only applying to damage as opposed to applying to loss or harm. What was your understanding at the
time as to whether or not unnecessary applied or was this not a close reading that you gave it at
the time?
LAWRENCE: I think I had a different view to earlier.
DE LA POER: So you think that "unnecessary" applies to loss and to harm as well? So it needs to
be unnecessary harm to focus on what we are concerned with?
LAWRENCE: I think it's unnecessary damage, unnecessary loss or unnecessary harm, yes.
DE LA POER: So for harm, which is what we are focused upon --
LAWRENCE: Yes.
DE LA POER: -- that is the most important thing because that is talking about patients as opposed
to property?
LAWRENCE: Absolutely.
DE LA POER: Unnecessary harm. And, of course, if we think about how harm was being interpreted at
that time, you have told us about how there's been a change in understanding and a more empathetic
approach to harm --
LAWRENCE: Yes.
DE LA POER: -- in fact, "harm" was meaning harm that the
NHS has or may have caused; is that right?
LAWRENCE: That is how I understand it.
DE LA POER: When we talk about harm, perhaps the most striking example of that, if we look at INQ0000111 -- this is the Datix for [Child C]'s death -- we can see that
this is right in the middle "subcategory expected/unexpected death." So the report is not about
some aspect of care but about the death itself. That is the pick list item?
LAWRENCE: Yes.
DE LA POER: And then result: "no harm."
LAWRENCE: (Nods).
DE LA POER: And that's perhaps the most striking illustration --
LAWRENCE: It is.
DE LA POER: -- because the notion that death isn't a harm to the patient is plainly ludicrous in
an ordinary understanding, but in the way that the word "harm" was being used for Datix it means
harm that we, the NHS staff, have or may have caused?
LAWRENCE: That's the way they were interpreting it back in 2015, yes.
DE LA POER: Absolutely. And when you combine it with the word "unnecessary" -- and we must be
careful not to be too lawyerly about this -- but "unnecessary" means something that could have
been prevented?
LAWRENCE: Absolutely. Avoidable.
DE LA POER: And so that really adds to the understanding about harm and the approach you should
take. Now, obviously we have got an exception to that because an unexpected death, or an expected
death for that matter, is in fact required to be reported by Datix. But that doesn't actually fit
within the hospital policy at the time, does it?
LAWRENCE: No.
DE LA POER: I mean, it's plainly an exception. It may not be if the death, whether expected or
unexpected, has been caused by some NHS staff action, but whether or not that happens -- and
[Child C] and the Datix is a clear example of how that was being thought about at the time -- the
mere fact of death is reportable?
LAWRENCE: Absolutely.
DE LA POER: So when we think about the position of the staff on the neonatal unit and how they
should be approaching a sudden, unexpected collapse that they have no explanation for at the time,
so no malpractice is suspected, no deficiency in care has been identified as being potentially
causative of that, we know why those collapses were caused now, under the policy, would the staff
have been expected to fill in a Datix?
LAWRENCE: It's a difficult one, isn't it, because the communication that went out said these
didn't need to be reported and yet they sit there on the pick list as you should report it.
Certainly --
DE LA POER: Forgive me, I'm sorry to interrupt you, but the pick list for death, yes. I am
talking about a collapse that is successfully resuscitated.
LAWRENCE: Oh, sorry, of course.
DE LA POER: So no death; so we can't use this category. We have got a sudden unexpected collapse,
resuscitation, a very high level of intervention is required, everybody is standing around
immediately afterwards saying, "I have no idea why that happened but I can't see that we did
anything wrong", no Datix would be required under the policy. Do you agree with that?
LAWRENCE: No, I don't agree with it. I think that is what happened, but I don't agree with it
because how do we learn from these events if we don't report them?
DE LA POER: My question was framed by reference to the policy.
LAWRENCE: Okay, sorry.
DE LA POER: Did the policy, bearing in mind what we have looked at in terms of unnecessary harm,
did that require a Datix to be completed?
LAWRENCE: I think it is unnecessary harm though, isn't it? If you can't understand it and you
can't explain it, then it should be reported because it fits into that category of "unnecessary".
DE LA POER: But then what would you fill in about what the potential cause of it was under the
policy?
LAWRENCE: Under the pick list or under the policy?
DE LA POER: Well, both. This is the --
LAWRENCE: Because the policy -- we really look at the policy when it comes to applying here and I
don't think there would be anybody in the risk team who would hold you against the policy for
reporting a collapse. They wouldn't report you for a deviation of the policy for reporting a
collapse on Datix.
DE LA POER: Absolutely. But I suppose what I'm really trying to get under the skin of is whether
you can criticise somebody for not reporting something which the policy doesn't appear to mandate
and it's just --
LAWRENCE: I suppose --
DE LA POER: -- you've described the best practice?
LAWRENCE: Yes.
DE LA POER: But what we are trying to do is -- and there is a different question about whether
the policy should have been different.
LAWRENCE: Yes.
DE LA POER: But judging people by the policy at the time, can you criticise those clinicians, as
opposed to the policy and other aspects of the hospital practice, for not having filled in the
form for those collapses?
LAWRENCE: I suppose it would be difficult. It would be difficult to criticise when the policy
doesn't support it. However, me being me, I would find it really difficult not to report it
because it's the right thing to do and how do we learn from things we don't understand if we don't
investigate? And I think that's some of the challenges that I experienced.
MR DE LA POER: Well, I am sure we can come to that. My Lady, I wonder if that is a convenient moment to break.
LADY JUSTICE THIRLWALL: Certainly. For how long, Mr De La Poer?
MR DE LA POER: If we could take a slightly shorter than normal break, I am sure everybody would appreciate that, but I look to the shorthand writer who is very happy to continue. So I am very grateful for that. So if we could reconvene perhaps just after or on 4 o'clock just so everybody can stretch their legs.
LADY JUSTICE THIRLWALL: Shall we say five past.
MR DE LA POER: Five past, thank you.
(3.54 pm) (A short break)
(4.05 pm)
LADY JUSTICE THIRLWALL: Yes.
MR DE LA POER: I am going to look briefly now at an NHS England document relevant to this issue
and in particular Serious Incident and what that means. INQ0009236. We see this is the Serious Incident Framework document I hope
you have some familiarity with?
LAWRENCE: I do.
DE LA POER: Page 12, please. Forgive me, it will be page 12 internally so that will be 13, thank
you, my mistake. Ms Lawrence, here we are not talking about incidents, which is what one needs for
a Datix, here we are talking about serious incidents which is what one needs to have in order to
report upwards to NHS England; Is that right?
LAWRENCE: Yes.
DE LA POER: We have got a broad definition there: "Serious Incidents are events in healthcare
where the potential for learning is so great." That is very much your point, isn't it?
LAWRENCE: Yes.
DE LA POER: That when it comes to a Serious Incident, there might be a substantial opportunity
for learning: "... or the consequences to patients, families and careers, staff or organisations
are so significant they warrant using additional resources to mount a prehensive response."
LAWRENCE: (Nods)
DE LA POER: And: "... they can extend beyond incidents which affect patients directly and include
incidents which may indirectly impact patient safety or an organisation's ability to deliver
ongoing healthcare." Then we have this: there is no definitive list of events, this is the next
but one paragraph: "Incidents that constitute a Serious Incident." And: "Lists should not be
created locally as this can lead to inconsistent or inappropriate management of incidents." Now,
we need to hold two things in our heads here. We have got what an incident is and that is Datix,
and then what a Serious Incident is. The advice here is that for a Serious Incident you shouldn't
have a preprepared list that you are working against?
LAWRENCE: (Nods)
DE LA POER: I just want you to just help us with how that interacts with the fact that in order
to create a Datix, you are looking at a pick list?
LAWRENCE: I suppose that the Datix system and the incident trigger lists are for specific everyday
incidents from low to no to moderate to severe or death associated with the incident or not. When
it comes to a Serious Incident, you can send even no harm incidents, no harm incidents -- so an
incident graded as no harm by the reporter could still be -- undergo an SBAR if felt significant
enough by either the local manager, so the manager at ward level or the Risk and Patient Safety
Lead. Sometimes there was occasions where there would be a cluster of no harms but, for example,
there may be complaints and so you might undertake an SBAR and send that to the Serious Incident
Panel for the Executives to consider a cluster of low harm incidents which may as it talks about
here, impact an organisation's ability to deliver ongoing healthcare, ie it may affect the
reputation of the organisation. So in terms of Serious Incidents like this, if it was serious
enough to warrant attention or it developed the Risk and Patient Safety Lead's interest enough, it
would go to the Serious Incident Panel but it would be
those Executives who decided in that panel as to whether it was reported or not.
DE LA POER: The only way it would in those cluster of individual incidents that in themselves are
not sufficiently serious the only way that they will get to the Executives is if a Datix has been
filled out for each of them?
LAWRENCE: Absolutely.
DE LA POER: So Datix is the gatekeeper?
LAWRENCE: It is.
DE LA POER: For whether or not something could be considered to be a Serious Incident, whether a
cumulative cluster or an individual event and bearing in mind that Datix operates on a pick list,
so you can't get near a decision about a Serious Incident whether it is a Serious Incident or not.
I am just wondering how that fits with the NHS England guidance which says you shouldn't operate
pick lists?
LAWRENCE: That is for Serious Incidents, though, so the Datix trigger list, there is an option of
"other". So somebody could report things under "other" and quite often we found that. So when you
made reference to the handler earlier, the handler would go into what we call a pool where all of
the Datixes that come in for the organisation are located in a virtual pool and in a holding bay
and it's for them to work through the incidents but sometimes they couldn't allocate it to a
certain area because somebody had selected "other" and that's where the risk in patient safety
leads or the Datix administrator would need to navigate that system to try and think of the best
appropriate place for that to go. So I wouldn't want you to think you couldn't report something if
you really wanted to because there wasn't a pick list for it because there would be a way to
navigate that somewhere.
DE LA POER: So in other words the pick list wasn't a closed list, there was an option for more of
a free text incident specific description?
LAWRENCE: Yes, it was closed in the sense that I wanted to add things to it and you had to go
through various different hoops to get the pick list altered, so that you could pull data from it
because you will have to appreciate when you are pulling data from another field, it's meaningless
because you pool that much there. So in order to be able to inform future healthcare provision or
quality improvement initiatives you have to have that narrowed down in that pick list. So getting
that changed was very, very difficult to do but you could get things added through "other".
DE LA POER: So a person could have if they had wanted to, thought: this is a unexpected very
serious collapse, we can't identify any failing in care that's responsible, but it's the third one
that I've seen in recent weeks?
LAWRENCE: Correct.
DE LA POER: Go on to Datix, access "other" if you can't find that adequately described?
LAWRENCE: Yes.
DE LA POER: And then put in a commentary?
LAWRENCE: And often we would see: I have not found this pick list here so but this is the third
case I've seen this week and so I am reporting it, file it under whichever various field you feel
necessary. And sometimes they would record things under a relevant Planned Care or Urgent Care, so
you wouldn't see it straight away but the beauty about that pool I mentioned earlier, so that
where all the Datixes come into is the experienced person working through that Datix trigger list
would realise actually that's not paediatrics, that is obstetrics and they would allocate it then
to the relevant person and it reduced that risk of error that incidents would be reported but go
unseen.
DE LA POER: Thank you, we can take that down and we are going to move away from Serious Incidents
because obviously that, as you have told us, is for the
Executives to decide and I think it was Ruth Millward who decided ultimately within your
department whether something went to a Serious Incident Review Panel; is that right?
LAWRENCE: Yes, at the SBAR we completed -- the "Recommendation" section of that SBAR would be to
forward on to the review panel to determine whether any further investigation was required and I
believe that was an instruction from the Executives because they wanted to be the people to make
that decision as to whether something was STEIS reported or not.
DE LA POER: Let's leave Serious Incidents and look at the culture and atmosphere on the NNU and
again we need to remember that over our relevant period you wore different hats?
LAWRENCE: Yes.
DE LA POER: You were a midwife, interacting with the neonatal unit in that capacity and then
latterly you were in the Risk Midwife role where you had oversight from a risk perspective of the
neonatal unit. Now, you say this in your witness statement of the neonatal unit: "I would describe
the relationship between clinicians and managers as far from equal. Nurse managers rarely
challenged the medical team even when
they knew they were deviating from process or guidance. They would just go along with what they
were told to do." Which of the two job roles that you held have you derived that impression
from?
LAWRENCE: So that is from the Risk and Patient Safety aspect.
DE LA POER: So post May 2016?
LAWRENCE: Yes.
DE LA POER: How would you know if you are based in the Risk Department that nurse managers are
just going along and not challenging the clinicians?
LAWRENCE: Because my role was very much an active role in that when there was Neonatal Incident
Review Meeting or a Term Admission Review Meeting, which is every baby who was born over the
gestation of 37 completed weeks, we would -- if they were admitted to the neonatal unit, we would
review their care completely to determine whether there was any ways of avoiding that mother and
baby separation. It was something that we were looking at quite closely in 2016 nationally not
just in the Countess of Chester. And I had lots of meetings with both the managers and the
Consultants, sometimes with senior nurses and junior nurses present, but there would be some
discussions and I would prompt the discussion or lead the discussion and I would be hoping for
support from the ward managers for that area or the senior nurses. And I don't feel they had the
autonomy or the confidence to -- to challenge the Consultants and certainly it frustrated me at
times because -- because I wanted them to -- to feel autonomous to say: actually from a nursing
perspective, that's not appropriate or: we are not going to do that. Or: if we could just pause
there and find out some more information. They were very much led by the doctors.
DE LA POER: Did you witness for yourself any overbearing authoritative dictatorial behaviour from
the doctors that might have created that or was the extent of your observation the fact that the
nurses weren't speaking up when you had hoped that they might?
LAWRENCE: I think a bit of both. Sometimes we would be in meetings where discussions were a bit
fractious and you could see tensions rise in that meeting and you could -- I don't quite know how
to describe it really other than the Consultants would become just that little bit louder and the
nurse voice would become that little bit lower and they would contribute less into that meeting
and then I would always follow up the meeting with a discussion to see if everybody was okay, to
see
if they felt their voices were heard, because sometimes it would be they would say: I don't feel
-- I feel we need to reconvene and I feel I can challenge it more now I have taken a pause, et
cetera. And it would just be decisions around clinical practice or next steps in terms of managing
nurses who may or may not have made a -- an error or judgment. For example, in a term admission
review or somebody might have contributed something, the clinicians would often influence -- we
need to have a conversation with this nurse or we need to do this or we need to do that and it
wasn't the same when it came to the doctors either.
DE LA POER: In these catch-ups that you had afterwards to check that everybody felt their voice
had been heard did anybody ever say to you: look, we just can't speak up at those meetings because
what the doctors want, they get, or was it never voiced as a concern like that to you?
LAWRENCE: Only from Eirian Powell who was the ward manager. But at the same time, when she had
said things like that she would say they have always been the same and: he will calm down, you
know, in a few hours and he will come and see me and he will come and apologise and it will be
okay. So she would ask for it not to be escalated further and she would say she would deal with it
and it was as though it was a long-standing
relationship that she was used to.
DE LA POER: You say there was definitely a hierarchy and some Consultants were more respectful
than others -- I will read that to you again: "There was a definite hierarchy and some Consultants
were more respectful than others"?
LAWRENCE: Yes.
DE LA POER: That is what you put your witness statement. So which were the respectful Consultants
and which were the non-respectful or less respectful Consultants?
LAWRENCE: Do you really want me to answer that?
DE LA POER: I wouldn't have asked it if I didn't.
LAWRENCE: Okay so some of our more respectful Consultants were our female Consultants, Mr John
Gibbs.
DE LA POER: Sorry -- just so you are aware there is a cipher list if you are going to mention
female Consultants?
LAWRENCE: Sorry, okay.
DE LA POER: So do consult it. It is on the desk in front of you. You said Dr Gibbs, does he fall
in the respectful category?
LAWRENCE: Respectful, absolutely and all of the female Consultants.
DE LA POER: So Dr Newby initially, although I don't think she overlapped with you, Dr Holt who
joined in March of
2016, Dr ZA and Dr V?
LAWRENCE: That's correct, yes.
DE LA POER: Yes.
LAWRENCE: Some of our less respectful Consultants were definitely Mr Brearey and Mr Jayaram,
although less often with Mr Jayaram.
DE LA POER: We are going to come and look at an email that Dr Brearey sent in a moment. What was
your relationship Dr Brearey?
LAWRENCE: It was a difficult relationship. I will be honest. Every communication I had with him
felt it was more difficult than it needed to be and I didn't understand why at the time. I have a
little bit more detail, having been prepared for the Inquiry, I've seen some emails one I think
that you are going to show me today which references him not being included in the decision to
appoint a midwife to the role, I think that may have been why he was very offhand with me when I
started in the role. It certainly -- I understand now as to why he felt the way he did at the time
and I think that was how our relationship started off on the wrong foot. I very much have an
appreciative enquiry, I will press and press and press. It's just in my nature and I don't think
it was welcomed or appreciated by Mr Brearey.
DE LA POER: We will come to that email in due course. Just concluding your reflections upon how
you perceived that department, you say this in your witness statement. "The neonatal team
considered incident reporting to be punitive"?
LAWRENCE: (Nods)
DE LA POER: Was that something that you inferred from their behaviour or was that something that
they said out loud?
LAWRENCE: That was something that was said out loud, certainly on several occasions by Mr Brearey
to begin with especially in the very first few weeks of me starting because I was trying to get
them to understand the importance of incident reporting and things that did not impact on the
outcome and that was a real culture shift around that time in incident reporting and risk and
governance because prior to that and around that time certainly in the neonatal units they were
reporting things that were related to the outcome, so something that may or may not have played a
direct part or process in what happened to the individual whereas within obstetrics we had moved
away from that and started to pre-empt improvements in care so we were looking at incidents
whereby something had happened related to something totally different but you found it as an
incidental finding. So in reviewing the care of a woman who may have experienced a stillbirth you
look at the care from the moment she booked and you look at the care right the way through until
she is discharged from your care and the incident you are looking at might be a post partum
haemorrhage at delivery. But if you found something in the antenatal period which didn't impact on
the outcome but was an opportunity for learning, we would report that as an incident because
otherwise we don't learn those lessons from it. And it's that that I am talking about we were
trying to apply to neonates and they perceived that culture change as our clinicians will see that
as punitive, they won't understand that it's around the next lessons learned. So ensuring the next
individual does not experience that same incident. And it was really, really difficult.
DE LA POER: So we are going to move to the --
LADY JUSTICE THIRLWALL: You said you had started that in the first few weeks when you arrived,
you wanted to introduce that shift?
LAWRENCE: Yes.
LADY JUSTICE THIRLWALL: Thank you. Can I just ask something else. Everyone else has referred to
Dr Brearey and Dr Jayaram and you are describing them as "Mr" which is the first time I have heard
them described as "Mr". Which is correct?
LAWRENCE: We normally call junior doctors "Dr" and the Consultants are normally referred to as
"Mr" in my experience in the NHS.
LADY JUSTICE THIRLWALL: I think "Mr" is usually a surgeon, isn't that it? I am just thinking of
all the other doctors, all the female doctors are "Dr" and they are all Consultants.
LAWRENCE: The women would be.
LADY JUSTICE THIRLWALL: Yes.
LAWRENCE: You wouldn't call a female Consultant "Mrs"; you would always call her "Dr". That is
just the way I have been raised within the NHS.
LADY JUSTICE THIRLWALL: I see just that everyone else has referred to them as "Dr" that we have
heard it may be entirely irrelevant.
LAWRENCE: Thank you.
LADY JUSTICE THIRLWALL: Sorry to take time about that, Mr De La Poer.
MR DE LA POER: Sure. We have seen the minutes of a meeting on 19 May of the Women's &
Children's Care Governance Board which
record you as being present in the role of Risk Midwife. I give you that date to try and help you
understand when you started the role.
LAWRENCE: Yes.
DE LA POER: Does that sound about right?
LAWRENCE: Yes, that was my first governance board.
DE LA POER: That was your first governance board. Had you had any handover from Mrs McMahon?
LAWRENCE: Yes -- yes, and no. I think to be fair to Mrs McMahon, she was doing two roles at the
time and there was a -- I suppose an overview given of certain things that needed to be completed
at that time but some things that she was close to completion with she kept hold of and we kind of
drew a line in the sand, if you like, for any incidents, new incidents or things happening after I
had been in post I think for two weeks I would deal with and she would keep everything up until
that point. Just for consistency and certainly from a patient experience perspective because we
link in with our women and families very closely, it made sense for her to conclude those elements
of it before.
DE LA POER: Now, we know the thematic review of neonatal mortality meeting took place an 8
February, we know that the finalised report was completed and dated 2 March?
LAWRENCE: Yes.
DE LA POER: You were in the hearing room this afternoon when I showed Mrs McMahon an email which
she and Ruth Millward were copied into receiving that report on the 2 March. Did Mrs McMahon speak
to you about that report as part of the handover or when you took over that role?
LAWRENCE: No.
DE LA POER: Did Ruth Millward speak to you about that report?
LAWRENCE: No.
DE LA POER: You have since learned the content of the report?
LAWRENCE: (Nods)
DE LA POER: Bearing in mind that we know that it arrived in both of their inboxes on 2 March,
should they have spoken to you or either of them spoken to you about that report when you took up
your role?
LAWRENCE: I think there is two things there, yes absolutely, they should have spoken to me. I
think in hindsight, today is the first time I've seen that and I think looking back into 2016, I
doubt very much that either of them opened the attachment to that email and as you pointed out in
your questioning of Mrs McMahon, that is likely -- it's likely due to the volume of work
that both had at the time. It's not -- it's not an excuse for them. But they should have opened it
and it should have been known when I took over in post and I was incredibly disappointed seeing
that email come up because what happened and the challenges I had upon trying to get hold of that
report and subsequently escalating that report should never have happened and I can see that now
by seeing that email dated 2 March.
DE LA POER: We will come to the conversation which you found out about it but let's just talk
about how you have characterised it.
LAWRENCE: Yes.
DE LA POER: Without any knowledge of that email, and the fact that Dr Brearey had sent to two
members of the Risk Department that report, you characterise the conversation that you overheard
and the reaction to your request as being a bit secretive?
LAWRENCE: Yes.
DE LA POER: Exchanging looks, reticence on their part that you perceived to providing you with
that report. I just want to give you an opportunity to reflect upon that in light of what you now
know and whether you think that is a reliable impression or not. I am not for a moment suggesting
you are right or
wrong about it but you now know that in fact it was shared with the Risk Department --
LAWRENCE: It was shared previously.
DE LA POER: -- on the day that it was published and not just with one person but with the head of
risk as well. So just to give you an opportunity to reflect upon your characterisation and
impression of those two as they spoke, and whether you think that that is a reliable impression
that you formed?
LAWRENCE: I would possibly say on reflection it can't have been the right impression because there
would have been an opportunity to take that report to governance both in the March given that it
was shared on 2 March, the March, the April and the May. So the fact that I got it and then took
it in the June is irrelevant because it was shared openly and transparently with the governance
team at the time.
DE LA POER: Reading between the lines, tell me if I am wrong about this, but you seem to be
suggesting that you got the impression that they did not want it to go to the Women's &
Children's Care Governance Board?
LAWRENCE: I did.
DE LA POER: That was your take-away from looking at their body language and the looks they
exchanged and the words that they used but I think you would be bound to accept
now that they can't have intended that, certainly not on 2 March 2016?
LAWRENCE: Well, I don't think in that email I saw there was any mention of it going to be the
governance board.
DE LA POER: No.
LAWRENCE: So that conversation might have come up if they would have known or seen it was tabled
as an agenda item, so we may have come to that conclusion further down the line, or we may not of.
But certainly, my impression was they didn't want me to see it, hence me now reflecting and
thinking although I must be not mistaken because I am very vivid of the body language I saw, I saw
from their body language there was something in that report that they did not want me to see and
that's why, when I went to it, I was looking for something specifically which is what I found, I
didn't look at the content of the mortality reviews in any detail per se because there was nothing
jumping out at me which is why I continued to look through the whole of the report because I was
looking for something that would tell me why they were -- why their body language showed the body
language in the way that it did and eventually I found it.
DE LA POER: Let's just deal with that conversation in terms of what was said, you have given us a
clear impression of the unsaid things. But you tell us you overheard the two of them speaking?
LAWRENCE: Mm-hm.
DE LA POER: Did they mention expressly in that conversation the thematic review or what was it
that caught your ear?
LAWRENCE: It was mortality review that -- that I meant that I heard and like I say, the
appreciative enquiry of me is: can I have a look at it? And they advised that -- sorry, Mr Brearey
advised that it wasn't for sharing and obviously I continued to press and I had asked: when has it
been to governance board because I knew I could go back and access the agenda and papers, I felt
it was important if there was a mortality review for an area that I was holding risk
responsibility for that I needed to see it and I needed to be aware of the content. And so I was a
little bit like a dog with a bone at that point, because I thought there was information there
which was important to my role and I needed to see it.
DE LA POER: If we go to the end, how did you end up receiving that?
LAWRENCE: Mr Brearey I think emailed it to me.
DE LA POER: So whatever had taken place in the conversation there came a point when he said he
would
give it to you and then he did?
LAWRENCE: He did, yes.
DE LA POER: Had it occurred to you in that conversation to go back to the Risk Department and ask
whether there was already a copy on file or did the conversation just evolve organically and there
wasn't that opportunity?
LAWRENCE: No, I did go back and I checked the -- we had what was called an S drive at the time, I
checked the folders and looked myself to see whether there was anything that would fit that
description and obviously there wasn't.
DE LA POER: So again, knowing how the Risk Department works and drawing an inference it would
appear that neither Ruth Millward nor Janet McMahon had taken it from the attachment --
LAWRENCE: Yes.
DE LA POER: -- and put it in the S drive folder?
LAWRENCE: Yes, they definitely hadn't otherwise it would have been in there.
DE LA POER: So you read the report when you received it and can you give us an approximate date,
was it before the end of May?
LAWRENCE: It was before the end of May, yes, I think it was very close to the end of May because I
am just thinking how I managed to get it on the agenda for
governance board for the June. So it would have had to have been at least the 30th, 31st or 1 or 2
June to have made that agenda. But yes, close towards the end of May.
DE LA POER: You read it as you have told us very carefully looking for something that might have
caused you to form the impression that you had?
LAWRENCE: Yes.
DE LA POER: What was it that you identified?
LAWRENCE: It was in the appendix section, there was a grid which you have shown during today's
proceedings which identified a number of babies who had been subjected to a unexplained or
unexpected death and there was a staff present and staff on duty grid and apart from the first
column on the page, every other column had a nurse's name identified in each of them and I got a
highlighter out and I went through it with a highlighter and I think once I had highlighted
through it, it kind of jumped off the page a little bit more obvious to me.
DE LA POER: Now, you heard me asks Mrs McMahon this question. Other witnesses have placed
particular store by the fact that Letby's name wasn't in the nurse allocated to the child column.
What was your view of the relevance of that to the significance of what you
were looking at?
LAWRENCE: I -- I did think about that at the time but I look at it to my clinical practice and
often we are not caring for individual women but we are involved in their care, so we might
respond to a normal buzzer, a care buzzer, an emergency buzzer and that would apply in the role of
neonates as well. You know, nurses have breaks usually, when we have got staffing levels we
relieve our -- our colleagues for breaks and just because she wasn't allocated that baby does not
mean she wouldn't have had access and for me it was something so obvious it just jumped off the
page to me.
DE LA POER: When you read the balance of the report, did you see any indication that what you
were seeing had been identified or discussed?
LAWRENCE: No, so I read it in more detail afterwards, after I went into Ruth and Ruth said what
she had around, you know --
DE LA POER: We will come to that in a moment but tell us when you read it in more detail?
LAWRENCE: I went back to it and read it and I thought I must have been wrong because when I had
looked through each of the case reviews there was nothing that anybody -- they just hadn't
highlighted it as a common denominator, there wasn't -- there wasn't the recognition, I think, it
wasn't obvious. So when I took it to governance board there wasn't that same discussion and I
certainly didn't mention it again after the conversation with Ruth.
DE LA POER: We will come to that governance board. So having read it, we will go back in time a
little bit?
LAWRENCE: Yes.
DE LA POER: Having read it, having applied your highlighter, having decided that you need to do
something, did you go and speak to Janet McMahon?
LAWRENCE: I did, yes.
DE LA POER: Just tell us briefly what did you say to her and what did she say to you?
LAWRENCE: I went to Jan and I said: Jan, can you have a look at something for me? Obviously I am
brand new to role, I am clinically very experienced as a senior midwife but this governance role
was -- I was only maybe two, three weeks in post at that point and I didn't know whether I was
seeing something that was really obvious or whether I was barking up the wrong tree. And Jan's
response was, she looked at it, she looked at what I had highlighted and she said: we need to go
and see Ruth.
DE LA POER: Up until that moment, whether said out loud between the two of you or simply in your
head at some
point, had you considered the possibility of deliberate harm?
LAWRENCE: I think that's what was jumping out the -- was jumping out the page to me because having
a cluster of deaths, it can be unusual it cannot be unusual. It's not unusual in maternity to have
a cluster of stillbirths if we have, for example, a community acquired infection, parvovirus, for
example, sometimes we can have clusters which wouldn't be unusual, but over the year they would
balance out. We don't normally have real spikes in stillbirths. But because I was new to the
neonatology world and new to risk it looked really, really obvious that there was a real anomaly
here that needed further investigation. But then I -- when I escalated it and I felt that I went
to somebody more experienced to say: is this something I have found when I got the response I got,
I thought maybe I had misunderstood and I didn't challenge that because I didn't have the
experience.
DE LA POER: There I think you are talking about the conversation you had with Mrs Millward?
LAWRENCE: Yes.
DE LA POER: So you have spoken to Janet McMahon?
LAWRENCE: Yes.
DE LA POER: She has told you that her view is you are not
barking up the wrong tree?
LAWRENCE: Yes.
DE LA POER: Did you go immediately to see Ruth Millward?
LAWRENCE: I did. I went straight to see Ruth, she did have a really open-door policy, she was very
amenable, I had only been there a couple of weeks at that point but that open-door policy
continued even after that, that incident. So I went to see Ruth and I explained to her first of
all the challenges I had getting hold of the report because I felt like that was -- that was
important. Without that background information, I don't think it gave the -- I don't think it gave
the same narrative. You know, I watched the non-verbals between two people who it felt at the time
did not want me have to have that report and I have since reflected this afternoon. It may be
because there is a link then to the information being shared within the maternity department, I
don't know whether they trusted me professionally at that point because they had only just started
to work with, me whether confidentiality would be maintained and maybe that's what the non-verbal
conversation was. I don't know. But I explained to her the challenges I had in putting my fingers
on the report and the non-verbals and
the reluctance to share it with me. I had shared that with Julie Fogarty as the Head of Midwifery
before that in our one-to-one, I had some very regular one-to-ones to begin with and she had said:
Mr Brearey is really amenable, go back to him, ask him for it again, et cetera. So I shared with
Ruth the challenges that had led up to me getting hold of it and that I had gone there
specifically looking for something to leap off the page and it did. And I showed her -- I had the
report out to show her but she didn't want to look at it.
DE LA POER: Can I just pause you there for a moment. Did she at any point in your conversation
say: I don't know why you had such difficulty getting it, you could have asked me, I had a copy
--
LAWRENCE: No.
DE LA POER: -- emailed to me?
LAWRENCE: No.
DE LA POER: Did she give you any indication at all that she had seen that before?
LAWRENCE: No, never. She didn't say she hadn't and she didn't say she had. She didn't look like
she didn't need to see it because she had already seen it before. She just didn't -- she didn't
look.
DE LA POER: I should have asked this at the time, but in terms of Mrs McMahon, again did she
appear to you to have seen that document before or did it appear to be new to her?
LAWRENCE: It appeared to be new to her. When I showed it to her she actually looked, she went
through because I don't know whether you could tell on the digital display but you had to turn
over several pages to look at all of the names because there were that many and she paid attention
to the document, she looked at it, looked at the highlighted and then there was again an unspoken
verbals between us and she said; you need to go to Ruth.
DE LA POER: I have gone back in time. Let's go back to Ruth Millward. Just tell us as close as
you can remember it what did Ruth Millward say to you after you talked her through the difficulty
you had, what you had found and the highlights you had applied?
LAWRENCE: As I have said in my statement the exact words I -- I couldn't tell you with 100%
certainty. But it was something along the lines of, you know, you need to be really careful,
Annemarie, you can't come in here and just start throwing accusations around about an individual
nurse being present for all of these deaths, you need to have -- you need to have evidence, you
need to -- just because she's present and on duty doesn't mean that there is a link and I know you
are new to Risk
and Patient Safety, you know, but you need to be really, really careful and mindful and you need
to have something proper to be able to go and like raise alarms.
DE LA POER: Did you form any impression about whether what you were suggesting namely that a
particular nurse was associated with an increase in mortality was something that Ruth Millward
already knew or whether she was talking in general terms about what you should and shouldn't
do?
LAWRENCE: I thought she was talking in general terms. I don't -- I didn't get the impression at
all she was aware of anything and I didn't know that until I got the information from the pack
that that was I believe the only -- the first time she did know anything according to -- to her
information.
DE LA POER: So she's warned you effectively not to make allegations like that, was there any more
discussion between you or was that the end of the conversation?
LAWRENCE: No, she just said you need to be really careful and really mindful that, you know, you
have got evidence to support what you are saying, you can't just go round saying these things. And
I left her office and I will be honest, I am under oath, I felt embarrassed. I felt extremely
embarrassed, I was new in post and I felt like I had embarrassed myself in front of my
boss. So I came away and I looked at the mortality review in detail and I went through all of the
information in the pack and -- and I thought: okay, I must be barking up the wrong tree because
there is no mention of this commonality in any of the -- the information within the pack and I
will just chalk that up to experience and I am new to role, so that was that.
DE LA POER: Did you think that the idea that you had had, namely that it required investigation,
effectively ended at that point or did you think that anything more would be done?
LAWRENCE: I thought it had ended at that point. I suppose in hindsight I kind of hoped something
might have happened afterwards. But obviously the next thing that happened was we had two further
deaths and ...
DE LA POER: There is one event that we need to look at between the conversation and that is we
will just briefly bring it up on screen INQ0003212, this is the Women's & Children's Care Governance Board
meeting. We can see it is on 16 June, we can see that you attended, you are listed under the
Planned Care department as Risk Midwife although in fact your role was across both divisions,
wasn't it?
LAWRENCE: Yes.
DE LA POER: If we go to page 5, we can see that it was
tabled at that meeting and who was responsible for that.
LAWRENCE: So the agenda is prepared under -- with discussion of the chair, whether that is Mr
McCormack or Mrs Fogarty in his -- if he is on annual leave. So if -- if it was Mr McCormack or
Mrs Fogarty I would need to see the front page again but generally the agenda is prepared for
under the instruction of the chair.
DE LA POER: But was this a spontaneous decision by the chair or did you have anything to do
with?
LAWRENCE: Oh no, I had asked for it -- I had asked for it to be put on the agenda having got hold
of it at the end of the month.
DE LA POER: We can see wording which is largely taken from the report --
LAWRENCE: Yes.
DE LA POER: -- concludes with: "There was no common theme identified in all cases."
LAWRENCE: Mm-hm.
DE LA POER: That's what the minutes show to anybody reading them. In fact, you had identified a
common theme, hadn't you?
LAWRENCE: I had, yes.
DE LA POER: So just talk us through your reasoning as to why, unless these minutes are wrong, why
that theme wasn't articulated and why instead the official record is no common theme?
LAWRENCE: I think at the time the report was tabled as an agenda item, we were looking at the
content of the report and what the report had found, that's generally how reports are received and
noted and minuted in governance. My theme that I had identified was outside of that report process
so this is -- is a snapshot of what the report had found rather than what me as an individual had
had seen outside of that fact.
DE LA POER: This being a governance meeting, attendees are entitled to scrutinise what is put in
front of them, it is not a rubber-stamping exercise.
LAWRENCE: They are yes.
DE LA POER: So the person you are now, attending a meeting like that, would that meeting have
been an appropriate forum to say: well, I have had a look at this report but I've seen a
theme?
LAWRENCE: The person I am now would absolutely have had that discussion in that -- in that forum
at that time and -- and looking back I think because nobody else had raised the issues that I
raised, I think it kind of confirmed to me that when Ruth had said; you need to be really careful
about this, nobody else had picked up on
it and I think it kind of cemented that I had obviously got the wrong impression and that wasn't
what I should have done, you know, I -- I didn't escalate beyond Ruth. That was my route of
escalation and if that was to happen now and I was still in a junior role, I would -- I would
absolutely have learned from what happened in 2016 and I would have continued to escalate. Me
being in the role I am in currently today I would be the person who was raising that in that forum
and then if it wasn't being escalated up through the Planned Care governance board I would have
been going directly to the Executives myself to say you need to do something about this and if I
wasn't satisfied I would continue to escalate.
DE LA POER: Did you think of the issue that you had identified as a safeguarding issue? Did you
think of it in those terms?
LAWRENCE: It would have been a safeguarding issue absolutely. You know, a member of staff doing
what happened, in this example is -- is a safeguarding concern. Absolutely. And your next question
will be why did I not escalate it to safeguarding?
DE LA POER: Exactly so.
LAWRENCE: Because I -- I was embarrassed about finding
something that I thought wasn't -- wasn't it was just something that was in my mind and nobody
else's.
DE LA POER: So we will just move forward to the deaths of [Child O] and [Child P] here really
just to illustrate a point. You didn't find out about those deaths until Monday, 27 June; is that
right?
LAWRENCE: That's correct.
DE LA POER: They having occurred on 23rd and 24th?
LAWRENCE: Yes.
DE LA POER: If we just run through your experience. You were on the central labour suite when you
overheard discussion about it and that led you to go into the neonatal unit; is that right?
LAWRENCE: The Practice Development Midwife Lorraine Millward, when I came on to the central labour
suite, seeing me and said: oh my goodness, Annemarie, have you heard that one of the triplets have
died? And I was shocked. I said: I haven't heard anything, nothing has been reported and she said:
none of us can believe it but one of the triplets have died. So I said: I am going to go there
now, the delivery suite was connected to the neonatal unit and so I made my way straight there and
there was a lot of people on the neonatal unit, several more bodies than I would ever normally
see, and they prevented me from entering
further into the neonates. Obviously they knew who I was, some people might not have done because
I was only in post a short time by that point. But those who didn't, I said I am the Risk Lead, I
have come here, I have heard one of the triplets have died and it's not been reported and one of
the staff nurses -- one of them got tearful and upset and the other -- another staff nurse said:
two of the triplets have died, not one.
DE LA POER: Who wouldn't let you on to the unit?
LAWRENCE: So there was a number of staff there, they had said that there was a meeting taking
place in the office and they were not to be disturbed. I asked them to disturb them and said: I am
the Risk Lead and I need to be involved, I need to know what's going on. But they wouldn't let me
in.
DE LA POER: Just again, who?
LAWRENCE: The -- the staff members present I didn't, I didn't --
DE LA POER: Were they doctors or nurses?
LAWRENCE: They were -- there were no doctors outside, they were nurses.
DE LA POER: So you asked to join the meeting that you were told was going on and you were told by
them that you couldn't?
LAWRENCE: Yes.
DE LA POER: Did they go and make an enquiry?
LAWRENCE: They did, I asked them to go, knock on the door and tell them who I was and what my role
was and they would let me in, and she did that and came back and said: they said they are not to
be disturbed.
DE LA POER: We don't need to bring these up but did you go back to the Risk Department to check
on the Datix system to see if you had overlooked --
LAWRENCE: I did.
DE LA POER: -- the filing of Datix?
LAWRENCE: I checked to make sure I had overlooked it but my normal practice is every morning when
I used to come in, we all did this as risk leads. Some of us like me actually did it the night
before we came in just to see what -- plan our workload and if things had happened the night
before sometimes I might go to -- you know, straight to -- to the labour suite because the
building we were in is not was not connected to the hospital. So sometimes I would look the night
before to see but I did go back to the office and I checked the -- the pool that I talked about,
the holding bay, and I also checked under the relevant searches. So, for example, somebody might
have put it in and put it under "paediatrics" for example. But I double-checked
everywhere with I think Joanna Donnelly and nothing had been reported.
DE LA POER: That was because we now know there was nothing to be found because the Datix --
LAWRENCE: Yes.
DE LA POER: -- for [Child A] and P are both dated the 29th, aren't they?
LAWRENCE: Yes.
DE LA POER: Now, we just need to deal briefly with a number of events and I will try to be as
efficient as I can about this, but you shouldn't feel inhibited by that.
LAWRENCE: Okay.
DE LA POER: You participated in a mortality review on 5 July of 2016, is that right, in relation
to [Child O] and [Child P]? Were you aware of that taking place?
LAWRENCE: I would need to --
DE LA POER: Well, I think in the circumstances I don't have any particular questions about the
detail of that so we will leave that one for now. Can we turn to the extraordinary meeting, as you
describe it, in July of 2016?
LAWRENCE: Yes.
DE LA POER: This was a meeting which was attended by Sian Williams and Julie Fogarty; is that
right?
LAWRENCE: Yes.
DE LA POER: Alison Kelly you tell us was also present?
LAWRENCE: Yes.
DE LA POER: So far as you can recall, was anybody else present?
LAWRENCE: There was lots of people there. Some I know to be Executives because I was -- around
that time I was trying to be staff governor so I was getting to be a bit more familiar with --
with who people were so I knew there was a couple of Execs there but I couldn't have told you the
names of them in that respect.
DE LA POER: Were you looking at staff rotas, is that what you were doing in that meeting?
LAWRENCE: No.
DE LA POER: What were you doing?
LAWRENCE: No, it was -- they had asked us to look through the Meditech and look and try and
identify any collapses or deteriorations and look for a name -- look for Lucy's name associated in
the notes.
DE LA POER: At that stage did you make the connection with what you had seen at the end of
May?
LAWRENCE: I did, yes. I think I made it a little bit before that if I am honest before that
meeting, after the babies had died.
DE LA POER: So far as any unspoken agenda for what you
were doing was concerned, did you perceive one or was it just as far as you were concerned a good
faith search for -- through the records?
LAWRENCE: No, I knew they were, when I say I know, I didn't know, nobody came right out and said
specifically. But I -- I knew based on what they were asking me to do that they were looking for
other cases that may or may not be connected to Lucy.
DE LA POER: You tell us that your notes of that work were taken off you at the conclusion?
LAWRENCE: (Nods)
DE LA POER: You also tell us that you undertook a Datix search subsequently for cases --
LAWRENCE: Yes.
DE LA POER: -- involving Letby and you found that there were missing records?
LAWRENCE: Not missing records in relation to the search per se, but there was a number of IT
systems that we searched and a number of reports that were run and they were put into a folder in
-- in our risk and governance S drive. I think if I remember it was Dean Bennett at the time --
and Jo Donnelly at the time who were also searching their systems. We all contributed into the
folder and then one day that folder had just disappeared and I don't think it was very long after,
a couple of -- couple of days, maybe a week or so and the folder just no longer existed.
DE LA POER: Did you ever speak to anybody about or get to the bottom of why that was?
LAWRENCE: I did ask Ruth where the folder had gone and she told me not to concern myself with it.
So I just thought it -- access has been restricted from me or that it had been moved to for
example one of the other department S drives or Y drives that clinicians such as me wouldn't have
had access to.
DE LA POER: I do need to ask you about an email that you have since seen sent by Dr Brearey. I
will just ask for it to come up on screen, please, INQ0006769. You have seen this email before. It is dated 15 July?
LAWRENCE: I have, I saw it on Friday.
DE LA POER: On Friday. So if we just scroll down to get the context so everybody can follow, your
boss Ruth Millward had made a request of Dr Brearey in terms of some information to support the
RCPCH review, we can see that down there?
LAWRENCE: Yes.
DE LA POER: We don't need to go to the detail of that. What we are going to be look at is what Dr
Brearey says about you so that you have an opportunity to comment upon it.
So if we just go back to the preceding page, we can see that Dr Brearey begins by making some
observations about the timing of providing the material. He then goes on to say that he's
completely underwhelmed by the support: "... your department [that is the same as your department]
has provided this year. Concerns are shared by colleagues, nursing staff on paediatrics,
neonatology and obstetrics." Then we can see: "To think the role of Risk Midwife was created
without any discussion with paediatricians or consideration that she would have to cover
neonatology is quite concerning. I also have concerns about Annemarie's competence. Both Eirian
and myself sat down with her at the beginning of her job to explain her role and our expectations,
the most significant [we will need to go over the page] of which was to arrange a monthly incident
review meeting. Seemingly forgotten. We are now at a point where I will be meeting to go through
three months' worth of incidents. I value her contribution to the weekly term admissions audit.
There have been times when busy on-call Consultants have come to review cases at agreed times and
she's not been present and not given her apologies. I have also
offered to meet to discuss with you term admissions reporting and yet I am yet to receive a reply.
I've not seen Annemarie for over a month. In addition ..." And he goes on to talk about the fact
that he's heard that there is criticism of the Datix reporting and he makes the point about the
fact that it's consistent with other neonatal units on the network. So really this is just to give
you an opportunity, Ms Lawrence, to comment upon this and whether it is right to your recollection
that Dr Brearey hadn't seen you, that you hadn't turned up for meetings without giving your
apologies, and that you were not supporting him and his colleagues adequately.
LAWRENCE: Like I say, I saw this on Friday. I was disappointed when I read it. It felt an unfair
representation. I had been in post at that point -- I had started in May. This was the 14 July, I
think. There was an awful lot that had happened between starting in post. Some mandatory training
-- obviously I had done some training in relation to risk and incident management and the NHS
England framework, so I have to have time to undertake mandatory training -- and I was also
working clinically at the time as well. So clinical credibility was extremely important to me when
I started in the role. And there was some
staffing challenges, so I also worked as a Band 7 labour ward co-ordinator, as well as my role, at
the time for probably the first six months but only maybe one long day every week or every
fortnight. I think the first sentence where he says he's been underwhelmed by the support from the
Risk Department for the most part of that year, I think he's got a fair point because when Debbie
left in February to ask another Risk Leader with a whole other service to cover two -- what would
be two whole time equivalent jobs is no small task. So I think you can't continue to run a really
good service with less people, otherwise we wouldn't employ these people to do the jobs and
certainly in Risk and Patient Safety at the Countess, it's got to be one of the most
under-resourced Risk and Patient Safety teams I have ever known in my experience in maternity,
maternity departments per se, and I have worked in a few units in my career across the north-west
and including the Midlands. So it would be fair to say he's got a point because there were some
absolute gaps in the service. I am disappointed that he says he's not seen me for a month and he
has issues around my competence because if he hasn't seen me for a month at that point, and I have
only been in post about nine weeks at that point, then he's made a summative assessment in a very
short space of time and I would have liked an opportunity to have commented at the time he sent
that, rather than left it unchallenged and unsaid.
DE LA POER: I have got two more topics to ask you about.
LAWRENCE: Okay.
DE LA POER: Both of them, I hope, brief. Take that email down, thank you. We know that Letby was
moved to your department. In summary, what was your view about whether it was appropriate for her
to work in your department?
LAWRENCE: I don't think it was appropriate and I certainly voiced that in the beginning and the
response was that she was working in the Complaints Team and wouldn't be working in the Risk and
Patient Safety Team. But what I think my Lady is not aware of is the Risk and Patient Safety team
and the Complaints Team are on the same floor. So we have only got a door that separates the two
of us with a very, very small corridor, not as long as where you are away from me. So although she
was working in the Complaints Team initially, she was working -- she was making tea and coffee in
our office because that is where the tea
machine was and I didn't think it was appropriate.
DE LA POER: Who did you say that to?
LAWRENCE: Ruth and I had a conversation initially and Ruth's response was that -- I think she said
she had asked for her in the beginning. She was concerned about how she would how it would be
handled with her and she felt like she wanted to give her a constant whilst the review process was
going on.
DE LA POER: So far as you were aware, did Letby have access to patient notes or reports such as
the thematic review had she wished to look at them?
LAWRENCE: I think if she wanted to look at them, she absolutely could have because she had access
to the Risk and Patient Safety team S drive. Now, I don't know whether her access was limited in
terms of what folder she could or couldn't access. But you will notice from my statement I talk
about her having information that I didn't have at that point and so I think it's fair to say that
if you were to ask me would she be able to access these things, I would say that would be a
possibility, yes.
DE LA POER: Did you think it was appropriate for her to have access to things that you didn't
have access to?
LAWRENCE: Absolutely not, and I did report that to -- that incident to Karen Rees at the time.
Just for the
benefit of my Lady, if she's not sure of the incident I am referring to, on coming to work one
morning, as I came up the stairs, Lucy came out of the office, out of her office on that corridor,
to greet me and she was very distressed. She almost jumped down my throat really with a "there's
been a collapse and a baby's been transferred out and does that mean somebody else is going to be
under investigation and I can go back to work". And she bombarded me with a lot of questions and I
didn't know what she was talking about because I wasn't aware of a collapse because, as you know,
at the time there was some challenges around whether we were reporting them or not. But she knew
this information and it hadn't reached me. It wasn't in the Datix system. It wasn't emailed to me.
And so I emailed Karen Rees to say, "I am concerned that Lucy has had access to information that
she shouldn't have. I wonder whether there is something in the neonatal unit who was feeding her
information". But it concerns me that she knows something clinically that I don't know as the Risk
Lead.
DE LA POER: Was that an email that you sent?
LAWRENCE: It was, yes.
DE LA POER: Can you give us an approximate date so that we can see if we can find that?
LAWRENCE: Oh, gosh. I would say it would definitely be the autumn of 2016.
DE LA POER: Thank you very much indeed. Finally on this topic before we just deal briefly with
root cause analysis, what you say in your statement is: "We were made to believe that she was
being made a scapegoat for poor medical care and a lack of team working which then conflicted me
further." So there are two parts.
LAWRENCE: Yes.
DE LA POER: We will get to the conflict in a moment.
LAWRENCE: Yes.
DE LA POER: But who was making you believe, or seeking to make you believe, that she had been
their scapegoat?
LAWRENCE: So that was conversations, lots of conversations were had, not directly with me because
I was a Band 7 Risk Midwife at that point, but conversations were had without I think any thought
to confidentiality. Lucy would have conversations with her Union rep and also some of the managers
and things would be overheard, they would walk along the corridors and there would be
conversations that would be happening and if you were walking behind them closely enough or if you
happened to be walking the other way, there was information that you were able to, able to glean
from their discussions or if you entered into a room it would take a minute or so before those
discussions quietened down.
DE LA POER: Who was saying that she was being made a scapegoat, was she saying that or were the
people she was speaking to telling her that?
LAWRENCE: Both, really. She had I think -- I think from the information I had available to me at
the time, and like I say it wasn't a conversation I was included in but it was something I was
listening to on a regular basis, they were conversations between Hayley Cooper who was her Union
representative, Lucy, Karen Rees, some discussions with Ruth but then Ruth left and then those
discussions took place with Julie Fogarty -- sorry Julie Fogarty after, after Ruth left so there
was often things that you could hear.
DE LA POER: And were the people you have identified Hayley Cooper, Karen Rees, Ruth Millward,
Julie Fogarty, were they simply offering a listening ear or were they contributing, making comment
themselves about whether it was true that she was being made a scapegoat?
LAWRENCE: I think at the time that's what they truly believed. I don't think they were
intentionally being unprofessional in terms of knowingly having
a conversation that would be overheard. But where they had those conversations and often with
doors that weren't closed it was -- it was obvious to anybody who was working nearby and many
times we have -- I say "we" me and other members of the team, who haven't been as close to the
door have got up and closed the door because you can hear things coming into the office and when
you are trying to concentrate and trying to write things and there is a group of people having a
conversation outside it can be very districting.
DE LA POER: The second part of what you said "then conflicted me further", I just want to give
you a brief opportunity to just comment upon how you were feeling about this whole situation
bearing in mind what had happened in May?
LAWRENCE: I was hoping you wouldn't ask me that question, if I am honest. It's something I have
reflected on for many, many years. It was a very, very difficult time. I was working alongside
somebody who initially I had thought had done some terrible, terrible crimes and then I -- I can't
say I was made to feel because nobody can make me feel anything but I felt ashamed for raising
them. And then I spent some time thinking if I had have just raised them a little bit louder
potentially I could
have prevented the deaths of two of those babies and I didn't. And then I had to work with her
alongside her listen to conversations that perhaps she might have been innocent and it was really
difficult. And having heard some of the things I have heard today and seen some of the evidence, a
lot of that was avoidable, certainly a lot of the deaths were avoidable and a lot of the
difficulties we faced as clinicians working in that department was avoidable.
DE LA POER: The final topic is the root cause analysis. You tell us that in April of 2017 you
were asked to conduct a root cause analysis in relation to [Child O] and [Child P] and that you
looked at Dr Hawdon's report and the RCPCH and generated those reports based upon that
content.
LAWRENCE: Yes.
DE LA POER: You reached three conclusions, three identical conclusions in each case and we will
just have a look at it. INQ0018008 and we will look at the conclusions that you reached in the root
cause analysis. We will go, please, straight to pages 9 and 10. So this is for [Child O] but the
text is exactly the same, I am sure you can confirm for [Child P]?
LAWRENCE: It is, yes, just very different timelines but the text is --
DE LA POER: The Coroner's cause of death instance was given as complications associated with
prematurity and in addition this investigation has identified no one singular root cause but
several that may well haven --
LAWRENCE: Contributed to the outcome.
DE LA POER: Which include, if we go over the page: we can see that at the top there is that
hanging paragraph in italics in the centre: significant sub optimal care that is possibly relevant
to the outcome, failures in care to recognise problems and a failure to act appropriately?
LAWRENCE: Yes.
DE LA POER: So the conclusions that you are reaching in this root cause analysis are pointing
towards NHS staff failings in care quality. I mean, firstly is that a fair summary of the
conclusions that you are raising as possible?
LAWRENCE: I think that is a fair representation of the conclusions but I must say I --when I --
when I was asked to put the findings of the various reviews into a report, I must say this is what
I have taken out of those and I have put together in a way that it can be read by the CCG. So the
majority of it is not my words or my thoughts. It's me concluding the documents that are available
to me.
DE LA POER: Did you know that in late March of 2017, the Executives were discussing putting
together a bundle of documentation for the Cheshire Police?
LAWRENCE: No.
DE LA POER: We know it wasn't until the end of April that the Cheshire Police were contacted
through the CDOP. But was it appropriate taking into account that fact that you were writing a
root cause analysis in relation to the deaths of [Child O] and [Child P] where you were
specifically drawing attention to failures in care as being a potential explanation for those two
deaths, whilst it was in active contemplation that those deaths may have been murders because the
police were required?
LAWRENCE: It was not appropriate, no and that information wasn't shared with me. Through Ruth
Millward, Ruth asked me to -- that she said that Alison Kelly had asked her to ask me to put this
information which was a number of documents could I culminate it into a template that could be
submitted to the CCG. And so when I sat there and it took me a significant amount of time to put
these documents together because I had to go from one piece to the next piece to the next piece
and so forth, it was on the understanding that the CCG were looking for an MPSA Level 2 report
that they could receive in the
Serious Incident Review Group.
DE LA POER: From the point of view of official paperwork a root cause analysis is a very well
identified way of capturing potential learning within the NHS, isn't it?
LAWRENCE: It is, yes.
DE LA POER: And it is the sort of document that might be shown to board members in the case that
they have an enquiry or to, as we know, the commissioning group and I just would like to just
tease out, if I may, your reflections, given particularly you hold a senior role now, about the
risk of creating a root cause analysis such as you did, in circumstances where other people might
read it and get the wrong idea that everything had been adequately investigated and ascribed to a
particular cause, can you just from your experience help us understand that, please?
LAWRENCE: Absolutely. So at the time, I was given an instruction and I acted on it. But in a
senior role now I can see that the submission of this Level 2 was an attempt to move from
reassurance to assurance. So we are telling you we are looking into it but here is of proof of
such in a Level 2 document. I can see how that could mislead many people in the organisation and
also outside agencies as well.
DE LA POER: Were you given any reason as to why
Alison Kelly wanted these reports created in April of 2017 because of course we know the deaths
occurred back in June, we know that the reports came in from the RCPCH and Dr Hawdon. But why
April? Were you given any information at all about that?
LAWRENCE: No. The only thing that Ruth had said was that they had been requested, they needed to
be -- they needed to be received at the CCG Serious Incident Review Group and I know from previous
where they have -- they perhaps have sent separate documents, the CCG have asked for them to be
collated into a thematic review or something that they can receive in their entirety. So I suppose
at the time, given my junior position I didn't really question it or question the integrity of the
ask, because it wouldn't have been unusual for the CCG to ask for a few things to be brought
together under one document if indeed that was the ask from the CCG based on what you have just
said.
MR DE LA POER: Mrs Lawrence, thank you very much indeed for answering my questions and can I particularly acknowledge the time, and I take full responsibility for that, there is no reflection on you. My Lady, I am told that although permission has been granted for Rule 10 it would appear that I have covered the issues that needed to be covered and so there are no further questions from the advocates for Mrs Lawrence.
LADY JUSTICE THIRLWALL: Thank you. Mrs Lawrence, I have just got a couple of questions myself.
When you went to see Ruth Millward, you say you gave her the or showed her the report and she
didn't want to look at it. But what did you say to her?
LAWRENCE: I -- I went in the room and I said: I wonder if you have got a minute which is how I
normally would start those conversations and then I had the report in my hands and it was open and
I said: I need to tell you about this report I have got here and the challenges I have faced in
getting it, because I need you to understand what it is I have found. And I proceeded to tell her
about the discussion that I witnessed between Stephen Brearey and Eirian Powell and the
non-verbals which I felt were particularly important and that I sat with that document purposely
looking for something based on the non-verbals and the reluctance that I had felt when I had asked
for a copy. And she did -- when I say she didn't look at the report, what she did was she said she
didn't want to see it but she did acknowledge that yes, okay, so you have got somebody present for
all of these deaths but, you know, what does that mean?
LADY JUSTICE THIRLWALL: Had you pointed out that that was what the report showed that there was
someone present for all, did you say that to her?
LAWRENCE: Yes, absolutely, I had highlighted -- each section on that table I had highlighted with
a yellow highlighter so it kind of made it a bit more real and it came off the page a bit more.
LADY JUSTICE THIRLWALL: Then that was when she said: you have got to be very careful, or whatever
it is she said, we have a note of that?
LAWRENCE: Yes.
LADY JUSTICE THIRLWALL: You don't need to repeat that. I just wanted to know what you had said
from your perspective after setting the scene. Then just one last thing. You sent an email to
Karen Rees about Lucy Letby's conversation with you which you have described?
LAWRENCE: Yes.
LADY JUSTICE THIRLWALL: Did you get a reply from Karen Rees?
LAWRENCE: I did. So I do believe there is access to my email, so it should be in my "Sent" if not
in Karen's "Received" and Karen then went on and sent a -- she sent a circulatory email through
herself and Eirian to say something around being mindful of professional
conversations, don't be discussing things outside of work. So I think they address addressed it
generically rather than specifically is my understanding but that information will be in the NHS
mailbox.
LADY JUSTICE THIRLWALL: All right. Thank you very much.
LAWRENCE: Thank you.
LADY JUSTICE THIRLWALL: Yes, those are all my questions, thank you very much for staying so late
--
LAWRENCE: Thank you.
LADY JUSTICE THIRLWALL: -- and being so comprehensive and helpful in all your replies. Thank you
for coming. You are free to go now, please don't wait for me to leave.
LAWRENCE: Thank you.
LADY JUSTICE THIRLWALL: Now, Mr De La Poer we start again on?
MR DE LA POER: Monday, 4 November, we will begin with Karen Townsend and then Ruth Millward will be heard later that day.
LADY JUSTICE THIRLWALL: Thank you very much. So we will rise now until 4 November but I hope that -- I won't say anyone will have a rest because I know you won't, but thanks for all the hard work to date. May I especially mention the shorthand writer whose efforts are Herculean and, as far as I know, uncomplaining. I am very grateful to her. We will rise now.
(5.20 pm) (The Inquiry adjourned until 10.00 am on Monday, 4 November 2024)
LADY JUSTICE THIRLWALL: Good morning, everybody. Ms Brown.
MS BROWN: Yes, if we could call Ms Townsend, please.
LADY JUSTICE THIRLWALL: Ms Townsend, would you come and sit in the chair by the table, please.
MS KAREN TOWNSEND (affirmed)
LADY JUSTICE THIRLWALL: Do sit down.
TOWNSEND: Thank you.
MS BROWN: Could you please state your full name?
TOWNSEND: My name is Karen Townsend.
BROWN: You have provided a statement to the Inquiry dated 21 June 2024, is that statement true to
the best of your knowledge and belief?
TOWNSEND: It is.
BROWN: I think it's correct that you did not previously provide a written statement to the police
and were not interviewed by Facere Melius?
TOWNSEND: Correct.
BROWN: In terms of your background, that is in operational management in healthcare and you have
no medical qualifications?
TOWNSEND: Correct.
BROWN: In terms of your employment, what was your role when you first started work at the
hospital which I believe was in 2001?
TOWNSEND: When I joined in 2001, I worked as a Health Record Supervisor. I then moved through the
outpatients department, became the Assistant Outpatients Manager and then progressed to be
Business Performance Manager, Acute Directorate Manager and then became the Interim Divisional
Director in 2015, and became substantive in that role in I think it was May 2016 as Divisional
Director for Urgent Care.
BROWN: Yes. And being promoted in September 2015 to Interim Divisional Director of Urgent Care,
can you recall when in September that was?
TOWNSEND: No, I can't, I'm sorry.
BROWN: It's correct that the neonatal unit fell within your division?
TOWNSEND: At that point in time it did, yes.
BROWN: Who did you replace in the role of Divisional Director?
TOWNSEND: I replaced Lorraine Burnett who was the Divisional Director at that point in time and
became moved to be Director of Operations.
BROWN: Did you receive a handover from Ms Burnett
when you took over?
TOWNSEND: It was a transitional process because she was still available and would still be my line
manager on a one-to-one basis. There was no formal handover; it was more transitional.
BROWN: Did she or anyone else draw your attention to the fact that there was a concern regarding
increased mortality on the neonatal ward in the three months prior to starting, so between June
and August?
TOWNSEND: No, not at all.
BROWN: You have referred already to the fact that you were promoted from interim to the
substantive post in May, so you spent several months interim and then the substantive post. Was
there any significance in that, any difference in role?
TOWNSEND: No, not at all.
BROWN: I think it is correct that you are still the Divisional Director of Urgent Care?
TOWNSEND: I am.
BROWN: But that now paediatrics and the neonatal unit are now within the separate Women's and
Children Division?
TOWNSEND: Yes, they have -- they have been separated and made into their own division.
BROWN: Can you say when that occurred, when was that
division reformed?
TOWNSEND: Approximately, maybe about -- no, I can't actually, I would be making a date up.
BROWN: I am sure someone can provide us with the date. If we could have up on screen, please, INQ0103833, this is at tab 3, my Lady, and this is an organisational chart.
So just so we can understand the structure. We see you there, your name at the top as Interim
Divisional Director for Urgent Care. Reporting to you over on the left we have Dr Martin Sedgwick
who is the Divisional Medical Director?
TOWNSEND: Correct.
BROWN: Below that, reporting to him, we have Dr Jayaram, who is one of the clinical leads, the
clinical lead for services. Also reporting to you next along we see Karen Rees who is the Head of
Nursing?
TOWNSEND: Correct.
BROWN: Then if we go along to the right-hand side of the page, we actually see your name appears
there twice, also as the Acute Directorate Manager which I think was your previous post?
TOWNSEND: Yes.
BROWN: Prior to being interim, did you hold both posts for a time or is that --
TOWNSEND: For a brief period of time I did until the recruitment was undertaken to fulfil my role.
BROWN: So in November, so you had been there a few months; that would be correct, would it?
TOWNSEND: That would be correct.
BROWN: You were still holding both posts?
TOWNSEND: Yes.
BROWN: Shortly after that, you would have relinquished that role, can you remember?
TOWNSEND: I relinquished that role. Somebody else was appointed to that role and then reported to
me as the Divisional Director.
BROWN: Can you give a date, approximate date, was that before Christmas or after, for
example?
TOWNSEND: That was probably the latter part of 2015/early 2016.
BROWN: Was that problematic, holding both roles, or was it something you were able to --
TOWNSEND: I think the division of Urgent Care is very busy and a very big part of the Trust. It is
all the inpatient wards, all the medical inpatient wards, it is the A&E department and all the
front door services and in addition at that time there was the paediatrics service. So it's very,
big very complex service, yes.
BROWN: But did you feel able to perform your role as Interim Divisional Director whilst holding
the other role as well?
TOWNSEND: Yes.
BROWN: Who did you then report to, we have seen who reported to you, but who did you report
to?
TOWNSEND: I reported to the Director of Operations.
BROWN: We know that eventually that became Lorraine Bennett?
TOWNSEND: Lorraine Burnett, yes.
BROWN: Burnett, sorry, who was that initially? The Director of Operations who were you first
reporting to?
TOWNSEND: Prior to that? I can't recall.
BROWN: Once you were in the post of director of Urgent Care, how did you ensure that you were
aware of the issues and concerns of staff on the ground, so to speak, within the units that fell
within it?
TOWNSEND: So as you can see on the organisational structure there is a significant team that sits
with -- beneath the Divisional Director, which is medical leads, nursing leads and also
operational leads, and I would receive information from those individuals participating in any
discussions, attending speciality meetings and through our governance forum, so our divisional
governance committee and our divisional committee and
also working with other partners, both internally and externally.
BROWN: How often in practice would you actually visit the ward or units within your division,
would you actually go down on to the wards and visit?
TOWNSEND: We would -- I would go to the wards. It was not regular, that has to be said. But I
would go and speak to staff in some of the key departments but no, it wasn't a regular part of my
working week.
BROWN: So approximately how often would you have visited the neonatal unit, would that be once a
month or once every six months?
TOWNSEND: No, I have probably been to the neonatal units about once every four to six weeks in
that short period of time.
BROWN: So that is going to the neonatal unit. In terms of meeting with divisional -- with the
clinical leads, so meeting with Dr Jayaram, obviously with Dr Brearey, how often would you meet
them on a one-to-one basis to find out about their concerns?
TOWNSEND: It would have been Dr Jayaram because he was the lead for paediatrics and probably about
once every couple of months.
BROWN: In terms of how you saw the role and responsibility of Divisional Director, can you just
--
are you able to sum that up?
TOWNSEND: Yes. So it's my responsibility to work alongside the medical leads and the nursing leads
to provide oversight for all the operational aspects of the division, for all our compliance, our
finance and support for our workforce and obviously the service users and patients.
LADY JUSTICE THIRLWALL: I wonder if I might ask: you said you work alongside them, but on the
chart it looks as though they report to you?
TOWNSEND: Yes. I appreciate that.
LADY JUSTICE THIRLWALL: Is that right?
TOWNSEND: But it's very much a triumvirate because I am not clinically trained so I am heavily
reliant on the medical lead and also the nursing lead so we worked as a -- we work cohesively as a
team, really.
LADY JUSTICE THIRLWALL: So they don't report to you or do they?
TOWNSEND: That indicates that they do but directly the Divisional Medical Director reports to the
Medical Director in terms of professionalism as does the Senior Nurse or Head of Nursing also
reports to the Executive Nurse for professionalism.
LADY JUSTICE THIRLWALL: So what do you bring, as it were, to those people?
TOWNSEND: So operational -- all the operational aspects, business, workforce, finance, compliance
in terms of our service delivery, in terms of our target compliance, and just the overall delivery
of the division in terms of the day-to-day running of it.
LADY JUSTICE THIRLWALL: Thank you. But so far as medical and nursing issues, that is not really
your responsibility -- is it your responsibility?
TOWNSEND: No, we would work together. If something was highlighted as a senior team, so medical,
nursing and operational, we would come together as a team and discuss those issues.
LADY JUSTICE THIRLWALL: Thank you. Thank you, Ms Brown.
MS BROWN: Just turning then to the Risk Registers. Can you explain the difference between the
different Risk Registers, there were Neonatal Unit Risk Registers, Divisional Risk Registers and
Executive Risk Registers. Can you just set out how they interacted?
TOWNSEND: Yes. So locally all areas and departments have the opportunity to add a risk at any
point in time. Those risks, if there are lower risks, can be held locally in, so in essence it's
up to the team or the unit to be able to manage that risk. Any significant risks go on are
reviewed by the division and received by
the division and we have some oversight and input into what those risks are.
BROWN: Just stopping you there. So when you say "come to the division" that meant come to you,
did it?
TOWNSEND: Yes, so they -- so they come through to the division so that would be myself, the
Divisional Medical Director and the Head of Nursing that would review those risks and we would
provide the input depending what that risk was.
BROWN: Then from you up to the Executive Risk Register, how did that operate?
TOWNSEND: Yes, so at the time, anything that was graded as a 15 and above would go up to the
Executives and that would be discussed through the Executive forum which was the quality Safety
and Patient Experience Committee and would be held by the Executive team.
BROWN: When you say 15 and above, what's the -- just explain the scale, please?
TOWNSEND: Yes, so anything that is -- anything less than 12 is often held as a local risk so
something that the department themselves can manage or resolve or address. Anything 12 to 15
sometimes requires a wider input, it could be financial, it could be operational, it could be
estate-wise. And then anything more significant than that would be held -- 15 and above would go
to Executive
level so that was where it would require something outside of the divisional sphere of
responsibility.
BROWN: What should be recorded on a Risk Register?
TOWNSEND: Anybody can enter a risk that they deem is appropriate in terms of any aspect of estate,
operational, workforce or patient safety issues.
BROWN: You say "anyone". That was going to be my next question: what are the routes by which
someone would put -- something would be put on to a Risk Register? You say "anyone"?
TOWNSEND: Yes, so usually it could be a ward manager, an operational manager, it could be a
clinician, it could be a senior manager, so anyone who identifies a risk at whatever level. So
local, divisional or otherwise. Anyone can enter a risk on the Risk Register.
BROWN: You refer in your statement to the Urgent Care Governance and Risk Lead. Who was that in
2015/2016?
TOWNSEND: That at the time I believe was -- my recollection is it may have been Nicola Brown but
that is only -- that is a vague recollection.
BROWN: You say it is in paragraph 13 if you want to look at it, you say that in relation to all
risks documented you would review the recorded risks, look at all documented risks across the
Urgent Care team. What did that review involve, what were you reviewing for,
what were you looking for?
TOWNSEND: So I would review the risks with the governance and risk leads and also in conjunction
with the senior nurse and the Divisional Medical Director as appropriate. We would review the
risk, we would ascertain what the risk was to be, whether or not there was any evidence to support
that and whatever mitigation or controls were in place to manage or support that risk until it
resolved. So we would review that from all aspects and if we felt there wasn't sufficient evidence
we would go back to whoever had logged that risk to ask for additional information as appropriate.
BROWN: You say as well at paragraph 13, in addition to reviewing the risks: "I do also discuss
risks as part of any discussion I have with operational, medical or nursing leads." So that is a
discussion you are having with the medical and nursing leads? The medical lead for the neonatal
unit would be Dr Brearey?
TOWNSEND: Yes.
BROWN: Who would you be categorising as the nursing lead for the neonatal; is that Eirian
Powell?
TOWNSEND: Eirian, yes.
BROWN: Between September 2015, when you took on the role, and December 2015, did you discuss
risks in the neonatal unit with either Dr Brearey or Eirian Powell?
TOWNSEND: Not with Dr Brearey. I do recall I have had discussions with Eirian Powell. I think
those risks were associated with workforce and there was significant workforce constraints on the
neonatal unit at the time.
BROWN: So between when you took post and December, which we will come to, when other matters came
to your attention, but up to December 2015, did Eirian Powell at any point in that period raise to
you a concern about a risk of an increased mortality?
TOWNSEND: No, not at all.
BROWN: So looking now at when you became aware of the increased mortality on the NNU, you say in
your statement -- this is paragraph 18 -- that you first became aware of the increased mortality
rates when you received the Women and Children's Care Governance Board minutes on 18th -- well,
the minutes are dated 18 December 2015. You were not -- that was a board that you were not on, but
you received their minutes?
TOWNSEND: Yes.
BROWN: You would be sent them as a matter of course as Divisional Director?
TOWNSEND: Yes.
BROWN: Generally how long after the meeting?
TOWNSEND: Sometimes it can be some weeks afterwards. That very much depends on when the minutes
were made available. Sometimes they often were delayed.
BROWN: Presumably the purpose of receiving these minutes was so that you were aware of what was
going on --
TOWNSEND: Yes.
BROWN: -- within the units that fell within your division?
TOWNSEND: Yes.
BROWN: Because the Women and Children's Care Governance Board, as well as dealing with obstetrics
side of things which was not within your division, it also dealt with paediatrics and neonatal
that were within your division --
TOWNSEND: That's correct.
BROWN: -- at that time?
TOWNSEND: Yes.
BROWN: So the minutes of the Women and Children's Care Governance Board on 18 December, they
referenced stillbirth and early neonatal death review and action plan and this is what you say
alerted you to the increase in mortality?
That in fact is a reference we know of the report of Dr Brigham. Did you ask to see that
underlying report when you became aware of the increase in mortality?
TOWNSEND: No, I didn't see that report at the time.
BROWN: Did you not think it was important, given the importance of an increase in mortality, to
see the underlying report?
TOWNSEND: So that as I believe is associated with the stillbirths and neonates and that would have
fell within the obstetrics and gynaecology aspect of Women and Children's rather than paediatrics
at that stage.
BROWN: So you understood that that report was an obstetric report, did you?
TOWNSEND: Yes.
BROWN: But you didn't see it, that was your clear understanding?
TOWNSEND: (Nods)
LADY JUSTICE THIRLWALL: At the time?
TOWNSEND: No, no, I understand that now, not at the time.
MS BROWN: So the position in December then is that you are aware that there is an increase in
mortality?
TOWNSEND: (Nods).
BROWN: And you are aware there has been a report --
TOWNSEND: (Nods)
BROWN: -- which you haven't seen, the underlying report?
TOWNSEND: (Nods)
BROWN: How are you then interrogating whether there is or isn't an issue in relation to increased
mortality in the neonatal unit, which obviously would be a very serious thing within the
division?
TOWNSEND: Yes. So at that point I wasn't involved in any discussions. I -- I was not made aware
other than what I had read in the minutes and I wasn't involved or party to any further
discussions after that.
BROWN: Well, you were aware there was an increase in mortality --
TOWNSEND: Yes.
BROWN: -- in the neonatal unit and you were aware there had been a report?
TOWNSEND: (Nods)
BROWN: So why were you not asking questions, for example, of Dr Brearey or Dr Jayaram as to
whether they had concerns about the mortality increase in the neonatal unit?
TOWNSEND: So I didn't meet with Dr Brearey. I had had some meetings with Dr Jayaram, Dr Jayaram
had never raised that with me and, to be fair, I would suggest that was part of my naivety of
being very new in that role and paediatrics and neonatal not being particularly part of my career
path in terms of my role to date.
BROWN: But you -- despite being aware in December that mortality rates were going up, you didn't
raise that with Dr Jayaram or anyone?
TOWNSEND: I don't recall raising it, no.
LADY JUSTICE THIRLWALL: Can I just ask: you were asked whether you asked to see the report and
you said you hadn't seen it.
TOWNSEND: I don't recall asking to see it.
LADY JUSTICE THIRLWALL: Did you ask for it?
TOWNSEND: No.
LADY JUSTICE THIRLWALL: No, thank you.
MS BROWN: It seems on the face of it surprising that as a Divisional Director, the first that you
became aware of the increase in mortality was just a reference to a report in minutes of a
meeting. Was there no system in place to alert you as Divisional Director of an increase in
mortality rates independent of governance boards, but simply an alert to mortality rates are going
up?
TOWNSEND: Not at the time, no. I -- there was nothing that I was sighted to or had in process to
make me aware of that.
BROWN: Just to be clear, you said you had some meetings with Eirian Powell. That you met I think
every few months with -- you would have met with Dr Jayaram. You never asked them about the
increased mortality rates when you became aware of them and is your evidence that they never
raised it with you either?
TOWNSEND: Correct. Not during that period of time at all, no.
BROWN: At paragraph 28 of your statement, if we could just look at that, you say: "In my opinion,
any concern associated with an increase in mortality or risk to babies on the NNU should have been
registered as a risk on the Risk Register." Once you did become aware in December of the increased
mortality rates, why did you not at that point put that on to a Risk Register?
TOWNSEND: So I -- I didn't have the detail associated with -- associated with that and I would
have felt it was entirely appropriate for a member of the clinical team who did have that report
and have access to it to put that on the Risk Register should they feel appropriate to do so.
BROWN: But we have just been through the fact that you reviewed over the board the Risk Register
so you
would have been aware that increased mortality wasn't on it. You are now aware in December, there
is an issue with increased mortality. Why were you not asking questions or raising the fact that
this was not appearing on your Risk Register and there was clearly an issue with increased
mortality?
TOWNSEND: Yes, no --
BROWN: -- because that was coming up in your minutes?
TOWNSEND: -- I acknowledge that but no, I didn't do that.
BROWN: At paragraph 29 of your statement, you say: "I was not made aware through any discussion
that there was any risk associated with an increased mortality on the NNU." Just setting aside for
a moment the terminology of risk and Risk Registers and just looking at the facts here. You were
being informed in December 2015 that more babies than expected were dying, that is what an
increased rate of mortality is, more babies dying on the ward. That was a unit in your division.
You hadn't seen the underlying report so you didn't have a reason to explain in fact that report
didn't give a reason in any event as to why more babies were dying. Regardless of Risk Registers
but why just out of curiosity and out of your role as Divisional Director
did you not go to either Dr Jayaram or Dr Brearey and say: what's this about? Is there a problem
here? I am being told more babies are dying, why is this? Why was that question do you think not
asked?
TOWNSEND: Yes. I think -- I think that was a gap and a failing on my point but neither was that
point raised with me either. I didn't have that discussion with Dr Jayaram or Dr Brearey. They
didn't come forward with that but actually no, I didn't go and ask them either.
BROWN: Then moving forward to paragraph 20 in your statement, we then see you refer to the
minutes again, later minutes of the Women and Children's Care Governance Board that were from a
meeting of 16 June. Can you recall when you would have received those minutes?
TOWNSEND: Those minutes actually came to Divisional Governance in July 2016, I think.
BROWN: Yes.
TOWNSEND: Yes.
BROWN: Which you go on to deal with. My question is would you -- so that is when they were
discussed by the next board up, so to speak, but would you have received and reviewed those
minutes at an earlier stage?
TOWNSEND: No.
BROWN: Those minutes refer to the thematic review now of the neonatal unit that was done in
February --
TOWNSEND: Mmm mm.
BROWN: -- with the involvement of Dr Brearey. Prior to you seeing the minutes in -- these June
minutes, were you aware that that review had taken place?
TOWNSEND: I was not, no.
BROWN: That was a review, as you are aware now, an outside Consultant was brought in to review
--
TOWNSEND: Yes.
BROWN: -- obviously the very serious issue of increased mortality. Why do you think it was as
Divisional Director you weren't aware of that?
TOWNSEND: So I didn't receive any -- I didn't receive any handover associated with any issues with
regards to this issue. I didn't receive any back papers, I didn't have any indication prior to
that event of any situation associated with the mortality on the neonatal unit.
BROWN: So you were aware in December that there was an increased mortality. Then in June this is
the first you are aware these minutes, the first that you are aware a review had been done in
February?
TOWNSEND: Correct.
BROWN: You have explained before that you were meeting every few months or so with Dr Jayaram
--
TOWNSEND: (Nods)
BROWN: -- and meeting I think more regularly with Eirian Powell?
TOWNSEND: Yes.
BROWN: Did you at no point, knowing that there was increased mortality, raise with them what's
being done to look into this increased mortality on the neonatal unit?
TOWNSEND: No, I had no discussion.
BROWN: But that would have fallen with something you as divisional director should have looked
at?
TOWNSEND: Had I have known that there was a thematic review from 2015 I may have done something
differently but I -- it wasn't discussed with me, I didn't know anything about it and meeting
Eirian or Dr Jayaram, neither of them raised that with me either.
BROWN: Once you did see the minutes and discovered that this -- this review had gone on, this
thematic review, did you ask to see the report then?
TOWNSEND: I didn't see the report then because this came out after the events and I wasn't
involved in the ongoing events after June 2016 at all.
BROWN: But did you, regardless of the fact things had moved on, did you not think it was
important to see what review had gone on within your division in February to
do with mortality rates?
TOWNSEND: Potentially but I wasn't -- they weren't made available to me.
BROWN: If we just look then at what you say about the discussion of those minutes, that they were
received -- paragraph 21 -- by the Urgent Care Divisional board on 14 July. Now by 14 July, you
had spoken to Dr Jayaram then so you were aware of his concerns --
TOWNSEND: Yes.
BROWN: -- that there was a member of staff harming babies?
TOWNSEND: Mm-hm.
BROWN: And you were also aware that there was an increased mortality issue on the neonatal unit.
At paragraph 23, you say: "I understood from consideration of those minutes [these are the Women
and Children's Care Governance Board minutes] no common theme had been identified across all the
cases and I understood there was no apparent evidence to suggest there was any risk within the
NNU." But by that time you expressly knew that Dr Jayaram was saying there is a risk on the NNU
and that risk is a member of staff?
TOWNSEND: But I think what I was making reference to is
what was within the minutes. So within the minutes, it talks about there being no apparent
evidence and suggestion of any risk, that was in the minutes from the board, not actually the
events that had taken place.
BROWN: Well, let's just look at the minutes, shall we? So if we could go to 0003212, at page 5. So this is the minutes of the 16 June 2016 meeting that
was then discussed at divisional level. So these are the minutes that you saw and were discussed
at divisional. It says there under "NN Thematic Review" there was a higher than expected mortality
rate, which you were aware of in any event. Then going down, there was an external reviewer. So it
was of significance that someone else was brought in from outside the hospital?
TOWNSEND: Mm-hm.
BROWN: It says what they were assessing was where all action points were completed, any new areas
of care improvement, any possible common themes, discuss if further action is required. There was
no common theme identified in all the cases. So it says there is no common theme. But you can't
tell from that whether there were any issues, whether there were areas of care improvement needed.
Did you not feel on seeing that note: I need to see this report, I need to understand what, for
example, the areas of care improvement are, what the explanation is if there is no explanation for
the mortality?
TOWNSEND: No. So I received that in the July as part of the Urgent Care governance. The situation
had been superseded by the events back in June and therefore this was being dealt with very much
by the Executives in conjunction with the paediatricians.
BROWN: Yes. Just going back, just look at paragraph 23 of your statement. You say there you
understood there was no evidence to suggest there was any risk within the NNU. That's wrong, isn't
it, you did understand there was a risk within the NNU then?
TOWNSEND: But I was referring to the notes in the minutes, sorry, that's the way I have reported
that. I am referring to the minutes -- obviously I received the minutes after I had had the
conversation with Dr Jayaram back in June.
BROWN: But given that you were aware of it, and you were discussing this on the Urgent Care
Divisional board, you say there was consequently no broad discussion as to these minutes within
the Urgent Care Divisional board. Sitting on that board, the point comes up in the
agenda presumably to discuss this report. Didn't you feel at that point you had to say: well, I
now have additional information, I know that there is a real concern. Why was that not a point of
discussion at the Urgent Care Divisional board?
TOWNSEND: Because as this had come to light and prior to that urgent board taking place, I think
on 14 July, this very much became an issue that was addressed between the Executives and the
paediatricians and it was not inclusive of members of the Division of Urgent Care.
BROWN: If we can go then to paragraph 32 of your statement. You say there if you had been aware
of any concerns about staff involvement and increased mortality you would have expected that to be
on the Risk Register. You see the last line: "... I would have expected that to be on the Risk
Register"?
TOWNSEND: Yes.
BROWN: So just understanding. I take it from that that you felt that if there was a risk that a
member of staff was harming patients, that that was something that was suitable to go on a Risk
Register?
TOWNSEND: Yes, absolutely.
BROWN: Did -- external bodies such as the CQC, they would have access to Risk Registers?
TOWNSEND: Yes.
BROWN: Did you consider that in fact influenced what in fact was put on Risk Registers, whether
there was a desire to keep this sort of risk off a Risk Register?
TOWNSEND: No, I didn't have any -- can you repeat that, sorry?
BROWN: Well, because they were open to outside scrutiny were you aware of any move to keep these
sort of risks -- you say you feel those risks should go on there, but were you aware of a view
that those risks shouldn't be put there?
TOWNSEND: No.
BROWN: We are going to come to the meeting with Dr Jayaram in a moment, but on 24 June, you
became aware of the risk of the concerns that Dr Jayaram had about a member of staff harming
babies. Why then at that point on 24 June did you not put that on the Risk Register?
TOWNSEND: Because I didn't have any detail. It was a very vague reference to, there was no detail
associated with that whatsoever, I wasn't given any evidence or anything to substantiate it and I
felt like I needed to raise that with clinical members of the senior team and -- and find some
additional information.
BROWN: If we can just look at what was put on to the
Risk Register. If we could go to INQ0004657, this is tab 19, my Lady, of your bundle. So we see at the top
there, so this is -- we see Urgent Care, we are looking at the first line, neonatology, the
handler, what does "handler" mean?
TOWNSEND: The handler is normally the individual that's actually input that particular risk.
BROWN: We see -- so this is the date the risk here was added, 11 July 2016 and we see the wording
there: "Potential damage to reputation of neonatal service and wider Trust due to apparent
increased mortality within the neonatal unit." Where did you get that wording from?
TOWNSEND: That was scripted following meetings with the Executive teams when we were making
preparation to go public with regards to the alleged increased into the mortality and the change
of the unit from a Level 2 to Level 1 status. So that was part of those briefing sessions early
July.
BROWN: But you were putting this on to your -- within your division your register as a risk?
TOWNSEND: Yes.
BROWN: What did you understand the risk that you were talking about was here?
TOWNSEND: So at that point yes, I had already had a conversation with Dr Jayaram. However, I still
did not have any detail or any clinical understanding of what those risks were and that risk was
scripted from the Trust perspective as how they wanted to register that risk on the Risk Register.
BROWN: Because the wording that -- you have explained where the wording came from but it says
"due to apparent increased mortality"?
TOWNSEND: Yes.
BROWN: Why was the word or why did you adopt their word for your Risk Register of "apparent"
increased mortality, because there was actual increased mortality, wasn't there?
TOWNSEND: Because at that point in time the Trust were still undertaking a number of fact-finding
avenues and looking at different external parties to support those reviews and that was the
decision that was made at the time before we went public, that was part of the information that
went out publicly as well. That was how it was asked to be added.
BROWN: But your understanding was on 11 July that there was actual increase in mortality?
TOWNSEND: Well, I had received some information to suggest so, but I didn't have any detail. I
didn't have any actual detail, I didn't have any clinical detail at
that point in time. It was just a raised concern.
BROWN: Because if there was potential damage to reputation, so this is talking about the
reputation of the Trust, due to the apparent increased mortality, is there not by definition then
beneath that the more serious risk which is the risk to any baby going on the unit that their risk
of mortality is greater?
TOWNSEND: Yes.
BROWN: The question is between September when you joined and this period in July, there is
nothing on any Risk Registers the risks that you reviewed to record that there was a risk due to
increased mortality and we are trying to understand why that was?
TOWNSEND: Yes, there were -- you are correct, there wasn't. I didn't put a risk on there until I
was part of those later discussions, nor did any of the clinical teams or the nursing teams within
the neonatal or paediatric unit either, nobody put those risks on.
BROWN: If there had been, if it had been entered on a Risk Register, either the NNU or the
Divisional Risk Register, either in June 2015 when the three deaths occurred in short succession,
that was before your role, or in December when you became as Divisional Director aware of the
increased mortality or on 16 June, when you became aware of the thematic review, what difference
would that have made, what -- how would these Risk Registers in practice working, what would have
happened in terms of reviews if a risk of increased mortality had been put on the register?
TOWNSEND: So at the time, I think there would have been more open conversations. I think there
would be a broader understanding of actions that needed to be taken and reviews and discussions to
be held. My experience at that time was it was very much dealt with in Executive level. We were
removed from those discussions and that process, there was a lack of transparency as to what the
detail was.
BROWN: So if we can turn now to the meeting you had with Dr Jayaram on 24 June 2016 at 11
o'clock. You deal with this at paragraph 40 of your witness statement. So Dr Jayaram's
recollection is that you met at his request. Does that accord with your recollection or can you
not assist?
TOWNSEND: I don't recall whose request it was.
BROWN: But your evidence is I think that this wouldn't have been the first time you met as with a
one-to-one with Dr Jayaram?
TOWNSEND: Correct.
BROWN: It wasn't the first time?
TOWNSEND: It wasn't the first time, no.
BROWN: Approximately since September, how many times would you have met with Dr Jayaram, do you
feel?
TOWNSEND: At least a couple.
BROWN: You describe the meeting in paragraph 41 and significantly the information that you recall
Dr Jayaram sharing with you is that a triplet had died on the neonatal unit, so a death, obviously
background to this you already aware of an increase in neonatal mortality?
TOWNSEND: Yes.
BROWN: But a triplet had died. Both Dr Jayaram and Dr Brearey had concerns that an individual may
be deliberately harming babies on the neonatal unit and you say that you recall that they were
very concerned for the remaining two triplets. So this must have been incredibly shocking
information to receive?
TOWNSEND: It was.
BROWN: You say that you can't recall if Dr Jayaram referred to Letby. Dr Jayaram's recollection
is that he did and that that's the recollection of Karen Rees in her account to Facere Melius.
It's likely, isn't it, that you -- I appreciate you can't recall that, but that you would have
asked: who is this staff member, it is a nurse or a doctor? That seems likely?
TOWNSEND: I think I made some very rough notes and I think I put the initials, I just don't recall
actually hearing it.
BROWN: Right. So do you recall Dr Jayaram informing you that he was uncomfortable with Letby
remaining on the unit unsupervised?
TOWNSEND: So we had a very brief conversation. We talked about other things and then we talked
very briefly about the concerns that himself and Dr Brearey and potentially others had and was
concerned around the individual being on the unit at that time, yes.
BROWN: At paragraph 42, you say here that -- and this meeting I think took in a coffee area
within the hospital?
TOWNSEND: It was in a coffee shop, yes.
BROWN: You say Dr Jayaram gesticulated to a drawer of doom?
TOWNSEND: Yes.
BROWN: What was he gesticulating to?
TOWNSEND: So he was, he was making reference to Dr Brearey having a drawer of doom where
apparently he had information or evidence and he was kind of doing this (indicated) kind of to
suggest a drawer.
BROWN: Do I understand from that that Dr Jayaram was telling you about concerns that Letby was
associated with previous unexpected deaths?
TOWNSEND: It was, he had evidence clinical evidence and detail is what the reference was.
BROWN: That was referring to past deaths --
TOWNSEND: Yes.
BROWN: -- on the unit?
TOWNSEND: Yes, previous -- yes.
BROWN: At paragraph 45, you say: "I was concerned there was a potential risk to the babies on the
NNU." Precisely what was the risk that you were concerned about at this point?
TOWNSEND: So in context that was a very ad hoc meeting that we were having, it wasn't a formal
meeting at all, it was in a coffee shop in an open area it was on a Friday and my immediate --
having heard that for the first time, my immediate concern was that I needed to go and speak to
someone to see if there was any actions that we needed to undertake because it was a Friday and
obviously going into a weekend.
BROWN: Just coming back to the question. What was the risk that you were concerned about?
TOWNSEND: The risk was that there was going to be further harm to babies on the neonatal unit.
BROWN: You say that and you have repeated I think just there orally what you say in paragraph 46
about the
fact this was raised in an informal manner and had not been raised previously. Do you mean by that
you were doubting that Dr Jayaram's concern was genuine?
TOWNSEND: I wasn't doubting it. It was the first time I have heard it and I just found it was
quite an unusual forum in which to give somebody that level of information so -- or that detail. I
was just quite shocked when I received it at that point in time.
BROWN: So you were taken aback but you weren't doubting that Dr Jayaram was --
TOWNSEND: I wasn't.
BROWN: -- sincere?
TOWNSEND: I wasn't doubting it, I think I was just shocked to receive it in that manner.
BROWN: Other than going to Karen Rees, who was the Head of Nursing, that we have seen while on
the structure reported to you, I think you say you worked alongside --
TOWNSEND: Yes.
BROWN: -- but was certainly -- you were the Divisional Director of which she was the Head of
Nursing, other than going to her, what did you do to address that immediate risk that Dr Jayaram
alerted you to and which you understood was harm to babies? And in
fact Dr Jayaram was talking about concern for the two remaining triplets, he was talking very
specifically about harm to babies imminent -- imminent harm, babies who were on the unit then.
Other than speaking to Karen Rees what did you do to address that harm, that risk?
TOWNSEND: So what I did at the time was, as I said before, I was very shocked, I didn't have any
clinical information. It was just I think Ravi had said at the time that they felt but there was
no actual factual information or evidence given to me. So I went to speak to Karen Rees, I am not
clinical by background, so I went to seek her support and advice and kind of ask her what should
we do in terms of those immediate next steps. And I think from that point on Karen then went to
speak or try and speak to the individuals to try and gain some additional information.
BROWN: Because just to recap where we were at that point. So this was on the morning of the 24th
so one triplet had died. You are being told there is concern for two triplets on the -- the two
remaining triplets who are on the unit then. You have got Dr Jayaram saying that he and Dr Brearey
had very -- were very concerned so the two most senior clinicians were concerned. They are telling
you there is -- you haven't seen it but there was -- they have got documents that substantiate
that. You don't doubt that those are genuine. Why at that point were you not going immediately to
the Executive level saying: we need to take -- immediate action needs to be taken at the most
senior level, rather than referring it to your Head of Nursing to make further enquiries because
that wasn't going to address the risk that there were babies at imminent risk of harm?
TOWNSEND: No, I understand that. But I think that was kind of my naivety in my role but also if Dr
Jayaram and Dr Brearey also had those real strong concerns, and obviously they had far more detail
than I -- why was that then transposed to me in a coffee shop meeting and why wasn't that actually
escalated direct to the Executives?
BROWN: You say naivety in role, but you had been in post for a year by this time, hadn't you?
TOWNSEND: I hadn't been in post a year but my true background is Urgent Care. Paediatrics and
neonatal were not within my portfolio in terms of my longer career. However, I did go and speak
immediately to Karen Rees to seek some support in that discussion.
BROWN: I say a year, it wasn't quite a year was it,
because you started in September and this was June?
TOWNSEND: No.
BROWN: Paragraph 48 then, you say: "On the day I received this information it was something I did
not expect to hear ... I had no detail, evidence or context regarding the comments made to me. I
therefore did not have sufficient information for these comments to be placed immediately on the
Risk Register." Because it seems from that that there was an over-reliance or over-concern about
putting it on the Risk Register and not sufficient recognition that actually what was needed here
was now immediate action to remove Letby from the ward so that there could be an investigation. Is
that -- is that fair that there was an over-reliance on Risk Registers and not -- clouding the
actual action that was needed to the present risk?
TOWNSEND: No, I don't think there was an over-reliance on the Risk Register at all. I think
following the discussion with Ravi I think yes clearly some action needed to be taken but actually
there needed to be some evidence, there needed to be some detail of what that concern was. I
didn't receive it on the Friday, I am not clear that Karen Rees received it on the Friday
either.
BROWN: Well, in terms of evidence, you have got the two most senior clinicians saying that they
have concerns about imminent risk to babies. A baby has already died. Is that not sufficient to
take the neutral role of removing Letby from the ward so that an investigation can then take place
because that would have changed the course of events, clearly?
TOWNSEND: So when I received that, there was -- like I say there was no detail, it was just how
they felt about something and I felt that needed further detail and needed to be delved into a bit
further. Hence my ask to go and speak to Karen Rees about it. But I do feel if there was that
urgency and not denying how Dr Jayaram and Dr Brearey felt, but they also could have acted on
that, and like I say, they could have gone direct to the Executives themselves.
BROWN: At paragraph 54 of your statement, you say it had taken quite some time before Dr Jayaram
disclosed his concerns to me, which we have talked about. "No concern had previously been
escalated or cited through the divisional process but this having now been raised appears to have
raised the expectation of immediate action in dealing with it."
Did you accept that immediate action was needed?
TOWNSEND: What --
BROWN: It seems to be suggesting it wasn't but did you accept that immediate action was
needed?
TOWNSEND: What number are you looking at, I'm sorry?
BROWN: Sorry, paragraph 54, actually it is over the page, so if you are the same pagination as me
it is the second half of that. So you say that Dr Jayaram hadn't previously raised it but once he
did raise it, he appears to have raised the expectation of immediate action and my question is:
did you think that immediate action was needed?
TOWNSEND: So yes. So I think that -- I think that relates to an email exchange the following week.
Obviously the paediatricians had had -- I wasn't aware, but had had some earlier conversations
with the Executives with regards to their concerns and following the discussion I had with Dr
Jayaram on the Friday and the subsequent discussion with Karen Rees, that then became an escalated
issue. More people were involved in those discussions and I think with Dr Brearey was now wanting
some immediate action to take place now we had gone that one step further and more people were
involved in the discussion.
BROWN: When were you informed of the death of [Child P]?
TOWNSEND: The Monday of the following week.
BROWN: You say at paragraph 59 when you became aware of the second triplet had died over the
weekend, if they have concerns about deliberate harm being caused by a member of nursing staff,
you say "if" there, but there were concerns there, weren't there, Dr Jayaram had expressed those
concerns: "... I wondered why they had not been escalated previously ..." Then you go on to say:
"... I could not understand why Dr Brearey and Dr Jayaram felt it was safe to go home that
weekend." Ms Townsend, did you feel it was safe to go home that weekend when you knew that or you
were -- had not been told that Letby had been removed from the ward. Was that not a worry that you
--
TOWNSEND: So my understanding was Karen Rees did go and seek both Dr Jayaram and Dr Brearey that
same afternoon and neither Dr Jayaram or Dr Brearey gave any detail or evidence with regards to
their concerns. I believe Karen did go and speak to two of our Executives and left it with the
Executives at that point in time. But neither -- neither of the clinicians would offer any further
detail at that time.
So from their perspective, there was very little else that they could have achieved on that day.
BROWN: But were you concerned about the baby's safety on the unit before you went home?
TOWNSEND: So I -- I was concerned. I was concerned but also when I heard that the clinicians had
not offered any more information I was also -- I was a bit confused as to why that would be.
Surely if they had those concerns and that detail why was that not raised and made available on
the Friday for any action to be taken?
BROWN: Did you take any action to ensure that Letby was not working over the weekend?
TOWNSEND: Not on that day, no.
BROWN: So when you left on Friday, what actions did you understand had been taken to address Dr
Jayaram's concerns?
TOWNSEND: I understood that Karen Rees had gone to speak to Dr Jayaram and had also gone to speak
to Dr Brearey or waited for Dr Brearey, I think he was in a clinic. I don't think he received any
information, I don't think he -- any further information was offered and I also understand Karen
Rees went and spoke to the neonatal unit manager or nurse in charge on the day and asked if they
had any concerns to which the answer was no at the time. And then subsequently Karen Rees then
went to
speak to the Executive team to make them aware.
BROWN: Yes. If we could go to INQ0005749 and page 2 of that document and this is at tab 16. So while we
are waiting for the document, this is an email that you sent to Dr Brearey and it's summing up
some decisions or actions from a meeting that was on 27 June. Can you recall whether you were at
that meeting or are you just reporting it? You may not be able to recall.
TOWNSEND: I don't recall. I am -- I am aware and familiar with the email and the content but I
don't recall if I was in the meeting itself.
BROWN: Well, just looking at the content of the meeting.
TOWNSEND: Yes.
BROWN: So this is the following week, so [Child O] and [Child P] have died and you are aware --
we have gone through the discussion you had with Dr Jayaram -- what he had shared with you?
TOWNSEND: (Nods)
BROWN: You say there at six bullet points down: "LL to remain on days for support, on annual
leave next week." So it seems to be saying that that week she would remain working. Did you have
concerns that she should
be allowed to remain on the unit given the concern that Dr Jayaram had in a sense escalated now
because what he had been very concerned about had in fact eventuated in terms of the death of Baby
P [Child P]?
TOWNSEND: I think there were concerns all around. But my understanding was that at that time,
there was still no actual evidence or detail and the Executive decision at that time was to remain
for Letby to remain on the unit until she went on annual leave. So the concern was still there
but, yes that action wasn't taken.
BROWN: You are referring to more evidence. One baby had died, now another. The two Consultants
have got real concerns about harm to babies. What more would have been needed before removing
Letby from the ward to undertake an investigation?
TOWNSEND: I am not clinical, I don't know any of the details associated with any of the babies
that have died unfortunately, and I am not clear what the connections were or I'm not sure we knew
at the time what the connections were with Letby as well.
BROWN: I mean, if we just turn to paragraph 62 of your statement where you are discussing a
meeting that was a discussion on 30 June about Letby returning to the NNU and you have got some
notes that you have referred to, we don't need to go to them because you have cited the bit from
your notes, "SB remove nurse or go to police"?
TOWNSEND: Yes.
BROWN: Just to be completely clear, "SB" would be Stephen Brearey, would it?
TOWNSEND: Would be, yes.
BROWN: Can you recall the discussion about going to the police on 30 June?
TOWNSEND: I don't -- I remember -- I recall the meeting, I don't remember the absolute context to
that. They were talking about the clinical incident -- they were talking about the incidents but I
can't recall -- they are my notes, I did make them in the meeting, but I don't recall the detail
of it, I'm afraid.
BROWN: What was your view then because as you say you are not clinically trained, but
nevertheless you are the Divisional Director, you have had it reported that someone is concerned
about a member of staff harming babies. That's obviously a crime, if that's the case?
TOWNSEND: (Nods)
BROWN: Did you consider that the police should be contacted, is that something you raised or
considered?
TOWNSEND: I didn't raise it. I felt -- I felt -- to be honest, I probably felt out of my depth
because I didn't have the clinical insight, I didn't have the clinical
knowledge and this was a very, very serious situation and I felt I was being very much led by how
the Executive team wanted to manage it at the time because of how awful a scenario it was.
BROWN: You go on to talk about meetings in the early July on the 8 July, briefings about the
downgrade of the NNU --
TOWNSEND: Yes.
BROWN: -- from a Level 2 to a Level 1 and the fact that you liaised directly with Arrowe Park.
Why did you understand the unit was being downgraded, what was the actual reason for the
downgrade?
TOWNSEND: The actual reason for downgrading was to reduce -- was to manage the risk around the
alleged mortality for neonatal, so moving from a Level 2 down to a Level 1 would mean the babies
of a much younger age would be managed in another organisation whilst the Trust tried to work to
understand what the situation actually was and what action they needed to take.
BROWN: Did you have any role in speaking to the parents of the babies who had died or collapsed
about that downgrade in terms of communications was that any part of your role?
TOWNSEND: That was not part of my role, no.
BROWN: If I could just turn you to one final document which is INQ0077575. So these are some emails I just wonder if you can assist us with
the context of this. If you could just go on to page 2 first, because it works backwards, so to
speak. There is an email there: can you confirm that the protection for Lucy Letby is still to be
continued? She has been receiving these payments since August 16. This is an email that was sent
on 14 February 2018 and if we go back to page 1, there are there is an email first of all from
Karen Rees and then you respond on 14 February --
TOWNSEND: Yes.
BROWN: -- at 12.23: please can these continue for the foreseeable future? Can you just assist
with what those emails are talking about, what payments those are referring to?
TOWNSEND: So what I can understand from this is that at the time Lucy Letby, although she wasn't
working on the neonatal unit, had been removed and was working in another part of the
organisation, I believe it was Risk and Governance, and as she had not been formally excluded she
was still in receipt of her salary, so that was just confirming that that was the case.
BROWN: That was an operational matter that came to
you because she was still formally within your division?
TOWNSEND: I'm sorry?
BROWN: That was a matter that formally came to you as Divisional Director because she was still
--
TOWNSEND: Yes, because even though she had been moved to work in another area, she still would
have been on the payroll within Urgent Care, yes.
MS BROWN: Yes, those are all my questions. There are going to be a few more questions.
LADY JUSTICE THIRLWALL: Mr Baker.
MR BAKER: My Lady. Mrs Townsend my name is Richard Baker. I ask questions on behalf of some of
the Families and in particular in this case the Family of the Triplets O, P&R.
TOWNSEND: (Nods)
BAKER: Your role at the time was Executive in charge of Dr Jayaram and Dr Brearey's division,
wasn't it?
TOWNSEND: Not Executive. I was Divisional Director, I am not Executive -- I am not an Executive
Director.
BAKER: But you were the most senior person within that division before we reach the
Executives?
TOWNSEND: Yes.
BAKER: It was a Band 8D role, which is a senior role?
TOWNSEND: Mm-hm, yes.
BAKER: Which carries a lot of responsibility --
TOWNSEND: Yes.
BAKER: -- within the NHS. Now, I just wanted to pick up one point that you made about the
doctors, you criticise them for not taking the issue to the Executives. But in fact they should
have taken the issue to you rather than bypassing you and going directly to the Executives,
shouldn't they, you are the most senior person within the division?
TOWNSEND: Yes, they could come to me.
BAKER: Not they could come to you, but you would expect following the hierarchy that having been
to people like Karen Rees or Eirian Powell, you would be the next most senior person to go to?
TOWNSEND: Yes.
BAKER: Do you recall what the purpose of the meeting with Dr Jayaram was on 24 June?
TOWNSEND: It was just a general catch-up, really. It wasn't a formal meeting, hence the setting in
the coffee shop.
BAKER: But you didn't have regular scheduled meetings with Dr Jayaram, that was your evidence,
was that they would happen every couple of months but they weren't
organised or regular; they were ad hoc?
TOWNSEND: No, we used to have regular -- well, not so regular but we used to have catch-ups, yes,
they were ad hoc unless I saw Dr Jayaram in a more formal setting.
BAKER: You see, Dr Jayaram's evidence is that he contacted you because he wanted to discuss
concerns that he and his colleagues had regarding unexpected unexplained deaths in the neonatal
unit.
TOWNSEND: That is not my recollection at all, no.
BAKER: And he recalls that you sent him an electronic calendar invite on 21 June 2016, three days
earlier before the meeting took place. So first of all do you agree that you would have sent out
an electronic calendar invite on or about 21 June?
TOWNSEND: I don't recollect that but yes, I probably would have done, yes.
BAKER: Yes, and what do you recall the impetus for this meeting being?
TOWNSEND: It was a general catch-up. Like I say it was in a very informal setting, so it was a
coffee shop in the Women and Children's building. We sat down about 11ish, we had some general
chat. We talked about a couple of the services within the paediatrics and neonatal and then Dr
Jayaram went on to raise his concerns.
BAKER: Yes, but if you had meetings ad hoc, presumably there would always be some impetus for a
meeting, Dr Jayaram would get in touch with you and say: can we just have a meeting to catch up,
for me to raise something with you?
TOWNSEND: Yes, and I would do likewise, it was -- but like I say, it was very informal, it was
just to touch base. We talked about a number of different issues.
BAKER: So if you arranged the meeting, I am assuming you agreed where the venue would be or said
where the venue would be yourself?
TOWNSEND: I think mutually agreed/
BAKER: Well, if you sent out the invite to the meeting presumably you also said: well, let's meet
in the coffee shop?
TOWNSEND: Like I say it was a very -- it wasn't a formal meeting at all.
BAKER: When it comes to that, though, was that your perception of it when you arranged it? It
doesn't necessarily mean it wasn't what Dr Jayaram was expecting?
TOWNSEND: Correct.
BAKER: Now, your evidence -- again just to be very clear, the meeting was arranged before the
death of [Child O] because [Child O], he died on 23 June and it was
arranged according to Dr Jayaram on 21 June?
TOWNSEND: Okay, yes.
BAKER: But it took place after the death of [Child O] --
TOWNSEND: (Nods)
BAKER: -- and before the death of [Child P]?
TOWNSEND: Okay.
BAKER: Now, are you saying, as I think you were, that prior to 24 June 2016, you had no knowledge
at all that the Consultant body were concerned about unexpected or unexplained deaths occurring
over the preceding year?
TOWNSEND: Correct.
BAKER: And that you were completely unaware that the Consultant body or anybody was concerned
about Letby's association with those deaths, not necessarily that she was causing them
deliberately, but that she was associated with those deaths by her presence at the very least?
TOWNSEND: Correct.
BAKER: So you were unaware of all of that?
TOWNSEND: Yes.
BAKER: Were you unaware that she had been moved to day shifts?
TOWNSEND: I wasn't aware of that.
BAKER: Before 24 June 2016 had you ever heard Lucy Letby's name before?
TOWNSEND: No.
BAKER: Now, you made a note of the meeting and it appears at INQ0102357. If we go on, please, to page 2 it is an exhibit to your witness
statement. So the note in question appears at the bottom of the page, 24 June 2016?
TOWNSEND: Yes.
BAKER: When did you write this note?
TOWNSEND: On the day.
BAKER: Were you writing it at the same time as the conversation was taking place?
TOWNSEND: Yes.
BAKER: Do you normally take notes during informal meetings?
TOWNSEND: I take lots of -- well, you can see from the prior note, I take a lot of notes. I
record, I have a to-do list all the time and I also record notes from any meetings.
BAKER: Yes, but if you are having an informal chat with someone in a coffee shop, you take your
notebook out and start writing what they are saying?
TOWNSEND: Well, we were talking about relevant points, we were talking about aspects of the
business, the service.
BAKER: So how informal are we talking, then? Not very if you are taking notes, it is obviously a
discussion about important things?
TOWNSEND: Well, they are very brief notes but yes, I made notes.
BAKER: And the first two lines, they are nothing to do with concerns about harm on the wards, are
they, I mean, I can't criticise --
TOWNSEND: No.
BAKER: -- handwriting, if you have seen mine, you would understand why.
TOWNSEND: No, no, no. The first one makes reference to paediatric hospital at home and some risks
around the service and some of the options we were discussing and the other one is workforce
issues, which was a regular theme within the paediatric and neonatal service and the resources and
then that is when we went on and Dr Jayaram noted the concerns that they had.
BAKER: So he's written NNU -- you have written, sorry~--
TOWNSEND: Yes.
BAKER: -- "NNU triplets"?
TOWNSEND: I wrote that when as we started that aspect of the conversation.
BAKER: So "one deceased", which is a reference to
[Child O]?
TOWNSEND: Yes.
BAKER: And then "? Second"?
TOWNSEND: Yes, because Dr Jayaram said that he was concerned and I can't -- I can't recall if he
said that the triplet was unwell, I can't recall that.
BAKER: Well, I will come on to that then. It's not concern about the other triplets or other
babies; it's specific concern about the second, which is [Child P]. So it would follow, and I can
take you through something of a chronology in a moment, but it would follow that [Child P]'s
condition was being discussed at that meeting?
TOWNSEND: Not in any detail, no. Not in any detail. It was a reference of. There was no detailed
clinical discussion.
BAKER: But it doesn't say "? Other two". It says "? Second." Now, we know from the medical
records that [Child P] suffered an unexpected collapse after Letby started her day shift on 24
June and had required resuscitation, and [Child P]'s notes describe chest compressions occurring
at 9.15 in the morning, so prior to your meeting taking place at 11, and discussions had taken
place at Arrowe Park at 10.30 am to transfer [Child P], okay.
So there was obviously concerns at or about the time of your meeting at 11 am about the condition
of [Child P] because there was -- a phone conversation with Arrowe Park had already taken place
and [Child P] had already had some resuscitation in the morning. So in light of that, do you think
it likely given that you have written "? Second" that Dr Jayaram was also talking to you about the
condition of [Child P] in this meeting as well?
TOWNSEND: I am not aware of any of the clinical detail associated with that and Dr Jayaram didn't
go into any explicit detail. I think it was -- and I have no clinical background so wouldn't
retain any of that information specifically. However, I think he did make reference to his
concerns about the second triplet, but there was no clinical detail. Like I say, I wasn't aware of
anything that you have just articulated.
BAKER: So he may not have put it in terms of: There's been a phone call to Arrowe Park, chest
compressions have been given. But he must have said, mustn't he: I am worried about the other one
as well because he has also taken a turn for the worse, or words to that effect?
TOWNSEND: I think he said he had concerns about the second triplet. There was -- you know, it was
a very brief discussion.
BAKER: Yes. But a reference to concerns about the second triplet, rather than the second and
third, must reference the fact that the second had taken a turn for the worse, mustn't it?
TOWNSEND: It may do, but, I can't -- there was no -- we didn't have a detailed discussion.
BAKER: Now, the records also show that [Child P] had deteriorated again at 11.30 in the morning,
so 30 minutes after your meeting began, and that there are noted interactions between Letby and
[Child P] at 10.46 and 11 am prior to that collapse. So we also can see from the notes that Letby
continues to interact with [Child P] during the course of the afternoon and that there are further
collapses and [Child P] receives CPR on further occasions. So to put this into context, your
conversation with Dr Jayaram about concerns and risk is occurring at the same time as [Child P] is
collapsing due to harm caused to him by Lucy Letby, but he is still alive. Now, in light of that,
and on reflection, do you think it required urgent action from you to escalate this and remove
Letby from that ward?
TOWNSEND: So all of what you have articulated I did not
know. I had no sight to nor did I hear anything. The conversation I had with Dr Jayaram was very
brief, it was very -- he, Dr Brearey and some of his colleagues, had some concerns. We didn't go
into any detail and there was certainly no -- no specifics that you have just articulated.
BAKER: How much detail do you need in this situation? A senior doctor says to you: I am concerned
that a nurse is attacking and harming babies. How much of an investigation do you need before
somebody acts and stops that harm continuing?
TOWNSEND: So the terms "attacking" and "harming" weren't used at all. They were raised to me and
at the time, based on what I had heard, which was brief, I did what I believed at that point in
time the right thing which was to come away and contact the senior nurse in Urgent Care and then,
as I have already explained, subsequently we then tried -- well, Karen Rees then tried to speak to
both Dr Jayaram and Dr Brearey to try and get some further and additional detail.
BAKER: Isn't that an escalation down the chain to Karen Rees because she is -- you are her
superior in terms of seniority and rank? Isn't that going down the chain?
TOWNSEND: But I think immediately in the moment -- and
on reflection yes, maybe that might have been the case, but my immediate was to go to my clinical
colleague to raise those concerns with her and seek her input as to next steps.
BAKER: In terms of the amount of time that all of this takes, [Child P]'s family believe that
there was a failure to act to stop Lucy Letby attacking and murdering their child on that day.
Now, [Child P] died in the evening. So there was time arguably to stop this. Do you think, on
reflection, urgent action was actually required following this information from Dr Jayaram?
TOWNSEND: I believe at the time, when I was given the information, I did what I believed was the
right thing at the time to go and seek that support, to gain some further information and to --
and what those next steps would be. I believe Dr Brearey and Dr Jayaram did not offer any further
information. I think Karen Rees was left then to go and speak to the Executive team. And I'm sorry
for the loss of those children.
BAKER: But the point is in a dynamic situation like this, there sometimes isn't time to set out a
full, fully articulated evidenced case against somebody. There is simply a reference to risk and a
need for
urgent action, isn't there?
TOWNSEND: I accept that.
MR BAKER: Thank you, my Lady, I have no more questions.
LADY JUSTICE THIRLWALL: Thank you very much, Mr Baker. I wonder, just before we conclude, Mrs
Townsend, it is nearly finished, I just have two short questions. You were taken to the Risk
Register where you made an input --
TOWNSEND: Yes.
LADY JUSTICE THIRLWALL: -- of a high risk and we have been through that in some detail and you
mentioned several times that it had been scripted for you and I also inferred from what you said
that it was the Executive team who said that had to go on to the Risk Register. Is my assumption
correct?
TOWNSEND: Yes.
LADY JUSTICE THIRLWALL: Right, thank you. So who scripted it for you?
TOWNSEND: A member of the communications team.
LADY JUSTICE THIRLWALL: Thank you. And that was after discussions with the Executive team?
TOWNSEND: Yes, as part of the build up to the briefings around going -- putting communication out,
public communications and advising all other external parties of this situation.
LADY JUSTICE THIRLWALL: Yes, thank you. Which, if you are aware can you let me know, which
members of the Executive team were involved in this decision about the Risk Register?
TOWNSEND: I think in the meetings there would have been Executive Director of nursing.
LADY JUSTICE THIRLWALL: So that is?
TOWNSEND: Alison Kelly, Executive HR director, which was Sue Hodkinson and potentially -- I can't
commit to the Medical Director being there at the time, actually.
LADY JUSTICE THIRLWALL: He may have been. We can check that. Thank you. Then finally, when you
went to Karen Rees, having spoken to Dr Jayaram, what did she say?
TOWNSEND: Well, she asked me what do -- what was the conversation, what detail did I have, what I
had been told and she immediately said: I will go and speak to them directly to see what
information I can find from them. And subsequently went off to speak with them.
LADY JUSTICE THIRLWALL: Did she say anything else about the doctor's motivation or anything like
that?
TOWNSEND: No.
LADY JUSTICE THIRLWALL: Right. Thank you. Subject to anyone wanting to ask any questions arising
out of that, that concludes your evidence. Thank you very much indeed, Mrs Townsend, you are free
to go.
TOWNSEND: Thank you.
LADY JUSTICE THIRLWALL: So we will start again at 20 to 12.
(11.22 am) (A short break)
(11.40 am)
LADY JUSTICE THIRLWALL: Yes, Mr De La Poer.
MR DE LA POER: My Lady, the person in the witness box is Mrs Ruth Millward who, as my Lady knows, has been granted a number of special measures, hence the arrangement of the room.
LADY JUSTICE THIRLWALL: Yes, thank you.
MR DE LA POER: I wonder if she might be sworn, please.
MS RUTH MILLWARD (affirmed)
LADY JUSTICE THIRLWALL: Thank you.
MR DE LA POER: Please could you state your full name?
MILLWARD: My name is Ruth Esther Millward.
DE LA POER: Mrs Millward, is it right that you provided the Inquiry with a witness statement
dated 7 June of this year?
MILLWARD: That's correct.
DE LA POER: And a statement dated 24 June of this year?
MILLWARD: That's correct.
DE LA POER: Subject to I think a correction that you are going to make in relation to -- this is
highly specific -- an SBAR written for [Child A], so subject to that which we will get to, is the
content of those statements true to the best of your knowledge and belief?
MILLWARD: It is.
DE LA POER: My first topic is just to introduce you and your experience. Is it right that you
qualified as a nurse in 1997?
MILLWARD: It is.
DE LA POER: The Inquiry is well sighted on the case of Beverley Allitt from 1991?
MILLWARD: (Nods)
DE LA POER: Did the murders committed by Beverley Allitt form part of your training?
MILLWARD: I don't recall. My training was adult nursing rather than children's nursing but I do
recall the case
from the press coverage.
DE LA POER: So by the time we get to 2015 would it be fair to say that you were aware of Beverley
Allitt's actions killing whilst on duty as a nurse?
MILLWARD: That's correct.
DE LA POER: Were you also aware of the murders carried out at Stepping Hill Hospital in 2011?
MILLWARD: I am.
DE LA POER: Were you in 2015?
MILLWARD: Yes, I was in 2015.
DE LA POER: Yes. Were you aware that shortly before the death of [Child A], that nurse was
sentenced for those crimes?
MILLWARD: I was.
DE LA POER: So going into the period that we are going to look at closely, was that something
that was in your recent memory?
MILLWARD: I -- I would say I was aware of those facts. It's difficult to say. In my recent memory,
I would say I was aware of those facts at the time.
DE LA POER: Well, we will come back to those when we get to our timeline. Staying with your
background, having qualified as a nurse, did you in the same year join the Countess of Chester
Hospital?
MILLWARD: I did.
DE LA POER: Where you worked as a nurse escalating to the position of Matron; is that right?
MILLWARD: That's correct.
DE LA POER: Now, on the way to becoming a Matron, did you act as the Quality Improvement
Facilitator between 2004 and 2011?
MILLWARD: I did.
DE LA POER: Was that in the Risk and Patient Safety Department or was that still a clinical
role?
MILLWARD: No, that was in the Risk and Patient Safety Department, the Quality Improvement
Facilitator role is essentially the same as the Risk and Patient Safety Leads that you heard from
previously. It's just a change in job title rather than a change in the position.
DE LA POER: In December of 2013, were you approached by the deputy Director of Nursing Sian
Williams to see if you were interested to go back to the Risk and Patient Safety Department?
MILLWARD: I was.
DE LA POER: So if we just picture this in our minds, 2011 you left the Risk and Patient Safety
Department, became a Matron?
MILLWARD: Yes.
DE LA POER: And then a couple of years later invited to apply to go back in but this time as the
head of that department?
MILLWARD: That's correct.
DE LA POER: Did you commence in that role in March of 2014 on a secondment or temporary basis
which was subsequently made substantive during 2015?
MILLWARD: That's correct.
DE LA POER: Now, as Head of Risk and Patient Safety, who did you report to?
MILLWARD: To Ms Sian Williams, the Deputy Director of Nursing.
DE LA POER: How many people were in your department?
MILLWARD: Initially it was a small team, around maybe 10 or 12 and then over the period of time I
was in post that increased to around 30 staff.
DE LA POER: And what sort of dates should we have in mind for when it reached 30 staff?
MILLWARD: I would say around June 2016, when a number of the departments came under my management.
DE LA POER: Did that result in any more Risk and Patient Safety roles or were they on the patient
experience quality side?
MILLWARD: Absolutely, it was, it became more integrated governance team, so the -- it wasn't more
additional
Risk and Patient Safety Leads; it was more that, as you say, patient experience, the audit and
improvement work, health and safety.
DE LA POER: In terms of who sat immediately beneath you in the department, who were they?
MILLWARD: I didn't have a deputy. So my team was almost sub teams, if you like, so I had the Risk
and Patient Safety Leads, so there were five or so of those, I had a patient experience or
complaints manager, who then managed a small group of co-ordinators, I also had an Audit
Improvement Manager who again had a small group of staff underneath and then some of the staff
around practice development nurses, the blood transfusion practitioners, health and safety and of
course my administrative support as well. So it was a very varied team.
DE LA POER: In terms of the focus of this Inquiry, we are focused upon the Urgent Care Division
and in particular the neonatal unit within that?
MILLWARD: (Nods)
DE LA POER: So who was the person in your department as at 2015 who was responsible for that?
MILLWARD: For the Urgent Care Division, for Urgent Care it would have been a lady called Nicola --
I am trying to think of her surname now, apologies.
DE LA POER: Perhaps it doesn't matter too much.
MILLWARD: But --
DE LA POER: Was there a separate person dealing with women and children?
MILLWARD: There was indeed and that would have been Ms Debbie Peacock who you met previously.
DE LA POER: How did you find working with Ms Peacock?
MILLWARD: Absolutely fine, she worked really well, she had a varied background which I thought was
really helpful in the post and I never had any concerns regarding her performance.
DE LA POER: Did you have regular meetings with her to understand what work she was engaged
in?
MILLWARD: Absolutely. We had a monthly one-to-one meeting with all my Risk and Patient Safety
Leads we had a weekly meeting which is Mrs Sian Williams also supported and we would have daily
team meetings again to look at priorities of the day or the week. So there were many sub meetings.
DE LA POER: So would you, as Head of Risk and Patient Safety, be expected to be aware of
important work that Debbie Peacock was undertaking?
MILLWARD: That's correct.
DE LA POER: Did your role involve you attending QSPEC?
MILLWARD: It did.
DE LA POER: So that is the Quality Safety and Patient Experience Committee?
MILLWARD: That's right.
DE LA POER: The Inquiry has heard that that is a committee chaired by a Non-Executive Director
that sits just below board level?
MILLWARD: That's correct.
DE LA POER: Was that an effective committee for ensuring safety?
MILLWARD: There was a cycle of business that the corporate governance team or the director of
legal services who oversaw corporate governance coordinated. There was feedback from the
divisions, it wasn't written feedback, it was verbal feedback and I think that's potentially the
gap that we had. My participation was providing oversight of our Serious Incident investigations
and there were a number of other reports that I would also support.
DE LA POER: So you will forgive me, you have described what it did. My question was: was it
effective?
MILLWARD: My -- my impression at the time was that it was effective.
DE LA POER: So was it your impression at the time that if it was informed of a significant
patient safety concern, action would be taken?
MILLWARD: That's correct. That would be my impression at the time.
DE LA POER: Well, knowing what -- you have caveated what you said twice with "at the time", do
you now have other knowledge that suggests that it wasn't as effective as you thought it was at
the time?
MILLWARD: I think my reflections over the time since the -- the events that occurred, there's been
an evolution of governance and how we report and how we provide assurances. At the time, as I say,
a lot of the assurances given from the divisions were verbal. In today's world you would see that
as a written report with levels of assurance linking it to risk management and key areas of
concern, so the escalation of -- of issues would be clearer and obviously it's around ensuring
that everyone's voice is heard. I think when you are providing verbal feedback it's easy to become
distracted by the conversation that happens in the room and maybe some of the other key points may
not be verbalised but by providing an assurance report you can be sure that your key messages are
heard at the right level.
DE LA POER: Was that improvement something that you should have ensured sooner than it did?
MILLWARD: So when I am talking around assurance and reporting arrangements, that is corporate
governance and the responsibility for that sat with the Director of Legal Services. So I was a
contributor to the QSPEC meeting, I was not -- I was not responsible for overseeing how the
service how QSPEC was managed. What I am sharing with you, sir, is, is my experience over time and
that's my observations being 10 years later.
DE LA POER: But as the Head of Risk and Patient Safety didn't you have a responsibility to make
sure that that committee which was just below board level was as effective as it possibly could
be?
MILLWARD: No, that is not my responsibility. As I say, what you are referring to is corporate
governance, assurance and reporting arrangements and the responsibilities for how that runs, the
cycles of business, Terms of Reference that sits with the director of legal services and for
quality and safety specifically, that sat with Mrs Kelly.
DE LA POER: But do you not have a say in this?
MILLWARD: I can contribute. If I felt that I had a report that needed to be submitted, I could
escalate that and ask for something to go on the agenda but it
wouldn't be my responsibility to request changes to the way assurances were provided.
DE LA POER: Even if you perceived that they were not being provided in as effective a way as
possible?
MILLWARD: As I say at that time, I felt the committee was effective, the way that communications
we were having, we speak about the learning and the evolution of governance over this time period.
DE LA POER: Just returning to your role and its progress over time. Was that role the subject of
a consultation in early 2017 resulting in it being placed in an "at risk" position?
MILLWARD: That's correct.
DE LA POER: Did you, (redacted), leave the Trust on 31 March of 2017?
MILLWARD: I did.
DE LA POER: But just so that we understand your dates, and we don't need to go into the detail,
was there a reason for you to be absent from work from the 3 March?
MILLWARD: I did. (Redacted).
DE LA POER: So in fact your last effective day would have been around 2 March?
MILLWARD: Yes.
DE LA POER: Now, in terms of improvements or changes that have been made since you left, firstly
can you just tell us something about deteriorating patient groups?
MILLWARD: So at the time one of the focus that the Trust did have was around sepsis and
recognising the deteriorating patients. It was very adult focused and it was a scheme of work that
the team was looking at. I think over time what organisations have looked at reporting incidents
and different schemes of work to improve patient safety but looking at it more widely than just --
just adults, so in the Trust at the time that deteriorating or that sepsis group was purely
focused in the adult environment, it didn't capture the children's, you know, service at the time.
So it was when you have a group like that, it drives the type of incidents you may see because it
is used as one of the ways of monitoring the effectiveness of the improvements that you are
putting in place and I think that may be one of the reasons why we didn't see some of the
incidents being reported for the children's areas in the way that perhaps we did see them being
reported for our adult areas.
DE LA POER: Whose responsibility would it have been to push for children's services to be
included in the deteriorating patient group?
MILLWARD: Well, it was -- as I say it was a sepsis group specifically which is a smaller subset,
if you like, of
the deteriorating patients. Well, there was a Trust Deteriorating Patient Lead who I believe was
one of the Consultant anaesthetists at the time so it would be appropriate to scope that more
widely, but essentially it would be -- the responsibility to ensure your area was involved would
be would sit with the clinical lead, so in this case it would be Dr Brearey.
DE LA POER: Ms Fogarty has listed in her statement, and you have been asked to consider, a very
large number of changes that have been made since you left. Obviously it's important that we are
focused here on those which are relevant to the Inquiry's Terms of Reference and I certainly don't
ask you to rehearse all of them, but were there any of those changes that you would pick out that
you consider represent improvements that may have supported a better response to the situation the
Countess of Chester found itself in?
MILLWARD: Well, I have looked at the list, obviously it is not in front of me, but I have looked
at that list that she has provided. A significant number of those listed were things that were
already in place and they would just again be the natural evolution of the service. I think one of
the positives that I did see was around a newsletter, some more communication around
learning and again how she appears to have managed the feedback from the Serious Incident Panel so
I would, you know, welcome those and they were good ideas.
DE LA POER: So we are going to turn now to look in a little bit more detail at how your
department functioned when you were the head of it. Firstly, were you a sufficiently well
resourced department to do what you needed to do?
MILLWARD: I think it's very difficult to say as a service adequately resourced because it is not
like a ward where you would have a, say, staffing level. Each -- each Trust will have a slightly
different model for governance or patient safety and that will depend upon the size of the
organisation and the type of, you know, organisation it is. Certainly I -- the only time I became
concerned around my resources was in February 2016 and that was when Mrs Peacock was already
leaving. I had another Risk and Patient Safety Lead who came to me saying that she would be
leaving for a promotion in another Trust then I was instructed to release another of my Risk and
Patient Safety Leads to go to a clinical role within the Planned Care Division. So at that point,
between February 2016 and I would say May 2016, the service -- there was a fragility there
and I did escalate that, Mrs Kelly was aware -- was essentially ultimately responsible for quality
and safety and I added that as a risk on the Risk Register at the same time just so that again I
could monitor and track all the different pieces of work that I was doing. I think one of the --
one of the reasons why I was keen to bring in the Patient Experience Team and the Audit and
Improvement Team was to have a more integrated governance approach but that in itself would mean
that there was closer collaboration and more support for essentially fulfilling the duties of the
team.
DE LA POER: In the period that you have described as there being a fragility --
MILLWARD: Mm-hm.
DE LA POER: -- do you think that that fragility impacted in any practical or real way on how your
department responded to the situation during those months?
MILLWARD: I think it was -- I think there was further contribution by -- it coincided with our CQC
routine inspection which was a full Trust inspection. So certainly that would have been my
priority at the time and the priority of a number of my admin team as well. Without doubt having
that gap in team members, you know, we tried to mitigate by putting interim staff members in
place. However, that is not the same as having that continued line of sight, you know, by a member
of staff who is permanent. So I have no doubt it will have had an impact, we did try to mitigate
as much as possible.
DE LA POER: Can you just help us to understand a little bit more your role as Head of Risk and
Patient Safety, a very important role I am sure you would agree; is that fair?
MILLWARD: Yes.
DE LA POER: But you have just said that at a time when your department was being depleted, your
focus was on the CQC inspection, can you just help us to understand how you see that inspection as
important but it might be thought that patient safety and risk is more important because that
affects patients' lives, so can you just help us with why you chose to give your attention to that
CQC inspection over patient safety?
MILLWARD: Well, it wouldn't be a case of that was all I was focused upon. But it would definitely
have been my priority. The CQC inspections are routine inspections that happen infrequently, when
they do it is a significant amount of work to prepare for. A significant number of documents are
required ahead of the inspection and all of those need validating and managing.
Certainly also there's work-around helping the staff prepare for such an inspection, encouraging
them to, you know, be open and honest about what's going on in their areas and ensure that they
have the information that they may need to hand as well. During the inspection as well, which is
only a few days, there are again multiple calls for different datasets and similarly afterwards.
You know, there was -- as head of risk, that was one of my key responsibilities was to ensure that
CQC was responded to and any questions that they had that we provided that information to them.
Obviously whilst I am saying it was my priority, I had a team I worked alongside with, they had --
you know, we continued with all those meetings, I explained so there was opportunity for us to
ensure that again there was line of sight, there was escalation of things that was happening and,
you know, I was supporting my staff at the same time.
DE LA POER: We know now that February of 2016 in terms of the thematic review that was conducted
that month is a very important month and a very important opportunity for matters to be
escalated.
MILLWARD: (Nods)
DE LA POER: Looking back on it, bearing in mind you have
told us that that was a period of the start of some fragility within your department, and you have
told us your priority was the CQC, do you think in fact you misprioritised and gave insufficient
support to your staff at that time?
MILLWARD: No, I don't believe that's true.
DE LA POER: If you would please just expand on why you say that?
MILLWARD: Because -- because my team, there was mitigations put in place, there were additional
staff that were put in place to help manage the gaps in staffing, those staff were supported, I
would meet with them regularly, I would go through things that they were raising if they had any
concerns. All of that remained in place. What the gap, the fragility, if you like, was that people
rather than being able to do or commit a full-time number of hours so 37 and a half hours being a
full-time contract, rather than being able to do that it would perhaps be, you know, a half-time
contract. So they had to focus themselves on what they could achieve in that time period. So again
at that point in time the incidents would always be the top priority of those staff members and
therefore if there was anything that they were concerned about, it would be that they would
raise them with myself.
DE LA POER: Okay, we will come back when we look at our timeline to that. Let's just deal again
with an overview. So the job title has changed over time, at the time we are concerned with it is
Risk and Patient Safety Lead.
MILLWARD: Mm-hm.
DE LA POER: Just help us to understand how that became Risk Midwife.
MILLWARD: Yes. So the Risk and Patient Safety Lead role is multi-faceted, it looks at incidents,
it is there also to support with some national guidance a variety of other schemes of work that
they do support but the incidents in the main. In or around 2015/16 there was a lot of national
information around maternity safety in particular and it was felt that -- certainly I felt it was
an opportunity with Mrs Peacock leaving to almost reframe the role so that that could be part of
the focus. There was a number of guidelines coming in and I thought that changing the role
slightly would help with that and support the maternity services. The maternity services were
always the larger part of the role anyway as Patient Safety Lead.
DE LA POER: It may be only a matter of semantics but this is a phrase or a title that you were
supportive of promoting, but it may be thought that moving from Risk and Patient Safety Lead which
covers all of the children's services to Risk Midwife is focusing on midwifery and obstetrics
potentially at the expense of the neonatal unit and paediatrics. Can you just help us with how
that didn't slip through the gaps, if it didn't?
MILLWARD: Absolutely. Well, obstetrics and neonatal team services, they are essentially a
continuation of care. You know, what happens for mum and baby during labour, that has an impact
upon the baby going into the neonatal unit. So there is natural flow. The role was still to focus
upon those areas. It was more, as I say, the fact that there was some national guidance coming out
and I felt it important that the team get involved in that and therefore by reframing the role
slightly to that as a Risk Midwife it wasn't forgetting about the neonatal or the paediatric
service at all; it was just a case of trying to ensure that those national guidance and those
improvements could be supported by a member of my team.
DE LA POER: Why did the title need to change if it made no difference to the role?
MILLWARD: Because it felt that -- I felt at the time
given the national focus that that was the important thing to do. I felt that it would help give a
-- give -- I felt that it would help us demonstrate that we were listening and responding to the
national guidance at the time and show that we were taking that seriously.
DE LA POER: So that is how others in the outside world would perceive you but in terms of the
day-to-day, internally, do you think there might have been a risk that the focus of the person
doing that role was weighted too heavily as a result on midwifery?
MILLWARD: No, because as I have said, the midwifery services was always the larger part of the
activity and it was never -- it was never anticipated that the neonatal or the paediatric services
would be cast aside as such. The expectation was always that that support would continue.
DE LA POER: So as we have covered already, Ms Peacock left in February of 2016?
MILLWARD: She did.
DE LA POER: Her role, as we have heard from Ms McMahon, was covered by Ms McMahon for the period
February 2016 to May 2016.
MILLWARD: (Nods)
DE LA POER: What Ms McMahon told us was that she was in effect doing two full-time jobs at the
same time during
that period. From your perspective, is that a fair characterisation of what was expected of
her?
MILLWARD: No. So again the expectation was to keep retaining oversight of the incident activity
and support the all of the areas with that and then escalate any matters of concern to myself. It
was not and never had been an expectation that Ms McMahon would essentially be fulfilling two
jobs, it is not a possibility.
DE LA POER: So let's just understand this. Ms Peacock had been a full-time role; is that
right?
MILLWARD: (Nods)
DE LA POER: When Ms Peacock left she was no longer able to do it, that full-time role?
MILLWARD: Mm-hm.
DE LA POER: Was it expected that Ms McMahon would do that full-time role?
MILLWARD: No, Mrs McMahon was also doing what was her normal day-to-day activity. As I said, the
focus for Mrs McMahon in covering the gap in staffing was that she would solely focus upon the
incident activity. The role of the Risk and Patient Safety Lead is broader than just the incident
activity and that was what I had asked her to do to retain oversight during that period.
DE LA POER: You will just have to help us, please, you have used that phrase a number of times,
"incident
activity", please can you just tell us what you mean by "incident activity"?
MILLWARD: So the number of incidents that have been reported by the local areas, so in that case
obstetrics, gynaecology, the neonatal unit and paediatrics.
DE LA POER: What about, as we will come to in much more detail shortly, the thematic review that
we know Dr Brearey authored?
MILLWARD: (Nods)
DE LA POER: Does that fall under incident activity or is that something different?
MILLWARD: So the thematic review was a review of incidents and other deaths so yes, that would
have fallen under so for her to retain oversight of where that was up to.
DE LA POER: As I say we will come to the detail of that in due course. Finally, to complete the
picture of the evolution of Risk and Patient Safety Lead to Risk Midwife, Annemarie Lawrence took
over as we understand it in May of 2016?
MILLWARD: She did.
DE LA POER: And just tell us what your experience was of working with Ms Lawrence?
MILLWARD: I thought Ms Lawrence was a really good employee, she worked very well, I had no
concerns about her performance. We met regularly. I was aware she was really struggling connecting
with Dr Brearey in particular. We met during our one-to-ones and spoke frequently around dealing
with or how to manage difficult and challenging relationships, how to try and ensure we are more
visible and responsive as needed but I had no concerns about her performance at all.
DE LA POER: So we are going to deal with the relationship with Dr Brearey now and if we could
please bring up INQ0006769 on our screen. It's an email dated 15 July, it's a snapshot in
time. So if we scroll to the bottom so that you can see the context, you have and we are here in a
situation following the deaths of [Child O] and [Child P]?
MILLWARD: (Nods)
DE LA POER: And the hospital's internal work, this was part of it. You requested for information
to be sent to Dean Bennett by a particular date, we can see that at the very bottom of your thread
there?
MILLWARD: Mm-hm.
DE LA POER: If we go up, please, in the thread and we will need to go one more page but we will
look at the bottom. We don't need to go over every line, I am sure you have had had an opportunity
to consider this email both
at the time and subsequently. But if I can summarise it in this way: Dr Brearey expresses a number
of concerns about Ms Lawrence?
MILLWARD: Mm-hm.
DE LA POER: We can see at the bottom of the page he raises concern about the creation of the role
of Risk Midwife which he says occurred without any discussion with paediatricians or consideration
that she would have to cover neonatology which he described as quite concerning. Let's deal with
that. What is your response to what Dr Brearey says there?
MILLWARD: With regards to the development of the role of the Risk Midwife?
DE LA POER: Well, firstly is it right that the role of Risk Midwife was created without any
discussion with the paediatricians or consideration that she would have to cover neonatology?
MILLWARD: I'm sorry, I didn't get the last bit.
DE LA POER: I am just reading from here, was the role of Risk Midwife created without any
discussion with paediatricians or consideration that she would have to cover neonatology?
MILLWARD: So I will talk you through a bit more detail so as I say there was a number of national
guidance that
came out which demonstrated that there did -- there should be a greater focus on maternity. I
spoke with Ms Julie Fogarty, who was Head of Midwifery at that time, to explore her thoughts on
that. She felt that that was an appropriate change and would support her area; as I am sure you
would appreciate, she would say that. I raised that with my line manager and also with Mrs Kelly
and Mrs Kelly fully supported that. At the point where I was going to go over to see Dr Brearey
and in fact Dr Jayaram, to talk through how this might work, I understood that Ms Fogarty had
actually already shared that information without my knowledge and I therefore attended a meeting
with the paediatricians to talk through how this could work and I had made it very, very clear
that this was not a case that the paediatric team or the neonatal unit that we were not forgetting
them, that that support would continue. My reflections of Dr Brearey's response is that he didn't
truly understand what the role was expected, if I may. So Mrs Peacock had been in post for a
number of years. It's a smaller environment, you can get closer and more involved with different
pieces of work and I think that Mrs Peacock did actually have those relationships already there
and therefore was -- was
being more involved than perhaps the role envisaged. When Mrs Lawrence took over, we were very
clear through her induction as to what was expected and Mrs Lawrence was following those
instructions and one of the reasons I say that is because in some of the communications from Mr
Brearey he keeps referring to quality improvement, you know, I expect the team to do quality
improvement. Despite the previous job title being Quality Improvement Facilitator, the team were
never involved in true quality improvement. The Trust had its own Quality Improvement Team. So I
think this is more Dr Brearey's understanding of what the role was, the role never -- well, didn't
change with regards to the support that was being offered to paediatrics and neonatology at all, I
think it was his interpretation of what he thought he should be getting and then obviously the
Risk Midwife title which as you say yes, was -- was approved by the Executives before they were
aware of but the opportunity that I had to go and speak to them Ms Fogarty had already shared that
information.
DE LA POER: I think that it comes to this, the decision had already been made --
MILLWARD: Yes.
DE LA POER: -- before paediatrics and neonatology were consulted?
MILLWARD: Yes. But at no point was this going to be a withdrawal of support for paediatrics,
neonatology.
DE LA POER: We can see next in the following sentence he says: "I have concerns about Annemarie's
competence. Both Eirian and myself sat down with her at the beginning of her job to explain her
role and our expectations, the most significant of [over the page, please] which was to arrange
and minute monthly neonatal incident review meetings. This was seemingly forgotten and we are now
at a point where I will be meeting to go through three months' worth of incidents." Again, can I
please invite your response to that criticism?
MILLWARD: Absolutely. I would say that it's not the responsibility of the Risk and Patient Safety
Leads to set up local incident review meetings. Our role is to facilitate the conversation and by
providing the information. And I think as I was alluding to before, I think Mrs Peacock perhaps
went over and above because she had already those that experience and had those relationships but
it would not be my expectation of Mrs Lawrence as Risk Midwife to set up those meetings.
To attend and provide the information and contribute to the discussion, yes, but to set them up,
no.
DE LA POER: So if we just pause there. The job title has changed?
MILLWARD: Yes.
DE LA POER: And the level of support to neonatology that was previously being offered has been
reduced?
MILLWARD: Obviously I would say no because my view is that -- my view is that it would not be the
responsibility of my team to set up an incident review meeting. That responsibility sits with the
clinical lead. You know, I -- I don't know whether Mrs Peacock did set up those meetings for them,
because I wouldn't have attended them but it would not be my expectation that Mrs Lawrence would
do so.
DE LA POER: It is probably my question. Whatever the job description, the title has changed and
the actual level of support that was being offered by the person doing the role had been reduced.
Is that -- I mean, in reality is that what Dr Brearey's experience of it will have been?
MILLWARD: I would say that is Dr Brearey's perception of it, yes.
DE LA POER: So is there a communication problem that lies
behind this?
MILLWARD: I -- I think, I absolutely think that that is the issue. I think, you know, looking at
this, you know, I think perhaps if I could have explained a little bit more around my expectations
of Ms Lawrence and explained that to Dr Brearey then perhaps we would have been on the same page.
It is apparent from this email that we were not.
DE LA POER: How much do you think the fact that it was presented not just to Dr Brearey but to
the paediatric and neonatologists as a fait accompli, how much do you think that had to do with
this breakdown?
MILLWARD: I honestly don't know. I know that when I attended that meeting it was very unpleasant.
I've referred in my statement to Dr Jayaram's approach towards me, his attitude towards me at that
meeting. I think obviously it wasn't helpful and it would have been better if we would have had
the opportunity to speak to them before Ms Fogarty had shared that information, to give the
assurances that from my view definitely there was no withdrawal of support for those areas.
DE LA POER: My final question upon this situation is this: it is just to help us to understand
the process whereby midwifery were consulted before it went to the
Executives, but paediatrics were not.
MILLWARD: Because by speaking to Ms Fogarty and exploring would it be of benefit to -- to the
service as in having somebody with my team supporting them more with these national guidance than
perhaps we had been involved previously, that was -- that was the primary change to the role so I
wanted to understand would that be helpful. You know, I fully accept it would have been helpful,
beneficial to have spoken to Dr Brearey, Dr Jayaram beforehand. But at that point, it felt
reasonable to go directly in and seek the Executive approval.
DE LA POER: We are going to look at an email from David Semple now which postdates your time in
the Trust, INQ0103134. So your last effective day was 2 March of 2017?
MILLWARD: (Nods)
DE LA POER: We can see that once you left Ms Fogarty is -- her title -- Interim Associate
Director of Risk and Safety and what Mr Semple lists is a number of what he describes as issues,
previous poor leadership within the Risk and Complaints Team, members of the Risk Team on very
short secondments, no time to settle into post before they move back, general lack of
communication from the Risk Team leadership to teams and the front lines staff, no feedback on
Datix reports, no feedback on incidents. I am not going to read them all out, but each one of
those is of potential relevance to the matters the Inquiry are investigating. I would like to give
you an opportunity to comment on whether those are fair and accurate criticisms of the department
under your leadership?
MILLWARD: It was very difficult to read this email. It was very disappointing but I have to say
not unexpected. My relationship with Mr Semple was not easy and all communications with him were
perhaps much harder than they needed to be. When I read this email I see somebody who is taking
over a service, who has no understanding at all of the continuous -- the journey of continuous
improvement that was put in place year-on-year but somebody who has picked up a service that
obviously at that point has not only lost myself but had lost the Deputy Director of Nursing as
well so had lost two of the -- of the main leadership roles. I don't agree with everything in this
at all. A number of those things were in place. You know, we refer repeatedly around feedback
around incidents and incident reports. You know, you only have to look at
the CQC reports from the time and that will tell you that every single area spoke that they did
get feedback from incident reports. I think you have already heard evidence that spoke around
feedback was provided through local boards of -- you know, communication boards. So there were
different ways and different routes of providing that feedback. Certain things around -- he says
no training in place. That's untrue. There was training in place and that had been -- we actually
set up a bespoke training programme called Clinical Human Factors in Patient Safety and that was
ran by our Head of Education. And again issues around report writing. Our reports were commended
by the CCG so I find that hard to believe. I think the one that concerns me and demonstrates to me
that Mr Semple didn't actually understand the remit of the role or indeed of myself is the last
bullet point when he talks about this plethora of committees with no clear reporting and
escalation. You know, that again is the corporate governance assurance reporting structure and
that again sat as the responsibility with Mr Cross as the Director of Legal Services. To -- to
infer that somebody in my position, so I was a Band 8A, that I would have that level of
influence is -- is just not plausible and just as I say just demonstrates to me that he didn't
really understand the team and of course at that point I will have left, as will have Mrs
Williams, so I don't think he would have had a handover to understand actually what the team was,
was responsible for delivering.
DE LA POER: I mean, were there a plethora of committees and boards within the Trust with no clear
reporting or escalation structure?
MILLWARD: There were -- there were obviously a series of committees and boards. The structure was
clear, it is in the risk management strategy. I think the Women and Children's Services by adding
in an additional governance board confused their process but the -- the route of escalation for
them, for the neonatal unit in that case would be from the neonatal unit meetings through to the
division of Urgent Care and up into QSPEC or the Corporate Directors Group. So there were a series
of meetings but there was a line of reporting.
DE LA POER: Might that email suggest that people didn't actually understand because it was so
complicated?
MILLWARD: Well, possibly, yes. I don't -- I don't know the back story to him completing this, this
email.
DE LA POER: Well, you have mentioned the risk management policy and we can take that down, thank
you very much.
We are going to turn now to consider the risk management policy. We will come back to some of the
relationships --
MILLWARD: Okay.
DE LA POER: -- as we go. But we will now look at that. Before we bring it up on screen, I just
want to remind you of something you said in your witness statement. You said this: at the time the
risk maturity of the hospital meant that the Risk Register tended to focus upon current issues
rather than emerging risks and I would just like you to help us to understand why you say
that?
MILLWARD: (Nods) Absolutely. So at the time the -- the Risk Register and completing risk
assessments was still a relatively new process in the organisation, so it was very much linked
with problems that were already happening, so current issues. But with risk management you also
want to look ahead, so if you have a strategic objective, whether it is local within the
speciality or within the division, so they would have had objectives that they would have set
themselves, what they want to deliver across the next 12 months, for example. If you were able to
look and use a risk management process you would be looking to see what risks may exist to
delivering those objectives and that's what I am referring to as emerging risks, not necessarily
things that happening today but may well do if perhaps a particular trajectory may continue. So
particularly around performance management, things like that.
DE LA POER: If we look at it in practical -- and I hope you will forgive me -- blunt terms, more
babies dying than are expected is a current risk?
MILLWARD: Absolutely.
DE LA POER: That has got nothing to do with the maturity level of the hospital; would you
agree?
MILLWARD: Yes.
DE LA POER: So would you expect that whatever the position in terms of strategic planning, the
hospital should have been well equipped to deal with that sort of current risk?
MILLWARD: As in identifying the risk?
DE LA POER: Yes.
MILLWARD: Yes.
DE LA POER: Well, let's have a look at the risk management policy. We are going to have a look at
the version dated December 2015 which is part of the way through, but the changes I am sure you
will be able to confirm
are not significant in terms of what we are focused on. So INQ0014962. So that is a document I hope you recognise and we can go to page
3, please. Again we will just, through you, Mrs Millward, introduce some of the concepts which lie
behind risk management according to this document and we can see the heading "Principles of Risk
Management" and there is a list including risks will be actively managed and positive assurance
sought. So presumably the prior step is to identify the risk so that it can be actively
managed?
MILLWARD: (Nods)
DE LA POER: The Risk Registers will be live, actively managed and review documents. The risk
management is the responsibility of all staff within their own sphere of work, high risk areas and
activities will attract greatest focus and attention. Then there will be learning from analysis of
incidents, complaints and claims and explicit rollout of identified problems. So that is the list
there?
MILLWARD: (Nods)
DE LA POER: Perhaps it goes without saying that hospitals experience death every day?
MILLWARD: (Nods)
DE LA POER: But if we look at the problem that was facing the neonatal unit in terms of a
significant increase in
the mortality rate, would you agree that that can properly be characterised as a high risk area
relative to the other risks that the hospital would be facing?
MILLWARD: I'm sorry, I didn't -- I didn't get what you have just said.
DE LA POER: No, I am happy to repeat it. Consider the issue facing the neonatal unit, an increase
a significant increase in the mortality rate?
MILLWARD: (Nods)
DE LA POER: Can that properly be described as a high risk area for the hospital to address?
MILLWARD: As in the neonatal unit or the deaths?
DE LA POER: The deaths?
MILLWARD: Yes.
DE LA POER: So there is a significant increase in the number of deaths?
MILLWARD: Yes.
DE LA POER: Would you regard that as a high risk area?
MILLWARD: I would -- I would -- it's the language there, it's the language.
DE LA POER: Well, you use the words you want to --
MILLWARD: Okay.
DE LA POER: -- answering my question as best you can.
MILLWARD: Okay, thank you. Certainly any area that would see an increase in,
in mortality would be an area of concern and it would be an area that we would want to know about,
it would be an area that we would want to explore to understand. So from a risk perspective it
would be something that we would absolutely want to understand and then if, if the mitigations
perhaps were not robust enough or we needed to do some further work before we felt that that risk
was adequately managed, then that would be where the Risk Register would come in. So you would
articulate those concerns on to the Risk Register.
DE LA POER: So we will go over the page to page 4, please. It is under the heading of the "Risk
management structure" and we can see that there is a committee, if that's the right word, called
the Corporate Directors Group who have delegated responsibility for reviewing the Executive Risk
Register and board assurance framework?
MILLWARD: That's correct.
DE LA POER: Now, the Inquiry has received information from the Countess of Chester that the
Corporate Directors Group was not used for this purpose from around autumn of 2016 and in fact it
was what was described as Part 2 of the Executive Directors group that was used. Is that change
something that you were aware of taking place while you were there?
MILLWARD: I don't recall. I don't recall when, when the Corporate Directors Group stopped.
Obviously you have provided some, some information in my bundle to assist me. But I -- I don't
recall and that certainly was not something that would have been, you know, my, my decision. I
can't account for the reasons why it would have stopped. That would be Mr Cross who essentially
oversaw the CDG.
DE LA POER: As head of Risk and Patient Safety, would you expect to be consulted about any
structural change in relation to the management of the Executive Risk Register?
MILLWARD: At the level that I was performing at, my responsibility was to provide that information
to the Executive team for the decision-making and oversight. It wouldn't have been my, my role to
try to influence the committee structure. That, that just would not have been my, my remit at all.
DE LA POER: Would it have been your role to be asked whether you had a view on it?
MILLWARD: Probably not at that point.
DE LA POER: Just to unpick that for a moment. The title of Head of Risk and Patient Safety --
MILLWARD: I think -- I think --
DE LA POER: If I may.
MILLWARD: Yes.
DE LA POER: -- tends to suggest that that is exactly the sort of role that you would have. Can
you just help us to understand that apparent disconnect?
MILLWARD: Yes. I think, I think the role is perhaps misleading to how you may be perceiving it. So
my role, my responsibilities was to essentially design and develop the systems and processes in
place in which we would have risk management or we would deliver risk management and incident
management, primary -- they were the primary functions. But it was very much around supporting the
local teams in delivering their clinical governance, so their incident management and risk
management. My level of influence isn't what you -- what you or what the Inquiry perhaps perceive.
I think the job title is a little bit misleading as to the level of influence there. It was very
much a head of department role and acting very much as an intermediary between the local teams and
the divisions and the Executive teams with regards to decision-making.
DE LA POER: One interpretation of that title is that you had principal responsibility for all
matters relating to
Risk and Patient Safety unless the Executive Directors needed to be involved. Is that not an
accurate characterisation of your role?
MILLWARD: No. So I wouldn't have ultimate responsibility for, for risk and incident matters. My,
my role, as I say, was very much an intermediary to ensure that my team was following our incident
and risk management policies, that we had a route of escalation and to ensure, as much as we
could, that the Executive team was sighted on those things. But certainly the -- as I say, my
level of influence isn't, isn't what you have -- what you believe.
DE LA POER: In terms of this document, would you have been consulted or had an input into the
content?
MILLWARD: So this is an updated document which I believe I added the -- there was a change with
the meeting structure further on I think in the appendices and Mr Cross sent that over. So I
updated it in line with, with that. But the actual content I think has remained the same for a
period of time.
DE LA POER: If we go over the page to page 5 we can see the definition of risk is given and in
particular, and it's just a small point, but given that you had some input into the content in
terms of the revision:
"Clinical risks are risks which have the ability to affect patient care and may cause harm to the
patient. This covers anything related to diagnosis, treatment and outcome of each patient.
Psychological harm or distress is also included. The following are some examples of clinical
risks." And then there is no list.
MILLWARD: (Nods)
DE LA POER: There is instead a change of topic. I mean --
MILLWARD: I can't -- I can't explain that, I'm sorry. It's obviously an error.
DE LA POER: Is that something that should have been picked up if this is a document that is
designed to help employees at the Trust to understand what the position is?
MILLWARD: Absolutely. Well, all documents go through a ratification process. This document as I
say with the updated committee structure would have been received at QSPEC and approved by QSPEC
members. So obviously I haven't seen that, that line, and I would also expect that the committee
members would have reviewed this document if they were approving it, which they did.
DE LA POER: Over the page is how risk is to be managed and we heard something about this this
morning from Ms Townsend, so we don't need to go over it in detail. But can I summarise it in this
way: that it's expected that it starts at the local level?
MILLWARD: (Nods)
DE LA POER: That it's expected that it will be escalated through various boards?
MILLWARD: (Nods)
DE LA POER: That there is a risk scoring system?
MILLWARD: (Nods)
DE LA POER: And that when a particular risk achieves a particular score, it will be escalated to
the next level?
MILLWARD: That's correct.
DE LA POER: Well, we will look at the scoring in a moment as we work our way through. Page 7, the
Executive Risk Register. We can see here that that's a risk score of 16 or above or if the risk
carries significant concern but with a lower risk score, and that is considered at the very top,
is that right?
MILLWARD: That's correct.
DE LA POER: And just taking a step back for a moment. Would you expect an unexpected increase in
mortality rate on the neonatal unit to make it up to the Executive Risk Register?
MILLWARD: I think it's very difficult because, as you say, clinical care is, is not linear; it is,
it is complex. So, you know, an increase in, in, in mortality rates it's about understanding what
is driving that and either if we hadn't got that information or that -- that we had got that
information, that information showed that we weren't mitigating those risks or controlling those
risks, then absolutely I would expect it to go on the risk register.
DE LA POER: Well, we'll come to what happened and the timing of it in due course.
MILLWARD: Thank you.
DE LA POER: If we go to page 9 we'll see your role is set out: "The Head of Risk and Patient
Safety [this is two-thirds of the way down] has the delegated responsibility for maintaining the
Executive Risk Register. The Head of Risk and Patient Safety also advises the organisation on
patient safety and risk issues enabling the organisation to achieve key governance and risk
objectives." So that latter part, you had an advisory role to the entirety of the hospital, is
that right?
MILLWARD: It is.
DE LA POER: On all matters of patient safety and risk, is
that right?
MILLWARD: Indeed.
DE LA POER: And so if we just circle back to your characterisation of your role previously and
its level of responsibility and its opportunity to influence. According to this document you are
the designated adviser on these topics, including up to the Executive level.
MILLWARD: I would -- I would -- if the -- if an issue was raised to me I would -- I would
obviously look at that with the, whether it's a local team, a divisional team or the Executive
team, I would contribute to the conversation as to whether a matter needed to go on to the Risk
Register, whether the controls put in place felt adequate or not, how that might link with our
board issuance framework for example. But obviously a lot of this is very much dependent upon
things being identified at local level and -- and that being shared.
DE LA POER: But you frame that in terms of if people ask you. But don't you have a positive
obligation to try and improve all matters of patient safety and risk by offering advice as and
when necessary?
MILLWARD: Yes.
DE LA POER: Finally by way of this document we will just
look at page 14, which is to see the risk scoring matrix, and this will become relevant in due
course. Just to understand, we know that two of the risks that we are going to have a look at were
given one a score of 20, one a score of 15. The way this table works means that there are two ways
you can score 20, either it's an almost certain, so there's a 1 in 10 likelihood of a major
severity event?
MILLWARD: (Nods)
DE LA POER: Or that you have a likely, which is characterised in with 1 in 100, catastrophic
event?
MILLWARD: (Nods)
DE LA POER: So either way, something very serious is at risk of occurring which will require
immediate action?
MILLWARD: Yes.
DE LA POER: And if we have a look at moderate, 15, which another risk we are going to have a look
at also scores that, that's either a almost certain moderate severity or a possible
catastrophic?
MILLWARD: Yes.
DE LA POER: Is the risk of an avoidable death of a child occurring catastrophic?
MILLWARD: Yes. So the top line, the 1 to 5 -- insignificant, minor, moderate, major, catastrophic
-- that's the -- that's obviously the severity.
DE LA POER: Yes.
MILLWARD: So yes, so if we are referring to the death of a child, then, yes, it would be
catastrophic.
DE LA POER: The avoidable death of a child?
MILLWARD: Would be catastrophic.
DE LA POER: Would be catastrophic.
MILLWARD: So it's considering the worst outcome from this risk.
DE LA POER: Thank you. We can take that down and we will have a look at the risks that I have
been referring to in a moment. But before we do, there's one other document I would like please
for us to have a look at which is the Incident Decision Tree. This forms part of the Trust
guidelines for the conduct of formal investigations. It is INQ0003324 if we can go to page 15 just to get the context of the chart. So
it talks about an Incident Decision Tree, which we are going to have a lock at in a moment,
appendix 1, which is -- we have some frequently asked questions. It's designed for use by any
manager dealing with staff involved in a patient incident. So that we understand what that means,
is a patient incident anything that would involve a Datix being produced?
MILLWARD: A -- yes, with regarding to clinical care,
yes. Obviously the incident reporting system included non-clinical incidents as well.
DE LA POER: Yes, but in terms of what the Inquiry is focused on --
MILLWARD: Yes.
DE LA POER: -- so a manager who is filling in a Datix would be expected, would they, to have
regard to this Incident Tree?
MILLWARD: All this was circulated to all managers, yes, as part the guidelines.
DE LA POER: And ideally it should be used as soon as possible after the patient safety
incident?
MILLWARD: (Nods)
DE LA POER: Whilst facts are still fresh in people's minds?
MILLWARD: That's correct.
DE LA POER: We can see that it's described as a flowchart but rather than looking at the words
used to describe it let's actually have a look at it over the page and really we don't need to get
past the first step. Start here in the top left-hand corner. The first question that any person
applying this is expected to answer is under the heading "Deliberate harm test" were the actions
as intended -- were the actions as intended?
MILLWARD: Yes.
DE LA POER: And obviously in the context of the phrase "deliberate harm test", has a member of
staff deliberately harmed a patient?
MILLWARD: Yes.
DE LA POER: That's the first question.
MILLWARD: Yes.
DE LA POER: So just help us to understand, because none of the doctors or nurses that we have
heard from so far have drawn attention to this or said that it was in their mind, and that
includes a number of nurse managers and doctors with managerial responsibility. Whose
responsibility was it to circulate this and ensure that everyone in the Trust understood it?
MILLWARD: So it's part of the Trust guidelines. It's -- I'm sorry, the page has moved on so I
can't tell you what specific guidance it is but it's a HR -- the HR processes.
DE LA POER: Yes.
MILLWARD: So the responsibility obviously sits with the HR team. This was circulated. I can
remember having various conversations with managers using the Incident Decision Tree. So it was --
it was in use throughout the organisation. So I can't account whether the staff you've spoken to
was aware of it because it was -- it
was in use.
DE LA POER: You said it was circulated. When was it circulated?
MILLWARD: Well, it will have been circulated when it was ratified originally and then obviously
the updates. The system that we had for the document management system would highlight to staff
when new documents had been updated or if a current document had also been updated. So all of that
information would have been there.
DE LA POER: And when applying this Incident Decision Tree, what level of confidence or certainty
would you have to have in the answer before progressing? And let me illustrate what I mean by
that. Were the actions as intended? Do you need to be sure of that? Does it need to exist as a
possibility? Does it need to be more likely than not? What should be -- when somebody is asking
themselves that question before they progress down that column, which ends up with, among other
things, contacting the police, what level of confidence does a person need to have to move
downwards?
MILLWARD: I think first and foremost the person needs to be clear as to what the incident is, you
know. So it's understanding in this case with the deaths is was -- was an incident -- was it a
medication error for example? So was it a drug, too much drug was given or too little drug was
given? So understanding and through discussion with the staff member, you know, did they intend to
give that level of, of medication? But did they -- did they know by doing so that they were going
to cause that level of harm as a result of it? So it's -- it's done through conjunction with the
individual through a reflective discussion with the individual and it would be around the ward
manager -- largely this is used for nursing staff if I'm honest -- having that understanding of
the individual and having thought whether or not there was something more sinister, if you like,
in their behaviour. I don't think we ever sat and said: oh, there's a defined level of evidence,
if you like, that needed to be provided and I don't think the national guidance did that either.
But it would be, you know, through that conversation with the staff member and understanding their
view and obviously that local investigation that that manager would be taking as well.
DE LA POER: So, in practice, if somebody had come to you during 2015 and said, this person being
a doctor: I am concerned that a member of staff is associated with
an increase in mortality --
MILLWARD: (Nods)
DE LA POER: -- I can't say that I have seen them do anything, but I think there is a risk and
that risk implicitly includes that they have done this deliberately, is that enough to progress
down to the bottom of that chart?
MILLWARD: I think that would be difficult to say so because, as I've said, it's about
understanding what has contributed to the harm. If we are referring to -- to the deaths of the --
of the children, you know, a -- a child, it sounds awful and I apologise to the families if it
sounds callous and it's not meant in any way, but a child -- a child may die, as I say, an
incident may happen, a medication -- medication errors are particularly easy to talk through. So a
medication error may happen. It would -- I'm not communicating very well, I apologise. So an
incident may come in. It would be -- it could be a medication error. It could be significant
enough that it has contributed to -- to the harm to a death of a child, but it could also be
reported as a no harm event as well. So it's -- it's around were the actions as intended, do we
intend to give that amount of
medication? But did we actually intend to cause the level of harm? It's -- it's not as
straightforward as saying: We have these deaths and I have got a staff member that I am concerned
about. It would be about understanding: Well, what do you mean by that? What was that staff
member's involvement and what, what do we understand has contributed to the death?
DE LA POER: But from a risk management point of view, you only need a reasonable concern to
provoke action, don't you?
MILLWARD: Yes, but it would be about exploring and trying to understand what has happened to --
for those people to have concerns about a staff member and to understand what has happened for
that child. It's very difficult for some incidents, for -- as I say, clinical care is not linear,
it's sometimes difficult for people to understand whether the outcome has happened as a result of
an incidence of something unexpected or intended that's happened to the patient or whether that is
unfortunately the natural trajectory of the patient's condition, or indeed is something in
response that we have tried to do to help improve the patient's condition. It doesn't necessarily
mean a -- a very poor
outcome does not necessarily mean that there has been a harm as such.
DE LA POER: I'm not seeking to dispute any of that with you. But this column here is specifically
catering for a circumstance in which the police may need to be involved, so it is contemplating
somebody like Beverley Allitt deliberately harming patients. That person is unlikely to admit to
it when you have your discussion with them?
MILLWARD: (Nods)
DE LA POER: And it may be that the only evidence before the police become involved is a clinical
judgement that too many incidents that shouldn't have happened have happened?
MILLWARD: (Nods)
DE LA POER: Is that not enough for the purpose of this?
MILLWARD: I don't think you would use the Incident Decision Tree in that way. This is around an
individual incident that is then applied to an individual staff member. What we are referring to
is multiple deaths and looking essentially at understanding those deaths. I don't feel that the
Incident Decision Tree would be used in that way.
DE LA POER: Would you expect Ms Peacock, in her role when speaking to people within the neonatal
unit about deaths, to have this decision tree in mind?
MILLWARD: Yes. Yes.
DE LA POER: Would you expect her to go so far as to talk through it with the person she's
discussing it with?
MILLWARD: Again, we would be talking through it based upon a specific incident, not -- not
necessarily -- and that is the difficulty some of the incident reports refer to a death but they
don't give a narrative as to, you know, what was thought to have contributed to the death.
DE LA POER: We can perhaps park that but if I can just put a bookmark for you?
MILLWARD: Of course.
DE LA POER: When we come and have a look at [Child I] it may be that my questions will take on a
slightly different perspective. But can we just look please at how this risk was managed and again
we have seen a little bit of this from Ms Townsend but I think we are going to take it to the next
level now. INQ0004657. So this is the Urgent Care Risk Register high risks. So that is
the risks rated 20, is that right, because it is red?
MILLWARD: I believe so. It's been many years since
I have used that particular scoring matrix.
DE LA POER: We can see the top one "Potential damage to reputation of neonatal service and wider
Trust due to apparent increased mortality within the neonatal unit" and it is dated 11 July, so
that is where we are going to start. I will ask you some questions globally, we just need to work
our way through the documents?
MILLWARD: Yes.
DE LA POER: If we then come to the next document, please, INQ0003213, this document is dated 19 July 2016. Forgive me, if we could take that down. That isn't in fact the correct reference. So would you just bear with me one moment, please. (Pause) Forgive me, I will give a different reference because that one clearly doesn't work. INQ0049845.
LADY JUSTICE THIRLWALL: I wonder if that might be a convenient moment?
MR DE LA POER: I think it will, my Lady. I don't know why that reference isn't working, but it will be my fault and I apologise.
LADY JUSTICE THIRLWALL: Thank you very much. So we will adjourn now and start again at 5 to 2.
(12.57 pm) (The luncheon adjournment)
(1.55 pm)
LADY JUSTICE THIRLWALL: Yes.
MR DE LA POER: Mrs Millward, we are just tracking the risks. We started at the divisional level
but we are going to take a step backwards now, INQ0003213, please. This is eight days after that Urgent Care Divisional
Risk Register. We are looking at the Women and Children's Care Governance Board meeting. You
weren't present at this meeting, but we can see that Mrs McMahon, Temporary Risk and Patient
Safety Lead, is identified near the bottom, do you see that?
MILLWARD: I do.
DE LA POER: And if we go to page 4, please, we can see new risks for escalation this month and we
can see at the Women and Children's Care Governance Board level identified first: "Potential
damage to reputation of neonatal service and wider Trust due to apparent increased mortality
within the neonatal unit." Given a score of 20, we are familiar with that one. But we can also see
as the next one down "apparent increased mortality within the neonatal unit" which is given a
score of 15?
MILLWARD: Yes.
DE LA POER: So just bear with me, one more document to
look at where we will see those again. Before we go there we just need to note that on page 5,
just so that you have this in your mind when I come to my questions, that according to the minutes
of this meeting there was nothing to report to QSPEC, that is the bottom entry?
MILLWARD: Yes.
DE LA POER: So we then come, please, thank you very much, to INQ0049845. This is the Executive Risk Register for July of 2016. If we go
to page 10, first, we will look at the detail of it but just so that you can recognise this. This
is prepared by you, according to the bottom right-hand corner there, for the Corporate Directors
Group on 27 July of 2016?
MILLWARD: Yes, the date there refers to the date that the report was pulled rather than the date
of the meeting.
DE LA POER: So let's go back up to the top to page 1. It is not a document we have looked at
previously so we will just take a moment to orientate ourselves. We can see that initially we have
got presented in tabular form a number of different ways of just gauging how many there are and if
we go over the page, please, we can see as at 27 July there were seven risks entered into the
ERR.
MILLWARD: Yes.
DE LA POER: The first is recorded as "potential damage to reputation of neonatal service and
wider Trust", that one that we have seen from the Divisional Register of 11 July now appearing on
the Executive Risk Register and the second one that we saw not on that previous register that we
looked at but at the Women and Children's Care Governance Board, "apparent increased mortality
within the neonatal unit" which is given a moderate corresponding with its score of 15?
MILLWARD: (Nods)
DE LA POER: Those are identified as 1508 and 1507 respectively and that is important because we
can see there is a note to this that you have added chairman's actions were taken on 11 July 2016
to add two risks to the ERR from Urgent Care and there we see the reference numbers, there are no
risks identified by the divisions for escalation to the ERR for July 2016. So this is a document
that you have prepared; is that correct?
MILLWARD: That's correct.
DE LA POER: You have delegated responsibility for the ERR; is that right?
MILLWARD: That's correct, yes.
DE LA POER: So let's just break down what we can see on the page here. Firstly, chairman's
actions were taken
on 11 July to add those two risks?
MILLWARD: (Nods)
DE LA POER: What is that a reference to, please?
MILLWARD: So that would be in reference to another meeting that has been held with the Executive
team. I can't tell you which meeting because the detail isn't there and the decision being made to
add these two particular risks. And obviously that will have included a discussion around the
wording and the scoring, the controls and actions.
DE LA POER: Now, the board chairman is Sir Duncan Nichol?
MILLWARD: (Nods)
DE LA POER: Is that a reference to Sir Duncan Nichol --
MILLWARD: Yes.
DE LA POER: -- when it says "chairman's"?
MILLWARD: So chairman's actions will be in relation to the chair of the meeting that the -- that
this is going to. Sir Duncan Nichol didn't -- I don't recall Sir Duncan Nichol actually ever
attending Corporate Directors Group so it would be chairman's actions in relation to either Mr
Cross or Mrs Kelly or indeed Mr Tony Chambers, I am not too sure who because they did alternate
the chair for Corporate Directors Group.
DE LA POER: Whoever was chairing on that occasion according to your note and is this something
that you
would have been told?
MILLWARD: That -- that would have been something I would have been in attendance for. I don't.
LADY JUSTICE THIRLWALL: So you would have been at that meeting?
MILLWARD: Yes. I'm not sure whether I am trying to understand when the actual Corporate Director
Group meetings were held. I don't have a list of the reports so I'm not sure if that was
chairman's actions from the Corporate Directors Group on 11 July, if you understand what I am
saying.
MR DE LA POER: Well, we know that 11 July was also the date that it appeared on the Urgent Care
--
MILLWARD: Yes.
DE LA POER: -- Divisional Register. Well, perhaps we can run that down separately. I think you
have given us enough information there for our understanding. I just want to ask you, as Ms
Townsend was asked, about the wording. Potential damage to reputation given the highest level of
rating?
MILLWARD: (Nods)
DE LA POER: Why was this risk framed in terms of damage to reputation?
MILLWARD: So that will have been a conversation that
took place at the meeting with the Executive team. At that time, the unit was being downgraded.
Obviously that had been put into the public arena and there will have been concern whether, you
know, how that would have been received and potentially reported back on, you know, through the
press and of course any concerns being raised directly to the Trust in relation to that.
DE LA POER: I will come back to that answer in a minute.
MILLWARD: Of course.
DE LA POER: I just want to ask you about the second risk which is apparently of a less high level
of concern. Apparent increased mortality within the neonatal unit, so that one similar to the
earlier risk but without reference to reputation?
MILLWARD: Yes.
DE LA POER: Simply focused upon the risk of death?
MILLWARD: So that will have been focused upon absolutely the clinical aspects of the care and, you
know, as you say, the risk of death. I can't recall the exact conversation but my view or my
interpretation of that would be that the unit had already been downgraded at that point and
therefore that would reduce, you know, the -- the challenges around those, though more high acuity
patients coming into the unit, that was the -- that was the view at the time and so I think that's
why that particular risk is scored slightly lower than the one around reputational damage.
DE LA POER: If you just take a step back.
MILLWARD: Yes.
DE LA POER: This does rather look like the Trust is more concerned with the comms messaging,
reputation management, than actually babies dying. Can you help us with that, please?
MILLWARD: Absolutely. So within the risk management scoring we are looking at both the severity,
so the level of harm, if you like, the outcome but we are looking at how much that likelihood --
you know, how likely it is to have that catastrophic outcome you have referred to. What we are
also looking at within that is the controls and the measures that are already in place to try and
manage that. So the view would have been, I believe, that because of the actions already taken to
downgrade the neonatal unit and therefore to take, you know, a different cohort of patients that
there was additional mitigations in place within the Trust control. Of course reputational damage
and media coverage and so on would be outside the Trust's control so they wouldn't have the same
level of assurances around the
effectiveness of the controls and that would have meant that would be reflected in the risk always
being slightly different.
DE LA POER: We are going to have a look at the control measures in a moment.
MILLWARD: Of course.
DE LA POER: What thought when these entries were being devised was given to the relative acuity
of the children who had in fact died?
MILLWARD: So this would have been a step, a moment in time, on 11 July as to, you know, this is
the situation we are in today. These are the actions that have already been taken to prevent
further deaths. And that would be why the score is the way the score is.
DE LA POER: Let's have a look, please, at page 4 where we can see some more detail. Here we are
looking at the first risk and the list of controls which speak for themselves in a number of
respects. Just again focusing here on two of the controls which is the closure of the intensive
care cots and the use of regional hospitals for babies of particular gestation. I mean, surely
would that not increase confidence in the unit?
MILLWARD: But the risk is around reputation to the Trust, so there are two different risks here.
Those
factors would be controls and considered increased confidence with regards to further cases of
mortality. This risk is in relation to media reputation -- well, reputation of the organisation
and so it's a different lens being applied.
DE LA POER: Well, why is the Trust so concerned with its reputation?
MILLWARD: Well, why wouldn't -- with respect, why wouldn't the Trust be concerned with its
reputation? At that point in time, we had a -- you know, we had a number of children who had sadly
died. There was a Royal College review being initiated by the Executive team, there was a change
in the way that the unit was being managed that was going to be or that was shared publicly. You
know, there is a level of how you manage those communications to try and assure that the public
using our services would have confidence to come in and get the care that they do need. You know,
I can't give you more than that, that is an executive decision.
DE LA POER: You have a role to provide advice, don't you?
MILLWARD: I -- I do and I will have been part of the conversation that agreed to put these two
risks on the Risk Register.
DE LA POER: So did you support the approach that was being
taken?
MILLWARD: I think at the time that felt very reasonable.
DE LA POER: Let's have a look at the control measures for 1507 which can be found on page 8 so
this is -- instead of focusing on reputation, this is actually focusing upon the risk of death to
babies.
MILLWARD: Yes.
DE LA POER: So we can see in a little more detail here, reference to the thematic review. I just
want to have a look and understand why the Care Quality Commission inspection in February 2016 did
not highlight any concerns is regarded as a control measure?
MILLWARD: So that would -- it would be regarded as a control measure because it is a level of
assurance, it is an external level of assurance. Therefore it's considered a higher level of
assurance than simply our own reviews of the cases.
DE LA POER: Do you know that when you agreed to that going in that the Care Quality Commission
had in fact investigated the increase in neonatal mortality?
MILLWARD: I was not aware at that time that the CQC had investigated. Obviously this is -- that
line is referring to the inspection and the report come back from the CQC inspection.
DE LA POER: Well, wouldn't it very largely depend on what the CQC was told as to whether or not
that provides any real assurance?
MILLWARD: And of course all the different documentation that is submitted and therefore validated
by the CQC.
DE LA POER: Did you submit the thematic review of neonatal mortality?
MILLWARD: Not at that time because that was February 2016 and obviously it was still being
developed at that point.
DE LA POER: So as far as you are concerned, or as far as you are aware, the CQC never saw the
thematic review?
MILLWARD: As far as I am aware, they did not see that, no.
DE LA POER: So again bearing in mind all of this is apparently emerging from the entry above, if
you knew that the CQC hadn't actually seen that report, how much assurance does that actually
provide?
MILLWARD: And that that's a valid question?
DE LA POER: Well, can you answer it?
MILLWARD: I think it was -- I think it was a best effort to try to understand the different levels
of assurance that the organisation had at that time. I think I agree with what you are saying, you
know, if we haven't submitted the thematic review to the CQC, or if we had it they may have given
a different view.
But at the time that was the level of -- of assurance that we had. It is very comprehensive, the
review process. It goes on for many, many months there is many, many conversations around it and
obviously it was something that, you know, in the conversation around adding these risks it was
something that was felt important to add in.
DE LA POER: One thing that isn't listed as a control measure is the removal of a member of staff
to a non-patient-facing role?
MILLWARD: (Nods)
DE LA POER: Why is that not included here?
MILLWARD: I can't answer that. I don't know.
DE LA POER: Well, as at 27 July did you know that a member of staff had been moved to your
department as a control measure?
MILLWARD: As at 27 July, yes, I did know she had been moved. Well, it was an agreement at that
time.
DE LA POER: So why, bearing in mind you had delegated responsibility, you are providing advice,
is that not listed here?
MILLWARD: So to be clear around the delegated responsibility, that does not mean I own the risk,
it means that I ensure that the risks are reviewed, that the report comes through up to the
Corporate Directors
Group, that, you know, there are actions put in place and those actions are progressed in a timely
manner I didn't own the risk. It will have been Mrs Townsend who would have owned the risk.
DE LA POER: But be that as it may, the person who had been moved was by this stage working in
your department. Did it occur to you to suggest that that was included as a control measure
here?
MILLWARD: I think the fact that the person involved who had been moved had been moved as a HR
process and a HR process is a confidential process, and therefore, we wouldn't normally transfer
something like that into the Risk Register because of the level of access and the number of people
that would see that.
DE LA POER: So was there a conversation around whether it should or shouldn't be put in?
MILLWARD: I honestly can't tell you that, I honestly don't remember.
DE LA POER: If we just look at this risk and how it's framed or how it begins, in terms of the
control measure, as it is listed, "clinical lead" is highlighted and "apparent increased
mortality". If it is right that that is a reference to the thematic review, which we know was
finalised on 2 March, does it follow that at the very latest, by mid-March, this risk should have
been put on the Executive Risk Register?
MILLWARD: I think absolutely it should have been added on to the Risk Register at an earlier
stage, yes.
DE LA POER: Well, my question is two parts, firstly by at the very latest mid-March and,
secondly, as far as the Executive Risk Register, which is where we see it now, do you agree with
both of those?
MILLWARD: Yes, yes, I would agree with that.
DE LA POER: Now, just trying to understand why -- we can take this down, thank you very much
indeed -- you say in your witness statement the governance arrangements, ie ward to board
reporting, were not sufficiently robust to ensure that the voice of the neonatal unit, a small
specialty within a much bigger adult care-providing division, was heard both at Divisional and
Executive level meetings?
MILLWARD: That's correct.
DE LA POER: Now, we know that before we get to the Divisional level and the Executive level, the
normal governance arrangements are that it would go to the Women and Children's Care Governance
Board?
MILLWARD: Mm-hm.
DE LA POER: We also know that it didn't go to the Women and Children's Care Governance Board
until June of 2016, so very shortly before we see these entries. So is that in fact anything to do
with the size of the neonatal unit and is it more to do with the fact that nobody at that local
level was escalating it?
MILLWARD: I think -- I think it's both. I think it's both. I think the -- I think, you know, the
neonatal unit paediatrics is a much smaller specialty, the division of Urgent Care, which is the
former route, obviously is largely adult-focused and I have reflected on the escalations that
went, particularly up to QSPEC, and they were largely focused, they were verbal for one, they were
not documented levels of assurance and points for escalation, but they were largely focused upon
patient flow because it's we -- the Trust had an emergency department and obviously patient flow
into the hospital and obviously exit out of the hospital was a primary area of concern. So having
them attend and raise their voice but do so verbally without a document that they can send up, an
assurance report, not the thematic review I am referring to, makes it harder for them to speak up
at that group and then that message, you know, continue up the points of escalation. But clearly
as you say, the paper wasn't tabled, there was a delay in tabling the paper at the Women and
Children's Care Governance Board as well.
DE LA POER: Well, we will come back to that and where responsibility might lie. Before we just
leave this general topic of the Risk Register, I would like, please, for you to look at INQ0042162. This is a list of ongoing patient safety incidents reported on
STEIS dated February 2016 and in fact the entry I am going to ask you to look at isn't anything as
far as we are aware to do with the neonatal unit.
MILLWARD: Okay.
DE LA POER: So if we go to page 2, please, and it's just to consider this issue of the Trust and
its reputation?
MILLWARD: (Nods)
DE LA POER: Do you see the penultimate entry which is right in the centre of the page?
MILLWARD: I do.
DE LA POER: "Potential for adverse media incident, police investigation into the circumstances of
the death of a patient." This is apparently reported on to STEIS as an NPSA level 2?
MILLWARD: Yes.
DE LA POER: Looking back on it, what, was there too great a focus upon the Trust's reputation, do
you think?
MILLWARD: If you consider the Serious Incident Framework and the three areas that they ask with
regards to
reporting what is classed as a Serious Incident, the potential for adverse media is included
within that. I think looking at this one I actually remember what this case is and it would have
absolutely have been appropriate to escalate that as a Serious Incident. It's not in relation to
the reputation of the Trust, that's in relation to a police investigation around a patient who was
deceased.
DE LA POER: So when it says adverse media?
MILLWARD: Because that's the category that you would select on STEIS.
DE LA POER: So that is not referring to the adverse media about the Trust?
MILLWARD: It's in relation to the death of a particular patient. I -- I believe I know what case
that is and it would not be appropriate to share any further information about that other than to
say it was a death of a patient that -- that was reported to the police, was progressed through a
police investigation externally to the organisation. But the patient died at the Trust, and
therefore that does generate media interest and does generate, you know, contact and under the
Serious Incident Framework that would be something that you would report on STEIS.
DE LA POER: Thank you, we can take that down.
I am going to turn now to consider the policy for reporting incidents and we can do so relatively
briefly. We heard from Ms Lawrence about this about a week and a half ago. INQ0006466. We can go to page 3, please and we can have what should be
reported as an incident and here when it says reported initially that means filling out a Datix;
is that right?
MILLWARD: Yes, of incident reporting in Datix, Datix is the incident reporting system.
DE LA POER: Now, what Ms Lawrence told us was that her interpretation of what should be reported
was effectively harm caused by something that shouldn't have happened?
MILLWARD: That's correct.
DE LA POER: In that way you can have death as a no harm incident because if death is a natural
process, then one doesn't need to identify it as an incident?
MILLWARD: Yes, yes. Well, yes, you wouldn't report a naturally occurring death on the incident
reporting system. You would only report -- you would report an incident in relation to the death.
DE LA POER: If we see this, Ms Lawrence's interpretation was that unnecessary harm to patients,
ie meaning something that shouldn't have happened and that could have been avoided?
MILLWARD: Yes. The language has changed over time. Today you would use the words "unexpected" or
"unintended".
DE LA POER: And who was responsible for the language here, is that taken from NHS England or is
that internal to the Trust?
MILLWARD: That would have been taken from some national guidance.
DE LA POER: Now, just bearing in mind that definition. If a baby suddenly and unexpectedly
deteriorates but does not die, so is successfully resuscitated and there is no immediate
indication that anybody has done anything wrong or done anything that they shouldn't have done,
would that be under this guidance a reportable incident?
MILLWARD: So again as I said earlier it's, you know, clinical care is complex. In this situation
-- well, normally we would be seeing if an incident has occurred as you say an incident has
occurred we would expect to see it reported where there are unexplained situations such as the
collapses you refer to, if they have generated a number of discussions because we can't understand
what has contributed to the death, then in my view, yes, that should be reported as an incident.
DE LA POER: Can you just help me with which part of this policy you say triggers that as a
reportable incident?
MILLWARD: So the clinical section where it says "clinical, ie affecting a patient, investigation,
diagnosis, treatment" and then you have "medical equipment" so on and so forward.
DE LA POER: Yes. That's a list of I think what "clinical" means, I think it is subject to what
appears above about "resulted or did result in unnecessary damage, loss or harm to a patient"?
MILLWARD: So as I say, the language as we would use today has progressed, we would be talking as
"unexpected" or "unintended". But if something is unexplained and we don't understand what has
happened what has taken place and it has triggered further discussion, then it would be absolutely
reasonable to report that as a clinical incident.
DE LA POER: As the Inquiry understands it, anybody can report anything, they don't have to be
within the policy. What I am really trying to understand is whether it's mandatory to report
--
MILLWARD: Right.
DE LA POER: -- such an event?
MILLWARD: No, the incident reporting system is broader than that.
DE LA POER: I think -- you tell me if I am right about
this -- what you are saying is you wouldn't criticise someone for not reporting such an event
because the policy doesn't require it?
MILLWARD: The policy doesn't stipulate exactly every situation that an incident would be reported.
As I say my view is if -- if an incident occurs in such a way as you say a collapse where there is
a level of concern because we have not understood what has happened then I would expect that that
is reported as an incident so that that can then be further explored and supported through,
through using our root cause analysis process.
DE LA POER: Does what you have just said, did that make it into writing or training or any policy
that existed back in 2015/16?
MILLWARD: I think that will have happened through conversations and discussions. Certainly there
was mandatory training that happened every two years. The junior doctors also had their own
bespoke mandatory training, induction processes, there was an induction checklist that spoke
around the use of the incident reporting system and when you should report and essentially none of
the team would ever discourage somebody from reporting an incident even if, you know, the outcome
of the investigation showed that no actual event actually happened.
DE LA POER: Well, we are going to look at it from the other end of the telescope which is whether
or not it is appropriate to criticise someone for not reporting it and the starting point, I think
it is fair to say, Mrs Millward, is that over the course of your time as Head of Risk and Patient
Safety you were critical of the neonatal unit's approach to reporting; is that fair?
MILLWARD: I -- I don't know if I would say I was critical. I would say that, you know, there were
occasions when I needed to speak to Dr Brearey about incidents and investigations and Dr Brearey
wasn't responsive.
DE LA POER: So if we have a look at a number of the contemporaneous documents at INQ0001888, please. So if we go to page 8. So we can see that this is a
paper that you drafted in July; is that right?
MILLWARD: That's correct.
DE LA POER: We can see that one of the things that you looked into was incident reporting?
MILLWARD: That's correct.
DE LA POER: Did that enable you to form a view at that time about the quality of the incident
reporting on the neonatal unit?
MILLWARD: Yes.
DE LA POER: And in summary how did you find it?
MILLWARD: I felt that the incidents being submitted were limited, narrow in focus. There were a
number of them, if I can recall, around closure of the unit, some staffing and also the quality of
the information you know, included in the incident reports was quite limited. So there was often
insufficient information to say what is the event that you are concerned about and obviously then
somebody like Mrs Peacock would go in and have those conversations.
DE LA POER: So this is as at July 2016?
MILLWARD: (Nods)
DE LA POER: Was that something that you had had experience of before this time or was it
something you only discovered when you did this piece of work in July 2016?
MILLWARD: I think a bit of both. We had had conversations around the use of the pick lists, the
neonatal unit pick lists, because again they were developed to -- well, they were developed by the
neonatal unit to help support them in driving incident reporting. There was a view, you know,
through NHS England and the Serious Incident Framework that perhaps these lists were perhaps not
quite as helpful and perhaps looking at incidents we need to look more broadly, I think
Mrs Lawrence may have alluded to that in her evidence. And as I say, with the cases that I did
pick up in the interim, I could see some of the content wasn't particularly detailed and you
wouldn't be able -- if you received the incident you wouldn't necessarily be able to see exactly
what the concern was and therefore, as I say, Mrs Peacock or -- would need to go in and speak with
the staff to understand the concern.
DE LA POER: Had Mrs Peacock complained to you that she was having that difficulty with the
neonatal unit?
MILLWARD: I think Mrs Peacock, because of her relationship with them, she was able to get the
information out, you know, from the conversations, I don't think she found it a concern.
DE LA POER: Because the way we understand it works is that the Datix is filled in by the person
who reports it, it comes to a handler within your department who allocates it to the right
person?
MILLWARD: That's correct.
DE LA POER: Codes it correctly and then in the case of the neonatal unit up until February 2016
Mrs Peacock would receive it, consider it?
MILLWARD: That's correct.
DE LA POER: You are telling us that she hadn't as at the time that she left fed back to you that
she thought it
was a problem?
MILLWARD: No, as I say because I think of her relationship with the unit she was able to -- to
work with them to -- to help understand what -- what the incidents were.
DE LA POER: Now, if we look at INQ0006769, this is Dr Brearey's email that we looked at earlier of 15 July.
If we go over the page, please, in his penultimate paragraph, he says he has heard criticism of
the risk in Datix reporting culture there. What you tell us in your statement is that your belief
is that he has heard what you have had to say about his department; is that right?
MILLWARD: Yes. I believe that that will have happened following the meeting that I had with the
Executive team around the position paper and the feedback and I believe that that therefore has
perhaps come from Mr Harvey when he then met with the paediatricians but I can't be certain, but
that is what I believe that alludes to.
DE LA POER: And so your concern is if we are clear about this, not that Datix aren't completed or
is that part of it? It is the quality of the content or is it both?
MILLWARD: I think it's both. As I say, the use of the pick lists meant that there was quite a
narrow focus at the time so as I say you would tend to see the same sorts of incident types being
reported and obviously
looking at some of them there was not a lot of information contained with them.
DE LA POER: Certainly for all of the children named on indictment, every single one of them was
the subject of a Datix indicating that their death was unexpected.
MILLWARD: (Nods)
DE LA POER: So that wouldn't be part of the problem that you are describing; is that right?
MILLWARD: So again, the -- the use of the pick lists means that the staff were selecting expected
or unexpected death but that's not necessarily an incident. The incident is what has contributed
to that death because an unexpected or expected death is a clinical outcome. So what I would be
looking for is to broaden the pick list more and broaden the way they were reporting incidents so
that -- again I will give reference to the medication incident that I've referred to earlier, so
that I would see it as a medication incident but then with a level of harm that says death and
then that way we can more clearly trend and theme our learning rather than having something saying
it's a death but a no harm because obviously that can be confusing and I think that's caused some
confusion here.
DE LA POER: Well, what it resulted in was a Datix form for every single one of the deaths which
might not have been filled in had somebody been taking the approach of well, is this an incident
where something about the NHS has caused harm? Answer: not that I can see, therefore no Datix. So
can you see that there was a potential advantage to the approach that was being taken on these
facts?
MILLWARD: Well, my understanding is that there wasn't an incident report for every one of the
deaths, some of the deaths were not reported. I am not saying that they shouldn't be reporting the
death, what I am saying is that within the incident reporting system the use of the pick list and
the category or subcategory as an unexpected death was not particularly helpful because it is not
telling me what has contributed to the incident, what element of the patient's care or treatment
you want us to look into, what element of the treatment you are concerned about. That's what I am
referring to.
DE LA POER: Now, in terms of the indictment children, all of those who died, died when Mrs
Peacock was responsible for the department, other than [Child O] and [Child P].
MILLWARD: (Nods)
DE LA POER: So we just need to be clear about each one of those deaths. So far as you were
concerned did Mrs Peacock express any concern to you about the way in
which they were reported?
MILLWARD: I don't believe she did, no.
DE LA POER: Well, we will look at the detail in just a moment but one last matter of ground rules
to deal with which is your email of 26 June of 2015. INQ0008157. Your email starts at the bottom, we can see it is dated 26 June
of 2015. If we go to the next page, please, we can see you have added a note to it. We have had
three neonatal deaths under review via specialty M&M. The plan is to arrange a specialty
specific SI panel for next Friday the 3rd -- in fact the meeting took place on the 2nd -- to go
through all three cases. Then you say this: "Child death is no longer included as a Serious
Incident by definition in the SI framework or on STEIS, however it may be reported as a Serious
Incident under another category eg, medication error"?
MILLWARD: Yes.
DE LA POER: So just help us to understand, please, why you added that information to the bottom
of your email and what you were seeking to communicate?
MILLWARD: Because as I have tried to explain that we are trying to understand the incident type
that has contributed to the death so my understanding at that
time was there had been changes in the STEIS categorisations and I believe it was also through
conversation through the Quality and Safety Regional Forum. So again I have used the medication
error. So it's not saying we will not report a child death if it has been directly attributable to
the incident, it's saying that I wouldn't report it under a category saying "child death", I would
report it under a category saying "medication error" because that's the incident type that has
occurred. The outcome is death, so in STEIS I would be reporting under the categories "category:
medication error. Outcome: death". And it would be it's the same incident, it's just how it's
categorised and this is important because it's how the themes are drawn at national level as well
as local level.
DE LA POER: If we go back up, we can see the recipients of this email are those who attended the
Serious Incident Panel. They are all operating away from a clinical role. Was the information that
you have put there communicated to the coalface, to the individual wards, so that they understood
what was required as well?
MILLWARD: Well, STEIS reporting is only something that
myself and the Executive teams would do, it wouldn't impact the -- the grass roots staff.
DE LA POER: But your reporting is based upon what you are told?
MILLWARD: Yes.
DE LA POER: So presumably it's important for people further downstream or rather upstream I think
it will be?
MILLWARD: (Nods)
DE LA POER: To know what you find useful so again was this information communicated to the ward
level?
MILLWARD: So again the neonatal pick list you have heard Mrs Lawrence explain that she was looking
to try and broaden the pick list because of this -- this more narrowed focus and to ensure that
the information that we were teasing out from it was more helpful, so that was work that was under
way. Obviously this is 2015, so that it would have been, you know, literally just happening at
that point in time, these changes. There was a lot of changes in -- in, you know, very quickly
things were being, you know, new frameworks coming in the way that the regional centre wanted or
the regional quality and safety forums wanted things reporting, so things were shifting and that
would have been at the beginning of some of that.
DE LA POER: So this is June of 2015?
MILLWARD: That's correct, yes.
DE LA POER: Mrs Lawrence doesn't come into post until May 2016?
MILLWARD: Yes.
DE LA POER: So --
MILLWARD: That is why I am saying this would be at the start of that process in understanding how
we need to start shifting the way we are incident reporting. Very much an evolving picture over
this time.
DE LA POER: We are going to have a look at the Serious Incident Report process in action. We will
start with a handwritten note INQ0003530, please. Do you know whose handwriting this is?
MILLWARD: That is Mrs Kelly's.
DE LA POER: I think I will be right in saying that it's only really the top quarter or third of
the page which is concerned with this what she's described as SUI review, but I think it is called
the Serious Incident Panel?
MILLWARD: It is.
DE LA POER: We can see your initials there and [Child A] [Child C] and [Child D] were all
considered. We know that only [Child D] was reported -- [Child D]'s death, I should say, was
reported as a Serious Incident?
MILLWARD: (Nods)
DE LA POER: Certainly these notes don't appear to explain why that decision was made. Is that
fair, using your understanding of the shorthand?
MILLWARD: Yes, that is Mrs Kelly's notes.
DE LA POER: Can you tell us why [Child A] and [Child C]'s deaths were not escalated as Serious
Incidents?
MILLWARD: Yes. So the Serious Incident Framework has three -- essentially three criteria
essentially for reporting or identifying incidents as Serious Incidents. So the first is around
any act or omission in care that has led to serious harm or death. That is the one that you would
hear most regularly at the time, that was largely the focus that was applied at the time. The
second is around all never events in respect of harm were reported, such as the position. Then the
third criteria is a broader discussion point around a number of different things. So at the time
we were applying that first criterion. So we were looking at acts or omission in care that have
contributed to or have led to serious harm or death. The information that was shared both by Ms
Fogarty and by Dr Brearey was that for both [Child A] and [Child C] there was sufficient --
certainly they -- they found
that it was likely that their clinical condition was more attributable to the death, if you like,
so the death there was a clinical -- it was progression of the clinical illness that the children
had rather than an incident. There were as part of the review aspects of sub optimal care and I do
recall Dr Brearey being very open, actually he was very balanced in his presentation in talking
through some of the gaps that he had identified in the care for both -- well, for all the
children. But they weren't found to be significant enough to have contributed to that level of
harm and as such did not meet that particular criteria of the Serious Incident Framework and
therefore were not reported as Serious Incidents.
DE LA POER: You have mentioned the third broader category --
MILLWARD: Yes.
DE LA POER: -- could either of those children's deaths have met the broader category?
MILLWARD: So within the broader category it talks about -- and forgive me, I haven't got the
wording to hand, but it talks largely around where there is sufficient concern around the
potential delivery of the
service or failures to the delivery of the service. The wording is along those lines. Had we, you
know, the members of the Serious Incident Panel, applied that third -- that third criteria in that
particular aspect as a collective, the three deaths could have been considered as a Serious
Incident but that would have been a collective review of the three deaths and more of a systems
process review of the neonatal unit rather than an individual Serious Incident Review of [Child A]
and [Child C].
DE LA POER: So we will come to the collective nature, but within that broader category, could any
-- either of the deaths on their own for [Child A] or [Child C] have met that criteria?
MILLWARD: I don't believe so, no.
DE LA POER: Let's see what was recorded for [Child A]. INQ0000016, please. So this is the Datix. We move through it, please, to the
SBAR, as it's referred to, which if we move through to the third page, I think it is, in fact one
more, please. And one more. There we are. Thank you. So this I think you have realised from an
email is an SBAR, Situation Background Assessment Recommendation, that you completed?
MILLWARD: Yes. I -- it would be unusual for me to complete an SBAR, that obviously is the primary
role of the Risk and Patient Safety Leads but I have seen an email and I understand from Mrs
Peacock's evidence that she was on leave and therefore I do believe that I pulled that together,
yes.
DE LA POER: So what we can see is that under the assessment, at present there is no explanation
for sudden cardiorespiratory arrest. Then in the final paragraph: "The initial PM findings did not
give any answers, however we are awaiting results from pathology slide examination. However if it
was due to a cardiac arrythmia then this would not show on this examination." So on the face of
the information that you filled in an entirely unexplained death even after an initial
postmortem?
MILLWARD: (Nods)
DE LA POER: Would that not be sufficient to make this a reportable Serious Incident?
MILLWARD: So the decision was that we would take this through the Mortality Morbidity Review which
is a more detailed review than the SBAR and obviously trying to join that piece of work up so it's
not just an obstetric review, it covers mum and baby and it was at that point that Dr Brearey gave
the information that he
did and at that point the decision was made not to take that forward as a Serious Incident. I
think -- I think with the three deaths in short succession things moved quite quickly. You know,
obviously this -- this -- you can see the date of the SBAR being completed, you can see that the
plan was to take it to the SI Panel, which it did, and you can see that the case was for further
review. Unfortunately, as you know, we then went on to have the further deaths and then the
decision -- I recommended that we pull the three cases together so we had a more comprehensive
understanding of each of the three deaths and obviously make the decision regarding, you know,
Serious Incident at that meeting.
DE LA POER: So we can see the record for [Child A] for that meeting that we have seen the
handwritten note for starts at the bottom, Ms Kelly present, Mr Harvey not marked as present?
MILLWARD: I have to advise you, sir, that that listing is incorrect. A number of those people were
not in post at that time so there has obviously been a coding error within the back of Datix, so
that is incorrect.
DE LA POER: Well, we have got Ms Kelly's note of who she records as being present?
MILLWARD: Indeed.
DE LA POER: So let's turn over the page. We can see that one of the items of discussion at the
meeting in relation to [Child A], right in the middle, that [Child B], as we are referring to
them, Twin 2 had similar difficulties. So in fact it would appear that there was a discussion at
this meeting not only about [Child A], [Child C] and [Child D] but also about [Child B]. Do you
agree that that follows?
MILLWARD: I don't recall. But I certainly don't recall there being a conversation that spoke
around unexpected collapses. It's difficult from that text to say whether or not the feedback was
thought that you know that again that was that collapse sudden and unexplained or was that
something that was thought to be part of the complexity of the child's condition?
DE LA POER: We can see in the four lines which appear shortly below: "Aware A/W PM findings
finalised." Can you help us with what that A/W?
MILLWARD: So that would be "awaiting".
DE LA POER: So does it follow then that as far as the meeting was concerned, there was still no
final postmortem?
MILLWARD: At that point, yes, and then to proceed with
mortality a furthermore Mortality Morbidity Review.
DE LA POER: Is that the level of investigation M&M?
MILLWARD: Yes, that's correct.
DE LA POER: Just going back to where I started this questioning. You have told us that it was
decided to be dealt with in that way. Could this have been reported as a Serious Incident, this
death, on its own?
MILLWARD: I can only talk you through what I recall from the time and from what I recall from the
time is that between Dr Brearey and Ms Fogarty they gave explanations as to the clinical
conditions that could have left or most likely had led to the death. When we talk about incident
reporting we talk about actual harm as we know it today and therefore based upon that definition,
no, that again would have been why we would not have reported [Child A] as a serious incident at
that time.
DE LA POER: In terms of what you say about Dr Brearey's explanation, according to the SBAR you
completed, there was no explanation for the collapse that led to death.
MILLWARD: However this -- the Serious Incident Panel had further information available because the
Serious Incident panel was held once the child had gone through obstetric secondary review and had
also gone through a first review by the neonatal team so there was additional information
available at the Serious Incident Panel than I had available at the SBAR. The SBARS tend to be
completed within 72 hours, they are a very quick review of what we know at that point in time.
DE LA POER: Can you just help us with what information is recorded as having been discussed at
the meeting that provided the necessary assurance, is there any particular entry that you have in
mind?
MILLWARD: Could you go up, please, so I could ... So I think under the assessment section, the
first paragraph there, where we talk about the clinical condition of mum and the complexity of the
case, again referring to a clear management plan, monitoring in place and involvement of the
specialties. So again it's trying to understand what has been the gap in care that has contributed
to the death and that essentially is the some of the assurance at least.
DE LA POER: We can take that down, thank you. You told us that under the category 3 of the STEIS
categorisation --
MILLWARD: Serious Incident Framework.
DE LA POER: Thank you, Serious Incident Framework, that all three deaths could have been
reported?
MILLWARD: That's correct.
DE LA POER: Now, we have seen from the email of 23 June
that you are effectively advising people on how the Serious Incident Framework operates?
MILLWARD: Mm-hm.
DE LA POER: And what they need to be thinking about.
MILLWARD: (Nods)
DE LA POER: Whose responsibility was it at that meeting to consider that third category?
MILLWARD: The decision-making always ends up with the Executive team, so at that particular
meeting I think it was Mrs Kelly who was the Executive who was present. So we would have a
conversation and everybody in the room would contribute to the conversation and the discussion
point but the final decision whether or not a case would go for a Serious Incident investigation
would sit with the Executive.
DE LA POER: Was it your role to advise on the options?
MILLWARD: Yes. And I -- I accept that. At the time, as I say, the way the Serious Incident
Framework has been applied within the organisation was narrow, the largest focus was of course
upon the acts or omission criteria. The third section, as I say, which talks around systems
failures, that wasn't really something that was considered at that time.
DE LA POER: Well, were you the person at that meeting expected to be most knowledgeable about
that framework?
MILLWARD: I think everybody at that meeting, the expectation certainly -- I say everybody but Mrs
Kelly, you know, the Executives present should have a working knowledge of the Serious Incident
Framework because that is what we are applying and then they are the ultimate decision makers.
Also in attendance would be my line manager and again she would have a working knowledge and
obviously I would be the person who was meant to operationalise it. All I can say is at the time
the way that the framework was applied by the organisation was that the focus was always on an act
or omission in care that has led to serious harm or death and that was, that was essentially the
majority of incidents that we applied. I think the other side of it is, you know, Serious
Incidents were against individual cases, so if you were to look at the list of Serious Incidents
that we will have reported over that 12-month period they will be against individual events,
individual patients. To consider more a systems process was not something that was really in place
at that time. Over time that has evolved and in fact today with our new patient Safety Incident
Response Framework, that is very much process-driven but at the time it really wasn't part of the
way that that we were thinking or
applying the framework.
DE LA POER: Should you have been thinking in that way?
MILLWARD: I think myself and everybody should have been thinking that but in practice, at the
time, that wasn't the way -- that wasn't the approach that was being -- being used.
DE LA POER: [Child E]'s death, you tell us in your statement, was another opportunity to report
the overall increase in neonatal deaths as a Serious Incident.
MILLWARD: Yes.
DE LA POER: As a matter of common sense, regardless of process, wasn't that quite a serious
situation that the neonatal unit was facing as at August of 2015?
MILLWARD: I think again when [Child E] died the feedback that was received from the unit was again
that there was clinical reasons that would have contributed to the death. I think as well, we
didn't have the further information available to us around the events of [Child B] and also [Child
F] and I understand from previous witnesses there was also an event prior to death of [Child A].
These were not reported within the incident reporting system so the fuller scope and understanding
of what was happening in the unit wasn't there because they weren't in the Datix incident
reporting system, there was no one version of the truth, if you like, and therefore what -- what
the Serious Incident Panel were looking at was deaths in which the clinical teams were giving us
assurances that the clinical conditions of either mum or baby had more than likely contributed to.
And I think I do need to reinforce that it wasn't like the specialties were coming and saying: all
the care was excellent and this -- this is just ... they were very transparent about gaps in care
that had happened, they were very clear where there was elements of sub optimal care and what they
planned to do to remedy that in future, and so it did feel -- certainly my interpretation of it,
it did feel it was a very -- they had undertaken a thorough multi-disciplinary review of the
cases.
DE LA POER: But wasn't it your role at those meetings to take a step back, look at the big
picture and say: I think we have a problem here that we need to notify NHS England about?
MILLWARD: I didn't consider it in that way because --
DE LA POER: Was it your role?
MILLWARD: I would say it was my role and also everybody who was in attendance at the Serious
Incident Panel.
DE LA POER: Had it been escalated as a Serious Incident, would that have prompted a more detailed
investigation?
MILLWARD: It would have -- it would have looked at having a review of the neonatal unit's
practices so that position paper that was undertaken in July 2016, something along those lines
would have likely been done earlier and it would have likely have been done by somebody external
for the organisation rather than being pulled together in the rushed manner that it was. So we
would have been given more time to have been done more comprehensively.
DE LA POER: [Child I] died on 23 October?
MILLWARD: (Nods)
DE LA POER: In the intervening period there were two non-indictment baby deaths in September?
MILLWARD: Mm-hm.
DE LA POER: So by the time we reached [Child I], we have the initial cluster of three plus [Child
E] and two more in September?
MILLWARD: (Nods)
DE LA POER: And a seventh who was [Child I]. Was that another opportunity to take a step back and
report what is now eight deaths in the space of four or so months, five months?
MILLWARD: So the -- the two deaths that occurred in between I don't believe I was aware of those,
they weren't reported as incidents. I think it's a valid
position to say that at the point of [Child I], we are in the same situation, which is again that
process could have been considered reporting as a Serious Incident, considering a systems failures
approach, but as I say at that point, at that point in time, that wasn't the approach that was
being taken in the organisation for the Serious Incident Framework.
DE LA POER: What we do know about [Child I]'s death is on the very day of [Child I]'s death,
Eirian Powell sent an email in which she indicated that she had thought about going to speak
straight to Alison Kelly?
MILLWARD: Mm-hm.
DE LA POER: You are aware of the email that I am speaking about?
MILLWARD: I believe I have seen it in my bundle, so yes.
DE LA POER: And she mentions a member of your team, Debbie Peacock, in that email and then that
is on the Friday?
MILLWARD: (Nods)
DE LA POER: Then on the Monday, the 27th, Eirian Powell talks about having spoken at length to
Debbie Peacock. One more piece of information for you to be aware of is attached to the first
email, 23 October, was a chart with eight deaths, the seven that I have just listed to you plus
one that occurred in April, with Letby's name
marked in red against the latter seven?
MILLWARD: (Nods)
DE LA POER: So that's information that was coming from the neonatal unit to Ms Peacock.
MILLWARD: Mmm mm.
DE LA POER: Did Ms Peacock speak to you about the fact that she had received that email, had that
in-depth conversation and seen a chart with Letby's name in red on?
MILLWARD: I don't recall such a conversation, no.
DE LA POER: Just so that we are clear about what that answer means, sometimes people say that
because they think it might have happened but they just can't exclude the possibility one way or
the other. It is also a way of saying that definitely didn't happen because I would remember it.
Which are you saying?
MILLWARD: I think I would have remembered having -- if I had seen a chart that had said that
volume of deaths.
DE LA POER: Was it something that you would have expected Debbie Peacock to have told you
about?
MILLWARD: I would have expected Debbie to bring it to my attention. Obviously there was an
increased mortality rate, she would have been aware of that and obviously there was some -- some
concerns there. So yes, I would have expected her to bring that to my attention.
DE LA POER: That there was identified a common member of staff with seven out of the eight
deaths?
MILLWARD: (Nods)
DE LA POER: And it was being treated so seriously that there was talk of going over Ms Peacock's
boss, you, and jumping several tiers of management to go straight to the Director of Nursing?
MILLWARD: Yes.
DE LA POER: If you had been told that, would that have -- would you expect that you would have
reacted to that information?
MILLWARD: At that time, I would have absolutely questioned, you know, to understand again the
usual pattern of deaths that we do see in hospital in the neonatal unit. I would have understood
at that point this was a considerably higher number of deaths and understood the level of concern
against that. So yes, if I had seen that, I am confident I would have took action and that would
have been re-direct that through the Serious Incident Panel. The Serious Incident Panel was an
opportunity to have direct communications with our Executive team and because it happened weekly
it was generally scheduled on Monday at 3 o'clock, you know, you were able to raise concerns quite
freely there and I would have -- I am confident
I would have done that.
DE LA POER: Should Ms Peacock have raised what she had been told with the Women and Children's
Care Governance Board?
MILLWARD: Absolutely, I think that should have been raised. You know, it's difficult to say is it
Debbie's responsibility? Certainly she would have been aware, it would have been appropriate for
her to speak about it. From a responsibility perspective, if it was Ms Powell who had identified
it I would have expected her to formally raise it there.
DE LA POER: If one looks at it this way, do you agree that it was information that should have
been given at that stage to the Women and Children's Care Governance Board?
MILLWARD: Yes, yes.
DE LA POER: And if in Ms Peacock's position, you saw that neither Ms Powell nor Dr Brearey nor
anybody else was raising it, wouldn't there then be an obligation, given her role, to raise it
herself?
MILLWARD: Absolutely.
DE LA POER: We will move forward to the thematic review. We know that meeting took place on 8
February of 2016. This was at a time very shortly before the CQC visit when you have told us your
priority was that. Ms Peacock attended that meeting. Did you know at
the time that she was attending a meeting about all of the deaths that had occurred recently on
the neonatal unit?
MILLWARD: When I was preparing my statement I couldn't -- I could not recall but I can see from
some of the correspondence that she did inform me that this was -- it was taking place and I am
satisfied with that to know that she would have shared that with me. But I don't recall, I cannot
recall it. As you say, my priority at that time was very much focused on the CQC inspection.
DE LA POER: The Inquiry knows that the purpose of that meeting was to look at all of the deaths
that had occurred and try and identify if there were any common features?
MILLWARD: Mmm mm.
DE LA POER: By then there had been a very significant number, more than the position in October,
even. Did you have an understanding at the time of that meeting that there was really something
very wrong on the neonatal unit?
MILLWARD: No.
DE LA POER: Well, is that something that Ms Peacock should have told you?
MILLWARD: I think yes, but also the specialty should
have raised that and again through the governance meetings it should have been escalated and
discussed and obviously I would have become aware of that route as well.
DE LA POER: Well, I appreciate you may be limited in answering this question as you don't have a
recollection beyond the emails that you have seen. But might you not have expected yourself if you
were told by Debbie Peacock she was going to a meeting that was going to try and get to the bottom
of what the common factors might be in all of the deaths that had taken place on the neonatal unit
that you would say well, hang on a minute, I haven't seen anything about that at QSPEC, I haven't
seen anything about that from any of the governance structures in place. Wouldn't that be a
reaction you would expect from yourself?
MILLWARD: I believe that my recollection at that time the deaths that I was aware of were the
deaths that were reported within the Datix incident reporting system. They were the deaths that I
was aware of. I don't -- I can't recall being aware of any other deaths. So the deaths that I was
aware of because they had been reported as incidents had all come through the Serious Incident
Panel. My understanding at the time therefore was that this was a further review of those deaths
but with an additional lens by an external Consultant to essentially see if there was any
additional learning available.
DE LA POER: So was it your understanding based on what you had been told that such a review
wouldn't need to be on the radar of any of the governance committees?
MILLWARD: No it should -- it should absolutely be received in and should have been notified
definitely through the Women and Children's board that would have been the most appropriate
because obviously this affects mum and baby.
DE LA POER: So we will come back to what the report actually said, but we had the CQC visit on 16
February and following and you have told us already in some detail that you were overseeing the
preparation for that. One of the aspects was a slide deck, which I think you say in your statement
was a presentation given to the Executives?
MILLWARD: That's correct.
DE LA POER: And if we can just bring up INQ0007947, and in particular page 6 which you tell us in your statement is
a self assessment by different parts of the hospital. 0007947. Well, let's try page 6. I think
that's
the slideshow at the end there. Could we crop in please so we can see it more clearly. Thank you.
Third from the bottom, Service for Children and Young People. We'll just look at what this says
and then we will try and understand where it came from. Self rated "good" for safe, "good" for
effective, "outstanding" for caring, "outstanding" for responsive, "good" for well led and then
this: "National staffing standard issues for neonatal unit nursing staff are reflected locally.
Trust is fundraising for a new neonatal unit. Strong clinical engagement with safety and quality.
The Facing the Future standards are a challenge to staffing which the Trust is working to address.
Robust processes for incident review and learning." So that is what's recorded there. Who is the
author of that self assessment or which category of person would have had input into that self
assessment?
MILLWARD: Yes, so the head of -- the head of CQC visit each of the core services, which is the
areas listed down the side and underwent a number of different schemes at work. There was a self
assessment done where we had a colleague who was working with me supporting the specialties in
completing this self assessment, so this
has come from the specialty themselves, this will have come from Ms Powell and, as much as I
understand it, Dr Brearey as well. Then I have essentially lifted that feedback into this slide
deck.
DE LA POER: At the time that you gave this presentation to the Executives, did you have any
reason to think that anything said there was wrong?
MILLWARD: Well, it's their self assessment, it is their view, their perception of the services
that they deliver and that was the ask of the Execs.
DE LA POER: But if you had good and strong reason to think it was wrong, you would have an
opportunity to say something about it?
MILLWARD: Yes, and we did have conversation around the -- the discussions in the comment sections
against each of the seven key areas.
DE LA POER: So if we just look at that. At the time that you made this presentation to the
Executives, was there any part of what the self assessment said about the neonatal unit that you
thought was wrong?
MILLWARD: That's difficult for me to answer in the sense that again it is their self assessment.
My view, you know, "good" is a variety, there is a wealth of information that sits below each of
-- each of these descriptions.
Certainly within the "Comments" section, we were aware of the staffing issues, we saw those coming
through the incidents and we were aware of the fundraising efforts going on around the neonatal
unit. Their view was that there was strong engagement with safety and quality and I do think that
is true in the sense that they were engaged because they would have the conversations. The
difficulty was it didn't necessarily translate through to the incident reports but they were
having the conversations and they were -- my view of the teams, they were driven to give good
care. I can't comment upon the Facing the Future standards, I don't know the detail for that. And
I have already alluded to the process around incident review. The learning, and you will have seen
through the CQC feedback, the learning around incident reporting, staff reported that they did get
feedback on incident reporting and the different ways of receiving that, they knew how to report
incidents and they knew there was a process for that. So it's not incorrect for them to -- to list
these things. It's -- you know, obviously, you know, with hindsight you would look and you would
say something differently.
DE LA POER: Well, at the time, wasn't that exactly consistent with what Debbie Peacock was
feeding back to you because she wasn't telling you there was a problem in any of these areas?
MILLWARD: And nothing was coming through, so as I say we had an additional colleague who was
supporting each of the services with their preparation for CQC and there was nothing coming back
via that route either.
DE LA POER: So does it come to this then: at the time when you are presenting this to the
Executives this accorded with your own view of that unit?
MILLWARD: I think that's reasonable to say.
DE LA POER: So when we come later to July, when we see the criticisms coming through, in fact
that was a change of view on your part that as at January/February time, you thought those things
were true?
MILLWARD: Yes. However, I had raised prior to -- to January/February time concerns with Dr
Brearey's responsiveness in supporting incident investigation reports through the Serious Incident
Panel and I -- as I say we had had conversations around the way that incidents were being reported
and the use of the pick list.
DE LA POER: Thank you, we can take that down. Just one very short topic before perhaps I could
invite my Lady
to take a break and that is the collapse of [Child K]. You say in your witness statement that it
would have been appropriate for that to have been reported as an incident for further review. It
is just to understand it, are you there suggesting that Dr Jayaram should have spoken directly to
you about it or that he should have filled in a Datix? What are you meaning by it would have been
appropriate for this to have been reported as an incident?
MILLWARD: So the Datix reporting system, it should be completed by any staff member who has a
concern around the care that has happened and certainly if something unexpected or unintended has
-- has taken place. Doctors are the same as any other member of staff, there is an expectation
that if they see something, they have identified a problem, then they should be reporting that as
an incident. Obviously, at that point in time, we were very much aligned with the Serious Incident
-- well, the view was we were very much aligned with the Serious Incident Framework, so that if it
was a moderate harm or above incident, the process was that the person who identified the event
should pick up the phone and give us a call, so that we could support them but also we could see
if, you know, the patient and/or family would need support as well.
So my view would be that if Dr Jayaram had identified an area that gave him that level of cause of
concern then he should have completed that incident form himself.
MR DE LA POER: Thank you. My Lady, I am going to move to another topic, I wonder if that would be a convenient moment?
LADY JUSTICE THIRLWALL: Yes, certainly. We will take a break until 3.30 pm.
(3.16 pm) (A short break)
(3.29 pm)
LADY JUSTICE THIRLWALL: Just wait a minute. I had understood there was one or two missing, I didn't realise quite how many. Anyway, let's get started. Mr De La Poer.
MR DE LA POER: My Lady, thank you. Mrs Millward, on 2 March 2016 you were emailed along with
other people a report by Dr Brearey entitled "The Thematic Review of Neonatal Mortality".
MILLWARD: Yes.
DE LA POER: In summary, that document set out an analysis of each of the deaths but reached a
conclusion that no common cause was identified but that there was a theme of sudden and unexpected
deteriorations leading to death
and that the majority of deaths had occurred at night?
MILLWARD: Yes.
DE LA POER: It also appended appendix 1, which showed the nursing staff either allocated to or on
duty at the time of the deaths, that is the document we are talking about?
MILLWARD: Yes.
DE LA POER: From your point of view as Head of Risk and Patient Safety, that was a concerning
document, was it?
MILLWARD: Yes.
DE LA POER: A document requiring action?
MILLWARD: Yes, I don't recall when I first saw the document but I do -- I do recall seeing it.
What I took from that report was that that it identified a number of areas of sub optimal care
which some of which had already been addressed and others that were continuing to be addressed.
DE LA POER: But the report did not conclude, did it, that those areas of sub optimal care
provided an explanation for why so many babies were dying?
MILLWARD: It -- from -- my interpretation of the report was that it I pulled out I think four
maybe five themes overall which were areas of care. I can't recall more than that.
DE LA POER: Well, let's have a look INQ0010037. So this is the start of the report?
MILLWARD: (Nods)
DE LA POER: And we will need to move down, please, to page 7 [not found - try INQ0003217_07.pdf] to see the start of this was there was no common theme
identified in all the cases; so that is a red flag do you agree from your point of view?
MILLWARD: I -- I perceived that as there being that there were a number of different factors that
affected each of the children and that the action plan that was put in place was to tackle those
different facets. I didn't perceive no common theme identified in all the cases as being an area
of concern. The -- the cases identified different aspects of sub optimal care and they as far as I
could see had been responded to by the actions.
DE LA POER: Number 1, sudden deterioration. Some of the babies suddenly and unexpectedly
deteriorated and there was no clear cause for the deterioration/death identified at the
postmortem. So that is the first theme?
MILLWARD: Yes.
DE LA POER: That is identified. Was that not a cause of very considerable concern to you?
MILLWARD: I have tried to explain in my statement
I don't recall seeing this report in any significant detail. I do remember reading it and I
remember going specifically to the actions and -- and looking at the actions. I can see reading
this that yes, of course it would the sudden deterioration of course that would be an area of
concern.
DE LA POER: You see, Mrs Peacock, who had attended the meeting, was no longer available as at 2
March?
MILLWARD: That's correct.
DE LA POER: You had Mrs McMahon who was effectively splitting her time between responsibility
that Mrs Peacock had and other work that she had?
MILLWARD: Yes.
DE LA POER: You were placed on copy for this report?
MILLWARD: Yes.
DE LA POER: Did you not have an obligation to read it carefully?
MILLWARD: I must get over a hundred emails a day at that time. Many will be copied into. I think
there is a very unhealthy culture in the NHS to copy people into emails so you can say "I have
told so and so" when in actual fact you haven't and from what I can see of the email thread if
this is not a final report, this is a report that says I have pulled together our learning,
can you all read through, can you advise if you want to make any changes? So there wasn't an
instruction to me and certainly at that time when I am still, you know, focused upon the CQC, I
can't -- I cannot give you any recollection that says when I saw this report at the particular
time. I do remember seeing it, I remember focusing upon the actions and seeing that the actions
many had already been put in place and many and some were still being, being taken forward but I
can't give you any further recollections around this. I don't have them.
DE LA POER: My question wasn't about your recollections so just focus on my question. Did you
have an obligation to read it carefully?
MILLWARD: When you are copied into an email with no specific instruction that says "Mrs Millward,
can you please ..." then I think it would be unfair to say that I am obliged to open that email
and open an attachment and read it.
DE LA POER: Did you have an obligation to make sure that Mrs McMahon read it carefully?
MILLWARD: And in the same sense I believe that Mrs McMahon was also copied into that email. The
communications were within the paediatric team themselves for them to action it.
DE LA POER: So my question was: did you have an obligation to make sure that Mrs McMahon read it
carefully?
MILLWARD: No, I don't believe I did have an obligation to expect Mrs McMahon to open it to read
it, as we were both copied into an email that was for circulation to the paediatricians which
wasn't a final document because it hadn't received all of their agreement.
DE LA POER: Well, let's have a look at the email that sent it INQ0003114. So just can you help me with which part of the email that you
are referring to?
MILLWARD: Well, the whole of the email from Dr Brearey refers to as you see: I have brought
together the summaries of the care, thanks to ... it includes basically I have been asked to be
signed off at governance board. That is where the report is finalised. So from my perspective,
this isn't a finalised report anyway until it's gone through the governance board and has been
approved. But both Mrs McMahon and myself and Dr Davies has all been copied into, there is no
instruction there to myself or to Mrs McMahon.
DE LA POER: You are the manager of a department?
MILLWARD: Yes.
DE LA POER: Do you need to be instructed to do something before you do it?
MILLWARD: Well, with respect with over 100 emails in your inbox every day, a number of those being
copied into, just so that somebody can say that they have told you is not -- is not an effective
way of communicating. If Dr Brearey felt that he needed me to do something, he should have
stipulated that very clearly in the email. From what I can see he's already had a conversation
with Mr Harvey and that the report once it's been finalised by the group is to go to governance
board.
DE LA POER: Did you have an obligation to ensure that this went to the Women and Children's Care
Governance Board?
MILLWARD: My team were not responsible for the cycles of business or agendas at the Women and
Children's Care Governance Board. That sat with the chair who I believe was Mr McCormack.
DE LA POER: Would you -- Mr McCormack isn't on copy here. Would your department have any
obligation to make sure that a report like this was seen at the appropriate level in a timely
way?
MILLWARD: The appropriate that once that the report has been received that it comes back to the
Serious Incident Panel, which I believe it did do, but as for the governance board, as I say it is
not our responsibility to co-ordinate that meeting or the agenda. Obviously
once reported back from Serious Incident Panel, then there would be a prompt to get this through
governance board at that point.
DE LA POER: Well, what we know is that once Ms Lawrence saw this report, she immediately tabled
it at the Women and Children's Care Governance Board. That was her reaction to reading it?
MILLWARD: Yes.
DE LA POER: It doesn't appear that that was your reaction or Ms McMahon's reaction. Should you
have done that?
MILLWARD: So as I say my understanding is that this report came through to the Serious Incident
Panel was received back through the Serious Incident Panel and was discussed there. You know that
-- it is -- I'm sorry, but it's not my responsibility or that of Mrs McMahon to stipulate what is
on the agenda at these governance board meetings. That meeting was run by the specialty and by the
specialties and obviously when we have line of sight of something I would agree we would sit and
say has it come through but my understanding was that this was not -- it was not a finalised
paper.
DE LA POER: If we move forward in time to 17 March, INQ0003089, you are copied in part way through an email thread. So if we go
to the bottom. Forgive me, next
page up. We can see that Eirian Powell, not copying you in, on 17 March, says that she's seeking
to arrange a meeting. She draws attention to the high mortality and the commonality of a
particular nurse and a doctor was identified as a common theme however not as many as the nurse
and you come into it, as we can see that four days later, 21 March, Alison Kelly copies you in to
her reply. Do you see that?
MILLWARD: Yes, I do.
DE LA POER: So does it follow that on 21 March, you were aware of both the high mortality and the
fact that a particular nurse had been identified as a commonality?
MILLWARD: I can't recall this email at all and I refer to what I said before I have been copied
into an email I would have had over a hundred in a day.
LADY JUSTICE THIRLWALL: Don't worry about giving the same explanation, it is understood.
MILLWARD: Thank you, Ma'am.
LADY JUSTICE THIRLWALL: So you don't remember it?
MILLWARD: No, I don't recall this.
MR DE LA POER: So we will move forward to Annemarie Lawrence when she joined which was around
May, so a couple of months after that. She has told the
Inquiry that she read that report and that she looked through the appendix carefully and she got
out a highlighter and she highlighted Letby's name.
MILLWARD: Mmm mm.
DE LA POER: Was that an appropriate and conscientious thing for her to do?
MILLWARD: Absolutely.
DE LA POER: Was that her effectively doing her job well within the Risk and Patient Safety
Department?
MILLWARD: Yes.
DE LA POER: So having done her job well, she came to see you to tell you what she had found. She
has described you as being dismissive of her concerns?
MILLWARD: (Nods)
DE LA POER: Just tell us, please, in your own words how you say that conversation happened and I
will just break it down for you so we can be very focused. Did she have the report with her?
MILLWARD: I don't recall seeing Mrs Lawrence bring a report to me, no.
DE LA POER: Did she tell you that she had been through the thematic review report?
MILLWARD: This -- the questions you are asking, sir, it is difficult because Mrs Lawrence has a
different recollection or I have a different recollection from Mrs Lawrence and I think Mrs
Lawrence refers to two separate occasions whereas I can only recall the one. That occasion, Mrs
Lawrence had been over to the neonatal unit, there had been some discussion that she had, you
know, observed and then she came back to speak to me. She shared with me that there were staff on
the unit talking about a particular nurse and how this nurse had been present at all or some of
these deaths, I can't remember the exact wording. We went on to have a conversation. My
interpretation of the conversation we had was that this was a suggestion of a clinical competence
or clinical practice issue and I am sure you will ask: did I caution her? I cautioned her with
regards to repeating that. A clinical competence or clinical practice issue is a HR matter, it is
confidential. It would not be for me or any of my team to go around repeating that. What I also
understood from Mrs Lawrence's conversation was that the concerns had already been escalated up
through and there had been some conversations with Mrs Kelly already about this. That's my
recollection.
DE LA POER: So you understood that a member of staff was being discussed as being a common
feature of deaths which had occurred?
MILLWARD: That's correct.
DE LA POER: Was that not a matter that you should have made it your business to find out more
about?
MILLWARD: It came across as being a gossipy conversation and as I say, I understood that it had
already been escalated to the Executive team. I have reflected on what actions did I take
following that and I have had to refer back to my Facere Melius statement or transcript because I
can't actually recall, but in that Facere Melius transcript I speak about taking this back through
the Serious Incident Panel and having the conversation with -- with obviously the Executives who
would have been there and that I believe I would have done.
DE LA POER: You think that you did do that?
MILLWARD: I think I did. Looking at my Facere Melius statement, that would have been the action
that I would have took.
DE LA POER: What does that mean in practice in terms of who you spoke to?
MILLWARD: That would have been whichever the Executives was at that the next Serious Incident
Panel and it would have been an informal conversation along the lines of my team are hearing this,
is there anything that is needed from my team or is this an HR matter? And as there was
no further action that I was aware that I have taken I can only assume that that the conversation
I had ended with it being, you know, it's being looked at. The chair of the Serious Incident Panel
tended to be Mrs Kelly and it would have been an appropriate conversation to have with Mrs Kelly;
if it is an HR matter for a nurse she would be the professional lead to have that conversation
with.
DE LA POER: But that isn't something that you have any recollection of having done?
MILLWARD: No. I can only take that from my Facere Melius transcript.
DE LA POER: In terms of Ms Lawrence's recollection, she told the Inquiry about going through the
report, highlighting it, coming to you to speak to the -- to you about the product of her
analysis. So not gossip but analysis?
MILLWARD: (Nods)
DE LA POER: Do you have any recollection of having had such a conversation with Mrs Lawrence?
MILLWARD: No. I have shared with you my recollection.
DE LA POER: If a member of staff had done that, would that be a prompt for you to take immediate
action, if they say they had been through a document identified a commonality and thought that
action was required?
MILLWARD: Yes, and again the action -- my action would be the same, to take it through to the
Serious Incident Panel as an informal conversation again to say my staff have identified this. Is
there -- is there anything here that you want myself and my team to act upon?
DE LA POER: So if we move forward to the Serious Incident Review for [Child O] and [Child P],
just one small matter to ask you about. You report in your statement there was a discussion about
the duty of candour and that you said you were not prepared to undertake initial duty of candour
disclosure to the parents of [Child O] and [Child P]?
MILLWARD: [Child O] and [Child P]?
DE LA POER: Yes.
MILLWARD: Yes, that's correct.
DE LA POER: Why did you say that?
MILLWARD: Well, first and foremost the parents of [Child O] and P had lost not just one baby but
two babies, obviously their third child was in another hospital, a telephone call of that nature
would be out of the blue and given as well the timing of it that we had or the Executive team had
made the decision to downgrade the -- the unit I felt that it was not a conversation that should
come from me, it should come from somebody more senior in the organisation and I remember feeding
that back through at the next Serious Incident Panel and saying that I wasn't prepared to do that.
My recollection is that Mr Cross and Mrs Williams were there and it was to them that I shared
this.
DE LA POER: We are going to deal next with three meetings that you had with the Executives on 29
June, 6 July and 13 July. This is what you say in your witness statement: "The Executive team did
show concern around the increased mortality rate on the neonatal unit. However, my interpretation
of the discussions was that there was a belief that the increase in mortality on the neonatal unit
was due to persistently higher acuity, nurse staffing challenges and clinical leadership rather
than any deliberate act to cause harm."
MILLWARD: Yes.
DE LA POER: So that we are clear about it, in those meetings, did the Executives say anything
about what the doctors suspected might be happening?
MILLWARD: I don't recall for the first two. The only thing I can remember about the doctors would
be in the third meeting, that I think is the 13 June and that was, it was more in relation to the
doctors stating that they would not have Lucy back on the unit, rather than an explicit concern
being, being said.
DE LA POER: In terms of where the Executives appeared to be getting their belief from, due to
persistent higher acuity, nurse staffing challenges and clinical leadership, what was the source
of that belief so far as you could discern?
MILLWARD: Yes. So as you will know from the position paper there was a number of graphs and charts
that were produced by the senior data analyst. They had been developed so Mrs Kelly and I believe
Mr Harvey also had conversations with the senior data analysts around what graphs they wanted to
see what data they wanted to see and I believe that was, that was shared and obviously had some
conversations that I wasn't party to and I think that was -- that was the result, that they
interpreted it in that way.
DE LA POER: Well, we have already looked at it and we are going to look at it again in just a
moment you put those graphs, I think this is right to say, in that position paper and commented
upon them?
MILLWARD: I would say the comments are what came from the data analyst. I am not a data analyst,
my job was to pull together the different data sources and put them into a paper that could be
tabled for the Executives to use to make a decision about next steps. So the analysis or the
comments are very much
driven -- were very much driven by the data analyst or data analysts.
DE LA POER: Alongside that piece of work, and as I say we will come to it, we know that Dr Gibbs
and Nurse Anne Martyn were commissioned to do a piece of work which they say resulted in them
being concerned about six cases that they looked at?
MILLWARD: (Nods)
DE LA POER: They were effectively looking at transfers out as a proxy for non-fatal
collapses?
MILLWARD: Yes.
DE LA POER: We also know that Ms Williams conducted a staffing analysis and we will hear from Ms
Williams tomorrow but we know what she said in her witness statement what she saw according to her
witness statement made her so concerned she thought the police needed to be contacted. Were either
Dr Gibbs or Ms Williams' conclusions discussed at any of the meetings that you attended?
MILLWARD: I don't recall receiving anything back from Dr Gibbs and I think I have alluded in my
statement to say that I understand from his statement he did submit them to somebody. But they
didn't make their way to me and I think I have referenced in the position paper that there would
be a need to do a further case review
because there was a suggestion that there may be other cases that needed to be looked at but I
didn't have that information. With regards to the staffing review Ms Williams and Ms Fogarty did
as I understood it, that was largely discussed on 13 July in the final meeting. There was a
spreadsheet that we had pulled that we, myself and Mr Bennett who is one of my administrators, we
had pulled together which brought together a number of different datasets and data sources and
that also included the staffing. So that would have been on the screen in front of the Executives
for that final discussion.
DE LA POER: And was Ms Williams present at that meeting?
MILLWARD: Mrs Williams was present.
DE LA POER: Mrs Williams?
MILLWARD: Yes.
DE LA POER: Did Mrs Williams voice what her conclusions were based on her analysis at that
meeting?
MILLWARD: The only reference to the police that I can remember at that meeting was Mr Cross -- at
the end of the meeting Mr Cross stating that he would have an informal conversation with -- he had
worked with the police previously and he had said he would have an informal conversation around
the decision-making that had been made. I don't recall any other conversation that spoke about
discussing this with the police at that meeting.
DE LA POER: Now, in terms of the spreadsheet that you talked being put up on screen, we are not
going to put it up on screen --
MILLWARD: Of course.
DE LA POER: -- because in its current form it has not been ciphered but so that everybody knows
what we are talking about, I know you do, it is INQ0002836 [not found],so people can make a note
of that so that they understand, but you I know Mrs Millward do know which one we are talking
about?
MILLWARD: I do.
DE LA POER: I think your initial recollection that of the 13 deaths, seven of them had an
association with Letby. That was going into the Inquiry process.
MILLWARD: That's correct.
DE LA POER: But you have now had a chance to refresh your memory from the chart that you know was
shown at that meeting. Is this right: in relation to those 13 deaths, Letby was shown as being on
duty at the time of 10 of them and that --
MILLWARD: Yes.
DE LA POER: There were two more, so 12 of the 13, those
latter two being Letby on duty at an adjoining shift?
MILLWARD: I believe -- gosh, I am trying to think now. I believe that it was -- I think it was
nine and an additional one at an adjoining shift, I am afraid I can't be more --
DE LA POER: The data will speak for itself.
MILLWARD: Thank you.
DE LA POER: The point is your initial recollection of seven you realised was wrong?
MILLWARD: Yes.
DE LA POER: But actually it was closer than that to 13?
MILLWARD: Yes. But to reiterate, that information was on the board and that is just my
recollection since events.
DE LA POER: So let's have a look at the position paper that you have spoken about, INQ0001888. Now, what you say in your witness statement is that your
understanding at this time was that the increase in the mortality rate was being attributed to
persistently higher acuity, nurse staffing challenges and clinical leadership?
MILLWARD: Yes.
DE LA POER: We have heard that phrase before. In fact, let's have a look at page 1: "The purpose
of this paper is to provide the Executive team with key mortality data and supplementary
narrative to enable an assessment of the patient safety concerns identified by the neonatal
clinicians relating to an apparent increase in the number of neonatal deaths." So is that your
text?
MILLWARD: Yes.
DE LA POER: So the patient safety concerns, as the Inquiry understand it, are that Letby may be
deliberately harming babies, that's what our understanding of the neonatal clinician's concerns
were. Did you have a different understanding when you wrote that?
MILLWARD: I think my understanding when we wrote that was that there was a much higher number of
patient deaths than would normally be seen and that there was -- the Consultants were stating that
there was a commonality with this nurse. At no -- my interpretation of that as I have said before
was that this was potentially a clinical competency issue. At no point did any of the Consultants
say to me: I am concerned that Lucy Letby is deliberately harming these babies. That was never
voiced to me and I don't recall being in a room where that was ever voiced.
DE LA POER: And at any time did you approach any of them
to better understand their concerns?
MILLWARD: Well, I attended these Silver Command meetings, I did spend some time in the room with
Dr Gibbs and Anne Martyn. My specific role, as you know from my statement, was to pull together
all these different datasets to understand. It was to -- this was to not a comprehensive review in
the way it would have been if we had reported as a Serious Incident; it was time limited, we only
had a couple of weeks -- it was to be completed whilst Lucy was on leave -- to understand if there
was a link in some way. And, you know, from my perspective, I was looking at pulling all these
different data sources together. I didn't speak more widely with Dr Brearey other than asking for
some of the mortality and morbidity case reviews and of course making sure I had the correct paper
and the same with Eirian Powell. She supplied some information around the staffing issues and the
challenges around the BAPM standards.
DE LA POER: So let's have a look, please, at page 4. Forgive me, if we go over the page, please.
We can see the graphs here. Did you conduct any analysis of those graphs?
MILLWARD: No. As I say, the graphs, the datasets that's included in the graphs were taken by the
senior data analyst having had further conversations with Mrs Kelly and I believe Mr Harvey and
therefore the text to describe those graphs is taken from the data analyst. I have literally
pulled those views, pulled those comments and graphs into this report so it's in one place with
all the different datasets that Mrs Kelly asked for.
DE LA POER: So page 11, we will see what the findings are. We don't need to trouble with the
common cause variation because that is discounted and activity is said not to be alone, able to
account for the increase but maybe a contributory factor. The first of the factors that you
identify as you thought the Executives thought was responsible is acuity and if we just scroll
down, please, forgive me, my mistake, it's -- look down. We can see that the conclusion, we don't
need to look at the analysis: "An increased and sustained acuity level may be a contributory
factor." So at its highest, it may have contributed?
MILLWARD: (Nods)
DE LA POER: So it may not have done anything at all, but it may be responsible for part?
MILLWARD: Yes.
DE LA POER: As far as nurse staffing levels is a contributory factor, we saw the report the self
assessment given to the CQC and there is other evidence to suggest that the staffing level had
consistently been below the BAPM level and was in fact was not out of step with the rest of the
neonatal network?
MILLWARD: (Nods)
DE LA POER: Here no conclusion is in fact reached about whether it did or didn't contribute. It
simply points out that it doesn't meet the standard.
MILLWARD: Yes, because it's -- as you see, it says "findings". It is not a conclusion. It was
prepared so that the Executives could review the data that was made available and for them to
reach a conclusion and decision-making around next steps.
DE LA POER: So nothing in the report that you pulled together that would found such a conclusion
firmly; is that right?
MILLWARD: It was not for me -- I didn't feel it was for me to make a conclusion. The request was
to gather together all these different datasets and provide them to the Executives so that
together with the spreadsheet we have spoken around that they could then make a decision around
next steps for the neonatal unit. As I said, I am not a data analyst, so I -- it
would be unreasonable for me to make a conclusion from that. Instead what I have done is I have
pulled together the findings and they were based upon the conversations that had taken place.
DE LA POER: The third factor was clinical leadership.
MILLWARD: (Nods)
DE LA POER: What was the basis of that because that doesn't appear to be in this report?
MILLWARD: No, so the clinical -- so I think really around the way that they had engaged with the
incident reporting and that there was limited incident reporting, we have alluded to the neonatal
pick lists earlier, I won't repeat. So that was the -- that was the sense that certainly I had
from the conversation.
DE LA POER: The neonatal pick list is unlikely, isn't it, in fact impossible for that to be the
cause of an increase in --
MILLWARD: No. Yes.
DE LA POER: In mortality?
MILLWARD: But reporting rates and reporting a breadth of incidents seen past the actual harm
events and trying to identify incidents that caused no harm but are important for learning because
they identify for you where the care has potential for causing harm and they give you
the opportunity to learn before a patient has been harmed; that's really important. So it's the
scope of the incident reporting and the responsiveness. I have already alluded to Dr Brearey
having somewhat not been very responsive with other cases so that was my perception from the
conversation that took place.
DE LA POER: But I am not seeking to dispute what you say about it being important, it undoubtedly
is, that in itself is not going to be an explanation for the increase in mortality, is it?
MILLWARD: No, but it is an example around clinical leadership and how -- how the clinical
leadership team value quality and safety and are working together as a multi-disciplinary team.
DE LA POER: Turn briefly to look at the decision for Letby to join your department?
MILLWARD: Yes.
DE LA POER: We can probably cut through this. You have said in retrospect it would have been more
appropriate to deploy Letby to another service?
MILLWARD: Yes.
DE LA POER: In fact, does one need retrospect, was it not obviously a bad decision even at the
time?
MILLWARD: In the moment, in that room where there are multiple Executives, clearly not -- having
conversation and stating -- I am absolutely confident that Mrs Hodkinson said something along the
lines of "there's not enough", meaning not enough evidence "there is not enough to exclude her,
suspend her". At that moment in that room, where I can see the Executive team wanting an answer to
-- and wanting -- for me wanting to support them, bearing in mind that Mr Harvey had already
voiced that he had invited the Royal College in, this was going to be a very quick turnaround for
an Invited Review, you know, as such she had -- Lucy was brought into the Complaints Team, not
into the Risk and Patient Safety Leads and I think, you know, the team was far bigger than just
the Risk and Patient Safety Team. She was in a different room, she was in a smaller room with my
administrative staff and it was always, always expected to be a temporary thing for around eight
weeks. That was my understanding from the conversation. You know, I believe I asked because I felt
I wanted to help, if I hadn't been in the room I probably wouldn't have offered, but I felt I
wanted to help, I also felt that, you know, given the fact that somebody was being moved with --
with no real explanation I felt that she did warrant to have some support in place and I thought
that would be helpful to have her in an area where she could be observed and -- and, you know,
supported in that sense. You know, events took over, the Royal College review as you know took
much longer and then we moved into this grievance, which at that point it was -- well, to be
honest, at that point I really should have said "I think we need to move her now" because there
was no end in sight at that point.
DE LA POER: Now, Ms Lawrence has told us that she overheard conversations in the Risk Department
to the effect that Letby was being treated as a scapegoat and she's identified you as one of the
people who were associated with these conversations. Firstly, did you participate in such
conversations?
MILLWARD: I don't recall. I have obviously read Mrs Lawrence's transcript, I don't recall that at
all.
DE LA POER: Did you think that Letby was a scapegoat?
MILLWARD: Did I think -- no, there wasn't sufficient information for me to make that comment. I
generally thought that the unit was being run poorly, that was my view. I didn't think she was
necessarily being made a scapegoat. I was awaiting for the Invited Review to say what else is
happening here.
DE LA POER: In an interview -- or a discussion, "interview" is the wrong word. In a discussion
with Cheshire Police in 2018, I believe it was?
MILLWARD: 2019.
DE LA POER: 19, thank you, there is a record made by a police officer that you said that you felt
it was unjust that Letby was being investigated as a person of possible interest given the
evidence presented by the Consultants. Was that something that you said to the police?
MILLWARD: I don't believe so, no. I have asked for my statement, my statement is not available.
Stating that something is unjust is not words that I would use.
LADY JUSTICE THIRLWALL: Can I just ask: what word might you use?
MILLWARD: To be honest Ma'am, I don't know, my Lady. The conversation that I had with the police
was -- was very, very short. It was a matter of minutes. I was essentially told I had nothing more
to offer them. I don't even remember having a conversation around my view of -- of Lucy at all.
MR DE LA POER: So I am going to turn now to your section of your statement headed "Reflections"
and what you say is -- and you can turn it up if you want, it is paragraph 263.
MILLWARD: Thank you.
DE LA POER: "By working around the governance arrangements in place and not utilising them for
the escalation of their concerns, the bundle of documents provided to me by the Inquiry suggests
that the Consultant paediatricians' opinion of Letby was not thought to be valid." So you
associate, if I have understood this correctly, the fact that the Consultants didn't use the
governance process as being a reason why they were effectively not taken sufficiently
seriously?
MILLWARD: Absolutely. So if -- so the governance assurance and reporting arrangements I have
spoken about previously, however I would have expected if you were that concerned about a -- a
staff member, you -- yes, escalate it to the Executive if you feel that that's significant enough.
However, it also needs to go through what we call line of sight reporting. There should be
something that comes from the specialty up through the division and the division therefore report
on it as QSPEC or Corporate Directors Group. If you are that concerned that something untoward is
going on, on the unit, then utilise the incident reporting system. So again there were these
sudden collapses that occurred. They were not reported. So again that sits outside the governance
arrangements that they were given, you know, that are in place for you to use to raise your
concerns and to allow to be reported. The same with the Risk Register.
DE LA POER: So just help us to understand. What exactly were you expecting the Consultants to
do?
MILLWARD: I would expect that they attend the Division of Urgent Care Governance Group and
formally feed into there their concerns around the increased mortality rate so then when Mrs
Townsend or one of the divisional management team went up to QSPEC she could raise those issues on
their behalf so that there was line of sight reporting from the specialty through division up to
the Executive level and their voice -- as I have referred to earlier that their voice was
therefore heard. They didn't do that. Because they bypassed all of that system and went directly
to have informal conversations with the Executive team through email, there's no -- there's no
traceability, there is no transparency, there is no critical challenge that you get from having
those conversations in a wider group meeting and that is the purpose of having the governance
boards at divisional level and then up to the QSPEC and Corporate Directors Group.
DE LA POER: What level of responsibility, if any, your department had to ensure that good
governance was observed bearing in mind what you know -- what you knew at the time, what Ms
Peacock knew?
MILLWARD: Absolutely. So some of that is around ensuring that our voice, the incidents are
accurately being reported, you are right about bringing the report through in a timely manner;
that is absolutely right. I think that the difficulty with saying should the thematic review have
gone to QSPEC? Absolutely. I think something along the lines, maybe an executive summary of, of
the thematic review could have gone to QSPEC because obviously it had patient information and you
wouldn't send that to a committee in that way. And -- and I fully accept you know, yes, I should
have, I should have done something around that. I didn't and I can't explain why I didn't other
than I suspect it's because things happened very quickly, I appreciate, for the Families, they
won't feel that way but from when the thematic review was received at the Serious Incident Panel
by the time it then went through to the governance board we are I believe in the middle of May by
then and then things have moved quite quickly with the sad deaths of the -- the children and then
the position paper and so on.
MR DE LA POER: My Lady, those are all the questions that I have, Ms Millward. There is permission and I see Mr Baker coming to his feet.
LADY JUSTICE THIRLWALL: Thank you, Mr De La Poer. Mr Baker.
MR BAKER: Mrs Millward.
MILLWARD: Good afternoon.
BAKER: I ask questions on behalf of a number of the Families including specifically here the
Families of the triplets O, P and R. I just want to pick you up on something that you said and I
just want to be sure that I understood it properly and it's what you meant?
MILLWARD: Of course.
BAKER: You were asked a question about knowledge. What you understood about the Consultants'
complaints. What you said was: "... my interpretation of that as I have said before ... this was
potentially a clinical competency issue. At no point did any of the Consultants say to me: I am
concerned that Lucy Letby is deliberately harming these babies. That was never voiced to me and I
don't recall being in a room where that was ever voiced."
MILLWARD: Yes.
BAKER: Are you saying that at no point were you aware that the Consultants were suggesting that
Lucy Letby deliberately harmed the children?
MILLWARD: I would say that what was being -- what was being said to me was that a staff member was
present at so many of these deaths and there was concerns about that. Nobody at any point said to
me that that was more than a concern around clinical practice.
BAKER: Competency?
MILLWARD: Yes.
BAKER: So what you said there in response to a question from Mr De La Poer was accurate then; is
that right?
MILLWARD: Yes.
BAKER: So at no point at all was it communicated to you that there were concerns by anybody that
this might be a criminal act?
MILLWARD: The only conversation that I can recall if we are talking -- you know, is I have alluded
to where we were in -- I was in a meeting with the Executives on the 13 July, when Mr Cross spoke
around talking to the police and with the sense of: is there anything further we need to do here?
Should we be considering anything further? That is the only conversation I can recall that would
have suggested anything different.
BAKER: Didn't that statement by Mr Cross strike you as somewhat incongruous if nobody was talking
about a criminal act?
MILLWARD: I don't really remember, sir. I -- I remember being in a room full of Executives. I --
despite my job title in all reality I was actually quite a junior member of staff as a head of
department, you know, to be in a room with seven or eight Executives, you know, it's -- it can be
quite daunting. You know, I am not -- I don't -- I don't know is ...
BAKER: Okay, memories memory can often --
MILLWARD: Yes.
BAKER: -- play tricks on us --
MILLWARD: Yes.
BAKER: -- but you made a definite statement. I want to be clear: is it possible that people were
talking about criminal acts and that is why Stephen Cross was talking about calling the police and
you don't remember?
MILLWARD: It is possible I don't remember anybody speaking to me in that way.
BAKER: Yes, but if Mr Cross was talking about
speaking with a friend of his in the police, then it sounds likely, doesn't it, that criminality
was being discussed?
MILLWARD: Well, it sounds like should we be doing a different investigation to having the Royal
College come in and do a clinical investigation, yes.
BAKER: Yes, but you don't call the police for competency issues, do you?
MILLWARD: No, absolutely.
BAKER: Okay. I want to ask you some questions about candour and you gave some evidence before
about that. Whose responsibility was it to ensure compliance with the duty of candour?
MILLWARD: So duty of candour is -- is difficult. There are two types of duty of candour, so there
is professional duty of candour, which is the responsibility of the clinical teams and -- and
that's a long-standing well-established process.
BAKER: But the organisation had a duty?
MILLWARD: That's a statutory duty of candour. So statutory duty of candour on a day-to-day basis,
I would oversee those conversations. In this particular case, as I have spoken about, I passed
that responsibility back to the Executive teams. I didn't feel it was appropriate, that I was an
appropriate level in the organisation to have that conversation.
BAKER: For issues of competency, it would be perfectly normal for you to have a duty of candour
exercise yourself, wouldn't it?
MILLWARD: I'm not sure what you mean by that.
BAKER: Well, if I put it this way, you passed it on to the managers -- the Executives, not the
managers, the Executives?
MILLWARD: Yes.
BAKER: Because of the severity of the allegations that were being made, that is why you asked
more senior people to deal with it?
MILLWARD: I asked because there were two babies that had passed, I understood that the father of
the children had become particularly distressed. I also understood that the unit was being
downgraded there may be some questions about that that I did not feel I was in a position to
answer. Therefore I passed it back for those reasons.
BAKER: You see, you had responsibility for ensuring compliance with the duty of candour?
MILLWARD: Yes.
BAKER: Organisational compliance. That doesn't require you to have a conversation yourself with
--
MILLWARD: No.
BAKER: -- a family member but it does ensure but it does require you to ensure that that duty is
fulfilled, doesn't it?
MILLWARD: I would agree with that.
BAKER: What steps did you take to ensure that the duty was fulfilled?
MILLWARD: I honestly cannot remember. I have really tried to reflect and to think about what has
happened. There would be or there should be some documentation within the Datix incident report
regarding duty of candour conversations.
BAKER: Yes.
MILLWARD: But outside of that, I'm afraid I can't recall.
BAKER: Well, let me assist you then. If we could go to INQ0001347 [not found - try INQ0008615], please. I am going to remain specifically on the Datix for
[Child O]. Now, we can see reported date 29 June 2016, so it's six days or so after [Child O]
died. We have location coding, risk grading, reference to risk grading is actual harm/death caused
by the incident, can you see that?
MILLWARD: Yes.
BAKER: If we go on, please, to page 2. So wave reference here to employees involved. Lucy
Letby.
MILLWARD: Yes.
BAKER: Now, obviously there were lots of individuals involved in the care provided to [Child O].
But only Lucy Letby is being named here, isn't she?
MILLWARD: Yes.
BAKER: And we also have a reference further down under "Linked records to Child P"?
MILLWARD: (Nods)
BAKER: And a reference there to death caused by the incident. Now, looking at that, it's clear,
isn't it, that this Datix is referring to an incident causing child or potentially causing [Child
O]'s death, potentially causing [Child P]'s death and linking Lucy Letby to that as the only
employee referred to?
MILLWARD: Yes by -- and that's the incident reporter who has submitted that information.
BAKER: Yes. But that's -- if I put it this way, isn't that reflecting concerns that Lucy Letby
deliberately or unintentionally was the cause of death in this case?
MILLWARD: You would have to ask Mrs Powell why she only gave Lucy's detail at that point. As you
quite rightly say, there will have been other staff involved.
BAKER: If we go then, please, to page 7. This is a duty of candour assessment. Now, these forms
are created for almost all of the children I represent and they are all the same, the duty of
candour assessment is blank?
MILLWARD: Okay.
BAKER: Why is it blank?
MILLWARD: I don't know. I don't know why it's blank.
BAKER: So if the Trust were complying with its duty of candour responsibilities, that should be
filled in, shouldn't it?
MILLWARD: Yes.
BAKER: If you could go please to the final page of that document. Again to confirm, your name
appears under "Notifications" --
MILLWARD: Yes.
BAKER: -- as it does in many of these forms. Is it part of your responsibility to ensure the duty
of candour is complied with?
MILLWARD: Well, yes, in my role, yes. The notifications list there is -- is the notifications when
a incident of a given level of harm goes to just a core number of people so that they have -- they
are aware it's been received. That's what that particular section refers to.
BAKER: You see, one of the criticisms made by Mr Semple in his email that you were taken to
earlier was about no feedback on Datix reports?
MILLWARD: Yes.
BAKER: Evidently nobody fed back in any of these cases that duty of candour was being omitted
entirely from the Datix forms, nobody was filling them in. Can you explain why that was --
MILLWARD: The duty of candour section would be completed by my team, not by the local team and the
duty of candour section is not feedback on incident reports, feedback on incident reports is
around learning from events that have happened from themes, from -- in a specific individual
instance.
BAKER: But in this case, duty of candour isn't about learning, it's about notifying or informing
family members if there is a suspicion --
MILLWARD: Yes.
BAKER: -- that something serious may have happened?
MILLWARD: Yes, that is what -- that is what I am saying, you are referring to Mr Semple's email
around lack of feedback around incidents. But the duty of candour section is that there's not
feedback around incidents.
BAKER: Well, let me offer an additional criticism then to Mr Semple. In the case of [Child O] at
the very
least, by July 2016, there are very serious conversations going on about potential harm being
caused to [Child O] --
MILLWARD: (Nods)
BAKER: -- by an individual.
MILLWARD: (Nods)
BAKER: The families should have been informed at the outset about that, shouldn't they?
MILLWARD: Yes, they should.
BAKER: Can I suggest a reason? Reputation. Because if word got out to family members that there
was concern amongst hospital staff that a member of staff was harming patients, that would have
been released to the world, wouldn't it, if families had been told about that?
MILLWARD: Absolutely, but to reassure you at no point did I ever hear a conversation that spoke
around prioritising reputation over the families or the learning or completing a Serious Incident
investigation. That was never said in -- I was never present at any such conversations.
BAKER: You see, I suggest that reputation and reputational harm was seen as being the primary
risk to the Trust out of this incident; that's correct, isn't it?
MILLWARD: I can't comment on that. That would be a decision for the Executives.
MR BAKER: Thank you, my Lady, I have no more questions.
LADY JUSTICE THIRLWALL: Thank you. Just one or two -- I am so sorry, are you about to ask some questions?
MS WOODS: Yes, my Lady, would you like me to wait?
LADY JUSTICE THIRLWALL: No, not at all, I will go at the end.
LADY JUSTICE THIRLWALL: There is no rush.
MS WOODS: Thank you. Ms Millward, my name is Leanne Woods. I am asking questions on behalf of
another group of Families which includes [Child A]. My questions are going to focus on [Child A]
who, just to help you, was murdered by Letby on 8 June 2015 and his Inquest was 16 months later on
10 October 2016.
MILLWARD: Okay.
WOODS: Can I ask first about your role in providing information for Inquest. So I can probably
short-circuit it Sarah Harper-Lea, who was the Head of Legal Services at the Trust, says that the
Head of Risk and Patient Safety was responsible for providing copies of any incident reports and
Trust reviews for onward
disclosure to the Coroner; do you agree with that?
MILLWARD: Yes.
WOODS: Did you have any other role in the preparation for Inquests?
MILLWARD: No.
WOODS: You attended the SI Panel meetings which I believe were held on a weekly basis; is that
right?
MILLWARD: That's correct.
WOODS: Other Executives attended too?
MILLWARD: Yes.
WOODS: While they were called SI Panel meetings, is it right that it wasn't just SIs and
potential SIs that were discussed, it was also cases that were involved in legal processes?
MILLWARD: That's correct. So we triangulated the information so that included both the incidents
that were for decision-making for serious investigation or not around new complaints or complaints
that were complex and maybe needed some support and as you say, any new legal claims or closure of
legal claims as well as any new Inquest notifications or feedback from Inquests as well.
WOODS: So if there was an ongoing Coronial process, issues relevant to that may be discussed at
the SI Panel meeting?
MILLWARD: Yes.
WOODS: Okay. Do you recall that from the end of January 2016 right through to [Child A]'s Inquest
in October 2016, the Coroner was repeatedly suggesting to the hospital that an SI should be done
in relation to [Child A]?
MILLWARD: I didn't recall until I saw some email correspondence in the bundle that was provided to
me this morning. So that is -- was not something I could automatically recall prior to that.
WOODS: But you are aware of that now?
MILLWARD: I have seen those emails, yes.
WOODS: I am just going to bring up a couple of documents on that, please. Could we have INQ0102364 and it is page 53, please. Thank you. So you will see at the
bottom of this page there is an email from Sarah Harper-Lea who the Head of Legal Services, to
Debbie Peacock and you as well. Do you see that?
MILLWARD: Yes -- sorry, yes, I was reading.
WOODS: 8 February 2016. I think you have seen this email before?
MILLWARD: Yes, I saw this this morning, yes.
WOODS: Okay. The bit I want to ask you about is Sarah Harper-Lea is saying that the Coroner has
asked
the Trust to consider an SI due to complications in the long line and catheter insertion?
MILLWARD: Yes.
WOODS: Okay and the reply from Debbie Peacock is above which says: "Dear Sarah, "Unfortunately I
did not see your email prior to the thematic review yesterday. I have discussed this with Ruth
this morning and she has advised that a decision regarding the next steps will be taken once we
receive the thematic review report from Dr Brearey." So you were aware the Coroner was suggesting
an SI agree?
MILLWARD: Yes, from this, yes.
WOODS: You were also aware that the thematic review was being done and indeed a meeting had taken
place?
MILLWARD: That's correct.
WOODS: What's being said and with discussion with you was that you were going to wait for that
thematic review report and then decide what should be done about an SI for [Child A]; is that
right?
MILLWARD: Yes, to take the thematic review back to the SI Panel for a decision to be made there.
WOODS: Would you agree that in order to make that decision or be part of that decision-making,
you would need to read the thematic review?
MILLWARD: Yes. It was presented to the SI Panel.
WOODS: You would need to read the detail of it?
MILLWARD: Yes, at that point, yes.
WOODS: So just to be fair to you, so you gave oral evidence today about reading the thematic
review and what you were saying was that you didn't recall reading it in detail you were talking
about the somewhat injudicious use of copying people into emails but you agree that to make a
decision about [Child A] and what to do next, you were under an obligation to read the thematic
review?
MILLWARD: Yes, and there is another document, an email from Mr Harper-Lea which tells you that it
went to the Serious Incident Panel which is where the decision would have been discussed with the
Executives around whether or not the case was to go to Serious Incident or not.
WOODS: Okay. Put that to the side one second?
MILLWARD: Okay.
WOODS: I am asking you about you reading the thematic review?
MILLWARD: Yes, yes.
WOODS: And did you read it?
MILLWARD: When it came to the Serious Incident Panel I am confident that I would have participated
in the
conversation there and therefore I would have had to have read it at the time, yes.
WOODS: Just focusing on what it said about [Child A]. I can bring it up if we need to but what it
said about [Child A] was that it was considered unlikely that the long line insertion had
contributed to his death, do you recall that?
MILLWARD: I -- you would have to bring it up, I'm sorry.
WOODS: But do you recall that well, ultimately [Child A]'s death remained unexpected and
unexplained?
MILLWARD: My -- I can only take you back through what I can remember and what I remember is the
information from the specialty that was clearly saying that there was clinical conditions, that
the child had clinical conditions that they believed had largely contributed to the death. I don't
remember the detail of the thematic review, I'm sorry.
LADY JUSTICE THIRLWALL: Do you want to bring it up?
MS WOODS: Yes, I believe it's -- bear with me -- INQ0010037, I think. I hope. Yes, and I think [Child A] is on page 3, I
believe. Okay. So if we start at the bottom of that page or that box in relation to [Child A] it
says:
"Agreement today that line related complication very unlikely to have caused arrest." Do you see
that?
MILLWARD: I do.
WOODS: Then it says: "No PM evidence of line or UVC related to complication." Do you see
that?
MILLWARD: I do.
WOODS: Let me approach it in a different way. Were you aware that the final postmortem report was
received by the Trust just before Christmas 2015?
MILLWARD: I -- I can't recall. I am not -- I am not that close to the -- you know, the pathology
reports as the legal team would be.
WOODS: Okay. Were you aware that it -- well, it was taken to the SI Panel meeting that the
conclusion of that postmortem was that [Child A]'s death was unascertained. Do you recall
that?
MILLWARD: I don't recall that. I believe I have seen some emails and correspondence this morning,
but I don't actually recall that itself.
WOODS: Okay. In any event, if I go then, please, to April 2026, please, so could we bring up the
document INQ0102364 and
it is page 89, please. Thank you. So again another email from Sarah Harper-Lea, this time to you,
Ms Millward, you know Debbie Peacock had left at this stage?
MILLWARD: (Nods)
WOODS: It's saying -- it relates to [Child A], submission deadline to HM Coroner: "We have today
submitted the majority of the witness reports required by the Coroner for this Inquest and we now
need to disclose the relevant investigation reports and action plan." Then the next paragraph:
"Can you have a review of this matter as soon as possible? Last time we talked this one through
you were going to have a look at the OSR report ..." Just pausing there, that is the obstetrics
secondary review, is it?
MILLWARD: Yes.
WOODS: "... and NNU review and chase up the action plan and consider duty of candour." Is the NNU
review the thematic review?
MILLWARD: I can -- I would suggest it is but I don't recall these events, so it's very difficult
for me to say but I would think that is the thematic review.
WOODS: What else could it be?
MILLWARD: Well, it could be the Mortality Morbidity Review for the individual patients.
WOODS: Given that the email we previously looked at in February 2016 talks about next steps being
dependent on the thematic review --
MILLWARD: Yes.
WOODS: -- it's likely that it is the thematic review, isn't it?
MILLWARD: It is, it is just the fact that it's referring to the OSR report which is an obstetric
-- essentially an obstetric mortality review essentially in this case. So that's what's confusing
here, but it's very difficult, I don't have any recollection.
WOODS: Okay. We are two and a half months on from that email in February 2016. What had you done
in relation to reports and reviews for [Child A]?
MILLWARD: My understanding here is that the case, the thematic review had already gone back, gone
to Serious Incident Panel. There is an -- I saw in my bundle, I was sent this morning an
additional email that showed that Mrs Harper-Lea had tabled it for discussion at the Serious
Incident Panel. Bearing in mind that no Serious Incident Report was submitted on STEIS I can only
conclude that the conversation that took place at the Serious Incident
Panel was that there was not going to be a further Serious Incident investigation into [Child I].
WOODS: Okay. Just look at this email if we could. So what Ms Harper-Lea is saying and she's the
one who prepares the legal reports for the SI panels, isn't she?
MILLWARD: She does.
WOODS: We now need to disclose the relevant investigation reports and action plan so that's --
that's your job to try to assist with?
MILLWARD: If it is a Serious Incident, yes. But this case did not go to a Serious Incident
investigation.
WOODS: It's saying can you have a review of this matter? Last time we talked this one through you
were going to have a look at the OSR report, the NNU review and chase up the action plan. So what
had you done?
MILLWARD: So as I have just said my understanding from the papers I have seen this morning is that
the thematic review went to the Serious Incident Panel, that at that point because there was no
Serious Incident report then completed on STEIS the decision there would have been made not to
progress as a Serious Incident. Therefore it wouldn't be for me to progress any further
investigation. So I can't answer in regards to the points that Sarah's written because I don't
have
that information available to me.
WOODS: Should I take from that that you don't think you had done anything?
MILLWARD: You can take from that that no Serious Incident investigation was -- was agreed at the
panel. It was not reported on STEIS, therefore statutory duty of candour which is, you are
correct, is my obligation would not have been required and it would sit under professional duty of
candour which would require Sarah to go back and liaise with the clinical teams.
WOODS: So when it says here an unconsidered duty of candour, what do you understand by that?
MILLWARD: So that will have been a conversation around the child's care with -- with the clinical
teams. I would only be involved if it was a statutory duty of candour and at that time duty of
candour was quite a mechanical process, it is not as fluid as we would see today so the statutory
duty of candour only came in for incidents that were reported as a Serious Incident, so my
assumption from that is there must have been some concerns raised by the family of [Child A] and
Sarah's feeling was that there should be some conversation with the family ahead of the Inquest.
But I am surmising, I do not know.
WOODS: So just so I am clear, are you saying that the
statutory duty of candour only applied if there was an SI --
MILLWARD: So.
WOODS: -- incident?
MILLWARD: Yes, so if you look at -- so statutory duty of candour applies when it is a notifiable
safety incident, so that applies whether it is moderate harm or above and so they would be cases
where we would review them as a Serious Incident. Lower level harms would be classed as a
professional duty of candour, a normal in a situation where something has happened and a clinician
would speak with the patient or the family about their care. So at that time, unless a case was
being taken through a patient's safety incident review, so predominantly as an SI, the statutory
duty of candour the bit that I am responsible for or was responsible for I would not be involved
in that duty of candour conversation.
WOODS: Would you agree that the way this email is written from Ms Harper-Lea suggests that a
decision had not been taken at this point that an SI would not be done, that it was still a
decision that was pending?
MILLWARD: I -- I don't actually know what her email is saying because if a decision had been made
that we were going ahead with an SI it would have been reported on STEIS and it would have been
done after the Serious Incident Panel. This -- and there would have been a decision made at that
point. This -- I don't know. I don't know.
WOODS: Okay. So if a decision for an SI is taken, a positive decision --
MILLWARD: Yes.
WOODS: -- that can lead to a certain steps?
MILLWARD: Yes.
WOODS: If a decision that an SI is not going to be done, well, that's also a positive decision,
isn't it?
MILLWARD: Yes.
WOODS: But there's that grey area in the middle where it is still undecided as to whether an SI
is going to be done. Is that what's going on here?
MILLWARD: That would be very unlikely because the sort of responsibility of the Serious Incident
Panel is to make that decision, so we wouldn't have cases just on a list waiting for a decision to
be made. So you know the outcome of the Serious Incident Panel is to make a decision one way or
the other.
WOODS: You have read the witness statement of Sarah Harper-Lea, have you?
MILLWARD: Yes, I have a few pages that I have seen.
WOODS: So in her statement she says that after this email she had to escalate the delay in
decision-making and action from you to Mr Cross, who arranged a meeting with you to discuss it. Do
you recall that meeting?
MILLWARD: I don't recall that. I have seen the emails.
WOODS: No recollection whatsoever?
MILLWARD: I just don't -- I have -- I am really sorry for the Family of [Child A] because I -- I
just don't have any recollection of this at all which says to me that the decision wasn't being
made or wasn't made around a Serious Incident because had that decision been made one way or
another, I would have known because as you say it's a positive outcome either which way.
WOODS: Okay. Let's jump on, please, to events at the end of June 2016 and the beginning of July.
Now, you have already been asked lots of questions about the chronology but can I ask you about an
NNU action planning meeting on 30 June. It is at INQ0014125. Okay. So you see at the top the nature of the meeting. You will
see that you attended --
MILLWARD: Yes.
WOODS: -- Ms Millward. Okay. You will see that there is a series of quite generalised actions to
be taken including, about halfway down the page, "Confirm off-duty for LL"; do you see
that that?
MILLWARD: Yes.
WOODS: Okay. If we could look -- I think it's on the next page, please, yes. So again about
halfway down the page it's got "[Child A] review Inquest prep" and it's allocated to you and is SC
Mr Cross?
MILLWARD: That would be Mr Cross.
WOODS: Okay. Then it says: "Case for the Coroner, date to be determined soon SB will be a
witness. SE chasing report from SB to support this case." Do you recall why in the context of this
action planning meeting, why you were being asked to review the Inquest prep for [Child A]?
MILLWARD: I have no idea. I mean, again it's referring to chasing a report. But as to what report
that is, it doesn't state. I don't know.
WOODS: Do you recall what you did to review the Inquest preparation?
MILLWARD: There was a meeting, wasn't there, put in, Sarah had put a meeting in. I don't know if
that coincides with timewise.
WOODS: Was the Inquest preparation for [Child A]'s Inquest being discussed in the context of this
meeting because it was a recognised it was recognised that there
was a concern about [Child A]'s death?
MILLWARD: I honestly don't know. I can't, I can't remember. I barely remember this meeting. I
remember attending a meeting in which there was conversations around -- particularly around
communication line being set up but I don't remember much more than that.
WOODS: Okay. You have told us about the decision not to do an SI into [Child A], the decision
made in July 2015?
MILLWARD: Yes.
WOODS: Things had significantly moved on by June/July 2016, hadn't they?
MILLWARD: Yes.
WOODS: So there was postmortem examination that you have no explanation for [Child A]'s death.
The Coroner had been asking for an SI report. There had been a thematic review which didn't
identify a clear explanation for [Child A]'s death. Mother A had raised concerns which I think you
are aware of. There were further deaths including [Child O] which we know did lead to an SI
investigation?
MILLWARD: (Nods)
WOODS: And there were very serious concerns about the involvement of a nurse whether that is a
question of competency or something else, ie police getting involved. At this point in time, an SI
investigation should have been opened into [Child A]'s death, do you agree?
MILLWARD: I don't have -- you are providing a lot of information there that I don't have in front
of me to apply the Serious Incident Framework to -- to say that. Certainly at that time, you know,
the concern of the organisation was to report a Serious Incident around the overall increase in --
in neonatal deaths with the understanding as I had at that time that each of the children's cases
would be reviewed individually. As we know, the Royal College review didn't actually do that and
there was a subsequent case review done. So it's difficult for me, without this extra information
you are providing in front of me, to apply the framework.
WOODS: What extra information am I providing --
MILLWARD: Well, you are providing me this information, I don't have it to hand to be able to
review it myself and to determine how much of that applies to the framework and in any which case
it's not my decision. The decision is made at the SI Panel with the Executive Team with the
conversation and discussion that takes place.
WOODS: Did you ever suggest to the SI Panel: actually
we need to look again at [Child A]'s death, we need to have an SI investigation?
MILLWARD: No. Because as I said, we had invited, there was a Serious Incident Report submitted in
relation to the Royal College review. At that time, it was my understanding certainly that each of
the children affected, their case would have an individual review by the Royal College. As I said,
we subsequently found out that that wasn't the case and I understood that there was another
Consultant who was going to take forward and review each of those cases.
WOODS: Could we please bring up INQ0008587. Okay, so just the first page so you see what this document is.
So it is described as an SUI panel so that is Serious Untowards Incident, but it is the same as
the SI --
MILLWARD: SI Panel yes.
WOODS: 4 August 2016. If we could turn, please, to page 7. Okay. So there is quite a lot of
detail here in relation to [Child I] but can we look in the middle column which has -- sorry,
[Child A], which has a description and towards the bottom of the page it says: "Format of NNU
investigation thought to be equivalent of SUI." Do you agree again the NNU investigation is likely
to be the thematic review?
MILLWARD: There's no -- there's no dates attached next to it but it would suggest that, yes.
WOODS: Okay. Do you know who thought this, that the thematic review was equivalent of an SI?
MILLWARD: I don't because we wouldn't be able to release it to the Coroner because -- or to the
family because obviously it was involving a core number of children and it was a thematic review
so I don't know and as I say because there is no dates next to it, I can't tell you further.
WOODS: So I think from your answers that you agree that the thematic review would not be the
equivalent of an SI investigation?
MILLWARD: No, you could use the information from the thematic review to firstly give you a steer
whether or not a Serious Incident could be -- should be undertaken if it fits the criteria, or
indeed use some of that information from it and provide a slightly different format of a report,
but it would obviously have to be individualised for the individual case.
WOODS: Because when you have an SI, one of the key things about an SI is that the family or the
patient is brought into the process, is that right?
MILLWARD: Yes.
WOODS: Families can put questions, they can meet with investigators to describe their concerns
--
MILLWARD: Yes.
WOODS: -- that's right, isn't it?
MILLWARD: Yes.
WOODS: And then typically a draft SI report is provided for comment --
MILLWARD: Not at that time, no.
WOODS: Okay.
MILLWARD: That's subsequent with the new piece of legislation --
WOODS: I see. But ultimately a family for a patient will receive a copy of the final --
MILLWARD: Yes.
WOODS: -- SI report? And as you say that, that wouldn't be the case with the thematic review?
MILLWARD: No.
WOODS: And as this Inquiry knows, Mother A did not receive a copy of the thematic review?
MILLWARD: (Nods)
WOODS: There are other differences though, aren't there, as well between an SI report and the
thematic review? So the SI report would go up internal reporting processes, do you agree?
MILLWARD: Yes.
WOODS: And also would be -- would have to be reported externally?
MILLWARD: That's correct, yes.
WOODS: So to the CCG?
MILLWARD: To the CCG there was a Serious Incident group that they received on a monthly basis and
they would receive all Serious Incident investigation reports.
WOODS: Do I take it from your earlier answer then that you -- well, can you recall expressing the
view that the thematic review is not the same as an SI and it shouldn't be treated in the same
way?
MILLWARD: Yes, it's not. You could, however, tease out the specific learning and ensure that that
was formatted in some way. But it wouldn't give certainly the format of the -- of the thematic
review that I have seen wouldn't give the level of detail that we would normally provide in a
Serious Incident investigation report.
WOODS: And we know that wasn't done.
MILLWARD: Yes.
WOODS: There wasn't an -- (overspeaking) --
MILLWARD: Yes.
WOODS: There wasn't --
MILLWARD: No, it wasn't done. No.
WOODS: The third or the final column on this page.
So you can see red font, capital letters, underlined --
MILLWARD: Yes.
WOODS: -- "Urgent and outstanding: duty of candour to be considered following neonatal review."
Can you help us with that?
MILLWARD: Well, unfortunately it's Sarah's report, so I -- I don't -- I don't know because it's,
as I say, it's not my report. Clearly there was -- you know, Mrs Harper-Lea had a concern around
duty of candour, it's a theme in her email correspondence. This, this obviously goes through to
the Serious Incident Panel for discussion and she's clearly flagging she's got a concern there.
WOODS: And I think you said earlier that you would be the person who would be responsible for
duty of candour discussions with families?
MILLWARD: Statutory duty of candour, yes.
WOODS: Okay. Do you recall raising this and saying: Well, why is this still on -- in this
paper?
MILLWARD: Well, to be honest I don't, but this is the Inquest monitoring process. I -- I don't
recall. I'm really sorry, I just don't recall at all around this.
WOODS: Can you help us with this then. By late September 2016 both the Coroner and [Child A]'s
family still thought there was going to be an SI
investigation, a thorough SI investigation. So if we can pull up a document, please, INQ0008943
[not found]. So this is a file note of a call in from the Coroner's office to somebody in the
Legal Services department: "Spoke to Mag at Coroner's office. Urgently requiring the SUI report
for [Child A]. Was expecting it by Friday, 23 September." Can you help us with why the Coroner, at
this late stage, still thought there was going to be an SI investigation?
MILLWARD: So I would have no liaison directly with the Coroner in my post at all. So I don't know
the conversation. The only thing of relevance I think I can say is that although the Coroner may
recommend a Serious Incident investigation, it wouldn't have been the Coroner's decision to do
that; that decision process sits with the hospital and with the Executive team. It would have been
the legal team's responsibility to feed that information back to the Coroner. Other than that, I
can't give you any further information on that file note.
WOODS: Well, the Inquiry will hear from the Coroner in due course and there's correspondence we
don't need to go to which demonstrates clearly that the Coroner
understood he could not tell the hospital to undertake an SI?
MILLWARD: (Nods)
WOODS: But what it looks like is that for whatever reason the Coroner believed that there was
going to be an SI. Are you saying you just can't help us with that?
MILLWARD: I'm afraid I -- I wouldn't be speaking with the Coroner, so I don't know the
communications that would have took place with, with them at all.
WOODS: Could we please have INQ0002042 and it is page 155, please. Okay. So this is a letter from
solicitors acting for the family of [Child A] and it's dated 28 September 2016, and you will see
it says: "I write further to disclosure of the one-page summary [we will come back to that]
regarding [Child A]'s death which was provided today by the Countess of Chester Hospital. We were
of the understanding that a full investigation is taking place at the Trust regarding [Child A]'s
death which would result in an a report detailing the chronology, the issues involved, whether any
errors were made, whether such errors could have caused or contributed to [Child A]'s death and
the lessons learnt." So that's, in effect, an SI report, isn't it?
MILLWARD: Yes.
WOODS: "We were told in August 2016 that this investigation was ongoing and we would be provided
with the Serious Untoward Incident Report." So again, just to give you the opportunity as you have
told us at the outset that you were the person who would be responsible for disclosing those kinds
of reports to the Coroner, can you help with --
MILLWARD: So to be clear, I wouldn't give them directly to the Coroner. They would go to Sarah and
to the legal team who would then act as the connection between the Trust and that. But obviously
that's only going to be for cases that have a serious incident investigation and in fact we would
liaise with the -- or the legal team would liaise with the Coroner regularly around timeframes, so
we could make sure that we did have Serious Incident investigations ready ahead of Inquest dates.
With regards to this, I -- I don't have any recollection of this and what I can offer is that the
expectation would be that this would be fed through the Serious Incident panel through the legal
services updates and then a further conversation happened at the Serious Incident panel. But, I
can't give you anything further. I can't add anything further to that.
WOODS: So based on either your memory or your review of the documents, when do you say a
decision, a positive decision was taken not to do an SI investigation --
MILLWARD: So from --
WOODS: -- on [Child A]'s death?
MILLWARD: So from the bundle of documents I saw this morning, there was an email that Mrs
Harper-Lea sent through to the Serious Incident Panel and then there was a feedback chain. I think
it was either late March or April 2016.
WOODS: So do you -- it's clear from this letter, well and the previous file note, that both the
Coroner and more importantly [Child A]'s family thought that there was going to be an SI report
right up to the end of September 2016. Do you agree that it's -- that that's entirely unacceptable
that they were led, that they were led to believe that when you say a decision had been taken
months before that there would be no such investigation?
MILLWARD: Yes, absolutely, and as I say, the liaison between or the liaison to the Coroner and
then from the Coroner to the family that comes from the legal team and the discussions at Serious
Incident Panel.
WOODS: Just one final document. If I could bring up please -- in fact it's in the same document
but it's page 777. Okay. So this -- I will just give you an opportunity to look at
that. This is the document that [Child A]'s family were provided with in the Inquest process?
MILLWARD: All right.
WOODS: It's dated 1 July 2015, do you see that?
MILLWARD: I do.
WOODS: Okay. Do you agree that providing that document to the family 15 months later was entirely
unacceptable?
MILLWARD: Well, yes, but it's provided for -- to the Coroner. That's obviously the summary of the
cases that Dr Brearey did at the time with regards to the three cases that were reviewed and
clearly it's a clinical review in that sense.
WOODS: But the document, it's out of date for a start, isn't it?
MILLWARD: Well, it's the review that was completed at the -- at the time, isn't it, from the -- I
-- I --
LADY JUSTICE THIRLWALL: I wonder, Ms Woods, if there might be other witnesses who could perhaps deal with this more helpfully?
MS WOODS: My Lady, the problem we have is that neither Mr Cross nor Ms Harper-Lea are giving evidence to assist us with this.
LADY JUSTICE THIRLWALL: And are they the only other two who might have been able to help?
MS WOODS: Based on I think our review.
LADY JUSTICE THIRLWALL: All right. Well, then this is the witness you have got.
MS WOODS: My Lady, I appreciate the witness may not be able to help, but I think it's important for the Family to try to ask.
LADY JUSTICE THIRLWALL: No, I quite understand.
MS WOODS: I'm grateful.
MILLWARD: It certainly is not in the style or format of report that we would share with the family
for an incident investigation and I can -- I can say that, but I am not in a -- I don't provide
the information to the -- to the Coroner other than with regards to the Serious Incident
investigations that those are the reports that I provide. This isn't a Serious Incident
investigation so I wouldn't have had -- I probably would have had knowledge that this was within a
bundle, but not with the recognition that this was all the family would have received.
WOODS: And just going back to the earlier documents we have seen, where it's suggested that the
thematic review is the equivalent of an SI investigation.
MILLWARD: Yes.
WOODS: This is obviously not the thematic review --
MILLWARD: No.
WOODS: -- or any element of the thematic review, is it?
MILLWARD: No, this is -- this will have been from Dr Brearey's initial review that was conducted
as it says in July 2015. The thematic review, as we know, was February/March 2016.
WOODS: By -- well, by the Inquest, by October 2016, so quite far on in the chronology, you --
well, do you agree that you were aware that there were concerns that Letby had harmed babies
including [Child A]?
MILLWARD: I don't know -- not necessarily that Lucy had harmed babies. That there was a concern
that she was present; yes. But not, no -- she... My understanding, as I have said before, is that
yes, I understood she was present at a number of cases, but where you are talking about
deliberately harming babies and that, as I say, was not what was being said.
WOODS: Okay. I think what your evidence was earlier was that at the very least you were aware
there were concerns about whether her competencies were --
MILLWARD: Yes.
WOODS: -- linked with babies coming to harm, if I put
it like that.
MILLWARD: Yes, but that's -- that's not the same as deliberate harm. That's a clinical competence
issue.
WOODS: Okay. And that would mean that something she was doing, some kind of substandard care, was
leading to babies coming to harm, do you agree?
MILLWARD: Well, that was the suggestion with the staffing grid that was produced, yes.
WOODS: Did you give any consideration to whether that information should be provided to the
Coroner?
MILLWARD: From the review that we did internally, you mean?
WOODS: It doesn't really matter whether it's a review or not. You were aware that there were
concerns about this link between Letby and babies coming to harm, including [Child A]. Did you
give any consideration to making the Coroner aware of that?
MILLWARD: I think I believe I understood that the Coroner was being informed of the Royal College
review and that that was where we were -- where the Trust was looking and obviously the cases were
being further reviewed. I -- I don't believe I raised it or discussed it to suggest that we
should, you know, disclose that we have an individual who's been moved out of the unit because
of these concerns.
WOODS: And is the reason for that because you thought others were informing the Coroner of
that?
MILLWARD: To be honest, I don't know. I don't know whether it's because it didn't come to mind or
because at that point my view was still that was, was that this was a -- potentially a clinical
competence issue for her rather -- and a service issue for the unit rather than anything more
deliberate.
WOODS: And is that still not relevant to the Coroner?
MILLWARD: Yes.
MS WOODS: Thank you, Ma'am.
LADY JUSTICE THIRLWALL: Thank you, Ms Woods. Just a few short questions from me.
MILLWARD: Thank you.
LADY JUSTICE THIRLWALL: Rather than bring you back another day. I think you would prefer to
finish off today.
MILLWARD: Thank you.
LADY JUSTICE THIRLWALL: You mentioned, very early on in your evidence, when there was the shift
from the name of the role that was taken on by Annemarie Lawrence, the shift between that and what
had occurred before with Debbie Peacock.
MILLWARD: Yes.
LADY JUSTICE THIRLWALL: And as I understand it, there was a lot of guidance and a lot of focus on
maternity services as there have been, has been on a number of occasions --
MILLWARD: Yes.
LADY JUSTICE THIRLWALL: -- over the years. And you were keen, as it were, to signal externally
that this was being taken seriously by the Countess and so you re-badged that job as Risk
Midwife?
MILLWARD: Yes, that's correct.
LADY JUSTICE THIRLWALL: But it didn't change the role?
MILLWARD: There was no significant change other than Mrs Lawrence would be -- was going to be
asked to be more involved with the response to those national guidance.
LADY JUSTICE THIRLWALL: Yes, and that's on maternity?
MILLWARD: Yes.
LADY JUSTICE THIRLWALL: Understood, thank you. Secondly, you were taken to the decision tree,
which again Mrs Peacock had given evidence about last week, and said she kept it on her desk so
that she always had it to hand. But when I asked her about it she said it had never been relevant
in this case and at that point I, for myself, hadn't seen the decision tree. I have now seen it
with you. But it seems to me that that decision tree isn't really adequate to deal with this
situation, is it?
MILLWARD: That's right. The Incident Decision Tree is about a specific patient safety incident and
a specific staff member and --
LADY JUSTICE THIRLWALL: If I can just pause there --
MILLWARD: Sorry.
LADY JUSTICE THIRLWALL: -- because you very helpfully told us that earlier. But what you really
need is not just a specific person; you need to know who the person is and you need to know what
they have done before you can activate the decision tree?
MILLWARD: Yes.
LADY JUSTICE THIRLWALL: So it doesn't help you, does it, at all, if there were a number of
concerns about in this case babies dying and a lot of worry about it, but you never get as far as
the decision tree.
MILLWARD: No.
LADY JUSTICE THIRLWALL: In fact, none of these processes that you have been taken through help
with that, do they?
MILLWARD: The Incident Decision Tree didn't help in this situation.
LADY JUSTICE THIRLWALL: No, and none of the other processes did either, did they?
MILLWARD: No, no.
LADY JUSTICE THIRLWALL: No. All right, thank you. And then moving to Mrs Lawrence. You said that
you had no memory of her showing you the list --
MILLWARD: Yes.
LADY JUSTICE THIRLWALL: -- which she had highlighted, and I just want to go back because
obviously that was the list that had been sent to you --
MILLWARD: Yes.
LADY JUSTICE THIRLWALL: -- in the email. I quite understand that you were getting a hundred a
day, but for a busy professional that's not particularly unusual, is it? So when you saw an email
coming in, I have forgotten, was it from Alison Kelly or from Dr Brearey?
MILLWARD: So the email originally came from Dr Brearey. So forgive me, my Lady --
LADY JUSTICE THIRLWALL: But that didn't come to you, did it, the one from Dr Brearey?
MILLWARD: I was copied into that.
LADY JUSTICE THIRLWALL: I beg your pardon.
MILLWARD: With regards to Mrs Lawrence, what I was trying to say --
LADY JUSTICE THIRLWALL: No, I am going to come back to Mrs Lawrence. I just want to set the scene
before we get there. Sorry to cut across you. So you were copied in on an email which was a reply
to someone else.
MILLWARD: Yes.
LADY JUSTICE THIRLWALL: And obviously that came into you. Presumably you would have clicked on it
because you didn't know that it was a copy only?
MILLWARD: Yes.
LADY JUSTICE THIRLWALL: And what was your usual system? If you saw something like that, did you
just ignore it or did you read it quickly and think: I will come back to that.
MILLWARD: I would have read it quickly to see if there was anything in there that I needed to
action urgently.
LADY JUSTICE THIRLWALL: Right. But you didn't -- you wouldn't have clicked on the attachment,
would you?
MILLWARD: With regards to the thematic review?
LADY JUSTICE THIRLWALL: Yes.
MILLWARD: I -- I am sure that I did.
LADY JUSTICE THIRLWALL: Yes.
MILLWARD: Because I remember, I remember reading and
I remember there was green writing on it and that's the -- and I remember looking at the actions.
So I do believe I looked at it.
LADY JUSTICE THIRLWALL: At the time?
MILLWARD: And I understood from the -- from the email that there was -- they were going to have
some further conversation and then take it through to the governance board.
LADY JUSTICE THIRLWALL: And you knew then there was the table on the back of it with the people
who had been on?
MILLWARD: I don't recall scrolling as far down. I don't recall seeing that, the actual table with
the staffing, and as I say -- but I accept that it was there in that attachment.
LADY JUSTICE THIRLWALL: Yes. So you may have seen it, but you didn't look at it carefully as you
recall it?
MILLWARD: Yes.
LADY JUSTICE THIRLWALL: Is that a fair way of putting it?
MILLWARD: Yes, that's a fair comment, yes.
LADY JUSTICE THIRLWALL: Right. Thank you. So then a little while later Mrs Lawrence comes to you
and she says something to you which you regarded as gossip, that she was passing on gossip. What
did she actually say?
MILLWARD: She said something along the lines, she said she had been to the unit, she had been
speaking with the staff and she reported back to me that the staff were talking about this nurse
and that this nurse had been at all of these, some or all of these deaths, words along those
lines. We had a -- there was a further conversation. I don't remember the detail, but certainly it
came across that that the unit was gossiping. There was no sense of alarm or concern. There was
certainly no suggestion of the thoughts of what was being said, said subsequently.
LADY JUSTICE THIRLWALL: Well, why do you think Mrs Lawrence was telling you about it?
MILLWARD: Because she was new in post and came back to see me to say: what do I do with this
information?
LADY JUSTICE THIRLWALL: And your response was to say it's an HR matter.
MILLWARD: My response to her with regards to repeating the matter was that it was an HR issue and
as I had said, I believe from my Facere Melius notes that I did raise it through the Serious
Incident Panel.
LADY JUSTICE THIRLWALL: And did it occur to you to
say -- to think about the issue of risk?
MILLWARD: Well, I think -- I think I would have because I would have took it through to the
Serious Incident Panel, so the issue of risk would have -- I don't believe I outwardly dismissed
it but by taking through to the Serious Incident Panel to ask, you know, is there something that
needs to be considered from a Patient Safety Incident Investigation because the HR investigation
and Patient Safety Investigation are very, very different.
LADY JUSTICE THIRLWALL: Just so that you are aware of this, she described it as having been very
embarrassing --
MILLWARD: Yes.
LADY JUSTICE THIRLWALL: -- that you told her not to, you know, make those sort of allegations
lightly, they were very serious. That is my recollection of how she put it.
MILLWARD: Yes, yes.
LADY JUSTICE THIRLWALL: Was that fair that she thought that?
MILLWARD: Well, I wouldn't want any of my staff to feel embarrassed coming to me and raising a
concern, they are absolutely right to raise a concern and talk it through. Certainly the view I
had from our conversation was,
as I say, this is an HR matter, HR matters are confidential, I wouldn't want for our team to be
seen as gossiping or adding to the gossip. You know, obviously I'm sorry that Mrs Lawrence felt
that way, but it wasn't said in a way to make her feel that. It was to say, you know, if it is a
HR matter we need to leave it to HR but clearly I do feel that I did raise it with the SI Panel.
LADY JUSTICE THIRLWALL: I think that is all of my questions. Anybody want to ask anything else?
No. Thank you very much, Mr De La Poer. Thank you very much indeed, Ms Millward, you are free to
go.
MILLWARD: Thank you very much.
LADY JUSTICE THIRLWALL: We will rise now until 10 o'clock tomorrow morning.
(5.18 pm) (The Inquiry was adjourned until 10 o'clock on Tuesday, 5 November 2024)
LADY JUSTICE THIRLWALL: Ms Langdale.
MS LANGDALE: Good morning, my Lady, may I call Mrs Williams.
MRS SIAN WILLIAMS (sworn)
LADY JUSTICE THIRLWALL: Thank you very much Mrs Williams, do sit down.
WILLIAMS: Thank you.
MS LANGDALE: Mrs Williams, you have in front of you a bundle of documents that we have given you
this morning and there should be your statement and a number of other documents we gave you, there
is also a screen in front of you and the documents will be called up on that screen.
WILLIAMS: Okay.
LANGDALE: So whatever is easier for you, I will give you a reference in the hard copy, there will
be a reference for the screen and let's see how we go in terms of how easy they are for you to
navigate.
WILLIAMS: Thank you.
LANGDALE: If there is any difficulty. Just say so. I will probably pick it up anyway but just say
so?
WILLIAMS: Thank you.
LANGDALE: So you have helpfully provided the Inquiry with a statement dated 11 June 2024. Have
you had an opportunity to read that again before coming here today?
WILLIAMS: Yes, I have.
LANGDALE: Can you confirm the contents are true and accurate as far as you are concerned?
WILLIAMS: As far as I am concerned I recollect they are true.
LANGDALE: If we go to paragraph 2, you set out that you qualified as an Enrolled Nurse in 1980,
then a Registered Nurse in 1986 and you worked as a Ward Manager from 1994 to 1998, Diabetic
Specialist Nurse from 1998 to 2003, Head of Nursing Medical Division, a Band 8, from 2003 to 2013.
Then you were Deputy Director of Nursing Band 8D from 2013 to 2017 when you retired and I think
you went into some commissioning work then?
WILLIAMS: Yes, yes.
LANGDALE: In terms of your time at 2015 and 2016 you set out at paragraph 4 that your position
was the Deputy Director of Nursing. Can you just tell us where that role sat in terms of the
hierarchy and the structure and the responsibilities at that time?
WILLIAMS: Okay. So when I came into post, Mrs Kelly was
employed as the Chief Nurse and then employed me as the deputy so it sat in such a way that the
hospital was broken up into divisions. So each division had their own Head of Nursing and who
reported directly to Mrs Kelly, the Chief Nurse, and I was the deputy so I was aside her. I did
have some reports, people report to me, I had things -- people like the transfusion hospital, the
wide transfusion who covered the whole hospital so didn't sit in a specific division. So some
nurse specialists like the Macmillan team. I also line-managed the Patient Experience Risk Team as
well. So they were my reportees. I then reported to Alison Kelly. The other heads, the Heads of
Nursing didn't report to me as deputy, they reported direct to Alison Kelly.
LANGDALE: Would Alison Kelly sometimes share with you what they had reported to her and have
discussions with you about anything?
WILLIAMS: I -- yes. I recollect she -- they may have shared the odd thing with her, but not in any
great level of detail.
LANGDALE: In terms of the neonatal unit, would Eirian Powell have had direct conversations with
you about the unit or reported to you in any formal sense?
WILLIAMS: Not formally, no, Eirian Powell reported
directly to Karen Rees is my recollection, she was the Head of Nursing for Urgent Care.
LANGDALE: Would you ever go down to the neonatal unit for any reason?
WILLIAMS: Not specifically. I did visit it when I first came into post because prior to that it
had belonged to another division, if you like. I did visit it I think as Head of Nursing I went
down there, you know, just to be nosy, I am that kind -- I am out and about, I am that kind of
person, really, you know.
LANGDALE: So when you were being curious, nosy, however you want to describe it, going down to
look at the unit, what was your impression of the unit: small, large, medium?
WILLIAMS: Very tight for space, very small. I was a little surprised given the -- the paediatric
unit had been updated and that hadn't, so -- but -- it was cramped, I would say.
LANGDALE: We know from the parents they couldn't be with their babies when their babies were
born, if they had C sections they were in another part of the hospital; were you aware of
that?
WILLIAMS: Not to that level of detail, no.
LANGDALE: Did you see any beds there or patient beds where parents could be with babies?
WILLIAMS: Sorry?
LANGDALE: Did you notice there was no facility for parents to sleep alongside their neonates?
WILLIAMS: I think I was informed of that, yes.
LANGDALE: Was that typical around that time in hospitals as far as you were aware, or you don't
know?
WILLIAMS: I couldn't say what other hospitals were -- were like because, you know, I probably
spent most of my adult working life there, really.
LANGDALE: By this time about 27 years in nursing, weren't you, by 2015/2016?
WILLIAMS: Yes, so I had never worked on the neonatal unit. I had no paediatric experience. When in
an adult ward and if a patient relative wanted to stay then we would try and accommodate them with
a fold-up bed or a recliner chair or something at the bedside. But I ...
LANGDALE: You say at paragraph 4 in the Patient Quality and Safety Team you worked alongside the
patient Experience and Complaints Team?
WILLIAMS: Yes.
LANGDALE: Did you ever get any complaints at the time around inability to be with babies on the
neonatal unit?
WILLIAMS: I don't recollect any specifically. There may have been some but I don't recollect any.
LANGDALE: We asked you at paragraph 6 about the culture
and atmosphere on the NNU at the hospital and you say you weren't involved in the day-to-day
running of the unit. Did you detect over that year any sense of the nature of the relationships,
for example between the nurses and doctors on that unit or generally?
WILLIAMS: No, I detected nothing.
LANGDALE: What about between doctors and managers, because you were at meetings, we will come to
them later, weren't you, with some of the Executives, Tony Chambers and Alison Kelly, and some of
the doctors? We will move on to the details of them in July time in 2016. Did you think the
relationships were still not worthy of comment in any way or what did you think?
WILLIAMS: I wasn't aware of any specific issues with the Exec Team at the point of when I was
appointed and you know up to 2015, you know mid-2015 or onwards. I wasn't aware of anything. I
wasn't operational so I -- you know, I didn't see them and Alison Kelly tended to, you know,
manage that side of it.
LANGDALE: Did you get on with all the doctors and nurses, you never had any difficulty with
anyone?
WILLIAMS: I never had any difficulties with any of the doctors.
LANGDALE: What were they like, if you can comment on
a group in the neonatal unit, doctors?
WILLIAMS: Pleasant. No issues. Constructive often. No, no, nothing that would concern me.
LANGDALE: What about the nursing group, did you have much to do with Eirian Powell as the ward
manager?
WILLIAMS: Nothing to do with her on a one-to-one basis. I might have seen her in passing if I
passed through. She used to come to the ward manager's meetings where Alison Kelly chaired and
that's probably it, really.
LANGDALE: Your impression of her and unit and the nurses and how they worked together?
WILLIAMS: I -- I couldn't give the impression because I wasn't there.
LANGDALE: We asked you about when you first became aware of the increased mortality rate in the
NNU. You say you can't specifically remember. Can I take to you a couple of meetings, QSPEC
meetings, and let's see where we get to with that. If we go -- it is in your enclosure 1, for the
electronic reference it is INQ0003200, page 3. It is the standing agenda item, Mrs Williams, number 12
--
WILLIAMS: Yes.
LANGDALE: -- on page 3 of that hard copy --
WILLIAMS: I have it.
LANGDALE: -- document.
LADY JUSTICE THIRLWALL: It is not on the screen yet.
MS LANGDALE: Thank you. We may find ourselves going faster than the screen, Mrs Williams.
WILLIAMS: Sorry.
LANGDALE: Not at all. If we look there, this is an Executive Directors Group meeting, Wednesday,
9 September --
WILLIAMS: Yes.
LANGDALE: -- in 2015.
WILLIAMS: Yes.
LANGDALE: We see there standing agenda item and you have reported that a baby death had been
reported to STEIS and an investigation was taking place. We know that that was Baby D [Child D],
one of the indictment babies, with an unexplained and sudden death. At the time, do you remember
now what you knew about that baby death and why it had been reported to STEIS?
WILLIAMS: I'm afraid I don't remember why it was reported to STEIS. I think at that point I was
sitting in for Alison Kelly, who was on leave, and it will be just information that she gave me to
tell the team. So I -- I don't recollect as to why it was reported to STEIS.
LANGDALE: That in fact was a third death in less than three weeks on the unit. We are going to
come to a Serious Incident Review that you were present at. When you made this report, you may
have been aware that that was the third death. Can you remember now?
WILLIAMS: No, I can't remember, I'm sorry.
LANGDALE: If, when we go to later documents, it looks like you are aware there is three Datixes
for deaths in that period, would there be any reason as far as you are concerned why the cluster
of deaths wouldn't be reported to STEIS rather than just the death or one death of Baby D [Child
D]?
WILLIAMS: No, I -- I wouldn't know the reason why.
LANGDALE: Who would be responsible for making the reports on STEIS system?
WILLIAMS: It would be -- I mean, anybody could make a report on Datix that then generates the --
into STEIS. So if my recollection serves me right, it would be somebody like Ruth Millward or her
team that would STEIS report it.
LANGDALE: You have said the Executive Directors Group, that it's being investigated?
WILLIAMS: Yes.
LANGDALE: You would expect that that would be followed up in further meetings, wouldn't you, and
discussion
about what had happened?
WILLIAMS: I would have expected a report to go through the governance process through the -- the
governance team, through the director, that type of thing and to the -- there is a panel that
would often go through the reports. I would expect something like that to have happened.
LANGDALE: Do you remember anything of that now?
WILLIAMS: I don't remember. That's not to say it didn't happen, I just don't remember.
LANGDALE: While you were in that enclosure, if we can go please to INQ0003204, page 5?
WILLIAMS: Yes.
LANGDALE: These, when they come up, are Quality, Safety and Patient Experience Committee minutes
of meeting 14 December 2015. So for you it's the second set of minutes in enclosure 1 at paragraph
11 which should be highlighted for you, Mrs Williams?
WILLIAMS: Yes, I have got it.
LANGDALE: Just a bit further down, paragraph 11. Thank you, Mrs Killingback, that is where we are
looking. We see there at this meeting that Julie Fogarty presented a review of neonatal deaths and
stillbirths at the Trust during January to November 2015. It had been recognised that there had
been an increase during the
period and therefore a panel was set up to independently review all of the cases again on an
individual basis to identify any common themes or trends and lessons to be learned. You are at
that meeting, as are a number of other people. What do you remember about that? Did you read that
report?
WILLIAMS: I don't specifically remember reading it, I couldn't tell you specifically yes or no.
However, what I can say, generally speaking, it would be my -- how I work that I tended to try and
read the reports beforehand, so if I had any questions I would have them prepared if -- so I would
try and read the information beforehand.
LANGDALE: Are you the sort of person that would ask questions -- you referred to yourself earlier
as nosy, but would you ask questions if you had any?
WILLIAMS: Yes, yes.
LANGDALE: We know having seen that report, and having heard from Mr McCormack and also Julie
Fogarty that, in fact, it dealt with obstetric issues, not the neonatal deaths and there was no
input from a neonatologist, and certainly not Dr Brearey, into that. Would you have remarked or
noticed at the time that despite its description, it didn't in fact address the
neonatal deaths and certainly unexplained deaths and their reasons?
WILLIAMS: I might have done, I might have remarked about it at the time. But clearly it was either
incorrectly labelled or, you know, there was a belief that that's how it was handled, if you like.
LANGDALE: Because it looks as though it's being flagged up that there is a need to independently
review all of the cases and that included neonatal, unexpected and sudden deaths. They were in
need of examination, investigation; that is what's being identified here, isn't it?
WILLIAMS: Yes, it does look like that.
LANGDALE: It doesn't look as we know that that was done for a long time. Can you think of any
reason for that given that that's been set out there?
WILLIAMS: No, I can't comment unfortunately.
LANGDALE: If we go further down electronically and for you and me, Mrs Williams, over the page to
paragraph 12, we see that at the meetings, there is Serious Untoward Incident updates and other
incidents. Those can come down because we are not interested in those ones now, if it can be taken
off. But the fact is at QSPEC SUIs are discussed, aren't they?
WILLIAMS: Maybe.
LANGDALE: Should be?
WILLIAMS: Yes, maybe not specific ones. Sometimes trends and themes, not always specific cases.
LANGDALE: Going back to your statement, if I may. At paragraph 13, you refer to having been on
QSPEC and you also refer to the Whole Hospital Monthly Ward Managers' meetings chaired by the
Director of Nursing; is that Ms Kelly?
WILLIAMS: Yes.
LANGDALE: So what's the purpose of those Hospital Monthly Ward Manager meetings?
WILLIAMS: So the purpose was to bring staff together so they work as a team, to share any good
practice, to give off information, you know, if there's issues that need to be raised, so it's
done in that way and give them the opportunity to ask questions and to raise anything they want to
raise, you know, with the rest of the ward manager group.
LANGDALE: What was the number that usually attended roughly?
WILLIAMS: It was a fairly big number so, you know, 20 plus, 30, sometimes it depended.
LANGDALE: I think Ms Powell said it could be around 40, I may have remembered that incorrectly,
but a number of
people?
WILLIAMS: A number of people.
LANGDALE: Was the NNU ever discussed, the neonatal unit, and rising mortality rates and any
issues across the wards?
WILLIAMS: I don't recollect any discussion.
LANGDALE: Because if people were worried about infection or something like that, they would be
discussing that in those meetings, wouldn't they, because obviously infections can go from one
ward to another, can't they?
WILLIAMS: If it was, if it was an infection issue, generally speaking, the infection control nurse
would attend, that would be my recollection and have a conversation if necessary.
LANGDALE: With everybody, with all the managers?
WILLIAMS: Yes.
LANGDALE: So generic issues that may impact on you all were discussed; is that the point?
WILLIAMS: Yes, generic issues that may impact just staff developments, ideas, sharing
opportunities.
LANGDALE: Ms Powell also referred to when the CQC inspection was going to happen in February
2016, that there were meetings that discussed preparation for that inspection?
WILLIAMS: Yes.
LANGDALE: Would that be right?
WILLIAMS: Yes, as in every hospital that I have been to, yes, that would be right, yes.
LANGDALE: So were you present at those meetings in preparation for the CQC?
WILLIAMS: Possibly, unless I was away.
LANGDALE: What sort of discussions would happen around an inspection, what were you
discussing?
WILLIAMS: Going through making sure everybody knew good practice, you know, how to raise concerns,
that -- that everybody had the basic knowledge.
LANGDALE: There is a document it's in enclosure 5, if we go to it at INQ0017298, page 1.
WILLIAMS: What did you say the number was?
LANGDALE: For you it is enclosure 5 at the very end, it is the engagement meeting agenda,
Countess of Chester Hospital, this one happens to be 22 December 2016 and you are present?
WILLIAMS: Yes.
LANGDALE: It is just a couple of pages. Is this an internal meeting? I just wanted to understand,
is this -- you are having a discussion with someone from the CQC here, inspection manager;
yes?
WILLIAMS: Yes.
LANGDALE: So what would be this kind of meeting?
WILLIAMS: They would go through areas of -- that they had picked up externally from organisation
-- from other organisations because you get those sort of things. As you can see the neonatal
review and other events, Serious Incidents, that type of thing.
LANGDALE: It says "Strategic update key risk areas". Can you remember what was updated or what
was discussed around maternity or neonatal services?
WILLIAMS: I can't remember. I can't remember, I'm sorry.
LANGDALE: That is the one in December.
WILLIAMS: Yes.
LANGDALE: If we go to INQ0017296, page 1, we see one for 24 August 2016, for you it's just a
couple of pages along, Mrs Williams: Last inspection, 15 February, action plan discussed for each
core area, assurance sought that plan is smart. What's that?
WILLIAMS: I think it's an acronym for --
LANGDALE: Another one.
WILLIAMS: I can't remember but yes, smart, you know, keep it brief, you know, make it focused, I
can't remember what it meant.
LANGDALE: What did it mean in practice?
WILLIAMS: It meant that it, it -- that it was focused, you know, rather than being a long action
plan, it was focused on the key areas is my recollection.
LANGDALE: Did you see the CQC inspection report that was done following the visit in February
2016?
WILLIAMS: I -- I -- I can't remember seeing it. I could have done in my role but I specifically
can't remember.
LANGDALE: How were they received as a hospital, important documents, presumably?
WILLIAMS: Yes.
LANGDALE: They get attention from Executives and senior managers, do they?
WILLIAMS: Well, they come via the Executives, definitely, yes.
LANGDALE: Is it important to any hospital, but from your experience the Countess of Chester, to
get a good rating from the CQC, is that important?
WILLIAMS: I think it's important, it -- for, for a, you know, a good rating. I think it then sends
out the right message but, you know, sometimes it can be over focused, if you like, but I think it
is important to get a rating that's acceptable.
LANGDALE: What do you mean "over focused"?
WILLIAMS: In that people become target driven.
LANGDALE: Expand upon that, if you will?
WILLIAMS: Well, just things like A&E targets, that type
of thing.
LANGDALE: A&E targets?
WILLIAMS: Yes, that was just an example.
LANGDALE: So they wanted to tick a box, just achieve something without thinking about it further,
what do you mean?
WILLIAMS: I think sometimes it is just you have to, you know, look at the bigger picture.
LANGDALE: Sorry I missed that?
WILLIAMS: You -- sometimes I think it's make sure everybody looks at the bigger picture, not just
one single area.
LANGDALE: Was that something you found yourself ever saying in discussions with Executives or
generally?
WILLIAMS: No, not -- I cannot recollect it. It's just --
LANGDALE: More your observation looking back?
WILLIAMS: More from other hospitals' observations as well.
LANGDALE: We can see there that there is references again to the maternity neonatal services. As
far as you were concerned at this point, what was being discussed in August 2016 about neonatal
services, we know you have done your staffing analysis and stuff by then, we will come to that
later. But what were they being told in
this discussion?
WILLIAMS: I don't recollect. The only thing I can remember, I would not even remember, I would say
possibly the external review.
LANGDALE: The RCPCH review?
WILLIAMS: Yes.
LANGDALE: So you think they likely just saw that?
WILLIAMS: Sorry?
LANGDALE: They likely had access to that but nothing else?
WILLIAMS: Well, I am not sure if it was completed by them, but maybe they were being updated.
LANGDALE: Right, when it was completed. So they would get the external review. Did they ever get
your internal review, your staffing analysis from Julie Fogarty?
WILLIAMS: I don't know.
LANGDALE: You never gave it them?
WILLIAMS: No.
LANGDALE: Were you asked to share that with them?
WILLIAMS: No.
LANGDALE: We know, and Julie Fogarty is giving evidence, when you had done that you had concerns
that the police should be called?
WILLIAMS: I did.
LANGDALE: Yes?
WILLIAMS: Yes.
LANGDALE: Is that something you would have thought to share with the CQC in one of these
meetings?
WILLIAMS: I think we were guided by the Executive Team as to what to share.
LANGDALE: Right. What was that guidance -- that can come off the screen thank you, Ms Killingback
-- what was the guidance on this topic?
WILLIAMS: Just that they were undergoing a review. I don't recollect specifically.
LANGDALE: Were you told that you could share your concerns about the staffing analysis with
anyone or not?
WILLIAMS: I wasn't told one way or the other, if I recollect.
LANGDALE: But either way you don't -- you didn't tell the CQC?
WILLIAMS: No.
LANGDALE: You tell us at paragraph 18 of your statement that you remember being involved in a
mortality review. Can we go, please, to enclosure 2, and it's INQ0003530, page 1.
WILLIAMS: Yes.
LANGDALE: We only need the top bit, please, Ms Killingback, which refers to C and D. Just that
bit. Thank you. So this is described as a Serious Untoward Incident Review and we can see there,
Mrs Williams, we have you, Dr Brearey, Alison Kelly and Ruth Millward, Head of Patient Safety, so
that is a senior team there, isn't it, meeting?
WILLIAMS: Yes.
LANGDALE: Apart from in the context of the neonatal unit did you have many meetings of that level
of combination of staff?
WILLIAMS: Not huge numbers. If there was a couple of Never Events in theatre or something like
that, then yes, we would get together.
LANGDALE: So less than fingers on one hand?
WILLIAMS: I can't -- I can't remember.
LANGDALE: But not many?
WILLIAMS: I -- I can't remember this being called a Serious Incident -- to be honest, I can't
remember the meeting but I can't remember it being called a Serious Incident Review meeting. I --
you know ...
LANGDALE: We don't see this, before we go to the detail, appear again in QSPEC, you know, we saw
earlier that Serious Untoward Incidents are reflected back into that committee. This is a sort of
standalone but it looks as though the Datix, or rather the deaths of Child A
[Child C] and [Child D] are being referred to in combination and we know those three deaths all
happened in a rapid successive period within three weeks?
WILLIAMS: (Nods)
LANGDALE: So the three of you are talking about that. Can you remember now what was being said
about that?
WILLIAMS: I can't. I have racked my brains, I can't remember it at all. That's the ...
LANGDALE: You told the police in a police statement -- you don't need to turn that up -- that it
was more in relation to an overview, not an individual?
WILLIAMS: Right. So I am not convinced they are the same. I think in my police statement I talk
about where Stephen Brearey, Ruth Millward, Alison Kelly, myself and I think Ian Harvey may have
been on leave. He had done a review of deaths and he -- we met him to go through it and --
LANGDALE: Was that with the Triplets or two babies that had died together?
WILLIAMS: I -- I can't remember. I think, you know, it might have been -- it might have been -- I
don't know, it might have been a bit wider than that, I don't know. I can't remember. But at that
point, you will have read, Dr Brearey didn't really come across as that concerned at that
point.
LANGDALE: In this point, July 2015 you are talking about that?
WILLIAMS: No.
LANGDALE: Just focus on this document --
WILLIAMS: I don't remember that.
LANGDALE: Right, so you don't remember this at all?
WILLIAMS: No.
LANGDALE: I am going to take you to later documents, don't worry, you will get a chance to
comment.
WILLIAMS: Sorry, I don't remember this one.
LANGDALE: So you don't remember this, although it looks like you are present when three deaths in
a very short period are being discussed?
WILLIAMS: Yes.
LANGDALE: But you don't remember it?
WILLIAMS: I don't.
LANGDALE: Looking now at that cluster, does that look like to you as though this Serious Untoward
Incident should have been followed up and followed through QSPEC and analysed?
WILLIAMS: If depending -- I'm not sure what the outcome of the Serious Incident Review was, so it
depended on the outcomes as to whether then it was escalated.
LANGDALE: You tell us at paragraph 31 of your statement,
we asked you whether the meeting considered the NHS revised Serious Incident Framework published
in 2015?
WILLIAMS: Yes.
LANGDALE: You tell us you couldn't recollect the meeting so you can't comment on it.
WILLIAMS: Yes.
LANGDALE: Who was responsible for compiling reports on Serious Untoward Incidents, it is clearly
not you from what you are telling us?
WILLIAMS: No.
LANGDALE: So who was?
WILLIAMS: So it would be members of the Risk Team that were specific for that area alongside the
-- the Consultants who would then because, you know, sign off the content that they were happy
with everything that went in and --
LANGDALE: So Ruth Millward is present for that one --
WILLIAMS: Yes.
LANGDALE: -- on 2 July so it would be in your view her responsibility?
WILLIAMS: Yes.
LANGDALE: Those -- just let me finish, those three deaths having been identified, her
responsibility to see that was managed through the Risk Team; is that the position?
WILLIAMS: Yes and -- and Debbie Peacock's, that is if -- if Steve Brearey agreed that, you know,
there were lessons to be learned, that type of thing.
LANGDALE: They would need to have information from him but presumably from what you are saying
this management of risk is what they are there for. That is their day job, isn't it --
WILLIAMS: Yes.
LANGDALE: -- so to speak. Just pausing there, so the doctors are doing the day job of the
doctors, they give information and then is it carried on through the management team and for those
who have management responsibilities and risk management responsibilities?
WILLIAMS: Yes, it's worked alongside together, yes.
LANGDALE: So in your experience, who should be filling in the forms and the details and the
documents where they are required and we see a number are required?
WILLIAMS: I would say it should be the Risk Team.
LANGDALE: So it is not the doctors who finished with one patient, go to the next. They can hand
over information verbally and the Risk Team have to deal with it?
WILLIAMS: Hand over information, go through it from the assurance purpose, go through the detail
as well and check the interpretations are correct.
LANGDALE: Paragraph 34, you tell us:
"I do not know if the deaths of [Child A], [Child C] or [Child D] were reported to the Child Death
Overview Panel or whether they were reported as Sudden Deaths In Infancy ... (SUDIC) ..." As that
wouldn't fall within your remit. Who would be responsible for reporting to the Child Death
Overview Panel?
WILLIAMS: I am not a paediatric nurse and I -- I am unsure to give the correct answer there. I
don't know. We did have a safeguarding paediatric nurse, so possibly from there. The Consultants
take some -- and maybe the Risk Team but I am -- I couldn't say for sure because.
LANGDALE: So risk or safeguarding?
WILLIAMS: Yes.
LANGDALE: Did you have any involvement with the paediatric department, the children's department,
or just the NNU?
WILLIAMS: No, I had no with the paediatric no. The paediatric safeguarding nurse reported to
Alison Kelly.
LANGDALE: Right and you tell us later you didn't actually have safeguarding training yourself or
child protection?
WILLIAMS: No, just the general safeguarding training that the hospital has.
LANGDALE: Did you ever in your time at the Countess of
Chester have to report something to safeguarding or to the designated people within the hospital
doctors or nurses?
WILLIAMS: I may have had some of the adult, because the adult safeguarding, I may have used her
for advice and reporting on a number of occasions.
LANGDALE: How did it work on the ground for adults, did you know who would you take a concern to
about an adult?
WILLIAMS: You take to the adult safeguarding nurse.
LANGDALE: Who was that?
WILLIAMS: Tracey -- I can't remember her surname.
LANGDALE: Right, okay, but you knew who she was, you knew who to go to?
WILLIAMS: Yes.
LANGDALE: Would you hesitate about doing that?
WILLIAMS: I think I would get the information to go there.
LANGDALE: You tell us at paragraph 45 of your statement: "I cannot recall being provided with, or
reading the report compiled by Dr Brearey considering the neonatal deaths ..." As opposed to
obstetric deaths. If this helps, at enclosure 4, if we can go, please, to INQ0003138, page 1.
WILLIAMS: Yes.
LANGDALE: For you it's just behind enclosure 4, the first two emails.
WILLIAMS: Yes.
LANGDALE: If we look there, we see Alison Kelly in the middle email, 4 May, sending an email to
Karen Rees cc'ing you. "Please see attached. Not sure you will have had previous sight of this.
Lucy Letby highlighted in red! I have not noticed this when I first reviewed. Can you please look
into this as per my previous email, many thanks." Then further down another email: "Can you please
look into this with Anne. If there is a staff trend here, we have already changed her shift
patterns [which we know they had in April] because of this, then this is potentially very
serious." Do you remember receiving that and seeing that table with her name in red?
WILLIAMS: I don't remember, now I -- I don't remember seeing it. I was copied in to it, I think it
went direct to Karen, I don't remember seeing it.
LANGDALE: Would you have looked at it when you were cc'd?
WILLIAMS: I may have, yes, I might have done, but I don't remember I don't recall seeing it.
Because Karen reported direct to Alison it was left very much with Karen. I might have been on
leave. I don't know.
LANGDALE: She sounds pretty alarmed, doesn't she, with her exclamation marks "Lucy Letby in
red!"
WILLIAMS: Yes.
LANGDALE: That is a concerned email, isn't it, would you say?
WILLIAMS: Yes.
LANGDALE: So is it the kind of email that you wouldn't have looked at the attachment just to see
what she meant and how important it was?
WILLIAMS: I might have looked at it I might have not looked at it at that time if I wasn't around.
LANGDALE: Right, so at some point you looked at it?
WILLIAMS: Yes.
LANGDALE: Do you know when you will have looked at it?
WILLIAMS: I don't, no.
LANGDALE: We know that on 23 and 24 June two babies died, two of three Triplets. If we just go
further on in that enclosure for you a couple of emails on INQ0047571 -- it is a different INQ
number Ms Killingback sorry, INQ0047571, page 1.
WILLIAMS: Yes.
LANGDALE: So it is INQ0047571, 0001. It's not there? Well, we have got a hard copy so I will
read out
Mrs Williams, so people can see what the email says.
WILLIAMS: Yes.
LANGDALE: We see there is an email from Alison Kelly on 29 June sent to Ian Harvey and she says
this: "Hi Ian, I am not at Execs this AM but have briefed Sian fully. I have discussed the actions
we are taking with her and I know we are commissioning an extra clinical review, but Sian and I
did also discuss the police. I know this is a big step but it is something we need to consider in
light of heightened concerns. Can we double-check that the babies have had a PM yet? I am assuming
the Coroner was made aware. Sian said she would try and speak with Stephen C prior to Execs for
his thoughts but this also needs to be considered in the Exec conversation." Then we see further
emails between Alison Kelly and Ian Harvey which they will be asked about but looking at what she
says about you, you have that in front of you, it looks -- well, that she's saying that you have
both by 29 June, had a conversation about calling the police and she's briefed you fully. What can
you remember she said to you about that time?
WILLIAMS: I don't.
LANGDALE: So this is after the Triplets have died?
WILLIAMS: Yes.
LANGDALE: The two Triplets?
WILLIAMS: I don't remember having that conversation with her. I am unsure if it was after the
reviews of the Triplets, I don't think --
LANGDALE: No, that is before, I am going to take you to the reviews of the Triplets which
actually happens on 5 July. So this predates that?
WILLIAMS: Yes.
LANGDALE: But the Triplets have died, so she says she's briefed you?
WILLIAMS: Yes.
LANGDALE: What has she told you about them?
WILLIAMS: I don't remember having this conversation with her. Obviously I -- it looks to me as
though I was covering her for not being at the meeting, so I don't remember what she had said, to
be honest.
LANGDALE: When you say "not being at the meeting", what meeting do you mean there?
WILLIAMS: Is it something to do with Execs or something it says.
LANGDALE: No she is saying "I am not at Execs this morning"?
WILLIAMS: Yes.
LANGDALE: So she is not going to be at the meeting but she's briefed you?
WILLIAMS: Yes. So she obviously was concerned about something, about the deaths being brought to
her attention. She -- she quite probably briefed me but I can't remember having the conversation
with her. I do recollect on a number of occasions having a conversation with Alison Kelly and the
other Execs about going to the police.
LANGDALE: About what time?
WILLIAMS: I -- I can't -- I can't remember. I -- a couple of times I, you know, said I think it
was more when they had done the review, that type of thing.
LANGDALE: Let's go have a look at the mortality review now of the Triplets. If we go -- continue
for you in that same enclosure, but it is INQ0005121, so 0005121, page 1.
WILLIAMS: Yes.
LANGDALE: We actually see on page 3?
WILLIAMS: Yes.
LANGDALE: Go to page 3 you see the reviewers. There is Dr Brearey -- just the reviewers' names at
the bottom, if we may, further up. Dr Brearey, Eirian Powell, yourself, Yvonne Griffiths, Dr U, Dr
ZA and Hayley Cooper. So this is where -- and the Inquiry has heard a lot of evidence about the
collapse and death of Baby O [Child O] and then Baby P [Child P]. This is when the people named
come together. What do you remember now about this meeting on 5 July and the concerns that were
being expressed at that meeting?
WILLIAMS: I remember the meeting because Ruth Millward was meant to go and couldn't, so I stepped
in and did it for -- with her, for her and Steve Brearey led it. It was a mortality review if I --
you know, rather than a serious -- it was a mortality review that the hospital did on any death,
be it adult or child. So I -- I don't have access to a lot of the record-keeping because they have
different systems in the neonatal unit. I don't recollect a specific name coming up, a nurse
involved. I do recollect there was some small areas of lessons learned, you know, sub optimal care
you know, so that, that's basically the meeting itself and it was late to finish. So ...
LANGDALE: Dr ZA gave evidence to say that at that meeting, Letby's presence was referred to and
Letby having something to do with the deaths, her continued association and that things had gone
beyond a coincidence and she must have been involved in some way, either deliberately or through
incompetence was made very clear at this meeting. Would you agree with that?
WILLIAMS: I -- I don't recollect that level of him
making that -- I don't recollect him, to be honest. I don't recollect that level of detail of
highlighting a specific nurse at that point.
LANGDALE: It may help to see your police statement nearer the time, INQ0001996, page 4. So if you go back it's behind your Inquiry statements,
Mrs Williams?
WILLIAMS: Yes.
LANGDALE: And it is page 4 of it. We will go to paragraph 2.
WILLIAMS: Yes. Yes.
LANGDALE: Actually it starts on the page before, page 3, if I may. You see at the bottom: "I
recall working on a couple of mortality reviews ..."
WILLIAMS: (Nods)
LANGDALE: "... around the same time. I can't remember the names of the babies. I think it was two
of the set of Triplets. Stephen Brearey was involved and it was clear that the clinicians were
become twitchy about the situation. Nurse Letby's name came up again during the review. It is
clear they were concerned the mortality review was about 10 days after the event but the
clinicians had kept a bag of fluids that one of the babies had been fed with at the time of death.
This was highlighted to me during the meeting and I was unsure
what to do with them so I phoned the Trust secretary, Stephen Cross, who has a legal background.
He informed me that given there was a suspicion of foul play I should ensure they were kept". Do
you remember that conversation with Stephen Cross?
WILLIAMS: (Nods)
LANGDALE: So it is clear at this meeting that was discussed, the retention of a sample, and you
followed that up with him and he said --
WILLIAMS: I did.
LANGDALE: -- suspicion of foul play. So the suspicion was clear, wasn't it?
WILLIAMS: It wasn't specific -- so there was a suspicion. I don't remember Letby coming up a great
deal during the -- the review. However, there was a suspicion by -- by some of the clinicians then
and because they kept the bag I didn't know what to do. It was 10 days after the event now so it
had been sitting on what we class as the sluice for 10 days and I think the Executives were more
aware of issues by then so they were keeping it very close to themselves.
LANGDALE: Well, not so close that it wasn't clear to you there was a suspicion of foul play; that
couldn't be clearer, could it, what Stephen Cross had said to you
there?
WILLIAMS: That is what he -- well, he came -- used that term to me.
LANGDALE: Yes.
WILLIAMS: Yes.
LANGDALE: So when he said that to you, what do you take "suspicion of foul play" to mean?
WILLIAMS: That she was on duty a bit of the time, that was it. So --
LANGDALE: Really? Just that she was on duty? Suspicion of foul play, that's not about --
WILLIAMS: They were his term --
LANGDALE: Yes.
WILLIAMS: Foul play.
LANGDALE: So what do you think that means?
WILLIAMS: Just because he's got a police background and he said to keep it, it could be evidence
and that's it.
LANGDALE: Evidence of what?
WILLIAMS: Well, that's what he said, of foul play.
LANGDALE: So you knew there was suspicion from the Consultants and from the Executives around
babies being deliberately harmed?
WILLIAMS: After that meeting and there at that point.
LANGDALE: That can come off the screen, please. If we go -- for us it's enclosure 4, and it's a
handwritten note of Stephen Cross before the mortality review, Mrs Williams.
WILLIAMS: Yes.
LANGDALE: The reference electronically is INQ0004314, page 1. So if you go back to enclosure 4, it's a handwritten
document a couple of emails in. And it's got at the top Monday 4 July 2016?
WILLIAMS: Yes.
LANGDALE: You have got that, thank you. So this is a meeting where discussion of the downgrading
of the NNU was happening and this is 4 July, so the day before --
WILLIAMS: Yes.
LANGDALE: -- the meeting you have just had. So they are discussing here downgrading the unit and
there are many pages of contributions. If you look at page 3, there is discussion, isn't there,
about getting the communications right for the families. Can you see that, Tony Chambers?
WILLIAMS: Yes.
LANGDALE: Tony Chambers talking about getting communications right?
WILLIAMS: Yes.
LANGDALE: Dr Brearey above, "Difficult issue re comms for parents whose babies have died". Do you
remember anything about this meeting and
discussion of communications with families?
WILLIAMS: Not to any level of detail, no. I don't. I have obviously contributed, there is my
comment there about some babies coming back.
LANGDALE: Did this feel a significant event in your mind, that the unit was being downgraded and
families needed to be informed of things, did that feel significant at the time or not?
WILLIAMS: I can't remember.
LANGDALE: You can't remember?
WILLIAMS: No.
LANGDALE: Had you been involved at all in another setting where units were downgraded?
WILLIAMS: No, the only time where a unit may close if is if an ITU is full or it has got poor
staffing and you can't risk putting another patient in there. So there might be a temporary
closure.
LANGDALE: If we go back to your statement, if we could, thank you, at paragraph 52, we come to
your staffing analysis and you tell us: on 11 July 2016, Julie Fogarty and I completed a staffing
analysis and fed back the findings to the medical staff. Can you just tell us in your own words
what that piece of work was about, what you both did and how you set about it?
WILLIAMS: So myself and Julie, there was a meeting in the organisation where the Execs had pulled
together a meeting and a number of us were tasked to look at specifics. My understanding and my
recollection is the Consultants had done a bit of a staffing review themselves and come up with
the name Letby. So we were tasked to go back and go through that which -- which is what myself and
Julie Fogarty did, we did it, we did it in my office but separately looking at it and we looked at
using Meditech like electronic notes of, you know, collapses, that -- you know the babies there.
And we came to this, a similar to the -- to the doctors that she was, and I did a quick
calculation, 80% more likely to be on duty either during or before a baby collapsed.
LANGDALE: What Julie Fogarty says is that at the time of the analysis you were both aware
appropriately trained professionals were undertaking a review --
WILLIAMS: Yes.
LANGDALE: -- of all aspects of the sudden collapses, is that what you understood?
WILLIAMS: Yes.
LANGDALE: That the sudden collapses, so the doctors were looking at --
WILLIAMS: Yes.
LANGDALE: -- first and foremost what had happened to the babies, what might have caused their
death. That was the main need for inquiry, wasn't it?
WILLIAMS: Yes.
LANGDALE: Then when you looked at that and if you had concerns about that there is questions
about who is present. Is that how you understood the sequence of events?
WILLIAMS: I don't recollect specific sequence. We were just given this piece of work to do. My
understanding is that John Gibbs was looking at the case note side of it with -- with -- I am
going to say Anne Martyn, but I could be wrong.
LANGDALE: Which babies were you looking at, those where there had been unexpected deaths or
unexpected collapses?
WILLIAMS: Yes, both.
LANGDALE: Right so you were looking at events that had been unexpected?
WILLIAMS: Yes.
LANGDALE: So you weren't looking at every baby that had deteriorated or died?
WILLIAMS: No.
LANGDALE: You were looking at unexpected events; is that what you remember?
WILLIAMS: Yes, I -- if I recollect it was the ones that the doctors had already looked at. We were
just going over that again.
LANGDALE: So you wouldn't recollect precisely which ones but you were going over a number?
WILLIAMS: Yes, and we also added another column of which medical staff were involved as well.
LANGDALE: You tell us at paragraph 55: "We reported our findings back to one of the Executive
Team, [you] think it was Sue Hodkinson ..."
WILLIAMS: Yes.
LANGDALE: But you can't be sure and you recall also telling the Medical Director, Ian Harvey,
that you were concerned?
WILLIAMS: Yes.
LANGDALE: Again, do you remember that or --
WILLIAMS: I do. I do remember that.
LANGDALE: So tell us about what you said to both of those?
WILLIAMS: So there were three babies that had collapsed that were fine during the day and then
overnight they had collapsed. So I was concerned when I saw that as we checked it out with Julie
Fogarty.
LANGDALE: Just pausing there, three babies or one baby
three times collapsing?
WILLIAMS: Sorry yes, one baby three times, I apologise.
LANGDALE: One baby had collapsed in the night, not in the day?
WILLIAMS: Three times, yes. So I -- when we fed it back we raised it there and I also took it to
Ian Harvey as the Medical Director specifically and said I was concerned about that and he said he
was going to check, if I recollect. So that's what we did.
LANGDALE: Now, the email I took you to earlier, the 29 June, is where Alison Kelly said she would
brief you and they were discussing the police. She was telling -- discussing the police in those
emails. Was Ian Harvey -- did you and Ian Harvey discuss around this time when you had done the
review going to the police or not?
WILLIAMS: I don't recollect.
LANGDALE: You can't remember?
WILLIAMS: No.
LANGDALE: But do you remember around this time in July there being conversation about going to
the police generally amongst the Execs, in your own mind or you and Julie Fogarty?
WILLIAMS: Yes. Yes. I do recollect.
LANGDALE: You also set out at paragraph 57 that you had
had experience before in an adult area where an allegation had been made and calling the police
and that you told the Executives about that?
WILLIAMS: I did on a number of occasion.
LANGDALE: Can you expand on that?
WILLIAMS: A previous Chief Executive.
LANGDALE: We don't need any names.
WILLIAMS: I am not going to. A previous Chief Executive, I was Head of Nursing then and the chief
nurse and the deputy were away at conference or something so I was there and I got a phone call
saying could I come down. So I went down to see him. He said that somebody had brought -- I don't
know who the somebody was, had brought this concern that somebody may be switching off pumps,
pumps are what you deliver fluids to patients in I think it was the high dependency setting. So we
had a very brief conversation and said that we both believed we should inform the police and the
police would make their decision then as to what they would do. They would either come in, say "do
your own investigation and keep us informed" or not be bothered. So they were the three things. So
he rang the police and they came in that night and I stayed until about 4/5 o'clock in the morning
with
the staff going through, supporting staff and going, you know, supporting the police.
LANGDALE: Which Executives did you give that account to?
WILLIAMS: I recollect telling Ian Harvey. I recollect telling -- well, I recollect if it was
mentioned at any meetings, the Executive meetings, I am pretty confident, well, you know, I can't
be 100% sure but I brought it up on a number of occasions definitely because I thought it was a
piece of information that could be utilised.
LANGDALE: Why did you think that?
WILLIAMS: Because of my experience.
LANGDALE: Sorry, why did you think it was a useful piece of information for them to hear?
WILLIAMS: Because I felt that, you know, they needed to consider the police. I did tell them I
spoke to Alison Kelly on a number of occasions, one I remember with Karen Rees in my office saying
that you need to go to the police and she said "I have taken advice" and that was it and she
wouldn't listen.
LANGDALE: By the time you and Julie Fogarty were doing this analyses and then there was other
reviews going on, did it at any time feel as though you were taking on the role of the police
trying to look formal information and retaining fluid bags and doing things without really the
resources or the knowledge or the expertise --
WILLIAMS: I think we were just tasked in a management responsibility to do it. Yes.
LANGDALE: Did that sit comfortably at the time?
WILLIAMS: It -- it was uncomfortable given what I had been through in the past which is what I
kept saying to them.
LANGDALE: Do you see referral to the police as essentially a neutral act just that an
investigation is needed where there is concerns for a child that may be harmed or may not be
harmed, that is the point of the referral?
WILLIAMS: I personally say that, yes.
LANGDALE: So you understood you don't need conclusive evidence or evidence of guilt, that is what
the police look for if there is evidence one way or another?
WILLIAMS: But the Executives said that they were -- had taken advice and they need that we had to
do our own investigation first.
LANGDALE: So your staffing analysis fed into that investigation?
WILLIAMS: Yes.
LANGDALE: You say: "I did consider going to the police myself but as I had been told by the
Executive Team that they needed to do their own investigation and as Stephen Cross was
WILLIAMS: ex-police officer and had a legal background coupled with the fact that the Consultants
didn't see the need to do this, I didn't take it forward as I was not privy to all of the
information."
WILLIAMS: No.
LANGDALE: Just pausing there. With the Consultants' position, you have said earlier that when the
Consultants had raised the concerns, it is for the Risk Team to manage that through the risk
process. Where the Consultants had raised concerns about the babies and very clearly in that
mortality review and subsequently, who do you think was responsible for making decisions about
going to the police?
WILLIAMS: I think you could argue everybody should have that responsibility.
LANGDALE: Including you?
WILLIAMS: Yes. Yes, I put that in my statement, I regret not doing it --
LANGDALE: Do you?
WILLIAMS: -- at that point. Yes.
LANGDALE: When would you have done it if you were going to do it?
WILLIAMS: I think by the time I had gone through the mortality reviews and there was a name then,
yes, then definitely.
LANGDALE: So the Triplets?
WILLIAMS: Yes.
LANGDALE: The O and P Triplets, so by July?
WILLIAMS: Yes.
LANGDALE: There was a meeting, wasn't there, on 13 July. If we go to enclosure 5 -- sorry, it's
actually enclosure 4, Mrs Williams, the last document, and it's INQ0003365, page 4. 3365, page 4.
WILLIAMS: The handwritten notes.
LANGDALE: Exactly.
WILLIAMS: Yes.
LANGDALE: This is about a discussion around Letby having supervised practice?
WILLIAMS: Yes.
LANGDALE: Moving down to the meeting on 13 July, reference from Ian Harvey, we are aware of your
concerns re one member of staff. Over the page, page 5. There is correlation with a nurse but we
know a change in acuity and activity. That is Tony Chambers. Further down: "Dr ZA, nurse worrying
correlation. One possibility criminal, it could be something else. Not necessarily criminal." "Dr
Jayaram: data is good. How do I feel?
A doctor would have been suspended." Over the page, Mr Chambers: "A week ago only option to ring
the police." Do you understand why he was saying: but there was not a need now to do that at this
meeting on 13 July, because we have seen the emails about the discussions and at this point he's
suggesting that is not the only option. Can you remember why that was the case?
WILLIAMS: I can't remember, no. There is no detail to say why he's come to that conclusion.
LANGDALE: Well, he carries on, doesn't he, two lines down: "We can create harm to nurse, fragile,
toxic, need to protect it." I think that says "need", anyway, he will deal with that in his own
evidence. But you see there is focus, isn't there, on Letby herself, do you remember that?
WILLIAMS: I don't, no, sorry.
LANGDALE: If we go further down: Dr Gibbs: not discussed with nurse, only nursing lead Eirian.
How can we Consultants accuse nurse but do not know if it is that nurse?" So some discussion
around: well, we don't know for sure it is her, we are worried about that; you see that? We don't
know?
WILLIAMS: That's what John Gibbs is saying here.
LANGDALE: Yes, and then if we go over to the next page, page 7: "Dr Jayaram: should not be
blinkered to the unspeakable. Fine balance, my objectivity compromised. Clarity re supervision and
cameras." There is discussion about having cameras, isn't there, at this stage?
WILLIAMS: (Nods)
LANGDALE: Sorry, you nod; that doesn't get picked up?
WILLIAMS: Yes. Sorry.
LANGDALE: Yes. So there is discussion about to achieve security on the unit, you need CCTV at
this point, yes?
WILLIAMS: That's the impression, there yes.
LANGDALE: We see further down: "Dr Gibbs: Cameras good. Corridors, deterrent. Someone killing
babies but don't know this, I do not feel we need to whistleblow, how do we sell cameras?" If we
go over the page, to page 8: JG [Dr Gibbs]: main worry is nurse therefore must be totally
supervised. Cast iron assurance total supervision." Then there is notes there: "Mass murderer,
coincidental, not involved."
You say, this is your contribution to this meeting: "Will affect staffing levels"?
WILLIAMS: That's right.
LANGDALE: So what was your thinking when you say "will affect staffing levels"?
WILLIAMS: So if it -- the conversation is -- I mean I can't remember the detail, but if there was
a competency issue with an individual and you have to supervise them, then it does affect it
because you have -- somebody has to work in a pair so there wouldn't be sufficient staff then to
staff the rest of the cots.
LANGDALE: So that meeting taking place as it does on the 13th, you are aware that it's Letby that
they are worried about but they don't know and they are worried about her being upset by it and
it's a difficult situation; yes?
WILLIAMS: I don't remember the detail, but clearly that's what it says.
LANGDALE: They are so worried about foul play they are talking about CCTV being introduced for
security on the wards?
WILLIAMS: Yes, that was a general belief anyway that neonatal units and areas need CCTV. So ...
LANGDALE: You say a general view. Where was that discussed between doctors and --
WILLIAMS: Other organisations having it routinely.
LANGDALE: Yes, other organisations?
WILLIAMS: Yes.
LANGDALE: But you as a group of doctors and nurses hadn't been having that conversation until
this meeting or had you?
WILLIAMS: No.
LANGDALE: No. So that can come down. You tell us that in your statement going back to that at
paragraph 61: "The Executive Team had made the decision that Letby was to be allowed to work in a
supervised capacity." So it looks as though you were tasked with writing a letter to her, to that
effect, enclosure 5, and the document reference is INQ0003147, page 1.
WILLIAMS: Yes.
LANGDALE: We see there when it comes up, your letter. If we look at the last two paragraphs on the first page you explain: "The review which has been undertaken to date has been unable to explain the collapse or deterioration of babies in a number of cases ... serious concern to the Trust. The review which has been undertaken has revealed that a small number of staff were regularly involved in the care. Their involvement was either on the shift or on the shift before a baby had unexpectedly collapsed or deteriorated. As we discussed during our meeting, you have been identified as one of these members of staff. The review has identified you as being more regularly involved in the care of babies concerned." And you continue. The next paragraph: "A decision has been made to provide additional support to all of the staff including you" --
LADY JUSTICE THIRLWALL: I'm not sure you have the right passage on there on the screen.
MS LANGDALE: Sorry. Page 2. Top paragraph. That is fine. "The review has identified you as being
more regularly involved in the care of babies concerned." And the next paragraph: "As we discussed
patient safety is of paramount importance." In the middle of that paragraph: "Therefore a decision
has been made to provide additional support to all of the staff, including you, who have been
identified in the review. I explained you will be the first nurse to undergo this process due to
you being identified in the review as being the most regularly involved." Who drafted this letter
with you?
WILLIAMS: Sue Hodkinson, if I recall.
LANGDALE: It then says in the next paragraph: "The Royal College of Paediatrics and Child Health
are undertaking an external review commencing on 18 August. The Trust has decided you will remain
subject to clinical supervision until the Trust has received feedback from the external review.
Other staff who have been identified as being regularly involved in the care of babies will also
undergo a similar process." Do you think this letter was transparent with the concerns that had
been raised and the true situation?
WILLIAMS: No.
LANGDALE: Why not and whose suggestion was it that it should not be?
WILLIAMS: It was the Executive decision. They proofread the letter and edited anything that was
...
LANGDALE: When you say "the Executive", which ones?
WILLIAMS: I am pretty sure it was Sue Hodkinson. Whether Alison Kelly also had input I'm not sure
but I am pretty sure it was Sue Hodkinson with an HR background.
LANGDALE: Did she give you any sense of why that was the
case, why it should be sugar-coated or set out in this way?
WILLIAMS: Because at that point, the -- the Executives were still of the belief it wasn't a single
person.
LANGDALE: Right. Which Executives didn't think it was a single person?
WILLIAMS: I am -- I'm not sure if you could say individual ones. I think it was a group.
LANGDALE: And did you truly believe when you sent that letter that she was going to be supervised
and then others would be or did you know that just would never happen?
WILLIAMS: Well, I was confident that they were going to do some supervision of the nurses there,
not supervision, retraining, skills updates, that type of thing.
LANGDALE: There's another letter, the next page for you, and if we can go, please, to INQ0002731, page 1. You here are sending to Eirian a draft, is that right?
Have a look at this. One says "It is good to go". Have a look at this email. Have you seen this or
had input into this draft?
WILLIAMS: I don't recall having any.
LANGDALE: It says: "In preparation for the external review it has been
decided that all members of staff need to undertake a period of clinical supervision. Due to our
staffing issues it has been difficult to determine how we undertake this process. We can only
support one member of staff at a time." So this is an email to be sent to everyone on the NNU,
isn't it, by -- we know it is sent by Yvonne Griffiths for clinical supervision, but it looks like
you or Eirian Powell have had an input into this letter. You have certainly seen this?
WILLIAMS: I don't recall having input but I clearly did see it, so I must have known about it,
yes.
LANGDALE: So you knew that this is what all of the staff were going to be told?
WILLIAMS: Oh, yes.
LANGDALE: Yes?
WILLIAMS: Yes, my understanding was that was going to happen, they were going to do some
supervised practice for other staff as well, just to give people additional training to make sure.
LANGDALE: Again, do you think that letter was transparent with the neonatal unit staff that in
fact there was suspicion of foul play and there was going to be an investigation?
WILLIAMS: With hindsight probably not, however --
LANGDALE: What do you think with hindsight that communication should have said at this point?
WILLIAMS: I think it's very difficult because at that point you know, naming a name wasn't an
option according to the Executives, so I think there was going to be some training definitely. I
think that was the belief; that they did need some additional training.
LANGDALE: When you say naming names wasn't an option, why was that?
WILLIAMS: Because it was an Executive decision. They felt it wasn't the right thing to do.
LANGDALE: Do you think that was realistic given that her name was coming up in mortality reviews,
at meetings, discussion around her commonality with all the internal reviews being done?
WILLIAMS: It depended on who they wanted to talk to, basically.
LANGDALE: Were people told not to mention her name and not to talk about her individually?
WILLIAMS: I -- I don't recollect that specifically, no.
LANGDALE: Well, you don't refer to her name anywhere in your communications, as I have seen it.
Do you remember that, do you remember having conversations?
WILLIAMS: No.
LANGDALE: You were at pains to say you don't remember seeing that mortality review with her name
in red. Was there a sense that you couldn't mention her name or you should not mention her
name?
WILLIAMS: I think the Executives were of the -- still of the impression that or the opinion that
you -- you couldn't mention her name yet. It wasn't cut and dry, if you like. I don't want to use
that saying, but --
LANGDALE: It wasn't crystal clear, "cut and dry", your expression?
WILLIAMS: Thank you.
LANGDALE: It wasn't cut and dry, so don't mention her name because it is a serious
allegation?
WILLIAMS: Yes.
LANGDALE: In that, there is a line, isn't there, between being misleading, not mentioning a name
and being misleading about the true circumstance; would you agree?
WILLIAMS: Looking back at it, yes.
LANGDALE: When the police were eventually contacted, did her name become known then?
WILLIAMS: I don't know, because I had left by then.
LANGDALE: Okay. If we go to another document in the same enclosure, 5 for you, it is INQ0005769 at page 2, this is a letter 14 July -- sorry, an email, 14 July
and you are sending it to Sue Hodkinson to run it by her. Page 2.
WILLIAMS: Yes.
LANGDALE: It's just above. You send this and you want her to have a look at it and if we go to
page 4: "Security. Sue outlined the proposal to install cameras in the NNU following a recent
security review. Can you please make sure you meet with Tim Lister to discuss the best place to
put them." Do you know if they were ever put in or why they weren't put in, if they weren't put
in?
WILLIAMS: I don't think they were ever put in.
LANGDALE: But it was being followed up by you, wasn't it, the need for cameras at this time in
the unit?
WILLIAMS: It was being followed: "Action; Eirian Powell to meet with Tim Lister."
LANGDALE: In fact, we know -- that can come down -- Letby was removed from the unit and she was
moved into the Risk Department. What was your view about that move to her into the Risk
Department?
WILLIAMS: I didn't have -- my view is it was probably not appropriate. I didn't have the -- I
didn't have an option as to where she was going so I made the -- I made the decision to keep her
in Patient Experience and PALS, you know, counting patient experience cards and making, you know,
pulling the comments out, rather than have her with the Risk Team per se.
LANGDALE: Did you share that concern about her being in the Risk and Patient Safety Team?
WILLIAMS: I am -- I can't 100% be sure but I am fairly sure I did say to Alison it was not the
best move. But I didn't have an option, so ...
LANGDALE: Were you concerned that she would have access to material about the babies on the unit
or generally or what?
WILLIAMS: I did raise that concern but she sat in the other office, she wasn't in with the rest of
the Risk Team.
LANGDALE: Is there a computer system where you have access to?
WILLIAMS: There is, I'm not sure whether or not she had access because not everybody has access to
it.
LANGDALE: At paragraph 74 of your statement, you say: "I personally did not consult with Stephen
Brearey, about his view regarding patient safety if Letby returned to the ward. The Executive Team
undertook all discussions with the paediatricians and Dr Brearey." Looking back, do you think you
could have had more discussions with Dr Brearey or Dr Jayaram or did that not seem
appropriate?
WILLIAMS: It would have been a viewed as inappropriate by the Exec Team because they were holding
the ring on
it.
LANGDALE: Because they were?
WILLIAMS: Holding -- they were holding it, if you like.
LANGDALE: Holding it, holding the reigns of the situation?
WILLIAMS: Yes, yes.
LANGDALE: Were you all aware of that, that it wasn't -- you weren't free to do whatever you each
wanted; there was a -- I don't want to say "party line" but a process that was going on? How would
you describe it?
WILLIAMS: That any conversations around that went via them first.
LANGDALE: Who's "them"?
WILLIAMS: The Execs.
LANGDALE: Right. Which Execs? Sorry to push you on that.
WILLIAMS: Ian Harvey and Alison Kelly, really.
LANGDALE: Right. Ian Harvey and Alison Kelly. What about Tony Chambers was he very directly
involved as far as you were aware?
WILLIAMS: He attended the meetings as you can see. I'm not sure he was as close to it as Ian
Harvey and Alison Kelly.
LANGDALE: Right. You tell us the Royal College of Paediatrics and Child Health report, you don't
recall, paragraph 79, ever seeing the Terms of Reference --
WILLIAMS: No.
LANGDALE: -- for that review. What did you understand that review was going to do?
WILLIAMS: I never saw the Terms of Reference. We weren't privy very to them. My understanding is
they were going to look at general staffing levels, care, just those sort of things.
LANGDALE: Looking at the babies, presumably? You realised they were getting some review of the
babies' care?
WILLIAMS: My understanding was that they would look at the care of infants in there per se. I
don't know if they were given specific details to look up this baby or that baby or ...
LANGDALE: So you didn't know which baby, but you thought they were looking at babies?
WILLIAMS: No.
LANGDALE: What -- if you were going to guess at that time, did you think about that at that time,
what babies they would be looking at?
WILLIAMS: I thought that it would be covered in their Terms of Reference; they would look at the
care of individual babies.
LANGDALE: And at the time, would you have expected that the parents of the babies they were
looking at would be informed that that was going to happen at the time that instruction was
made?
WILLIAMS: I think it would have been fairer to have told them at the time because often parents
can share concerns or bring information that can contribute.
LANGDALE: As far as you were aware, had any of the parents of the babies named on the indictment
who died had any input or conversations with the Exec Team?
WILLIAMS: I don't know. And as far as I am aware probably not, but I couldn't say one way or the
other.
LANGDALE: Did you ever ask that and say: Look, you know, we have seen there was discussion about
communication with families. Look, these families need to know if their babies are being
reviewed?
WILLIAMS: I don't recollect saying that, no.
LANGDALE: Did you ever think it?
WILLIAMS: I can't remember at the time. I -- it was very much left with the Executive Team to --
to deal with that. I would have expected Alison possibly to have said it.
LANGDALE: If you were asked what your view was at the time, what would you have said in terms of
what they should know?
WILLIAMS: That they should know that it was happening, that we were reviewing the care.
LANGDALE: And that they should know when a report comes back and --
WILLIAMS: Yes.
LANGDALE: -- what it says?
WILLIAMS: Yes.
LANGDALE: Was there ever a discussion about that --
WILLIAMS: I don't think there was.
LANGDALE: -- that you were involved?
WILLIAMS: Well, obviously when it came back, I think there was some, you know, area communication
to the families.
LANGDALE: Moving on to the topic of the grievance. We know Letby took out a grievance
subsequently and Dr Christopher Green was the investigating officer as part of the grievance
investigation and you had an interview with him. What did you think the grievance was about?
WILLIAMS: I never saw -- I have -- I never saw the terms, the grievance, I never even saw the
outcome of the grievance until the bundle came to be fair. I was led to believe it was to do with
how Lucy Letby was being treated by the Consultants, that's, you know, the allegations that were
being made. That's
all.
LANGDALE: Okay. So can you remember who told you that? Was that --
WILLIAMS: I'm not sure. I -- I -- I can't remember.
LANGDALE: But before you were interviewed, you thought it was about her complaints about how the
Consultants had treated her?
WILLIAMS: That she had raised a grievance is what I had been told. But I didn't know the level of
detail, so I would just be assuming.
LANGDALE: You say at paragraph 83: "I recall asking the Director of Nursing, Alison Kelly, if it
was appropriate to continue with the grievance process given investigations such as that by the
RCPCH were ongoing."
WILLIAMS: Yes.
LANGDALE: So can you expand upon that, please? What did you say about that?
WILLIAMS: I did recall, when the grievance was issued, that a number of staff were having to be
interviewed and I recall saying to Alison that I didn't feel it was appropriate and would it not
be better to wait until we had all the information together because we had not got the Royal
College position report and it's -- it just felt it wasn't the right thing. Now, if I recall
right, she said she had taken advice and it was going ...
LANGDALE: What were you thinking was the right thing?
WILLIAMS: To wait for the outcome of the rest of the information.
LANGDALE: The investigation, effectively --
WILLIAMS: Yes.
LANGDALE: -- as you thought it may be with the RCPCH?
WILLIAMS: Yes.
LANGDALE: So have the results of the investigation. Why was that necessary to have that before
looking at a grievance? It may seem obvious, but can you explain your thinking?
WILLIAMS: My thinking would be that they had made -- you know, until you get it all together and
you look at the bigger picture sometimes people make decisions that, you know, they haven't seen
it and they miss something and miss the opportunity if you like. So my -- I would have waited
until it all came together, got the bigger picture and then you can decide the most appropriate
course of action at that point.
LANGDALE: Did you think she needed to be investigated?
WILLIAMS: Do I... ?
LANGDALE: Did you think there needed to be an investigation into Lucy Letby, whether it was
disciplinary or a police investigation?
WILLIAMS: I -- as I said on a number of occasions, I felt the police needed to be involved, not --
to look at the deaths and make that decision as to whether it was an issue or not.
LANGDALE: Because there was suspicion around these deaths and they needed to find out who it was
if someone was causing the deaths?
WILLIAMS: Yes. There was -- they were unexplained and there were a number of unexplained
collapses, yes.
LANGDALE: Your interview with Dr Green is at enclosure 9, which is INQ0003164, page 1. So you are being interviewed by him because you now
understand from what you have said that it is a grievance she's raised about how the Consultants
have treated her. Did you think you were particularly being asked about one topic or did you feel
it was quite an open interview when you look back?
WILLIAMS: I can't really remember to be honest. When you mean one topic?
LANGDALE: Okay. If we go to the first box, you say: "I was told that Lucy was swapped from nights
to days. I would have expected..." No, it's further up -- there we go, thank you: "I was told that
Lucy was swapped from nights to
days."
WILLIAMS: Yes.
LANGDALE: "As a result of that, I would have expected an investigation."
WILLIAMS: Yes.
LANGDALE: So that was in April 2016. So when she was moved to day shifts, you would have expected
an investigation, you tell Dr Green that. Did he ask you why or what your thinking was about
that?
WILLIAMS: I don't know. If it's not in the transcript, you know, probably not.
LANGDALE: If we go over the page, the top box, so page 2, top box?
WILLIAMS: Yes.
LANGDALE: "There were no red flags", you say: "Sudden deterioration in neonatal babies is
apparently common. Although I am not neonatally trained I didn't find anything more than that. I
asked how the sudden deterioration could happen and was told they are more unstable than adults. I
met Lucy in my office with EP and explained that she featured in terms of attendance so we will
start with her doing supervision clinical competencies then work down the list of staff and finish
with the ones that only work one shift." You don't mention here -- you say there is
increased deaths, you don't mention there was suspicion of foul play and the Consultants were
really worried about that. You don't say that, do you?
WILLIAMS: No.
LANGDALE: Why not?
WILLIAMS: I cannot recollect as to why not. I don't think it was a specific question that was
asked, so ...
LANGDALE: You don't think you were asked whether the Consultants had concerns, whether they were
worried or whether it was genuine?
WILLIAMS: Not unless it appeared on here, no.
LANGDALE: You were asked by Dr Green: did you tell her that there had been allegations from the
Consultants about her specifically? And you say: I was using the phrasing I was asked to by SH and
AK. So Sue Hodkinson and Alison Kelly had told you what you could say to her; is that right?
WILLIAMS: Yes, yes.
LANGDALE: Did you feel a bit like you were the messenger in this?
WILLIAMS: Yes.
LANGDALE: Did you think it was the right thing to do, what you were telling her?
WILLIAMS: With the benefit of hindsight, I should have stood up a bit more to her.
LANGDALE: With the benefit of hindsight should you have told Dr Green the Consultants had genuine
concerns they were worried and indeed you thought the police should have been contacted and they
had -- if they had, as far as you were concerned?
WILLIAMS: (Nods) Yes.
LANGDALE: Do you think you should have told him that?
WILLIAMS: Possibly. I -- I have a feeling he probably knew.
LANGDALE: What's that?
WILLIAMS: You know, the -- about the -- the -- because he knew, the allegations had come forward
so I think he probably knew that there were allegations but I wasn't specifically asked.
LANGDALE: Do you think he knew that the Consultants were genuinely worried about babies
unexpectedly dying and collapsing and one person being present?
WILLIAMS: Maybe not the one person being present but yes, I think he probably knew about the
deaths.
LANGDALE: Why do you think he knew?
WILLIAMS: Because I -- this was after the meeting. This date here is October 2016 and we had that
meeting where Sue Hodkinson pulled it together in the boardroom that time and he was part of that
meeting. So, yes, I think he probably knew.
LANGDALE: He does ask you, doesn't he, near the bottom of the page, the last but one: "Have you
heard about any allegations about Lucy?" You say: "I am aware that they feel she is to blame. I
was told by someone else that one of the doctors had referred to her in the context of there's a
murderer on the loose out there in one of the outpatient clinics, but not by name." Pausing there,
did you ever have a name of anybody who had heard that allegation given to you? Heard that
suggestion that there is a murderer on the loose out there was said?
WILLIAMS: That was a second -- the conversation somebody had said they had overheard it and told
me but I never heard it firsthand.
LANGDALE: Hearsay?
WILLIAMS: It was just hearsay.
LANGDALE: Who told you that?
WILLIAMS: I can't remember who it was --
LANGDALE: A nurse?
WILLIAMS: -- to be honest. It could have been or it could have been one of the other managers, I
don't know.
LANGDALE: In all your time there did you hear anyone
speaking like that?
WILLIAMS: I didn't, no. No. I personally didn't.
LANGDALE: So of all the things when he asked you about allegations about Lucy, why is it that you
come up with that, which you had never heard and you had sat in mortality reviews and heard Dr ZA
express concerns about what had happened to the babies?
WILLIAMS: Because at the mortality reviews, you know, would name -- sort of harp on about a
specific name of those things, I don't remember those specific things, just the care of the
babies.
LANGDALE: If you go to the end, page 3: "Is there anything else you want to tell me? If the
Consultants really believed she had done it why didn't they go to the police and why have they
come to that conclusion?" You didn't go to the police either?
WILLIAMS: No.
LANGDALE: You thought you should do. So again do you think you have you are having a pop at the
Consultants there for something that you say you could have done and should have done?
WILLIAMS: I think they were much closer to it than I was. They had done quite a lot themselves,
but I agree, with the benefit of hindsight, I should have
gone to the police.
LANGDALE: Do you think this interview, you might have communicated what you communicated in your
police statement subsequently a number of issues?
WILLIAMS: I don't know what --
LANGDALE: Let's go to -- that can come off the screen INQ0001996, page 4. It's at the back of your Inquiry statement, the police
statement and it's paragraph 3. "I remember being at another meeting ..." Sorry, it is just up on
the screen now at the top, do you have it, Mrs Williams? "I remember being at another meeting
after the review I had done, with the Consultants and the Medical Director, the clinician staff
were clearly twitchy about the whole situation. I recall one of the female Consultants, possibly
Dr ZA, suggesting the deaths might have been caused by the injecting of air. The meeting was very
upsetting." So you knew when you told the police that at least one doctor you had heard that being
said?
WILLIAMS: It was the meeting that was referred to -- I am pretty sure this is the meeting that is
referred to where the Exec Team were there, Tony Chambers was there, everybody was there. I think
it was one of the big meetings where one of the Consultants walked out who was upset, so I think
it was that one.
LANGDALE: Okay. Do you think that was before the grievance on 24 November 2016 or after?
WILLIAMS: I think it probably was before the grievance.
LANGDALE: Before, okay. So you had that information before you spoke to Dr Green?
WILLIAMS: (Nods)
LANGDALE: Was there an atmosphere in the context of that grievance, you say you knew it was
raising concerns about the Consultants and how they treated her was the atmosphere that that is
what you were there to talk about what the Consultants had done or said or behaved like rather
than what had happened to babies?
WILLIAMS: It -- it was what their behaviour was, rather than the babies.
LANGDALE: You agree from what you have said before that what was needed at that point was either
a disciplinary or police investigation, a police investigation?
WILLIAMS: Yes.
MS LANGDALE: Contact with parents. You set out at paragraph -- I see the time actually, my Lady. It might be a good place to stop. We've been going for an hour and a half, Mrs Williams.
LADY JUSTICE THIRLWALL: Very well. So we will take a break now and we will start again at quarter to 12.
(11.28 am) (A short break)
(11.45 am)
MS LANGDALE: Mrs Williams, before I move to contact with parents, can I just take you back to
paragraph 19 of your Inquiry statement and you are speaking of July 2015 and the Serious Untoward
Incident review we went to and you think it was around that time -- you say at that time where the
mortality rates were discussed Dr Brearey was not overly concerned at that stage and indicated
that peaks in deaths can sometimes occur. You can't recall the date but it looks as if it is
around that A,C,D, time; do you remember him raising that with you?
WILLIAMS: I -- I am not convinced it's the 2 July one. I think it's like a neonatal review that he
did separately. I am not 100% convinced of the date. It might have been late in 2015, October time
round. But I couldn't swear to it.
LANGDALE: You remember he wasn't overly concerned but you say as things continued he became more
concerned; is that your evidence?
WILLIAMS: Yes, yes, basically.
LANGDALE: If we go now, please, to enclosure 6 for you, the second document and INQ0012622, page 3. This is a letter sent from Mr Harvey in February 2017
and this is a letter intended for parents of the bereaved children and we see he sets out there:
"Following on from your conversation please find enclosed a copy of our report ... explain to you
we asked for this external assessment from the Royal College. This step was taken because we
wanted to better understand why there had been a greater number of deaths than we would normally
expect. In the report it describes no single cause or factor to explain the increase we have seen
in our mortality numbers." It continues: "You will see in the report one of the recommendations
includes a thorough review of the specific care and treatment each baby received. This is personal
and confidential to you and your family and we would welcome the opportunity to meet and discuss
with you the care your baby received." The -- you tell us that you were involved in contacting
families and indeed just before that letter on a page dated 3 February 2017, we see ciphered names
and ticks where you have presumably indicated things by your ticks. If we have that page, INQ0012622, page 1.
People will see what that means. That's something you had pulled together and you were using that,
were you, as you made telephone calls and the like when you contacted parents; is that right?
WILLIAMS: Yes. I think the -- the admin team pulled it together and supported me in the process as
well.
LANGDALE: So the admin team supported you and you were making the calls. That can come down?
WILLIAMS: Yes.
LANGDALE: The Inquiry has heard evidence from the parents of the babies named in the indictment
and there are two stages where they were not informed where I am sure you would agree they should
have been and the first was when there was a press statement announcing the RCPCH review, the
parents should all have known about that review, shouldn't they, before that announcement was made
in the media?
WILLIAMS: Yes, we discussed that before because I believed they should have been part of the
process.
LANGDALE: Then there was the occasion of the report itself being leaked to a newspaper and the
parents being contacted by you on a Friday evening to tell them it was about to be leaked in a
newspaper. Deplorable, isn't it, that that's how they should hear about it?
WILLIAMS: Yes, I can't disagree with that.
LANGDALE: We heard from different parents, we heard from Mother C who was expecting another child
and was still in contact with the Countess of Chester, her mobile details, her presence at those
antenatal visits and no effort made to tell her about that which she did not know; that the RCPCH
report was being conducted, and I think it was you and Alison Kelly who spoke to her about that
when she found you and came to speak to you about it?
WILLIAMS: Yes.
LANGDALE: Do you remember that?
WILLIAMS: I -- I don't remember it but I have seen her recollection --
LANGDALE: It's right that she came and spoke to you both?
WILLIAMS: Yes.
LANGDALE: She says that you were apologetic at that time and she assumed there would be good
communication moving forward and yet she was one of the number who were not told about that report
when it was available to the Countess and learned about it in the run-up to the publication?
WILLIAMS: (Nods)
LANGDALE: Why was it that that level of communication or lack of communication took place?
WILLIAMS: I am unsure as to why the Exec Team made that decision. I recollect -- well, I don't
physically remember it, but I have looked at my notes and I did call members of families. I don't
recollect as to why they -- the Executive Team weren't more proactive. I do, looking at an email
which I have seen, here email them in February because I left the Trust at the end of March and in
February I emailed Stephen Cross to say I was concerned that the communication wasn't as it should
be and, you know, we desperately needed to try and improve it and that, you know, I couldn't
emphasise how anxious the parents were when I spoke to them on the phone.
LANGDALE: You do communicate that. We have seen an email that you say they are anxious. You were
contacted by Mother D, she was waiting for an Inquest, pushing for an Inquest, wanted to know what
was being done about her baby girl. She shouldn't have had to phone you to find that out?
WILLIAMS: Yes, I mean the Trust don't do the Inquest per se, it is for the -- the Coroner. But
however, yes, we there's little doubt in -- with the benefit of hindsight, and I hate to keep
saying that word --
LANGDALE: Mother E and F as well?
WILLIAMS: We should have been more proactive and we
should have -- you know the Trust should have -- if there's nothing to say at that point then the
Trust should have said nothing, we have got nothing to update you but, you know -- that's, you
know, how it should have been dealt with.
LANGDALE: When did you learn, if at all, that babies had been administered insulin, deliberately
administered insulin? Did you know which babies?
WILLIAMS: No.
LANGDALE: Were you ever asked to communicate that to the parents of those babies?
WILLIAMS: No.
LANGDALE: Mother I, she had no idea that the review or RCPCH was ongoing and even being conducted
until she received a letter, did she, again?
WILLIAMS: No. I think I -- we had tried on a number of times to ring but sometimes there were no
numbers or we got, you know -- you know more, worryingly out-of-date numbers, that type of thing.
LANGDALE: Well, that is challenged in some cases, Mrs Williams, and it's often said, isn't it:
you have moved house, it is the wrong number and that is certainly challenged in one case, someone
who hadn't moved house, Mother C, and it depends how hard we try to find people doesn't it?
WILLIAMS: Yes, I agree. I -- I cannot dispute sitting here defending the communication because it
was poor, little doubt it was poor.
LANGDALE: With little compassion or understanding of their anxiety and their position?
WILLIAMS: I -- I -- I can't dispute that, I have not been in their position. You know, on
reflection that's the one area -- sorry, we could have improved. Sorry.
LANGDALE: It sounds as though you and Alison Kelly when you first met Mother C recognised that
and apologised so why was it -- obviously a question for Alison Kelly too -- that there wasn't
more proactivity, you had seen someone in the flesh, it is often very different when we meet them
directly, isn't it, you have them in mind, you understand the suffering --
WILLIAMS: Yes.
LANGDALE: -- better, arguably, than when you don't have a person in mind and these parents were
reaching out to you?
WILLIAMS: Yes.
LANGDALE: So why was it that wasn't proactive from you and her?
WILLIAMS: Because that was the Exec decision that I was being told what to do and how to do it and
that type of thing, so it was down to that. I was actually away a significant part of February. I
had gone on holiday and I didn't come back until sort of mid-March and then was only there for 10
days after that. So, you know, I didn't ...
LANGDALE: You took a call, didn't you, from Father O, P and R, bereaved Father, both O and P we
now know murdered, and he was not happy, was he, with the follow-up? No contact since the death of
his boys, no bereavement support, and made the point too it wasn't -- the support there wasn't
like at Liverpool Women's just generally when he had been there. Do you remember that
conversation?
WILLIAMS: I -- I don't remember the call but I have seen some notes. Yes.
LANGDALE: So you agree that level of communication was coming in at that time from the parents of
bereaved families?
WILLIAMS: Mmm and it was not recognised and not dealt with appropriately.
LANGDALE: When you say it was an Executive decision, which Executives -- sorry to keep pressing
you on this, but there is a number, so who do you say was the most sighted on that issue and made
those decisions?
WILLIAMS: Probably Alison Kelly.
LANGDALE: Right. So it's for her to explain to us what
the reasoning was behind that. As far as you were concerned, would you have made calls at any time
if you had been asked to do so and provided information that you were told to provide?
WILLIAMS: I would like to have thought I would, I -- you know I'm -- yes, I am the type of person
who likes to -- if there is nothing to say, like I say, ring them up and say "there is nothing to
say"; at least then you maintain contact.
LANGDALE: One more document, please, at appendix 8, for you, enclosure 8, and it is INQ00028790120. This is the safeguarding guidance and consideration of
referral to the LADO, Local Authority Designated Officer, when it comes up. We just see in the top
two bullet points, if there is a concern raised or an allegation made about a person who works
with children, whether a professional staff member, foster carer or volunteer that they may have
behaved in a way that has harmed a child or may have harmed a child, possibly committed a criminal
offence, what should happen. You tell us you weren't aware of that policy, you tell us also that
you hadn't worked with children other than your contact with the neonatal unit?
WILLIAMS: No.
LANGDALE: Is that the case that at the time you weren't aware of the child protection or
safeguarding measures that applied?
WILLIAMS: Not to that level of detail. No. I didn't work with children, like I say, and as Alison
Kelly led the Safeguarding for Children Team, you know, she knew the level of detail and used to
attend the meetings.
MS LANGDALE: Yes, thank you. I have no further questions, Mrs Williams. There are some questions, my Lady, from Mr Sharghy first and then Mr Baker.
MR SHARGHY: Mrs Williams, good -- I think it is still just about morning and I am going to be
asking you questions on behalf of a number of Families. Although I represent the Families of
[Child I], I am also going to be asking questions on behalf of [Child A], B, L, M, N and Q. You
have been taken through a lot of documentation and in particular focusing on your staff matrix
review that you carried out with Mrs Fogarty which was completed on 11 July 2016?
WILLIAMS: (Nods)
SHARGHY: I am not going to go through the background to
what it was and why you were asked to carry out that role but I would like to know a little bit
more about the reporting you made to the Executive Team but you specifically highlighted Alison
Kelly, Ian Harvey and Sue Hodkinson. When you reported your findings to those individuals, and
perhaps at some point to the entire Executive Team, how clearly and forcefully did you present
your findings and in particular your concerns?
WILLIAMS: So there is two answers. I reported it to, like you say, the Executive Team and myself
and Julie were clear, we had worked out the percentage of how often Letby appeared during that
shift or leading up to a collapse, so we reported that in that clarity. And -- what was the other
one I was going to say? The other one is I spoke to Ian Harvey independently before because when
we had looked at the collapses, I don't know if the meeting was the next day or later on but it
might have been the next day, I was concerned and I went to Ian Harvey and I escalated it to him
and said that this is what we had found. So he and I used the percentage again of those. So I was
as clear as that.
SHARGHY: Can I just ask you two follow-up questions from that?
WILLIAMS: Yes.
SHARGHY: Was Mr Harvey present at the Executive Team meeting approximately a day before when you
presented your findings?
WILLIAMS: I think he was around but I couldn't swear to it. I couldn't swear to it.
SHARGHY: Okay, was there something in particular that led you to go and seek him out for a
further meeting which was a one-to-one meeting?
WILLIAMS: So I think I told him, I think we would just happen to cross paths and I think we were
down in the Executive office and that's when I told -- well, no, I would seek him out, actually, I
went down to tell him specifically -- I went down to tell -- I think it was just him that was down
there so I told him and, you know, he said he would check it out as well.
SHARGHY: Would it be fair to describe your concerns as quite significant for you to have taken
those steps?
WILLIAMS: Yes.
SHARGHY: It would perhaps have gone in terms of what you discovered beyond what in your
experience would have been coincidence?
WILLIAMS: I mean, yes, I -- to have a member of staff on that percentage of time, and we could
look too and say she did -- over time she did this that and the other,
but I was still -- and myself and Julie were concerned.
SHARGHY: I believe I caught your answer in terms of what Mr Harvey's reaction or response was to
what you had told him and I believe you said that he had indicated to you that he would go and
check?
WILLIAMS: Yes.
SHARGHY: Did he say what he was going to check?
WILLIAMS: He said he was going to check it, check the information and look himself because I think
he was going to look at some of the notes as well.
SHARGHY: But by this stage, and again I hope I understood your evidence correctly, one of the
purposes of you and Ms Fogarty carrying out the review was to check the same sort of process that
the Consultants had already undertaken?
WILLIAMS: It was, it was.
SHARGHY: So in other words, this is now a further opportunity --
WILLIAMS: Yes.
SHARGHY: -- that you believed Mr Harvey was looking to check that --
WILLIAMS: Yes.
SHARGHY: -- same information?
WILLIAMS: Yes.
SHARGHY: Did he or any other member of the Executive
Team seem surprised or indeed worried by what you had told them about your findings?
WILLIAMS: I don't recall them being -- saying anything that would give me that impression.
SHARGHY: Did they express any concern either for the families of the babies who you had looked
into or indeed babies who were still being cared for on the neonatal unit?
WILLIAMS: I don't recollect anything to do.
SHARGHY: You say in your witness statement, and I won't take you to it, because I will read the
section that is relevant at paragraph 83 that you felt that the Executive Team were clear in their
minds that the deaths were due to poor care and that Letby was not deliberately harming babies.
What led you to that belief?
WILLIAMS: I will need to look at my statement, is that okay?
SHARGHY: Yes, paragraph 83.
WILLIAMS: So this is where the conversation about the grievance procedure and that type of thing.
I had spoken to Alison about it and I think Karen Rees, that might have been the occasion that
Karen Rees was with me at that point and we had both said and she was adamant that she had taken
advice and they were to carry on with
what the course of action they were taking.
SHARGHY: But in particular, what was it about the Executives' belief that you felt had
effectively dismissed the concept of deliberate harm and it could be more incompetence in
care?
WILLIAMS: Because I think by then I think if they believed that, they would have gone to the
police.
SHARGHY: You have told the Inquiry that you were in a rather unique position because you had
already had some experience in a clinical setting where deliberate harm had been suspected and the
police had been called.
WILLIAMS: Yes.
SHARGHY: You gave the circumstances in relation to that. Was that why you continued on a number
of occasions to press for the police to be contacted?
WILLIAMS: Yes. Yes.
SHARGHY: Did you accept that what the Trust had indicated they wanted to do, which is carry out
their investigations first, sufficient not to call the police?
WILLIAMS: No. I don't accept that.
SHARGHY: Can you elaborate on why not?
WILLIAMS: Because of the information, because of the position I had been in before and that's not
the information, the police -- they were quite -- came in straight away. They didn't want you to
do your own investigation or anything like that.
SHARGHY: Who discouraged you from going to the police yourself?
WILLIAMS: Well, I would like to -- I just -- I wasn't privy to all the information because the
Executives kept -- and there is stuff that's come to me since that I had never seen before. And I
-- I reflected on it: why didn't I go and I should have gone? However, you know, the Exec, the --
the Consultants who were, didn't do it, you know, all those type of things so that's what stopped
me from doing it, to be honest.
SHARGHY: Did you know, because either of your experience on the previous occasion or just
generally in everyday life, that you could have contacted the police but anonymously?
WILLIAMS: I never even thought about doing it anonymously.
SHARGHY: That never crossed your mind?
WILLIAMS: No.
SHARGHY: In terms of the number of times you raised this issue about calling the police and it
not being accepted, did you feel that there was something wrong with the structure or the system
within the Trust, that effectively didn't listen to concerns --
WILLIAMS: Yes.
SHARGHY: -- of senior individuals such as yourself?
WILLIAMS: Yes. I -- I just think that they were -- they had taken -- I got the impression they had
taken advice, where from I couldn't say, and that they firmly believed they were following what
they should have been doing and didn't listen either side, you know.
SHARGHY: You are clear that you believed or you were told that they had taken advice --
WILLIAMS: Yes.
SHARGHY: -- specifically about --
WILLIAMS: Yes, yes.
MR SHARGHY: Mrs Williams, thank you so much that is all my questions.
LADY JUSTICE THIRLWALL: Thank you, Mr Sharghy. Mr Baker.
MR BAKER: Good morning, Mrs Williams.
WILLIAMS: Morning.
BAKER: My name is Richard Baker, I ask questions on behalf of a number of the Families. In this
context specifically I want to ask you some questions about your interactions with the Mother of
[Child C]?
WILLIAMS: Okay.
BAKER: Now, I don't know if you recall, she's in
court so you should be able to see her behind me, so do you recognise her?
WILLIAMS: I don't, no.
BAKER: Okay. Well, let me assist you with some context. Your first meeting with Mother C was in
the summer of 2016?
WILLIAMS: Okay.
BAKER: When she became aware of a leak or a potential leak of a news story and got in touch with
the Trust?
WILLIAMS: Yes.
BAKER: And came into the hospital and met with you and Alison Kelly?
WILLIAMS: Yes.
BAKER: Now as of the summer of 2016, you have been through it already quite a few times with
other people asking questions, but you had recently completed an investigation yourself or a
staffing rota analysis yourself?
WILLIAMS: Yes.
BAKER: You had concerns not just about the association between Lucy Letby and these collapses,
but also the nature of these collapses as well, that they were occurring in babies who appeared to
be stable?
WILLIAMS: Yes.
BAKER: I want to take you to a quote from your police
interview and what you say there it is reflected in the evidence you give but there is a bit more
detail given and you say to the police officer who's questioning you: One of the babies was fine
during the day, collapsed overnight, fine during the day, collapsed overnight?
WILLIAMS: That's right.
BAKER: Fine during the day, collapsed overnight. And the officer says yes. And you say: it was
her that was on duty --
WILLIAMS: That's right.
BAKER: -- overnight. The officer says yes. You say: and it -- that spooked me. I have to say that
spooked me?
WILLIAMS: (Nods)
BAKER: Do you remember saying that or at least that sense?
WILLIAMS: Yes. I remember talking to the police and telling them that, yes.
BAKER: Yes. What did you mean by "spooked"?
WILLIAMS: That during the day that the baby seemed very stable but then overnight, there was a
sudden collapse and back again during the day, that's the concern and that's the one that I
highlighted to Ian Harvey.
BAKER: Yes and that when Lucy Letby was there, this stable baby suddenly deteriorated and when
she wasn't there, it got better?
WILLIAMS: Yes.
BAKER: Now, you had had conversations with doctors who had said: look, we are keeping a bag of
feed behind from the most recent case.
WILLIAMS: Yes.
BAKER: You must have known they were keeping that so that it could be checked for poisons?
WILLIAMS: It's 10 days after the event but I think Letby's name had come up but not in any great
detail in there and they said oh, they had kept the bag of fluid and I thought what -- by this
time I think they were, you know, suspicions that ... So I that's what I thought: what do I do
with that? So and it was late, so I rang, came home, I rang Stephen Cross and he said get Chris
Green to remove it and store it.
BAKER: Yes, but you must have known they were keeping it because they thought somebody might have
tampered with it?
WILLIAMS: Yes, that is what but they never said that, they never --
BAKER: No, but that is the obvious inference, isn't it?
WILLIAMS: I think with the benefit of hindsight yes, but
they never specifically said that. You can keep pieces of kit that are faulty or what have you,
you know, we have had areas before we investigated something like a piece of kit has been faulty
so people have kept it behind, that type of thing. But I was a bit surprised.
BAKER: But if we put it into what Stephen Cross said to you about foul play --
WILLIAMS: Yes.
BAKER: -- and we begin to draw all that together?
WILLIAMS: Yes.
BAKER: You feeling spooked?
WILLIAMS: Yes.
BAKER: Doctors keeping feed bags, Stephen Cross talking about foul play?
WILLIAMS: Yes.
BAKER: Bringing all that together, then the suspicion that was being voiced was that somebody,
Lucy Letby, might be deliberately harming babies?
WILLIAMS: Yes, yes.
BAKER: Yes.
WILLIAMS: Coupled with what the Consultants were saying as well, yes.
BAKER: Yes. Your view was if that's being raised as an issue, it's the police who need to look
into it?
WILLIAMS: Yes, absolutely.
BAKER: So that's the context to the discussion with Mother C that I will come on to in a second
but we are going to hear evidence from Dee Appleton-Cairns, who is an HR person. She says in her
witness statement: "I know that we discussed communications which were being led by Sian Williams.
Sian was to compile a list of stakeholders to be informed which was noted as a priority for the
Executives. I recall that the parents of the babies who had died were to be included on that list
of stakeholders." So is it correct, first of all, that you compiled a list of stakeholders?
WILLIAMS: I do -- I don't -- I don't recall it being part of the parents. The stakeholders I would
have put on that list were the people like NHS England, local CCG, that type of thing. I don't
recall it being the parents on there.
BAKER: Well, should the parents have been involved at the outset?
WILLIAMS: The -- the parents should have been involved at the outset, there is little doubt and I
was just following the instructions of what to do. They should have been involved in looking at
the -- the inquiry for the Royal College, we should have listened to them
because they may have had real relevant information, that type of thing. Absolutely.
BAKER: Well, that is a very important point the relevant information because it has been spoken
about in terms of compassion, sort of keeping people informed, but actually parents might have
really relevant information?
WILLIAMS: I -- I -- I lost count of the amount of times I have dealt with patients and families
who have not been happy with the care and we have involved them and I am unsure as to why the
Executives didn't want to do that in this case.
BAKER: The facts of this case, we know that Mother E, if somebody had spoken with her, she would
have described having an interaction with Lucy Letby and that would have suggested that Letby had
falsified the notes?
WILLIAMS: Yes.
BAKER: So that would have been a really important piece of information?
WILLIAMS: Without a doubt.
BAKER: Yes. So coming on to your meeting, your first meeting with Mother C. This occurs in -- it
is in the summer, June or July of 2016. So that is when we find out an article in the Chester
Chronical newspaper about an investigation. So this meeting occurs shortly after then and it's
with you and Alison Kelly and you were sat in a room with her and you both advised her that their
child, [Child C], was part of the investigation. You have already been asked about contacting them
and how easy it would have been to contact Mother C, so I won't repeat that. But Mother C recalls
that: "They advised me that the investigation was just a formality to check staffing levels
because there had been a small increase in the number of deaths but they didn't think it was
significant. They said there was nothing more to say at that stage and they would find out more
when the report was done." Now, at that time, you knew; in fact you had your own suspicions,
perhaps?
WILLIAMS: (Nods)
BAKER: You sat in a room and either said that or allowed that to be said?
WILLIAMS: Allowed it to be said is what I would probably say.
BAKER: It was untrue, wasn't it?
WILLIAMS: It wasn't as clear as it should have been, I think it should have involved --
BAKER: No, I will go further than that. You knew that there was a real suspicion that a nurse had
murdered their baby and that your own view was that the police should be called. It's misleading,
isn't it, not to keep a parent informed if that's a real concern?
WILLIAMS: Yes.
BAKER: So you must have bit your lip, mustn't you?
WILLIAMS: It wasn't a -- I don't remember the meeting but it's not a place I would, you know, want
-- want to be -- we were told what we could and couldn't say, that type of thing.
BAKER: So I think that's an important point. You were told what you could and couldn't say.
WILLIAMS: Because the inquiry hadn't completed yet, the Executive Team was still probably of the
opinion that it wasn't foul play, that type of thing.
BAKER: What was being said to Mother C wasn't; there are suspicions but there's going to be an
inquiry and we can't prejudge that inquiry. What was said to her, if her words are accepted is
that there was -- nobody thought anything significant was going on, there was just a small spike
in the number of deaths that needed to be investigated. Now, I appreciate your evidence is that
you were --
your evidence is you were told you couldn't say any more?
WILLIAMS: Yes, I don't see I don't specifically recall the meeting, so I can't recall what the mum
said.
BAKER: There might have been a number of these meetings but you must recall sitting in meetings
with parents and having to bite your tongue about what you could and couldn't say?
WILLIAMS: I don't recall it, that's the sad bit in all of this. I wish I could.
BAKER: I mean, you must have a recollection, though, of being part of a cover-up at this
point?
WILLIAMS: I recollect when I have looked at some of the notes -- some of the notes in the parents'
things are not my handwriting. I can see where I have gone in afterwards, that type of thing and
contacted them or had to because we couldn't do it the first time or there had been further
contact. So ...
BAKER: I know, I can see from the notes that you were contacting parents, but your own personal
view is that the police should be called?
WILLIAMS: Yes.
BAKER: You were communicating with people who -- parents who will say that it was said to them
that there was nothing significant going on. You must have had
a sense of being part of a cover-up?
WILLIAMS: I was uncomfortable with the whole thing and that's why I kept going back to the: why
don't you bring the police in?
BAKER: I mean, if it's accepted that those words were said by you or in your presence to Mother
C, in the summer of 2016, is there anything that you would want to say to her?
WILLIAMS: How desperately, desperately sorry I am for the lack of communication, for the whole
situation, that on reflection how much it could have been so different.
BAKER: You see, I'm sorry to keep picking you up on this, but lack of communication is the sort
of thing that is said in an entirely different context. This is parents who are being misled. And
there was a further meeting in January 2017, when you first of all called Mother C while she was
on holiday, do you remember calling Mother C while she was on holiday?
WILLIAMS: I vaguely do remember, I think, and there was a conversation about picking the report
up, if I remember right.
BAKER: She made arrangements to pick the report up, she asked you if it could be emailed to her
but you said it couldn't be emailed, it could be posted, do you accept that that's what would have
been said?
WILLIAMS: I can't recall it but I am not disputing it, no.
BAKER: Is one of the reasons why it couldn't be emailed that it might be easily disseminated
beyond the parents if it was sent by email --
WILLIAMS: No.
BAKER: -- were the Trust concerned about that?
WILLIAMS: That wouldn't cross my mind, I don't know why it wasn't emailed.
BAKER: Do you remember having a meeting with Mother C on 6 February 2017, where, again, it was
suggested that there is a report but again some babies would need further investigation, but that
[Child C] was probably not one of them?
WILLIAMS: I don't -- I don't recall that, no.
MR BAKER: Thank you, my Lady, I have no more questions.
LADY JUSTICE THIRLWALL: Thank you very much indeed, Mr Baker.
MS LANGDALE: My Lady, one question arising if I may?
LADY JUSTICE THIRLWALL: Yes, certainly. Further
MS LANGDALE: Mrs Williams, you said to Mr Baker that I was uncomfortable with the whole thing.
Can you expand on that?
WILLIAMS: Well, throughout with the whole, the not having the police involved, that's ...
LANGDALE: And not telling the truth, the full truth?
WILLIAMS: Well, not telling giving them the information that we had so far. Yes.
LANGDALE: Was there ever a conversation in those terms in the way they have just been put to you
with the Executives about: we are not telling the truth, we are concealing this?
WILLIAMS: No.
LANGDALE: But that is what you felt uncomfortable with that that's what was happening?
WILLIAMS: Yes.
LANGDALE: Yes, sorry, you nod. We don't pick that up on the transcript but yes, that is what you
were uncomfortable with?
WILLIAMS: Yes, sorry, yes.
MS LANGDALE: I understand. Thank you. I have no further questions
LADY JUSTICE THIRLWALL: Thank you very much. Mrs Williams, I don't have any further questions for you either, so thank you for coming and you are free to go.
MS LANGDALE: My Lady, the next witness is Lorraine Burnett and I hand over to Ms Brown who will be taking her evidence and I think she is ready to start, or will be in a moment.
LADY JUSTICE THIRLWALL: Thank you very much. We will let this witness leave the witness box. (Pause)
MS BROWN: If we could call Lorraine Burnett, please.
LADY JUSTICE THIRLWALL: Ms Burnett, if you come forward, please, you will be sworn.
MS LORRAINE BURNETT (affirmed)
LADY JUSTICE THIRLWALL: Do sit down.
MS BROWN: Thank you, can you please state your full name.
BURNETT: Lorraine Burnett.
BROWN: You provided a witness statement to the Inquiry dated 28 June 2024 and is that statement
true to the best of your knowledge and belief?
BURNETT: It is, yes.
BROWN: In terms of your qualifications you qualified as a nurse in 1990 and worked as a staff
nurse at Manchester University NHS Foundation Trust in the children's hospital; is that
correct?
BURNETT: That's correct.
BROWN: I think you continued to work as a nurse for
approximately 10 years?
BURNETT: Yes.
BROWN: Did you ever work as a neonatal nurse during that period?
BURNETT: No.
BROWN: You then decided to move to a management role, you obtained a Bachelor's of Science in
Child Health and then a Master's in Health Service Management in 2010?
BURNETT: Yes.
BROWN: Turning to your employment at the Countess of Chester, you started employment in March
2013 as the Divisional Director for Urgent Care?
BURNETT: Yes.
BROWN: At that time, the neonatal unit was part of Urgent Care and that fell within your
remit?
BURNETT: Yes.
BROWN: You continued in your role as Divisional Director for Urgent Care until September 2015
when Karen Townsend took over the role. Do you recall, was that the beginning or the end of
September?
BURNETT: My recollection would be the beginning of September.
BROWN: And you then moved to a temporary role to support winter and emergency care plans but by
the end of January/early February 2016, you had been promoted to an Executive role?
BURNETT: Yes.
BROWN: And that role was Interim Director of Operations, which became permanent in May 2016?
BURNETT: Yes.
BROWN: And I think there was a title change in April 2017, to Chief Operating Officer?
BURNETT: Yes.
BROWN: But that role, the role of Interim Director, then actual Director and Chief Operating
Officer, although we have got three titles, that was in effect the same role; is that correct?
BURNETT: Yes, a slight change in portfolios, things I was responsible for, but yes, generally the
same role.
BROWN: So just to recap. Up until September 2015, you were the Divisional Director of Urgent Care
which included the neonatal unit?
BURNETT: Yes.
BROWN: In terms of the matters that this Inquiry is considering specifically that meant you were
Divisional Director at the time of the deaths of [Child A], [Child C], [Child D], [Child E] and
the collapses of [Child B] and the deterioration of [Child F]?
BURNETT: I am unsure, but if that was what's in the documents then yes.
BROWN: Well, those events occurred between --
BURNETT: If those events took place before I moved roles, then yes.
BROWN: Before the beginning of September. From the end then of January 2016/beginning of February
you were promoted to the Executive Team and that was the most senior tier of managers in the
hospital?
BURNETT: Yes.
BROWN: You remained part of the Executive Team until you left the Countess of Chester in December
2019?
BURNETT: Yes.
BROWN: What is your current role?
BURNETT: I am Chief Operating Officer at Barnsley Hospital.
BROWN: So is that a role of equivalent seniority or is that a promotion relative to Countess of
Chester?
BURNETT: It is equivalent to the role I was doing in 2019 in Chester.
BROWN: So turning first to the period when you were Divisional Director of Urgent Care and just
looking at the structure first of all, you were the Divisional Director and reporting to you was
the Medical Director of Urgent Care, who was Dr Sedgwick, I think?
BURNETT: It was Dr Sedgwick, we were more colleagues
than reporting to me.
BROWN: Sorry?
BURNETT: It is more that we were both -- we were colleagues rather than him reporting directly to
me.
BROWN: Then the Head of Nursing, Jane Evans initially and then that became Karen Rees?
BURNETT: That's correct.
BROWN: Just there when you say colleagues, is it correct that the Head of Nursing and the Medical
Director both had a reporting structure, professional reporting structure to their Director of
Nursing and the Medical Director of the hospital but they also reported to you as Divisional
Director?
BURNETT: Yes. There was two reporting lines, a professional reporting line and a day-to-day
reporting line.
BROWN: For the day-to-day reporting line they reported to you as Divisional Director but they
also reported out, so to speak, to Director of Nursing and --
BURNETT: At that time until it changed in -- I think we changed it -- it's in my statement but I
think it is 2018 that the structure was changed.
BROWN: But the time we are looking at --
BURNETT: At the time, yes.
BROWN: -- that was the position.
Looking just at the culture, you were in post as a Divisional Director for two and a half years
approximately. How did you consider the relationships between nurses and doctors within the
hospital?
BURNETT: I felt that they -- we were a single team, people worked together as a team and people
tended to group themselves in their particular specialty or the area that they worked. But doctors
and nurses within that area would be focused on what they were delivering for their patients and
worked together as a team.
BROWN: Specifically obviously we are concerned with the neonatal unit. Did you perceive doctors
and nurses working well together within that unit?
BURNETT: Yes.
BROWN: How often would you have visited the unit as the Divisional Director approximately?
BURNETT: It's hard to say now looking back, but it would be something maybe every few months.
BROWN: We are aware that at this time neonatal was in Urgent Care and obstetrics were in Planned
Care. How did you view the working relationships between obstetrics and the neonatal unit or
between the maternity ward and the neonatal unit?
BURNETT: I wasn't aware of any problems.
BROWN: So that is at management level you weren't aware of any problems?
BURNETT: No, at management level I wasn't aware of any problems and nothing was ever told to me
that there were any concerns.
BROWN: More at ground level in terms of relationships between midwives on the maternity ward and
nurses and doctors on the neonatal unit, was that something you were aware of any -- there being
any problems?
BURNETT: I wasn't aware there were any problems.
BROWN: Turning now then to [Child A], [Child C] and [Child D] specifically. You were the
Divisional Director when these children died and they died, we know, within a two-week period in
June 2015 and you say in your statement that the then Head of Nursing for Urgent Care, Jane Evans,
informed you of the deaths. Can you just explain how that took place in practice, how did you come
to know in practice?
BURNETT: Yes. So myself and Jane Evans and later Karen Rees were in the habit of meeting up around
about 8 o'clock so at the start of the day so it was an informal meeting over a cup of coffee,
what happened yesterday, any challenges we have got at the start of the day and what we -- what
our focus was going to be. So in regards to those three deaths, I was told I think it was probably
the following day by Jane Evans
that there had been a death on the neonatal unit, we had a conversation where I asked was there
any learning, is there anything that we didn't do --
BROWN: Just pausing there.
BURNETT: Okay.
BROWN: So you were told one death at a time, so to speak?
BURNETT: Yes.
BROWN: Yes, carry on?
BURNETT: So then after each death, so each time I was told of a death, I asked, you know, was
there anything from that death that was of a concern. Then I would ask how were the family and had
we put support in place and how were staff and had we put adequate support in place for those
members of staff.
BROWN: Just pausing there for a moment. You said this was an informal update over coffee in the
morning. Had it not been for that update, was there any other means by which you as Divisional
Director would have been informed of this increase in mortality of these deaths?
BURNETT: We -- we had regular more formal updates around what was happening in the hospital on a
daily basis so I would have been informed, possibly later than I was.
BROWN: So there was a system, was there, for informing you as Divisional Director of when there
were deaths within your unit?
BURNETT: Not particularly deaths. There were processes in place for informing me when there are
had been any indents or any concerns.
BROWN: Was that a concern to you, that there wasn't a formal system so that you were always aware
of any increase in mortality rates in any formal system?
BURNETT: In my role as Divisional Director it wasn't something that concerned me in terms of
having a formal route to know about the increased mortality. My assumption at that time is that
that is something that would be escalated through the nursing and the medical route through the
professional leads.
BROWN: After you had heard obviously in rapid succession by the time you heard of the third death
in the neonatal unit, presumably that was pretty shocking and had never happened before in your
career at the Countess of Chester?
BURNETT: It isn't something that I was aware of happening before. I am not -- I can't recall when
there had been three deaths in such a short space of time.
BROWN: What were your immediate concerns after you had learned of three deaths within a two-week
period?
BURNETT: I think my concerns were after each death and I asked if -- if anything needed to happen.
At each time I was assured that no concerns had been raised and I think by the third death it was
well, we are just having a bad run and there's -- and there is no concerns that there has been
three deaths in a short space of time.
BROWN: Well, you were the Divisional Director?
BURNETT: Mm-hm.
BROWN: You have got three deaths within a short period, something that had never happened before.
Was it acceptable that you just accepted: we are having a bad run? Did you not consider -- what
did you consider your role and responsibility was as the Director of Division once you had been
informed of three deaths within two weeks?
BURNETT: Well, I'm not sure. I don't know whether it had ever happened before. I wasn't aware. It
hadn't happened while I was there, but that was -- I would have only been there for a short period
of time and it hadn't happened in that -- since 2013. But I was assured by my Head of Nursing that
the clinicians had looked at the deaths, they had no concerns and that the relevant processes were
in place and each death would be further looked at through the mortality review and then they
would come back to me if there was anything that came out of there that I needed to be aware of.
BROWN: Just to return to the question, though. What did you consider your role was as Divisional
Director having heard of the three deaths? Did you consider there was a role for you as Divisional
Director?
BURNETT: Not a particular role. I felt there was a role for the Head of Nursing and the clinical
lead in paediatrics and the lead for neonates and that it was a clinical concern; there would be a
clinical review. If there was anything relating to the management of the unit, that would be
brought to my attention later once an initial investigation had been completed.
BROWN: You say in paragraph 25 of your statement: "Jane also assured me the deaths were going
through the internal governance process and that if anything of concern came out of those reviews
it would be escalated to me ..." What internal governance process did you understand the deaths
were going through?
BURNETT: My understanding was that there was a Women's and Children's governance process where
they reviewed any deaths or incidents in the unit.
So I had -- I was -- had the assumption that all of those deaths would go through that meeting and
would be reviewed and that if there was any concerns that those would then be raised further
through the risk management team and through routes that were then managed by the Director of
Nursing or the Medical Director.
BROWN: And did you make any proactive moves to enquire what had happened with those reviews that
you thought were going on? Did you say: I need to be kept informed. Can I have an update next
week", for example?
BURNETT: Not that I recall, but it was -- it's a very busy job with a lot of responsibilities
outside of areas other than the neonatal unit.
BROWN: Well, obviously a very busy job. But this, this has to be at the highest level of severity
of anything that could have crossed your desk with three deaths in the neonatal unit. Did you not
think, as the Divisional Director, you needed to make sure you were informed about what
investigations were going on and what the result of those investigations were?
BURNETT: As the Divisional Director, I felt that I had confidence in my Head of Nursing and my
Divisional Medical Director that they would pick those up and move take them forward. They had the
knowledge and the
skills to do that.
BROWN: Did it occur to you to go to speak to Dr Brearey, to simply walk to the unit and ask him
about whether he had any concerns?
BURNETT: No because it -- it was being picked up and followed by my Head of Nursing.
BROWN: Because you say you were being assured there were no concerns. But, in fact, the doctors
involved in fact considered these deaths to be unexplained and unexpected. Was that communicated
to you?
BURNETT: No.
BROWN: The fact of three babies dying within two weeks was obviously a concern to you?
BURNETT: Yes.
BROWN: You recognised, did you, that it was something that needed to be addressed and kept under
review?
BURNETT: I recognised that it was unusual.
BROWN: And that it needed to be kept under review?
BURNETT: And that the people in charge of the neonatal unit, so the clinical lead and the nurse
manager, needed to understand if there was any concerns from those three deaths.
BROWN: Was that not something that you also needed to understand?
BURNETT: I was assured that the process we had in place
in terms of incident reporting, the business and governance meetings that if there was anything
that came out of there that I needed to be aware of and take forward that that would be escalated
to me.
BROWN: You said that it was a concern, it needed to be something kept under review. Setting aside
colours, numbers, risk ratings, in essence, that's a Risk Register, isn't it, a list of concerns
and an acknowledgement that that needs to be kept under review?
BURNETT: The Risk Register is -- there are risks that are reported, there are incidents that are
reported, things that can't be managed or mitigated may find themselves on to the Risk Management
Register and that's where you are aware of incidents that could occur and you would manage that.
BROWN: Because you have got a concern here, it's something that needs to be reviewed and it's not
appearing on the urgent care Risk Register. Why is that?
BURNETT: I was concerned that there had been three deaths. I was told that each of those deaths
had -- were -- had a cause, that there was no concerns about any of those deaths. It was just --
BROWN: Well, just pausing there for a moment. So this was an informal meeting over coffee --
BURNETT: Yes.
BROWN: -- with Jane Evans?
BURNETT: Yes.
BROWN: And is that the extent of the information that was given to you about these deaths? You
say you were assured?
BURNETT: Yes.
BROWN: Did you not think that something more was needed to reassure yourselves rather than Jane
Evans, the day after the death, at which point there would have been no postmortem, probably no
debrief and certainly no neonatal mortality review at that point; was that sufficient that over
coffee the nurse was saying: There are no concerns about this death?
BURNETT: At that point, it was. And then there were regular business and governance meetings in
the Women's and Children's division where those things were discussed and they were discussed with
the people with better skills and knowledge than me, so those clinical skills, to understand
whether there was any concerns. For me as Divisional Director in my role it was more about the
business and the oversight of the -- of the division. I don't think I would have had the skills to
be able to understand what had happened in that neonatal unit.
BROWN: And you say you had an oversight role. What was the oversight here that you were
conducting?
BURNETT: So performance targets, finance.
BROWN: Sorry, the oversight of this incident -- of these incidents, these deaths?
BURNETT: Of these incidents, so the oversight of these incidents. I think it was more I was
informed so I was aware it had happened. The oversight was through the medical, the medical and
the nursing teams and the infrastructure that was in place that went through from the neonatal
unit to the Women's and Children's division, then up through the quality and safety meetings that
went through medical and nursing.
BROWN: We will come to that in a moment. But in terms we are discussing as well the Risk
Register, just to understand why it was that these deaths and the concerns about the increased
mortality were not put on the Risk Register.
BURNETT: You wouldn't put deaths on a Risk Register. In a Risk Register would be things such as
there was a leak in the roof, we can't fix it and therefore there is a concern that the
environment may not be conducive or there -- so they were risks around what might happen, not
things that actually happened.
BROWN: So a concern about increased mortality is not something that you considered to be put on
the Risk Register?
BURNETT: I think it's something that could be put on the Risk Register. It didn't need to be me
that put things on the Risk Register and actually, as a Divisional Director, it would be unlikely
that you would. You would see what went on there, but other people would escalate that up.
BROWN: Karen Townsend, who obviously succeeded you in the role, her evidence was that she would
review all risks on the Risk Register for Urgent Care. Is that something that you would do?
BURNETT: Yes.
BROWN: And so you were aware, were you, that the increased mortality rate that you were aware of
was not on that Risk Register?
BURNETT: I wasn't informed there was an increased mortality. I was informed there had been three
deaths, that that was unusual in a short space of time, but there had not been a lot of deaths
previous to that. So I wasn't -- it was never classified to me as an increased mortality rate.
BROWN: Was that not something you thought you ought to find out about as Divisional Director?
BURNETT: No, because mortality and management of mortality sits within nursing and medical within
the clinical skill set and, therefore, they would be aware of an increased mortality. I -- I
wasn't in a position to understand the difference between a cluster of deaths and those happening
because, you know, there'd been a number of sick people or whether that was unusual. And at the
time I was told that -- I was never told there had been an increase in mortality.
BROWN: If it had been put on the Risk Register that there were concerns about an increased
mortality, what difference would that have made?
BURNETT: If a risk is put on the Risk Register then you would categorise what the -- the size of
that risk and you would put actions in place to mitigate it. So you would try and reduce the risk
to the minimum level.
BROWN: One of the results as well presumably would have been that when Karen Townsend took over
she would have been aware that there was a concern about deaths on the neonatal unit?
BURNETT: Yes.
BROWN: And when you briefed her -- or was there a handover period with Karen Townsend?
BURNETT: There wasn't a formal handover because Karen had been my deputy, so she was aware of what
was happening in the division before we had a handover formally.
BROWN: Did you brief Karen Townsend about your concerns about these three deaths?
BURNETT: Not formal because as I was told about the deaths from Jane Evans, then that was
cascaded. So Karen would have been aware, as my deputy, that there had been a death in the
neonatal unit.
BROWN: Well, Ms Townsend's evidence was that she wasn't aware. How -- just be clear here. How do
you say she would have been aware? You didn't inform her.
BURNETT: I don't remember informing her directly, but it was known in the division that there had
been three deaths. So we were all aware that there had been three deaths in that month and the
service manager definitely was aware.
BROWN: The case of Beverley Allitt, is that something that you were aware of? Was it covered in
your Master's in Health Service Management for example?
BURNETT: Beverley -- I know about Beverley Allitt because that case was in the early '90s as I
qualified as a paediatric nurse.
BROWN: And Recommendation 13 of the Clothier Inquiry into Beverley Allitt was that:
"Beverley Allitt's 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." Now, I'm
not suggesting you would probably be aware of the exact wording or the number of the
recommendation. But as someone working in hospital management and with a qualification in that,
were you aware of the possibility of deliberate harm as a cause of unexplained clinical
events?
BURNETT: I am aware that this happens, even if it's a very rare occurrence, but I wasn't told that
any of the deaths were unexplained.
BROWN: But your mind was open to the possibility --
BURNETT: Yes.
BROWN: -- that if you had three deaths in close succession that that was one of the things that
had to be considered?
BURNETT: If -- if a clinical -- if a clinician had told me there had been three deaths and they
were unexplained then, yes, that would have been something that I was open to.
BROWN: But, Ms Burnett, you didn't talk to any clinicians to find out whether these deaths were
unexpected or unexplained. You just had a briefing over
coffee with Jane Evans who wasn't involved directly in these incidents. So how could you satisfy
yourself that there was no linking factor between these deaths that was a concern that you ought
to be investigating?
BURNETT: The -- the division of Urgent Care is quite a complex and large division. We had layers
of -- we had a hierarchy and we had layers of management and clinicians in there that would manage
things to a separate level. So for me I had a senior manager who liaised directly with the unit,
with the neonatal unit, with the clinicians, who was involved in their regular business meetings.
I then met with them on a monthly basis where they escalated to me if anything had come out of
there that was out of the ordinary or of concern. And at no point was it ever escalated to me that
there had been unexplained deaths. So I was assured by the meeting with Jane Evans where she told
me that the clinicians had looked at the deaths and they had no concerns and --
BROWN: Sorry. Just stopping you there. The clinicians had looked at the deaths. This was the
morning after the deaths.
BURNETT: It was the morning after. But they -- they
were able to give assurance to Jane and the matron or the Head of Nursing for paediatrics that
they didn't have any concerns, but that they would look again at the deaths and there would be a
better, a more in-depth review.
BROWN: And who did you understand was the clinician who was assuring Jane Evans?
BURNETT: I don't know exactly, but I would -- my assumption was that Steve Brearley(sic) as the
lead for neonatal unit was involved in those conversations.
BROWN: If we just look at paragraph 26 of your statement. You say: "The Trust's governance
structure was set up to provide appropriate avenues for any concerns to be reported." And you go
through in that statement and you go through Serious Incident reporting, where there was a risk
that going on to the Risk Register, that being escalated to QSPEC and then in turn any issue
raised with the Executive Directors group. Well, in this case of course we know that that fell at
the first hurdle in the case of [Child A], [Child C] and [Child D] because it was decided that
there was no further investigation of commonality between their deaths.
BURNETT: (Nods)
BROWN: Ruth Millward's statement to the Inquiry accepted that the failure to conduct a full
investigation of that cluster of deaths was a missed opportunity. Do you agree with that?
BURNETT: In hindsight, yes.
BROWN: Looking back now, do you consider that as Divisional Director you should have made sure
that you were informed and satisfied yourself that sufficient investigation had taken place of
those three deaths?
BURNETT: No. I don't think that is the role, the overall role of Divisional Director. That was why
there was a Divisional Medical Director and a Head of Nursing who covered off the clinical aspect
of the division.
BROWN: Turning to [Child E], were you informed of the death of [Child E]? [Child E] died on 4
August?
BURNETT: Not to my knowledge. Not -- but, again, it was a long time ago. I don't recollect that.
BROWN: So you have explained, I think by then it may have been Karen Rees who had taken over the
role, that you had the informal meetings with Jane before that. Was there no other -- you said
before that there was a mechanism whereby you would be informed of deaths. Did that not happen in
the case of [Child E]?
BURNETT: I can't recollect. I think that the reason that the three deaths stood -- stuck in my
mind and
being told about them was because it was unusual to have three deaths in a short space of time. I
don't recollect that anything in, in the August -- I don't know if I was -- I may have been on
holiday, annual leave, there could have been lots of reasons why, but the specifics of that do not
stick in my mind.
BROWN: The unusualness of the three deaths was that if there was something in common between
those deaths --
BURNETT: Yes.
BROWN: -- that was a very serious matter that needed to be investigated and you recognised
that?
BURNETT: I recognised that and I asked each time this -- and on the third death: You know, this is
three. This is a lot. What, what's going on? And I was again assured that there was no concerns.
It was just unfortunate we'd had three very sick babies in a short space of time.
BROWN: Did it also make -- that was the thought process you had when it got to number 3. Did it
also make you think: I must be very alert to see if there is another death, which in fact occurred
with the death of [Child E]? Were you not very alert to the fact that you needed to be very aware
of whether there was any other death
because that could cause you to reconsider the issue of commonality between the deaths?
BURNETT: I was aware that the right people were aware there had been three deaths. So the
clinicians were aware and they were on the -- they were keeping a heightened awareness that there
had been more deaths. That was enough to assure me in a non-clinical role that the right people
were looking at the information.
BROWN: Because Ruth Millward says that the death of [Child E] was another missed opportunity to
consider in more detail those deaths. Would you accept that that was a further missed
opportunity?
BURNETT: Yes. As I say, I don't recall being informed of that in August.
MS BROWN: My Lady, I don't know if that would be a convenient moment because the next section is going to look at the role of Ms Burnett and the Executive Team. So I don't know if that would be a convenient moment to break.
LADY JUSTICE THIRLWALL: Yes, certainly. So we will break now and we will start again at 5 to
2.
BURNETT: Thank you.
(12.55 pm) (The luncheon adjournment)
(1.57 pm)
LADY JUSTICE THIRLWALL: Sorry to keep you all waiting. Ms Brown.
MS BROWN: So, Ms Burnett, we are going to turn now to the period when you were on the Executive
Team and that commenced at the end of January/beginning of February and that was a team of eight
individuals that included Ian Harvey, Tony Chambers, Alison Kelly, Stephen Cross, Sue Hodkinson,
Ian -- Debbie O'Neill, later Mr Holden and yourself; that is correct, is it?
BURNETT: Yes, it was a long list.
BROWN: So there were eight of you and you were the most senior managers?
BURNETT: Yes, and I joined the Executive meetings from September and then became the Interim
Director of Operations, I think it was it is in here but --
BROWN: I think you are recorded on a meeting at the end of January with that title so it would
seem from the end of January 2016 you had the title but you had sat in on the Executive meetings
in fact before then?
BURNETT: Yes.
BROWN: How often approximately did the eight of you, or the Executive Directors Group, that
relatively small group, how often did you meet?
BURNETT: We met weekly. We had a scheduled meeting on a Wednesday morning.
BROWN: What was the overarching purpose of those meetings?
BURNETT: There was an element of sharing information, checking in, seeing how things were going
but then it would also serve a step-in where we would hear business cases and proposals for the
hospital. We received reports et cetera, things of that nature.
BROWN: How would you just briefly describe what your role was as Director of Operations, what was
your particular remit?
BURNETT: So my particular remit at that time was around managing winter, so bed pressures, A&E
discharges and the difficulties we had with discharges working across with community and Council
colleagues.
BROWN: But as you said presumably the weekly meetings was to try and ensure that most people knew
what everyone was doing, broadly, in a broad fashion?
BURNETT: Yes, so we shared information, it was also -- it was a gateway where papers would come to
that meeting to be agreed and approved before they went to committees or to board.
BROWN: At paragraph 20 of your statement, you say: "From my recollection no one person had a
dominant voice within the EDG [the Executive Directors Group], we all took turns offering our
thoughts and advice
dependent on the topic of discussion and our personal expertise." So you are describing there a
collaborative style of meeting?
BURNETT: Yes.
BROWN: One of the areas of expertise that you came with was that you had previously been Director
of Urgent Care and the neonatal unit, which obviously we are concerned with here, had been within
your area of responsibility?
BURNETT: It had. But what I would say is what I brought to the Executive meetings was my
experience in managing A&E patient flow, bed capacity. The neonatal unit was a very, very
small part of my remit in Urgent Care.
BROWN: With regard to that comment about no one person having a dominant voice, obviously we are
going to come to this from the end of June 2016 right up to the time when the police were involved
there were a lot of meetings of the Executive Directors Group and a lot of meetings about
difficult issues, discussions with Consultants, issues of downgrading of the unit, dealing with
the concerns about Letby. Did that remain the case, that there was no one dominant voice or did a
dominant voice emerge over that
period and over that issue?
BURNETT: Not particularly. I think there was the scheduled Executive meeting on a Wednesday where
we would talk about things wider than the neonatal unit. Then there was significant number of
meetings that were -- every time we would get together we would make notes of any meetings that we
discussed around neonatal unit and -- and concerns. In a number of cases those would be chaired by
Tony Chambers. So he would introduce why are we meeting today, what has happened in the last 24/48
hours. But then there would be elements of Stephen Cross from the legal perspective, also input
from Alison Kelly and Ian Harvey depending on which elements we were discussing.
BROWN: So obviously everybody would come in there as expertise but would you describe even
dealing with the issue of mortality and the issue of Letby, did they remain collaborative style
meetings or was someone then directing them in a different way?
BURNETT: No. I mean, they were chaired, they were chaired and Tony Chambers would in the main
chair them, but I would still think they were collective meetings where everybody spoke up against
their particular element.
BROWN: At paragraph 15 of your statement, you say: "In my view the structures and processes for
the management and governance of the Trust did not contribute to the failure to protect babies on
the NNU." Just examining that a little bit more. We know that there were concerns amongst some of
the paediatricians before June 2016?
BURNETT: Mmm mm.
BROWN: And I think June 2016 we are going to look at that meeting in a moment, but is it when you
say you first became aware of the concerns about Letby?
BURNETT: Yes.
BROWN: So we know that there were concerns before that, certainly by January 2016 when Dr Brearey
was initiating a neonatal review using an external Consultant, Dr Subhedar, that those concerns
were considerable about the mortality rates?
BURNETT: Management mm-hm.
BROWN: But that that thematic neonatal review by Dr Brearey, we know that wasn't raised at the
Women and Children's Care Governance Board until the middle of June 2016. We know that prior to
the end of June 2016, increased mortality on the neonatal unit wasn't put on to any Risk Register
and we know that it wasn't raised, the concerns about mortality on the neonatal unit, the concerns
with Consultants didn't reach the Executive Team, didn't reach you --
BURNETT: (Nods)
BROWN: -- until the end of June. So contrary to what you say at paragraph 15, doesn't that in
fact indicate there was some failure of management and governance and certainly of risk
management?
BURNETT: I think the structures and the processes were in place. But as I said in my statement I
don't think things were reported although structures and processes were used as they should have
been in, you know, looking back what's been said now.
BROWN: So the system didn't manage to bring the concerns up to the Executives?
BURNETT: The systems were there. The people involved didn't use the systems.
BROWN: Just looking then at June and July and when there were these series of meetings, dealing
first with 29 July, and there was more than one meeting on 29 July, you deal with these from
paragraph 34 of your statement. You attended a meeting just of the Executive Directors Group and
we don't need to turn to it but we can see from a note there that there was reference to there
being an NNU neonatal update on that day and you
go on to deal with what was said at that meeting. You say -- paragraph 35 this is: "Tony confirmed
that the Consultants had raised concerns regarding increased mortality on the NNU and that they
felt uneasy about Letby." That's the first you are aware of an increase in mortality and the
concerns of the paediatricians, is it?
BURNETT: Yes.
BROWN: We go on at paragraph 36, you say: "There were ... discussions around the fact that Letby
always seemed to be on duty when deaths occurred, however it was also flagged that she worked
full-time and often picked up extra shifts." So the concern here was, it wasn't a conclusion, but
it was a concern that Letby was involved in some ways in those deaths?
BURNETT: I don't recall -- excuse me, I don't recall the exact conversation. I remember that there
was concerns raised around the deaths and why they were occurring. I remember at some point in the
meeting we started to talk about Letby, so I make an assumption that that had been raised.
BROWN: Well, you are saying the fact that Letby always seemed to be on duty when deaths, so that
-- the obvious suggestion there is that there was possibly some
link between her and the deaths that is what was being discussed?
BURNETT: Yes, so I don't recall exactly when it was raised but in the course of those meetings on
the 29th, we had the conversation about Letby being on duty and then the comment was made that she
was -- worked full-time, that she did extra shifts et cetera.
BROWN: You say at paragraph 37: "The tone of the meeting was very much one of shock and concern
..." Was the shock there that it was being suggested that a member of staff may be involved in
harming babies which obviously would have been shocking?
BURNETT: I think it was a -- it was a combination. So it was a shock at the number of deaths that
we were being informed of, there was shock that that hadn't been brought out sooner; and there was
a shock that there was some concern that somebody was undertaking something malicious.
BROWN: You say there the main focus was being to find the cause and I think it goes hand in hand
with that to find the cause, one of the things that have to be investigated was: was that concern
about Letby genuine, was that a cause, was she a cause of those deaths, that was one of the things
you would have to investigate to
find out the cause of the increased mortality?
BURNETT: From my perspective it -- everything we did was about finding out why and we and keeping
an open mind as to what that could be from something that was very unlikely, to the most likely.
But being aware of anything.
BROWN: I think you have accepted already that you were aware of Beverley Allitt and were aware
that one of the possibilities you had to be alert to was a member of staff harming -- deliberately
harming children?
BURNETT: Yes.
BROWN: You say there: "I was shocked by the concerns being raised as I was unaware of the
increased mortality on the NNU ..." At that point did you reflect back on the year earlier when
you had been informed the three deaths?
BURNETT: Not in that particular meeting. It was when we heard the information from -- I have
forgotten the Consultant's name, when they had done the review the neonatal unit and they came
back with a significant number of cases, that was when I put -- realised the three deaths in the
previous summer.
BROWN: Then you go on from paragraph 38 to discuss the further meeting and then there was a
further meeting that day at 5.10 pm, when the Consultants also attended.
BURNETT: Yes.
BROWN: If we could go to the notes of that meeting, that is INQ0003371. It's tab 6 in the bundle, my Lady.
BURNETT: Can you put it up, I haven't got any of the documents?
BROWN: No, it's going to come on to the screen so you can see it.
LADY JUSTICE THIRLWALL: It will come on to the screen.
MS BROWN: So we see there at the top this is Wednesday, 29 June 2016 and we see the initials. So
Tony Chambers, Alison Kelly, Ian Harvey, that is Dave Semple, Steve Brearey, Dr Jayaram, Dr
Saladi, your initials and Stephen Cross who are there?
BURNETT: Yes.
BROWN: Just picking out a few of those notes. We see that Dr Brearey four lines down, some PM
report but not all inconclusive, so postmortem reports, some were inconclusive. Going further
down, unexplained collapses. And then in fact Dr Brearey he does make the connection between those
three earlier deaths. He says: met July 2015 three cases. That was the [Child A], C and D. "Common
theme was nurse."
You was that the first that you were aware that there was a common theme amongst those three
deaths A, C and D that you had been told about by Jane?
BURNETT: Yes, yes. As I said previously I was told that they were all unfortunate but not
suspicious.
BROWN: Then we see that Dr Jayaram also contributes to this meeting, he says: "Babies were stable
and then deteriorated, why always this nurse?" Then if we go over the page. Stephen Brearey says
more than -- or the notes say: "More than just an association with this nurse"?
BURNETT: Mm-hm.
BROWN: Dr Saladi is noted next to his name: "Don't suddenly deteriorate. These babies were
relatively stable, sudden deterioration and collapse." Then next to the initials TC, Tony
Chambers: "Why did we call the police?" Then your initials a bit further down, LB: "Unsafe unit
agreed." Can you recall what you were saying there?
BURNETT: I can't and I think that is a paraphrase of what I was said so I think we were probably
discussing whether the unit was currently safe and what did we need to do.
BROWN: Then if we go on to page 3 there seems to be a sort of list of concerns, obviously these
are just notes: "Concerns shut unit, Commission review, then police ..." Or they seem to be
listing different orders of doing things, police and consequences. We see a bit further down there
"safety paramount" and then we see: "Nurse cannot be excluded." Do you recall a discussion there
now looking at that note about suggesting that the nurse couldn't be excluded, that is a reference
to Letby?
BURNETT: I don't recall that, I recall at the meeting we were informed that Letby was on leave for
two weeks and therefore we had two weeks to, if you like, get our thoughts together as to what we
should do.
BROWN: Yes. If we can just go back to your statement then, so that can come down, thank you. Just
to be fair to you, because you also discuss this meeting in your statement and you say at
paragraph 40 that your recollection in your statement is you recall Tony being adamant that she
could not return to the unit until all concerns had been resolved. Just fill us out on what your
recollection was of
what Mr Chambers was saying then?
BURNETT: My recollection is that the paediatricians were raising concerns, they were raising
concerns about Letby. Tony Chambers was adamant until we have got to bottom of this and
everybody's agreed that she had no part to play, then she couldn't go back on the unit and I
recall that being said in a number of meetings.
BROWN: So what you are saying is he was adamant that until it was decided whether or not she had
any connection with the deaths, she must not be on the unit?
BURNETT: Yes.
BROWN: This may seem obvious to you but if you could spell it out: what was the risk that you
understood Mr Chambers to be concerned about?
BURNETT: I think there was a risk of for her if she went back on the unit and that was -- that was
-- it hadn't been explained, but the overarching risk for all of us is that we didn't want any
more deaths, we didn't want any more unexplained collapses.
BROWN: Did you agree with Tony Chambers's adamant position at that meeting that you were in
agreement with it?
BURNETT: Yes.
BROWN: At paragraph 41, you say: "I also recall Tony specifically [we have seen this in the
notes] mentioning police involvement ..." We have discussed Beverley Allitt and you have
acknowledged there was a possibility of deliberate harm here. You go on to say: "I cannot recall
that anybody wished for the police to be called ..." Given that there was a possibility of
deliberate harm, why was it that your recollection is that nobody wanted the police to be called
at that time?
BURNETT: My recollection was that people were open to there -- to a number of explanations,
everybody in the room, and therefore we needed more information to inform the next steps. So at
that point we needed to understand more about what was happening, what had -- could happen and
then whether we needed to call the police.
BROWN: That's -- your understanding was that was the tenor of the whole meeting, that there was
agreement that it was that they should not be going to the police at that stage; is that your
recollection?
BURNETT: Yes.
BROWN: If you can go down to paragraph 43, you say: "We talked through all the options available
to the Trust, concerns raised by the Consultants about increased mortality and something being
wrong with
Letby." What do you mean there by "something being wrong with Letby"?
BURNETT: That was how it was described by Dr Brearey and Dr Jayaram, they -- they couldn't give an
example or anything that may have happened. But they described it as she's not right, there's
something wrong, things don't feel right with her.
BROWN: But you were clear that when Tony Chambers was adamant she be removed that was because
there was a concern that she could be harming babies and she had to be removed from the unit?
BURNETT: I think it was two-fold. One, if she had been harming babies -- and that was the concern
from the clinicians -- we needed to take a seriously; but two, if she hadn't and we left her on
the unit and anything else happened we wouldn't have been able to define what had occurred.
BROWN: At paragraph 44 you then say following the meeting you had a conversation with Dr David
Semple who informed you that medical staff had been overheard using the phrase "angel of death".
First of all, are you aware who those staff were, were you given names?
BURNETT: No, it was kind of -- the comment was, you
know, people are talking because something was said in a queue at the coffee shop.
BROWN: First of all you discuss that words those words were inappropriate?
BURNETT: Mmm mm.
BROWN: But then you say: "I remember saying that we had now initiated a process to get to the
bottom of [this] issue ..." The "we" there is the Executive Directors Group, that is the Executive
Team, is it?
BURNETT: No I think I included the clinicians and the Women's and Children's in that statement,
because we had all been in the room and we had agreed our way forward.
BROWN: So the "we" there is really the "we" from that meeting on 29 June, the one where the
Consultants were present too?
BURNETT: Yes, yes.
BROWN: You said "we had initiated a process to get to the bottom of the issue", so we had the
reference to the "angel of death" and "the bottom of the issue" and you are talking there are you
about getting to the bottom of the issue about whether Letby was or was not responsible for the
deaths?
BURNETT: I was talking about getting to the bottom of what had happened, to the babies that had
died and one
cause could be Letby, so it was the whole thing. Let's find out, we have initiated a process, we
will follow that process through until we get to the end conclusion.
BROWN: But you were clear that one of the things that had to be sorted out was: was Letby
involved in these deaths or was she not?
BURNETT: Yes, but because I was open to there have been any -- could be a number of reasons.
BROWN: Yes. We then come to the issue of downgrading of the unit. You say at paragraph 48 you
were required to focus on many responsibilities in your role as Chief Operating Officer, including
the downgrading of the NNU. Can you just explain what your role was in terms of the downgrading of
the unit?
BURNETT: Yes. So following the meetings late June/early July one of the things we agreed was to
minimise the risk to the neonatal unit going forward until we knew actually what was happening. So
one of those things, and I spoke to Dr Brearey was in the meeting where we discussed this, was to
reduce the acuity of the babies on the unit. So working with Dr Brearey and Dr Jayaram, we wrote
the protocol around what the threshold was for babies being in our unit, I took on the role of
linking in with the neonatal network to inform them that we were moving to not quite Level 1 but
Level 1 unit and also spoke to some of my colleagues in neighbouring Trusts around the impact that
might have on their unit.
BROWN: In that liaison with other hospitals, which obviously was something that would have to be
done, what reason were you giving and what reason did you understand for the downgrading of the
unit?
BURNETT: The reason that I gave was that we had had increased mortality, a number of deaths that
we didn't have full explanations for, we were investigating and until we had an answer for that,
we wanted to minimise any risk to babies on the unit and therefore we were going from a Level 2 to
a Level 1.
BROWN: So you were clear that you were downgraded because of the increase in neonatal deaths and
you were clear that it was unsure why those deaths had happened, they were unexplained?
BURNETT: Yes, I was clear that the action was being taken on the grounds of patient safety.
BROWN: Did you in any of your communications with the other hospitals mention the fact that there
was a concern that a staff member may be involved?
BURNETT: No. Not that I recollect.
BROWN: In relation to that communication with other hospitals, what about communication with
parents, was
that something that came under your responsibility?
BURNETT: No. We -- there was a sheet produced that we put all the actions on and we put people's
names against them.
BROWN: So you didn't get involved --
BURNETT: I wasn't involved in that at all, no.
BROWN: -- in discussing that aspect. Just turning to the RCPCH, then. You deal with this at
paragraph 49 and you say it was discussed -- this is paragraph 50 of your statement -- by the
Executive Team as a method of trying to ascertain an answer to rising mortality on the NNU and
address the concerns raised by the paediatric Consultants. We have looked at what their concerns
were, one of their concerns was that Letby had an involvement in these deaths. How did you think
the RCPCH review was going to address the concerns about Letby?
BURNETT: So I think at that point it -- the concerns that were being raised were more generic. So
there was concerns about the number of deaths, there was concerns that Letby had been around on
the unit, there was not -- it wasn't a consolidated view of this is what's been happening. So my
view was that the Royal College would give us an independent view, would collect information from
the
staff, have a look at what was happening on the unit and come back to us with, with their view in
terms of what they thought might be happening.
BROWN: Because we looked before a bit at the comment of "angel of death" and a phrase you used
was "getting to the bottom of the issue". The RCPCH was not going to get to the bottom of the
issue of whether Letby was responsible; you understood that, did you?
BURNETT: That -- I think -- what I thought was that the College review would potentially come to:
we do agree that there are concerns being raised around Letby and therefore we think, you know,
that's what we would say. And I think that would have then directed the next steps for us.
BROWN: Because I think you accept at paragraph 51 you say it would have been your practice to
read the emails, you don't recall them specifically now, but in terms of the Terms of Reference
for the RCPCH, there's no mention of Letby in those Terms of Reference. But your understanding
was, was it your understanding that they were going to be looking at whether Letby was or was not
involved in these deaths?
BURNETT: My understanding was that they were going to look at the increased mortality, the
unexplained causes of the deaths and the concerns that were being raised by
the paediatricians.
BROWN: How did you think the issue of whether Letby was or was not involved in these deaths was
going to be resolved?
BURNETT: I think --
BROWN: She was -- you were aware that she had been taken off the unit?
BURNETT: Yes.
BROWN: So you have got a member of staff who has been taken off the unit because of concerns.
Somebody has to resolve that concern at some point and as a member of the Executive Team, what was
your understanding of how you were trying to resolve that?
BURNETT: So it all comes back to keeping an open mind and making sure that we were open to any
cause from Letby to an issue in the unit. So I think, you know, for me, the Royal College review
would have kind of narrowed that scope down a little bit and allowed us to sort of think what our
next steps might be. So, no, they were never going to be able to tell us: Letby did X, Y and Z,
but they could have told us: we feel that, you know, that is a likely route you need to go down
or, or not.
BROWN: When you appreciated that, if you appreciated that that at the time that RCPCH were
conducting their review, did you reconsider: at this point we are going to have to get the police
involved, because it's the police who can conduct an investigation of Letby back in September when
the RCPCH were doing the review?
BURNETT: I think at that point my overriding concern was to make sure that there was no further
deaths on the unit and that was what I was most concerned about and then it following the process
so that we eliminated or narrowed the number of reasons why those -- those deaths had happened.
BROWN: Yes. If we could just go to INQ0004327, I might have given too many zeros there, 0004327, and it is tab
14, my Lady, in your bundle. This is a meeting that was on 14 July 2016, so a few weeks after the
one where the problems and the concern about Letby has been brought to your attention. Halfway
down there, so it is Thursday 14 July we see at the top, and we see your initials along with Tony
Chambers, Mr Nichol, Stephen Cross, and the other initials we have got there at the top. But the
middle of the paragraph is the point I want to come to where it says under your initials: "Culture
and obstets paeds broken plus breakdown between doctors and nurses". So you told us at the
beginning of the evidence
that when you were the Divisional Director you didn't perceive there to be any problems between
doctors and nurses and here you are talking about a breakdown between doctors and nurses. What was
-- what led to that? What led you to that view?
BURNETT: I am not -- I'm not sure that I actually said this so I think I probably did say staffing
issues and we need to understand the vacancies. So we knew that we had issues with the trainee
doctors that were coming into the unit because there weren't enough in training, we knew that, you
know, we had business case in train for additional paediatricians, we knew that we weren't
compliant with BAPM standards for nursing. So I recall at that -- I recognise that, but the bit
underneath I don't recognise. So whether that was a paraphrase of a conversation.
BROWN: But they are only notes --
BURNETT: Yes.
BROWN: -- of course. But looking from this angle then was it your view at that time that there
were there was a breakdown between doctors and nurses?
BURNETT: No. I think that was -- it was at this point when Letby had been removed from the unit, I
think the
nurses felt strained, but I wouldn't have said culture was broken or breakdown between doctors and
nurses.
BROWN: So insofar as that's a note you don't think that was something attributable to something
that you said?
BURNETT: I don't think it is something that I said. I think it's likely a paraphrase of the
conversation that was taking place at the time.
BROWN: If we could just take that down, please, and go to INQ0007197. This is tab 17. Just one point on this document right at the
bottom of that page. Sorry, have I given the wrong number? 0007197. That is the number on there.
Sorry, it is page 132. That is page 1 we have got there and it's page 132. Right at the bottom of
that we just see a reference to neonatal dashboard: "LB presented the dashboard, the daily record
of key activities and risks, the number of deliveries to be added to give overall denominator and
the [going over the page] number of Datix incidents. Staffing to be increased." And so on. Can you
just explain what the neonatal dashboard was, when it was introduced and what it was aimed at
achieving?
BURNETT: So following the meeting on the 29th and then the subsequent meeting where Dr Gibbs -- it
was Dr Gibbs presented his review of the neonatal unit, it became clear that there was a bit of a
disconnect and we weren't aware of exactly what was happening in the unit. I think that was more
pronounced for me because when I had been Divisional Director in 2013/14, we only had three or
four babies on the unit, it was empty a lot of the time. So then to find out it was often over
occupancy I think we recognised there was a gap in our knowledge and understanding, so we
introduced a daily report that was emailed into the Exec suite by 10 clock in the morning telling
us what had happened the day before, how many babies on the unit, any transfers out, any
incidents, any collapses, any deaths. So then we could look closer if there had been any concerns.
BROWN: So going back to the evidence we had about when you were Divisional Director and you say
then that you couldn't recall being made aware of the death of [Child E], with the neonatal
dashboard that would have been impossible?
BURNETT: Yes.
BROWN: Because the death would have been recorded on the --
BURNETT: Yes, by 10 o'clock the following morning we would have known anything that had happened
the previous day at an Executive level.
BROWN: That was -- the neonatal dashboard was just introduced post 29 June --
BURNETT: Yes, when we were --
BROWN: -- 2016?
BURNETT: When we were aware there was an increased mortality and there were concerns around the
neonatal unit.
BROWN: And that -- was it successful, did it carry on while you were on the Executive Team?
BURNETT: Yes, it continued up I think until about 2018, maybe longer. Originally it was two
sections to it; there was the maternity section and a neonatal section. After the first few months
the maternity section was stepped down.
BROWN: Yes, if we could just turn then to a meeting that was on 30 December and this is INQ --
take that one down, INQ0004299. So if we wait for that meeting to come up but this was a meeting
that was held on 30 December, while we are waiting for it to come up. It was attended by Duncan
Nichol, Tony Chambers, Ian Harvey, yourself, and Mr Cross and we see those initials halfway down,
we see Friday, 30 December and
then there is passage blocked out and then 10.15 neonates and then the initials, including your
initial, there. Just to recap of where we were at this stage. So by this stage, the RCPCH had
conducted their visit on 1 and 2 September, they had reported dealing with that report, had you
seen the full unredacted report of the RCPCH?
BURNETT: I can't recall.
BROWN: Were you aware there were two: an unredacted and a redacted version of the report?
BURNETT: I was aware there was two because in the unredacted version I think there was some names
included.
BROWN: So that seems to suggest you had seen the unredacted version even if you can't
specifically recall it?
BURNETT: I -- I recall the conversation about why there was a redacted version, I can't recall
whether I absolutely saw both versions or not.
BROWN: I mean, that would have been a very significant report, wouldn't it, because you were
looking at that report to potentially answer some of your questions about why there had been an
increase in mortality and that related to your particular area of
concern which was the upgrading or the downgrading of the unit?
BURNETT: Yes.
BROWN: That was under your remit?
BURNETT: Yes. At some -- at some point I did see the Royal College report. I don't know if it was
here and then or whether it was later, but I do recall that I did see that report.
BROWN: That report didn't answer the question, did it, of whether Letby was or was not
responsible for the deaths on the unit or the collapses?
BURNETT: No, it didn't.
BROWN: So running through as well what stage we have reached by now, so the RCPCH have visited,
they have reported, Jane Hawdon has been instructed and she sent out her advisory report to Ian
Harvey recommending a broader forensic review of [Child A], [Child I], [Child O], and [Child P]
because those deaths remained unexpected and unexplained. Were you aware of that?
BURNETT: I was aware that one of the recommendations in the Royal College report was that there
was a pathologist review of certain cases.
BROWN: Were you aware that Jane Hawdon had been instructed initially?
BURNETT: I was aware of her having been instructed but it was just a name to me. I didn't know who
Jane Hawdon was.
BROWN: And so can you recall whether you had or had not seen her report?
BURNETT: I didn't see her report.
BROWN: Letby's grievance had been heard on 1 December, that was the other significant event that
had taken place?
BURNETT: Mm-hm.
BROWN: Also on 22 December, Letby and her parents had met with Hayley Cooper, Karen Rees, Tony
Chambers Ian Harvey Alison Kelly and Sue Hodkinson. Were you aware of that meeting, you weren't at
it but were you aware that meeting had taken place?
BURNETT: I was aware possibly afterwards but I wasn't sort of aware at the time it was happening.
BROWN: So that's the context and now let's just look at what was discussed at this meeting in
December. So can we have that back up on the screen, sorry. INQ00004299. So in the bottom part section of the third of the page we have
got: "Unredacted version, should it go anywhere?" and then "distribution". It seems what was being
discussed there at this meeting at which there were the five Executives present, was what should
be done with the RCPCH report. Do you recall that discussion?
BURNETT: I recall a discussion about where the report should go to.
BROWN: What discussion was had, what was the discussion that was had at that meeting?
BURNETT: I don't -- I don't recall the outcome of the discussion. I just remember there was a
general discussion of the Royal College report, where it went to, whether it was redacted or
unredacted and how did we keep the right people informed.
BROWN: What were your views about first of all the Consultants seeing an unredacted version of
that report, did you feel that they should be seeing that?
BURNETT: I think at that point I didn't -- I didn't have -- I think I was listening to what people
were saying. I don't think I had a strong view one way or another. I didn't -- I didn't feel that
I could fully make a decision on whether it should be redacted or unredacted.
BROWN: What about we have seen there under the heading "Distribution -- parents", what about your
view -- you obviously had a background in nursing as
well as your qualifications in management. What was your view about whether performance should be
seeing what report; did you have a view on that?
BURNETT: I think my view was that parents needed to be given -- kept up to speed on all
information. My understanding of when we initially contacted the parents where parents were
initially contacted at the end of June/early July is that part of that conversation was about how
the parents wanted to be communicated with and the level of information that they wanted to
receive. So again I think that I probably could see both sides of what was being discussed. I
didn't have a strong view and therefore I was comfortable with people who were more -- who were
closer to it than me.
BROWN: Just in terms of the people who were at this meeting, we have got Duncan Nichol, Tony
Chambers, Ian Harvey, Stephen Cross. Do you know why there were only five at that meeting, there
weren't the full eight Executives, I mean?
BURNETT: I would imagine it was who was available at that particular time.
BROWN: Just going over the page, then, to page 2 of this document, there is a reference then sort
of a third of the way down the page: "Difficult meeting with Lucy and family.
Commitment to them at meeting." Was it explained to you what commitment had been made to Lucy and
her family at that meeting?
BURNETT: I don't recall the -- the details of that meeting. But I just recall that our priorities
were around making sure the unit was safe and there was no more deaths.
BROWN: We see then next to that "Safety of babies". Was that still something that you were very
alert to?
BURNETT: Yes.
BROWN: The safety of babies in the unit?
BURNETT: Yes, yes.
BROWN: And further down it says. "Challenge of return of Lucy to unit. Trust will manage this
return." Why did you understand it being said, and it seems to have been decided at this meeting,
that Letby should be being returned to the unit when the RCPCH hadn't concluded whether or not she
was responsible for the deaths and you had supported Tony Chambers and said she had to be moved
off the unit, the priority was safety? Why now was it being decided that Lucy should be returned
to the unit?
BURNETT: I think again these are just somebody's notes
and I think I recognise there was a challenge of returning her to the unit and we would have to
manage it if she did return. So I -- I read it that this isn't saying we were looking to return
her to the unit at that time. But by this time, my focus was on the day-to-day functioning of the
unit and babies that may need neonatal care moving forward. In terms of Letby and what was
happening with the HR, I left that with that department and in terms of the reviews and
understanding mortality, I left that with Alison Kelly and Ian Harvey.
BROWN: If we go over to the next page, page 3, we see against your initials and as you said your
involvement was particularly with the level of the unit, next to your initials it says: "Business
case, do we need Level 2? Looking at the last six months, no deaths." You were tasked with looking
at the level of the unit and in discussing the level of the unit you had to be sure, did you, that
it was safe, that was one of the considerations you -- that fell within your remit in terms of
what level it should be?
BURNETT: So it was part of -- the role that I was given in managing this was keeping that unit
safe. My personal view was that we -- we had done that because we hadn't had any more deaths and
therefore until we had the absolute answer we should stay at that level.
BROWN: If we could just go down, then. We see further down next to TC, next to Tony Chambers's
initials, "Sequence". It says Lucy meeting, board meeting, then meeting with paediatric
Consultants. So it seems to be setting out the next steps of what was going to occur. Then over to
the right-hand side of the page, it says: "Formal acceptance of reviews." And then: "Action plan:
reserve its position on Level 1 or Level 2. Endorse transition of Lucy back into the unit." So
this meeting, at which you were one of five people present, seems to be making a decision to
endorse the transition of Lucy back into the unit.
BURNETT: Again, I think this is the way I did -- these handwritten notes are written, I think it
was more of a discussion and, you know, do we endorse the unit -- Lucy back into the unit rather
than is that, where do we get to that in that being a step rather than this
meeting having made that decision.
BROWN: What was your view about whether Lucy should be returned to the unit?
BURNETT: My view was that until we knew exactly what has happened, we should maintain where we
were right then. So Lucy wasn't on the unit, we were a Level 1 unit, there had been no more
collapses, been no more deaths, that seemed to me to be a safe position and one that we needed to
continue until we got to the end, and the end was everybody agreeing.
BROWN: Because we know in fact what went on from this is that there was a decision and Lucy Letby
had been informed that she would go back to the unit and the Consultants then raised their
concerns about this but the Executive decision following this meeting was that Letby should go
back to the unit and you were one of five people at this meeting. Why do we not see your views
expressed here that at all costs Letby must not go back on the unit?
BURNETT: So again, I don't know why -- why it doesn't say that I wasn't concerned, but it was a
collective decision. So there were a number of people in there and people had different --
different views. It isn't a transcript. It's somebody's notes.
LADY JUSTICE THIRLWALL: What were your views
expressed at the meeting?
BURNETT: I can't recall exactly what my views were and what I actually said in this meeting or if
I said anything, because I was still quite new to the Executive Team and sort of understanding the
role of an Executive but my view was always just to maintain the safety of the unit and it seemed
very safe to me at that point. So I was more -- I felt comfortable about where we were at that
point in time.
LADY JUSTICE THIRLWALL: That was without Lucy Letby on the unit?
BURNETT: Yes, and without the very sick babies on the unit.
LADY JUSTICE THIRLWALL: Yes, there were two things.
BURNETT: Yes.
LADY JUSTICE THIRLWALL: But one of them was Lucy Letby not being on the unit?
BURNETT: Yes, yes.
LADY JUSTICE THIRLWALL: Looking back, do you think you said anything about that?
BURNETT: I'm not sure that I did because I -- I kept separate from any of the conversations that
were going on. I don't recall ever meeting Lucy Letby, I don't remember having ever having read
anything around her or
what had happened. So I think that was probably something that I felt other people in the room
were better informed.
LADY JUSTICE THIRLWALL: So you didn't say anything about that, you don't think?
BURNETT: It's difficult to say. I can't remember exactly what I said in the meeting, but if I
think about my thoughts, my thoughts were that by Lucy not being on the unit and it being at a
Level 1, that it was safe. We hadn't had any more concerns raised, we hadn't had any more
collapses or deaths and I felt assured that the risk had been minimised.
MS BROWN: Did you understand at that meeting the import of the meeting, this was the five most
senior people in the hospital of which -- at that meeting of which you were one and a decision was
being made about whether to return Letby to the unit. Did you understand how significant that
decision was?
BURNETT: I don't recall that the decision was made in that meeting to return Lucy to the unit.
BROWN: Looking back now, you were involved as a Divisional Director when the first cluster of
deaths occurred, that was in the neonatal unit, and you then sat on the Executive Directors Group
meetings from September through to the point where there was a report of Letby to the police.
Looking back now, why do you think it took so long for the Executives to refer Letby to the
police?
BURNETT: Looking back now, and having read some of the transcripts from the Inquiry, at no point
were the Executives made aware of any insulin results or any concerns about any of the blood
results. We were told that there was no explanation for the deaths. I think if some -- if some of
those concerns that have since come to the forefront had been made known to the Executive Team,
then we would have taken a different course of action.
MS BROWN: Thank you, I have got no further questions and I don't believe there are questions from any of the Core Participants.
LADY JUSTICE THIRLWALL: Just one from me, if I may. You said you were asked some questions about
systems which obviously did not result in the issue of Lucy Letby coming to your attention or to
the board's attention and you say the systems were there but people didn't use them?
BURNETT: Mmm mm.
LADY JUSTICE THIRLWALL: I just wondered if that's the case, does that mean that the systems
perhaps weren't appropriate for this situation?
BURNETT: I think that's a possibility. I think that the hospital was very much focused, it was --
it is a district general hospital, there was a significant focus at that time on urgent emergency
care, the pressures around beds, so that bigger part of the hospital, rather than neonates Women's
and Children's. So I think that is a possibility; that those systems weren't appropriate for the
neonatal unit and could have been different.
LADY JUSTICE THIRLWALL: Thank you. Just arising out of your answer, we know there was a
restructure which meant that women and children were effectively in a management sense sort of
downgraded in terms of their representation on the board. Is that something that may have
contributed, do you think, to them being a bit disconnected?
BURNETT: So I wasn't in -- when I joined the Countess --
LADY JUSTICE THIRLWALL: I know you weren't.
BURNETT: -- it had already happened.
LADY JUSTICE THIRLWALL: Yes.
BURNETT: I think it was around 2016, 15/16, when there
had been the Inquiry into Morecambe Bay, one of the recommendations was that Women's and
Children's services should sit back together. So I had spoken to my counterpart in Planned Care
and we put a proposal to the Executive Team for the Women's and Children's to come back together,
not in its own division, but as a directorate mindful the resources that we had available to
manage the services. So I think so that would suggest that the answer could be yes, but I think we
recognised there was recommendation from the Kirkup Report and that it would be in the best
interests for them to sit together.
LADY JUSTICE THIRLWALL: Yes, those are my questions. Thank you very much indeed, you are free to
go.
BURNETT: Thank you.
LADY JUSTICE THIRLWALL: I think we are waiting, Mr Bershadski, for the next witness, Ms Appleton-Cairns.
MR BERSHADSKI: Yes, my Lady.
MS DEE APPLETON-CAIRNS (affirmed)
LADY JUSTICE THIRLWALL: Thank you, do sit down.
APPLETON-CAIRNS: Thank you.
MR BERSHADSKI: Good afternoon, could you state your full name, please, for the Tribunal?
APPLETON-CAIRNS: Deborah Lynne Appleton-Cairns.
BERSHADSKI: Thank you. I think you have made a statement for the Inquiry dated 30 July 2024; is
that right?
APPLETON-CAIRNS: Yes.
BERSHADSKI: Have you had an opportunity to consider that statement recently?
APPLETON-CAIRNS: Yes.
BERSHADSKI: Is it true and accurate to the best of your knowledge and belief?
APPLETON-CAIRNS: Yes.
BERSHADSKI: Thank you. Ms Appleton-Cairns, is it right that you started working in the human
resources sphere in 1999?
APPLETON-CAIRNS: Yes.
BERSHADSKI: So by the time of 2016/2017 you had some 17 years' experience in HR; is that
right?
APPLETON-CAIRNS: That's correct.
BERSHADSKI: I think you have got some professional qualifications in HR as well; is that
correct.
APPLETON-CAIRNS: It is, yes.
BERSHADSKI: Thank you. I am just going to begin, Ms Appleton-Cairns, by asking you about some of
the HR policies that may be relevant to some of the issues we are going to discuss. Could I first
ask you to turn to the disciplinary policy and if we could have that up on the screen, it's INQ0108329. It can take a little bit of time for documents to present
themselves on the screen.
APPLETON-CAIRNS: Okay.
BERSHADSKI: Ms Appleton-Cairns, I think you have provided the Inquiry with this copy of the
disciplinary policy; is that correct?
APPLETON-CAIRNS: Honestly, I don't know, because there were a number of versions and I did provide
an additional one to the Inquiry that I had.
BERSHADSKI: Thank you. Is there anything within this policy that as far as you can recall is
significantly different from the policy that you think would have been in place in 2016?
APPLETON-CAIRNS: Not of significant difference, no.
BERSHADSKI: Thank you. I am not going to take you through the entirety of this policy but if we
could just turn, please, to page 15 of the policy. Were you familiar in 2016 with this part of the
policy, appendix 6, consideration of referral to the Local Authority Designated Officer?
APPLETON-CAIRNS: Yes.
BERSHADSKI: What was your understanding of, in essence, the purpose and effect of this aspect of
the
disciplinary policy?
APPLETON-CAIRNS: So this is if somebody was being disciplined under this policy, then there would
be consideration, this was an appendix to that.
BERSHADSKI: Yes.
APPLETON-CAIRNS: And that if there was something that required -- so if they were under
disciplinary and it was something to do with harming children, then there would be consideration
to refer that to LADO.
BERSHADSKI: The way it's phrased, if we can take it at the top, it says if there is a concern
raised or an allegation made about a person who works with children, whether a professional staff
member, foster carer or volunteer, that they may have done various things, including possibly
harmed a child, then a referral should be made; is that right?
APPLETON-CAIRNS: Yes.
BERSHADSKI: So would it be fair to say that the very fact of a concern being raised or an
allegation about somebody who works with children that they may have harmed a child, that that
would be sufficient to trigger a referral to be made to the Local Authority Designated
Officer?
APPLETON-CAIRNS: I guess there is a couple of things. First of all it's under the disciplinary
policy and nobody was
being disciplined at that stage. However, I think that if there was evidence with regard to
somebody who was harming a child, if something had been raised in that -- in that context then the
person who was the conduit between the Trust and the local authority could have made that
referral, yes.
BERSHADSKI: Would it be fair to say that you as the deputy director of HR at that time would be
expected to have a particularly sound knowledge of this policy and other HR policies within the
Trust?
APPLETON-CAIRNS: Yes.
BERSHADSKI: Now, is it right that within this section of the policy, it doesn't talk about any
particular evidence being provided or of any evidential threshold for a referral to be made; it
simply says that if a concern is raised, a referral should be made; is that right?
APPLETON-CAIRNS: Yes.
BERSHADSKI: Is it right that the disciplinary policy isn't the only policy which discussed
referrals of this nature?
APPLETON-CAIRNS: I would have to see the other -- the other policies to which you are referring.
BERSHADSKI: Okay. If we could please turn up the Speak Out Safely policy, it is INQ0003012. Now, is this
a policy that you would have been familiar with in 2016?
APPLETON-CAIRNS: No.
BERSHADSKI: Why is that?
APPLETON-CAIRNS: Because the Speak Out Safely policy was dealt with entirely by Alison Kelly and
Sue Hodkinson.
BERSHADSKI: Are you saying you would never have looked at it --
APPLETON-CAIRNS: No.
BERSHADSKI: -- in 2016?
APPLETON-CAIRNS: No, I am not saying that at all. But I wasn't involved in the -- there was
numerous versions of this policy that were going backwards and forwards.
BERSHADSKI: Yes.
APPLETON-CAIRNS: And at that particular time, I was overseeing two very major jobs and that's why
they were doing this policy --
BERSHADSKI: Right.
APPLETON-CAIRNS: -- with the Union.
BERSHADSKI: Well, let's just try and establish if we can whether this is the policy that would
have been in place at the time. We can see on this page the Trust policy statements on the screen
and it is dated November 2013?
APPLETON-CAIRNS: Mm-hm.
BERSHADSKI: Yes. Now if I could just ask you if we could flip through to page 12 of this
document, please. We can see it says "Review" in the middle of the screen then: "This policy will
be reviewed every three years in consultation with the Trust's partnership forum, it can, however,
be reviewed earlier if the need arises"?
APPLETON-CAIRNS: Yes.
BERSHADSKI: So is it right to say that the prima facie position would be that this is the policy
that would have been in place probably until November 2016 unless a particular situation had
arisen that required a review before then?
APPLETON-CAIRNS: I think it was reviewed before that review period because of the campaign that
was run by the RCN. But as I say, it was -- it was something I had very little to do with.
BERSHADSKI: Okay. If we can please turn one page back to page 11, can you see "Monitoring
arrangements" --
APPLETON-CAIRNS: Yes.
BERSHADSKI: -- sort of two-thirds of the way down on the screen and if we look there, it says:
"Process for monitoring and annual audit is undertaken to ensure compliance with the policy
current legislation and best practice." Then underneath that it says: "Responsible individual:
deputy director for HR and
OD"?
APPLETON-CAIRNS: Yes.
BERSHADSKI: Was that you at the time?
APPLETON-CAIRNS: That was me.
BERSHADSKI: Were you undertaking annual audits to ensure compliance by the Trust with this policy
as it seems to state that you should be in the policy?
APPLETON-CAIRNS: In -- all policies were reviewed and they could be reviewed earlier if there was
a change in legislation or whatever, but I do recall that this one was reviewed earlier and one of
the things that makes me think that is because you have got UCAT as one of the unions and UCAT
stopped being a recognised union. So that makes me think that this isn't what was in place at the
time.
BERSHADSKI: Okay. But had you at any point between 2013 and 2016 been undertaking audits to
ensure that the Trust was complying with the Speak Out Safely policy as it suggests you were
responsible for? Had you undertaken those reviews or not?
APPLETON-CAIRNS: Sorry, could you say that again?
BERSHADSKI: Okay. I am sure I'm not making myself clear. This policy dated 2013 --
APPLETON-CAIRNS: Yes.
BERSHADSKI: -- states that you are responsible for
undertaking audits to ensure compliance by the Trust with this policy; that is what it seems to
say?
APPLETON-CAIRNS: (Nods)
BERSHADSKI: Did you do that or not?
APPLETON-CAIRNS: The partnership forum that included all the unions, that it was a general review.
It wasn't just me because I had no power to change a policy unless I had the partnership forum's
agreement. So it would be the annual audit was -- was done as a partnership forum just with my
name on it.
BERSHADSKI: Yes. So were you responsible for it?
APPLETON-CAIRNS: Yes.
BERSHADSKI: So are you saying that even though you might not personally undertake the audit, you
would make sure that it was done and put your name to it?
APPLETON-CAIRNS: Yes, if somebody said that they needed to have a change or whatever but I also
had a head of policy as well, because obviously, you know, I had an awful lot of other
responsibilities including the policies, so I had a head of policies who I would maybe give that
-- give that task to do.
BERSHADSKI: Okay. Would it be fair to say that given that you had responsibility for signing off
annual audits for compliance with this policy, that you should have had a pretty good working
knowledge of this policy or its
equivalent in 2016?
APPLETON-CAIRNS: Well, I would like to see the one from 2016 because, as I say, I didn't have
responsibility for the one that came after this.
BERSHADSKI: Okay. Well, this is the version that we have. If I could ask you if we could turn the
page to page 9, please, of it, do you see again a section headed "Consideration of referral to the
Local Authority Designated Officer"?
APPLETON-CAIRNS: (Nods)
BERSHADSKI: So it is a similar title to the bit we just looked at from the disciplinary
policy.
APPLETON-CAIRNS: (Nods)
BERSHADSKI: Again we can see it says: "In cases where there is concern with regards to patient
care, the senior manager informed of the allegations needs to consider referral of the matter to
the Local Authority Designated Officer ..."
APPLETON-CAIRNS: Yes.
BERSHADSKI: "... in conjunction with the head of service." Can you see that?
APPLETON-CAIRNS: Yes.
BERSHADSKI: Then if we skip to the middle of the paragraph or in fact seven lines down, we can
see it says: "A referral must always be made if the employer thinks that the individual has harmed
a child or poses a risk of harm to children."
APPLETON-CAIRNS: Yes.
BERSHADSKI: Would you -- is it likely, do you think, that whichever precise version of this
policy was in place in 2016, that this requirement to make a referral would have been in
place?
APPLETON-CAIRNS: I don't know what the other version said. However, what I would say is that
Alison Kelly was the LADO conduit, was the lead person for that. So it wouldn't have been me who
would have made the referral. And I agree, a referral must always be made if the employer thinks
the individual has harmed a child. Yes, I do think if people thought that children were being
harmed, then they had that responsibility to make a referral to the local authority.
BERSHADSKI: Well, do you agree that they had that responsibility not just if they thought an
individual had harmed a child but if they thought that the individual posed a risk of harm, that
they also had that responsibility? Would you agree with that?
APPLETON-CAIRNS: I think if they had evidence of that, then yes, absolutely.
BERSHADSKI: Okay. All right. Thank you. I am just going to ask you a few questions about
the NNU action plan in meetings and your role within that and that is a topic that you cover from
paragraph 17 onwards of your statement. If we could please have up on screen INQ0005196. Now, this was an action planning meeting regarding the neonatal
unit which you attended on 30 June 2016.
APPLETON-CAIRNS: Yes.
BERSHADSKI: Were you aware of concerns about increased mortality on the neonatal unit prior to
this meeting or is this the first time that you became aware of such concerns?
APPLETON-CAIRNS: The first time I -- and unfortunately I cannot get the chronological dates in my
head completely right because it's a long time ago.
BERSHADSKI: Yes.
APPLETON-CAIRNS: However, the first time I heard about there being a spike in mortality rates and
then being drilled down into it being neonates, I believe I was at that meeting, I can't remember
when, and I believe it was the Medical Director Ian Harvey that raised it and that he was
instructed by the Chief Executive Tony Chambers, along with Alison Kelly, to go and understand
exactly what that meant.
BERSHADSKI: Okay. So you think that by the date of this meeting, you had already heard about the
concerns from
Ian Harvey; is that right?
APPLETON-CAIRNS: Yes.
BERSHADSKI: Okay. Now, can you just give us a summary of what your understanding was of the
purpose of this meeting?
APPLETON-CAIRNS: The meeting was around -- well, it was, it was to understand what was going on on
NNU and it was also to discuss whether Lucy Letby should be -- be removed from that meeting --
from that department and from her duties. So that -- that was it in essence.
BERSHADSKI: What was your understanding of the reason why consideration was being given to remove
Lucy Letby from the unit?
APPLETON-CAIRNS: It was due to the fact that there was a spike in -- in the -- in the neonates.
But they couldn't understand what had happened, but according to two of the Consultants, they felt
that it could possibly be to do with Lucy Letby being on duty. There was a commonality between her
being on the unit when some babies had died.
BERSHADSKI: I am going to just jump straight to the point, if I may. Surely already by that
point, that was an expression of a concern by individuals within the hospital that Lucy Letby may
pose a risk of harm to children and it should have triggered, as you should
have known from your knowledge of the policies, a referral because it was a concern of a risk of
harm; would you go with that?
APPLETON-CAIRNS: Sorry, just say that again, please?
BERSHADSKI: Well, I am suggesting that if this meeting was called as a result of a concern that
Lucy Letby had harmed children, then that was a concern of a risk to children which should have
triggered a referral under the sections I have taken you to from the Speak Out Safely policy and
also the disciplinary policy. And I am just asking whether you agree with that analysis or
not?
APPLETON-CAIRNS: It was far more vague than that. So I can't give you a yes or a no and I think
it's really important. When the Consultant -- and I was very much on the periphery, so forgive me
if I am just saying about hearsay, but you couldn't pin them down to what, what is it or who is it
or when is it that you think that these that there is something happening and all they could say
is well, we just think that Lucy's on duty more often than not and we had already looked into that
and certainly the commonality, the spreadsheet that I saw and I only saw it for a few moments, did
not look like the one that was presented to the jury, it was far more comprehensive, there was far
more dates on there, there was far more babies on there, there was as far more staff on there
including doctors as well. So there wasn't that commonality and it wasn't that people were
looking, that they were trying to avoid the situation. We were looking for the answers and -- but
with regard to your question about should it be referred to LADO, that question was raised, as I
recall; is this now a LADO situation? I didn't raise it. I didn't. But it was raised. I can't tell
you if it was at that meeting or not, but it had been raised and then it was up to Alison Kelly to
decide whether she went, as that LADO lead for the Trust, to refer it.
BERSHADSKI: Who raised that question?
APPLETON-CAIRNS: I just said I can't remember. It wasn't me.
BERSHADSKI: Was it an Executive, was it a doctor? What type of -- do you remember what kind of
person it was, in roughly what position they occupied?
APPLETON-CAIRNS: On the basis that I can't remember who it is --
BERSHADSKI: Yes.
APPLETON-CAIRNS: -- then I am not prepared to speculate.
BERSHADSKI: Okay. Do you have any sense of what period of time that would have been raised was it
around the time that you became involved when you were at this action
planning meeting or was it significantly later than that?
APPLETON-CAIRNS: It was either slightly before or at this -- it probably was around this meeting
-- it could have been at this meeting. I am trying --
BERSHADSKI: Okay.
APPLETON-CAIRNS: I'm sorry, it is a long time ago.
LADY JUSTICE THIRLWALL: Sorry. Just so I am clear, so it may have been at this meeting that this
was said?
APPLETON-CAIRNS: Yes, it could have been.
LADY JUSTICE THIRLWALL: Well, if it were, it would have been said by one of the people on the
list.
APPLETON-CAIRNS: Yes.
LADY JUSTICE THIRLWALL: And it wasn't you?
APPLETON-CAIRNS: It wasn't me.
LADY JUSTICE THIRLWALL: Thank you. Shall we move on?
MR BERSHADSKI: Now, your role in this meeting is set out at the bottom of this page, isn't it:
"Actions to be taken: Clarity re LL working in other units and [query] bank hours." Can you see
that?
APPLETON-CAIRNS: Yes.
BERSHADSKI: Then it says "KR" which I think probably
stands for Karen Rees; is that right?
APPLETON-CAIRNS: Yes.
BERSHADSKI: "/DAC."
APPLETON-CAIRNS: Yes.
BERSHADSKI: So with reference to that, what was your task as a result of this meeting?
APPLETON-CAIRNS: Okay. So we had a recruitment section within the -- department within the
hospital and it was a shared service with Arrowe Park Hospital, so it was an autonomous subsidiary
of both organisations so I was the conduit to go into them and say, you know, is -- because we had
a bank, an agency group that would look -- if anybody had any spare shifts or wanted any spare
shifts, then they would book them through that bank and agency department. So I went to find out
A, if she had been doing any additional shifts in any of the departments within our Trust, but
also to see whether she had actually been working at Arrowe Park on any other shifts as well and I
couldn't find any evidence of that.
BERSHADSKI: What was the purpose of you undertaking that exercise?
APPLETON-CAIRNS: Just -- I guess just to understand exactly where she had been working. And, you
know, what -- what I found at that particular time was that we had nurses
that were exhausted, that were -- and so if they were being asked to work other shifts or they
were working other shifts, or there could be commonalities with Arrowe Park if they had
experienced a spike in neonatal deaths she had been working there, but there was nothing, nothing
that I found.
BERSHADSKI: If we go over the page to page 2, we can see that -- sorry, if we go to INQ0005101 [INQ0005151]. There were two meetings that day, weren't there, and this is
now the second of those meetings in the afternoon; is that correct?
APPLETON-CAIRNS: Yes.
BERSHADSKI: If we just go over the page. At the top we can see that in relation to that action
that we looked at before --
APPLETON-CAIRNS: Yes.
BERSHADSKI: -- it's now been filled out: "LL not working ..."
APPLETON-CAIRNS: Yes.
BERSHADSKI: "... anywhere else, ie at another Trust or agency."
APPLETON-CAIRNS: Yes.
BERSHADSKI: "Trained at Chester. Lives alone. Has elderly parents"?
APPLETON-CAIRNS: Yes.
BERSHADSKI: Now, do you think the reason that you were checking that she wasn't working anywhere
else at another Trust or agency would be that if she had been that contact would be made to make
sure she was no longer working at any of those other locations?
APPLETON-CAIRNS: I don't know. That's what I was asked, that is what I was asked to do is to find
out if she was working anywhere else because I think the view was that they were then going to
take her off the unit and put her into the governance team and on that basis then we would
probably have to inform other Trusts that this is what we were doing.
BERSHADSKI: Is that because of a concern that she may pose a risk to children at any other units
that she was working at as well as at the NNU at the Countess?
APPLETON-CAIRNS: I can't, who -- are you asking me personally?
BERSHADSKI: Yes. I am asking you about your knowledge of what the purpose was of you establishing
whether she had been working anywhere else?
APPLETON-CAIRNS: My understanding is I was asked to -- to find that information out, which I did,
I brought it back. That was the information that I found. I think Karen Rees had put the "Trained
at Chester, lives alone, has elderly parents", I think that was Karen. But the bit about not
working at any Trust, that
was just what I was asked to find out, did I -- did I personally believe that there was evidence
to show that she was harming children anywhere at that time? I would have to say no --
BERSHADSKI: But what?
APPLETON-CAIRNS: -- if you are asking me.
BERSHADSKI: What investigations had you conducted into the evidence of Letby harming children by
that point?
APPLETON-CAIRNS: I had done no investigations at all because I wasn't aware there was any evidence
--
BERSHADSKI: Right. Well --
APPLETON-CAIRNS: -- at that time.
BERSHADSKI: On what basis was it your role to come to a conclusion about the evidence of Letby
harming children?
APPLETON-CAIRNS: It wasn't. It's just a question you asked me.
BERSHADSKI: Right. Would you agree looking back on it that given that clearly the concern by this
point was that Letby might pose a risk to children, that if you had applied the policies that I
have taken you to you should have recommended a referral be made to the LADO?
APPLETON-CAIRNS: So based on the fact that there was no evidence that I was aware of at that time
and I didn't raise the fact that it should be a LADO referral, the person who should make the
referral was the LADO lead,
who is Alison Kelly and it had been raised so there was no reason for me to raise it again.
BERSHADSKI: Do you think that you should have given your analysis of what the HR policies said
about the criteria for making a referral given your particular familiarity and role with those
policies?
APPLETON-CAIRNS: It would not have occurred to me to mention the disciplinary policy because
nobody was being disciplined at that time.
BERSHADSKI: Well, about the Speak Out Safely policy?
APPLETON-CAIRNS: As I have -- as I have explained, I was not involved in the review of that
policy. Alison Kelly was responsible along with Sue Hodkinson and she was the LADO lead so she
must have been more than aware of what her responsibilities were with that.
BERSHADSKI: Okay. So you have explained that you had checked that Lucy Letby wasn't working
anywhere else at this point. Did you take any steps to make sure that she wouldn't be able to work
anywhere else in the future?
APPLETON-CAIRNS: No, because it was -- it was going to be -- my understanding was it was going to
be made clear to Lucy Letby that if she wanted to work anywhere else then she had to declare that
to -- I believe it was Karen Rees.
BERSHADSKI: But forgive me, what was to stop her not complying with that instruction and seeking
work elsewhere?
APPLETON-CAIRNS: Nothing.
BERSHADSKI: Were you aware that Lucy Letby visited the Alder Hey Hospital on a number of
occasions and that she was only stopped from doing that in June 2017?
APPLETON-CAIRNS: No.
BERSHADSKI: Were you aware that plans were made for her to go on a course to another hospital
Glan Clwyd?
APPLETON-CAIRNS: No.
BERSHADSKI: Can we have another document up on screen, please, INQ0073053. I am just going to ask you a couple of questions about a series of emails to do with this issue of Letby working elsewhere and these emails were sent a little bit later on in the chronology, in October and November 2017. If we just go a few pages forward, please, to page 3, to pick up the theme. Can you see there an email from somebody at Warrington Police Station asking -- and it is about a quarter of the way down the page: "Can I just ask that you can confirm that Nurse Lucy Letby is unable to work on any other hospitals at present?" That email is sent to Claire Raggett?
LADY JUSTICE THIRLWALL: Raggett.
MR BERSHADSKI: Thank you, my Lady, and that is forwarded on and if we go to page 1, we can see
that Claire Raggett sends this chain of emails on to Sue Hodkinson. It is then sent on to you on 3
November 2017 from Claire Raggett to you, Dee Appleton-Cairns: "Please see below the request from
the police"?
APPLETON-CAIRNS: Okay.
BERSHADSKI: Can you see that?
APPLETON-CAIRNS: Yes.
BERSHADSKI: Did you respond to this email or do anything in response to this?
APPLETON-CAIRNS: That was 3 November?
BERSHADSKI: Yes.
APPLETON-CAIRNS: Is that 2017?
BERSHADSKI: 2017.
APPLETON-CAIRNS: It -- I don't know -- okay. So this is -- so Steve GR is Steve Gregg-Rowbury and
he was the lead for this shared service. So I -- that would that was who I had liaised with
initially to say is she working at any other hospital. And I think he -- no, I don't know. I'm
sorry. I don't know.
BERSHADSKI: Because it appears to be a concern from
a police officer to make sure that Nurse Lucy Letby is unable to work at any other hospitals which
ends up making its way to you. Did you take any action to address that police officer's concerns
as far as you can remember?
APPLETON-CAIRNS: I can't recall this email at all.
BERSHADSKI: Well, can you recall taking any steps to make sure that Lucy Letby couldn't work at
any other hospitals such as making a referral at that point to LADO, or taking any other step that
you may have considered?
APPLETON-CAIRNS: One of the things that we would -- that I would do is we had a Deputy Director of
HR Network, with all the HR directors, the deputy directors in a -- in a group for Cheshire and
Merseyside. And we had a group, an email group and also I was very friendly with Claire Scrafton
who looked at -- who was -- who was the Deputy Director at St Helens and Mersey and they dealt
with people who, you know, if you had extra shifts or whatever, then -- then they would or there
was spare in some way then they would usually go through St Helens. So I would likely have sent an
email round to all the deputy directors to say to them: you know, "If you get somebody who wants
extra shifts or whatever on your
neonatal or paediatric unit, then please contact us in the first instance", is what I would do.
But if I did that or not I can't tell you, I can't remember.
BERSHADSKI: Okay. I am going to ask you a few questions about the legal advice that you obtained
from DAC Beachcroft and you discuss this within your witness statement from paragraph 25. Do you
recall contacting Ian Pace at DAC Beachcroft on 5 July 2016?
APPLETON-CAIRNS: No, the first time I recalled it was when I saw his statement in my bundle.
BERSHADSKI: Okay. Well, you have said in your statement --
APPLETON-CAIRNS: Mm-hm.
BERSHADSKI: -- that you contacted him on 5 July 2016: "The purpose of the call was to seek advice
from Ian as to the organisational risks around removing Letby from the NNU."
APPLETON-CAIRNS: Yes.
BERSHADSKI: So are you able to recall now --
APPLETON-CAIRNS: Yes.
BERSHADSKI: -- what prompted you to call --
APPLETON-CAIRNS: Yes.
BERSHADSKI: -- him?
APPLETON-CAIRNS: Yes.
BERSHADSKI: Can you just explain to the Inquiry why it was that you decided, what particular
concerns you had that led you to call him?
APPLETON-CAIRNS: Yes. So we had -- whenever you are going to remove somebody from their role, then
you have to have grounds, you have to understand, you know, why is it, why is it that you are
going to be removing this person. And ideally you would want some evidence or you would want some
payment that said, you know, they had -- they physically had seen somebody do something or they
had some physical evidence and then you would have the grounds then to remove them. At this
particular point, we didn't. It was quite vague. So I was just checking if we were to remove Lucy
Letby from the unit, then what would be our risk from another direction, which is the direction of
Lucy Letby who was being heavily backed by the RCN and what that risk would be if we were to move
her. What we -- what we came to in the end was that obviously the -- that risk was not as big as
the risk that she may be harming babies and in which case we had to move her.
BERSHADSKI: Were you particularly concerned about a possible dismissal and then a claim for
constructive dismissal from Lucy Letby?
APPLETON-CAIRNS: It's my role to look at all angles, it is like playing three-dimensional chess.
You have to look at the players, you have to look at what all the possibilities are and then you
are able to offer an informed opinion about what can and can't happen.
BERSHADSKI: Was that a significant concern for you, that there might be some form of proceedings
brought by Letby in response to her removal?
APPLETON-CAIRNS: Yes, yes, for the Trust, yes.
BERSHADSKI: Is that a scenario that you had come across on previous occasions or was it a
particular problem that you had to deal with often at the time?
APPLETON-CAIRNS: I wouldn't say it happened often but yes, I had been in that position before.
BERSHADSKI: The Inquiry has heard evidence from a professor, Professor Dixon-Woods, who has told
the Inquiry or said to the Inquiry that there can be a challenge when people who are behaving
badly engage in all kinds of counterclaims, grievances, they may be strategically advised by their
Union representatives on what to do in order that they essentially don't end up with a
disciplinary outcome. Is that a challenge that you recognise that you were facing at the time?
APPLETON-CAIRNS: Not the exact one but yes, I think there's, that is the essence of -- of what I
was thinking at the
time.
BERSHADSKI: Were you having to engage quite regularly with these kinds of claims for constructive
dismissal by employees at the Trust?
APPLETON-CAIRNS: There were many and varied ways of prolonging the inevitable outcome. There were
-- you know, people got to know the policies really well and they would try and find the loopholes
or whatever. So it was -- it was tricky dealing with so many different unions and quite strong
unions as well.
BERSHADSKI: If we just look at the note of your call with Ian Pace, INQ0101934. It is at tab 6 of your bundle, my Lady.
LADY JUSTICE THIRLWALL: Thank you.
MR BERSHADSKI: 0101934. So you call Ian Pace, you mention issue on the neonatal department. "An
alarm", in quotes, has gone off --
APPLETON-CAIRNS: Yes.
BERSHADSKI: -- due to an increase in death rates. The alarm has gone again, we can see in the
second paragraph. Four or five lines down: "They are all pointing fingers at each other, the
staff. There has been an instance where a Consultant has referred to a midwife as Beverley
Allitt."
Were you aware of the case of Beverley Allitt at the time that you made this call?
APPLETON-CAIRNS: Yes.
BERSHADSKI: Did you have any concerns that you might be facing a similar situation at the
Trust?
APPLETON-CAIRNS: The Beverley Allitt case was where she was addicted to Code Blue, where she would
try and resuscitate the babies. So it was a different -- I thought that was a different case and
she was also a midwife.
BERSHADSKI: Yes, well --
APPLETON-CAIRNS: So it was a different case.
BERSHADSKI: Were you making reference to Beverley Allitt because you were concerned that you
might also have somebody who was deliberately harming?
APPLETON-CAIRNS: No, I was saying there's been an instance when a Consultant has referred to --
referred to a midwife as Beverley Allitt. I don't think he's written that very well. "There has
been an instance where the Consultant has referred" and it shouldn't be a midwife, a nurse "as
Beverley Allitt." It was the Consultant, not me.
BERSHADSKI: Yes. And you go on, it says in the next sentence: "Dee is satisfied that there are no
malicious issues involved."
APPLETON-CAIRNS: Yes.
BERSHADSKI: How were you satisfied by this point that there were no malicious issues
involved?
APPLETON-CAIRNS: Because the -- the Medical Director Ian Harvey, Alison Kelly, all of the clinical
team had been to look at, had been through this and they had given me those assurances that there
was no -- it wasn't malicious. The only thing that -- and they -- I kept asking: have we got
anything at all? Have we got any evidence whatsoever? Has anybody seen anything? Anything untoward
that we can look at? And the answer was always no.
BERSHADSKI: Well, were you aware that there had been a large number of unexplained, unexpected
deaths on the neonatal unit?
APPLETON-CAIRNS: At that point it wasn't that, it wasn't that many because they were talking -- we
had had the Coroner's report that -- I can't remember the date, but it was they were, they were
commissioning a report from the Royal College of Paediatricians in there. There was no commonality
on the -- on the spreadsheets that I saw and then there was this, and then there was this Dr
Brearey saying he had a drawer of doom but he wouldn't let anybody see what was in the drawer and
it was all just very vague and odd.
BERSHADSKI: Well, were you aware by this point that there were a number of Consultants who had a
genuine concern that there was a nurse deliberately causing these deaths?
APPLETON-CAIRNS: The only Consultant that I knew of that was expressing any kind of concern for a
long, long time was Dr Brearey. I wasn't aware that Dr Jayaram had concerns until quite far along
in this process and that just might have been because I wasn't close enough to it. At that point
there was a lot of people involved and I wasn't in that kind of inner circle.
BERSHADSKI: Did you go and speak to Dr Brearey about why he had these concerns?
APPLETON-CAIRNS: No.
BERSHADSKI: Well, how were you able to tell your legal adviser that you were satisfied that there
were no malicious issues involved when there had been an increase in deaths and a Consultant, as
far as you were aware, was concerned that they were being deliberately caused by a nurse?
APPLETON-CAIRNS: Well, I would like to have seen what was in his drawer of doom, but --
BERSHADSKI: Did you ask to go and see his drawer of doom?
APPLETON-CAIRNS: Well, no, because I had said to Alison Kelly:
send somebody down there, this is ridiculous. Somebody needs to -- he needs to give us whatever
he's got. Why -- why isn't he doing that?
BERSHADSKI: Right, so --
APPLETON-CAIRNS: But -- but to answer your question, Andrew, I kept asking -- don't forget, I am
not an Executive, I am on the peripheries, I am doing the day-to-day job and I kept saying, you
know, have we got any evidence yet, is there anything at all we can hang our hat on here? And I
just kept being told: no and that they were looking into it, that Ian Harvey had gone through
every case, Alison Kelly had gone through every case and the -- there was nothing untoward from
the Coroner. So for me there was -- there was nothing here other than Dr Brearey saying he had
some concerns about a nurse, a specific nurse.
BERSHADSKI: How could you be satisfied that there were no malicious issues if a Consultant was
saying as far as you were aware that there were malicious issues, you hadn't even spoken to him
about his concerns and as far as you were aware, he had a drawer of evidence of some description
that you hadn't even seen; so how could you be satisfied that there were no malicious issues
involved despite all of that?
APPLETON-CAIRNS: Can I first of all say this is not my note.
Ian Pace has written this note so I don't know what my exact words were. But I was satisfied that
we had no evidence of any wrongdoing at that time because I kept asking the question.
BERSHADSKI: But you knew by this point, because this was now a number of days after the NNU
action planning meeting, so you knew that Letby had been removed from shift and that you had
undertaken the task of checking that she wasn't working anywhere else, so there was surely enough
of a concern to have taken those steps that there might be malicious issues involved?
APPLETON-CAIRNS: I -- at that point, my view was if we take her off the unit, let's see if there
is a correlation between, you know, the -- the spike and there not being now a spike. But then the
unit was downgraded which muddied the waters somewhat. But the other thing that bothers me though
is regardless of what you think I think, the fact is Lucy Letby was removed from the unit but
those -- and those Consultants didn't do anything. So it was like: Well, yes, she's a baby killer
but now she's gone, well, we're just not going to do anything. They didn't do anything for months.
BERSHADSKI: Sorry --
APPLETON-CAIRNS: From my perspective. That's what I saw,
Andrew.
BERSHADSKI: Yes.
APPLETON-CAIRNS: That that didn't happen. And as I say, you know, my role as a deputy really was
the operational running of the -- of the Trust and I was -- you know, I had a big -- two big day
jobs that I was consumed with at that time. I was asking for assurance from Sue Hodkinson, from
Alison Kelly: do we have anything? Every opportunity, anything at all?
BERSHADSKI: Just before we leave this document, can you see towards the bottom Ian Pace is
recorded as saying: "I explained my [view this is three lines up in the last sort of substantive
paragraph] was the priority was to investigate these issues that were arising bearing in mind the
potential consequences and suspicions that have arisen." Did you initiate an investigation under
the investigation policies, the HR investigation policies, in response to that advice?
APPLETON-CAIRNS: Okay, so this is Ian's view.
BERSHADSKI: Yes.
APPLETON-CAIRNS: Not my view?
BERSHADSKI: Yes.
APPLETON-CAIRNS: Okay. Yes, so when you say about an investigation in a hospital, when it's to do
with clinical, the HR team is very much advisory. We don't go in and do the investigation. We
don't do that because what are we looking for? It would be like asking you to go in and have a
look, it's not your specialism. So you would look to have the Royal College of Paediatricians go
in and review the cases. You wouldn't get a HR admin person to do, you know, even a senior one, I
wouldn't go and look at that. I wouldn't know what I was looking for.
MR BERSHADSKI: My Lady, I think we normally have a break around this time. Is now a convenient moment?
LADY JUSTICE THIRLWALL: Yes, certainly. So we will take 15 minutes and we will come back in at 5 to 4.
(3.40 pm) (A short break)
(3.55 pm)
MR BERSHADSKI: Ms Cairns, just before I resume my questioning I am going to ask you refer to me
as "Mr Bershadski" rather than by my first name, if you don't mind.
APPLETON-CAIRNS: Sorry?
BERSHADSKI: I am just going to ask you before we get back into the questions that you refer to me
by
"Mr Bershadski" rather than by my first name, if you don't mind, in your responses?
APPLETON-CAIRNS: Sorry.
BERSHADSKI: Ms Cairns, just before the break, I think you said that one of the reasons that you
thought there were no malicious issues involved when you spoke to Ian Pace on 5 July 2016 is
because there hadn't been that many deaths as far as you were concerned. Now, are you aware that
there had been 13 deaths in the space of just a little bit over a year by that point?
APPLETON-CAIRNS: No, I wasn't.
BERSHADSKI: How many deaths did you think there had been?
APPLETON-CAIRNS: I can't remember.
BERSHADSKI: The --
APPLETON-CAIRNS: But that wasn't how many were being looked at at various stages.
BERSHADSKI: Yes. Now, the thematic review document that had been prepared by Eirian Powell had
looked at 10 deaths, hadn't it, for which Lucy Letby was on shift at or just prior to the death
for nine out of those 10; is that right?
APPLETON-CAIRNS: I didn't see the thematic review.
BERSHADSKI: Okay. Well, would you agree with me that it's completely wrong to say that there
hadn't been many
deaths by the time that you spoke to Ian Pace in July 2016?
APPLETON-CAIRNS: Well, as I said before the break, that was Ian Pace's notes. I don't recall
saying -- could you bring it up again for me, please.
BERSHADSKI: Yes, well, I am just asking about your evidence, not about the note. You told this
Inquiry that you thought there hadn't been that many deaths?
APPLETON-CAIRNS: Yes.
BERSHADSKI: Now, I am suggesting to you that that was completely wrong and there had been a very
high number of deaths compared to the usual two to three average deaths per year that the neonatal
unit experienced up until 2015?
APPLETON-CAIRNS: There had been a spike in deaths but at that point when I spoke to Ian Pace, I
didn't think that there had been anything other than that spike.
BERSHADSKI: Yes, that is a spike of 10 deaths that Eirian Powell had looked at in her thematic
review. So on any account it was a very significant spike and very many deaths, wasn't it?
APPLETON-CAIRNS: Yes.
BERSHADSKI: So would you agree that you were then in your mind minimising the problem compared to
what it actually was when you spoke to Ian Pace?
APPLETON-CAIRNS: I don't believe that was my intention, no.
BERSHADSKI: I am going to ask you a few questions about the Silver Control exercise that you took
part in on 7 July. If we could have up on screen, please, document INQ0004319. Now, we can see your name roughly in the middle of the document.
Can you just give a little bit of background to the Inquiry what this series of meetings on 7 July
2016, was their purpose was?
APPLETON-CAIRNS: Excuse me. Was this Silver Control?
BERSHADSKI: Yes.
APPLETON-CAIRNS: Okay. So Silver Control is when you have an incident like the -- the only other
Silver Control I have ever been involved in is when there is a doctors' strike. So it's a hub
within the centre of the hospital where you bring together quite senior people and information is
fed in and out and things are looked at and it's headed up by the Chief Executive and this one was
to do with NNU.
BERSHADSKI: I am just going to ask about your role within that. If we go to page 3, please, of
the document. We can see just one line up from 145 it says: "Dee Appleton-Cairns confirmed review
of permanent files completed"?
APPLETON-CAIRNS: Yes.
BERSHADSKI: So can you just tell us what you did by way of review of personal files?
APPLETON-CAIRNS: Yes. So every employee within the Trust has a personal file and it's kept in the
HR department. Now, I would like to tell you that there's only one file and that it's always
complete and that's the only place where information is kept but we had the personnel files and it
would start when you started your employment with the Trust and then you would add things to it,
pay increases, references and appraisal information, that sort of thing. So I asked -- I didn't
have a lot to do that day, as I recall, so I felt a little bit like a spare part so as I thought
it would be a good idea to get the porters to bring me over all of the personal files to do with
NNU, everybody from the -- from the administrators and the housekeeper right through to the
doctors that were on there and to bring them over to me and for me to go through them one by one.
I can't tell you what I was looking for particularly but sometimes, you know, whenever there is a
situation I always go to the -- I always go to the root and that's usually the personnel file and
sometimes you can find things on there and sometimes you don't.
BERSHADSKI: Now, by this point, Lucy Letby had been
identified as a person of particular interest, hadn't she, because you had attended the meeting on
30 June where there was a confirmation that she was no longer on shift, et cetera. So presumably
you would have paid particular attention to her personal file when conducting this review; is that
right?
APPLETON-CAIRNS: I paid particular attention to all of the files.
BERSHADSKI: Is there any reason why you wouldn't particularly focus on Lucy Letby considering she
by that point was the particular individual?
APPLETON-CAIRNS: I would not -- I wouldn't want to miss anything.
BERSHADSKI: Okay. So did you look at Lucy Letby's HR file?
APPLETON-CAIRNS: I did, I did.
BERSHADSKI: Okay if I can just bring up a couple of documents from her HR file. If we could pull
up INQ0008961, and page 45 within that. When conducting your review, you would
have seen this document, would you, relating to a drug error --
APPLETON-CAIRNS: No.
BERSHADSKI: -- and Lucy Letby's role?
APPLETON-CAIRNS: No. This was not on her file.
BERSHADSKI: Well, how are you able to be so sure now?
APPLETON-CAIRNS: Because I had never seen it before until it came in the third bundle, last
Friday.
BERSHADSKI: Well, this is one of the pages within a file called "HR Bundle". Now, is it possible
that you don't recall having seen this document --
APPLETON-CAIRNS: No.
BERSHADSKI: -- at the time, but --
APPLETON-CAIRNS: No.
BERSHADSKI: But if you looked at the HR files for every single person who worked on the neonatal
unit --
APPLETON-CAIRNS: Yes.
BERSHADSKI: -- it's surely possible that you simply can't now recall having looked at this at the
time because you had looked at so many documents?
APPLETON-CAIRNS: No.
BERSHADSKI: Very many?
APPLETON-CAIRNS: No.
BERSHADSKI: No?
APPLETON-CAIRNS: I did not see this because this is -- I mean, I don't know much about this
because I am not clinical, but this is drugs error.
BERSHADSKI: Yes.
APPLETON-CAIRNS: This goes to when there is a drugs error and
they happen quite often in a hospital.
LADY JUSTICE THIRLWALL: Where do they go?
APPLETON-CAIRNS: Sorry.
LADY JUSTICE THIRLWALL: What were you going to tell us about where they go?
APPLETON-CAIRNS: They go to the Clinical Governance Department who then review them and they look
at whether it's, you know, very serious sort of Never Event, that type of thing, or they go to the
education -- Clinical Education Department where you are looking at, you know, do you need to
re-educate, re -- re -- you know, to check whether this person knows exactly what they are doing.
So this would be -- I wouldn't see this, this wouldn't necessarily come to HR. This is a clinical
educational matter and pharmacy would have an overview if it is a drugs error.
BERSHADSKI: Yes, well, let's go over the page. If we go to page 47, please. Now, this relates to
the same incident: "Lucy has commenced a continuous infusion of morphine at the end of her night
shift." Now, I am going to suggest that this is likely to have been within her HR bundle that you
would have looked at because it is within a document called "HR Bundle" that has been --
APPLETON-CAIRNS: No, I have never seen this document before.
BERSHADSKI: -- disclosed?
APPLETON-CAIRNS: This was not in her HR file.
BERSHADSKI: And it --
APPLETON-CAIRNS: It might be worth asking Dr Christopher Green, who is Chief Pharmacist, about
these kind of documents.
BERSHADSKI: Well, let's also look over two pages to page 49. Do you recall seeing this document,
April 2016, a note by Lucy Letby, "Reflection on drug error"?
APPLETON-CAIRNS: No. I don't recall it.
BERSHADSKI: Well, do you think it's possible that you simply missed these documents contained
within Lucy Letby's HR bundle when you conducted your review?
APPLETON-CAIRNS: No. Absolutely not.
BERSHADSKI: How can you be so sure if you were looking through every single HR -- I mean how many
HR bundles do you think you would have looked at?
APPLETON-CAIRNS: Between 20 and 30.
BERSHADSKI: Did you look at all of them in the course of one day?
APPLETON-CAIRNS: Yes.
BERSHADSKI: Presumably some of them are fairly long bundles for people who have been employed by
the Trust for a significant period of time?
APPLETON-CAIRNS: Yes.
BERSHADSKI: Well, isn't it possible that you would have missed some documents if you were looking
through 20 to 30 bundles?
APPLETON-CAIRNS: I did not miss these documents. But can I just say, even if they had have been
there, drugs errors occur on quite a regular basis within a hospital.
BERSHADSKI: Well --
APPLETON-CAIRNS: In both hospitals that I have worked at.
BERSHADSKI: You explained earlier that you don't have a clinical background yourself?
APPLETON-CAIRNS: No.
BERSHADSKI: So you wouldn't know yourself necessarily the significance or the rarity of any
particular drug error; is that right?
APPLETON-CAIRNS: Yes, that is true.
BERSHADSKI: Now, we have heard evidence, the Inquiry has heard evidence that this was a very
significant, potentially fatal, drug error.
APPLETON-CAIRNS: Okay.
BERSHADSKI: The 2013 one?
APPLETON-CAIRNS: (Nods)
BERSHADSKI: Also the Inquiry has heard evidence this one that is on screen now in April 2016 is
an incident that should simply have never happened because Gentamicin was
not a drug that was prescribed for a baby to whom Letby gave it? Okay. So I am going to suggest to
you that it is possible because you didn't have a clinical background that you yourself looked at
these and didn't think they were -- they didn't particularly jump out at you as being significant
because you didn't have the clinical knowledge to understand that these were both very significant
incidents?
APPLETON-CAIRNS: I did not see these documents when I looked through the personal files.
BERSHADSKI: Well, if we go to just page 1 of this document and put it into context, does this
look like the sort of HR file you would see, "Learning contract from 2012"?
APPLETON-CAIRNS: This is more clinical education. So the clinical educators would -- would hold
this kind of information. It should be on ESR as well -- sorry, ESR, Electronic Staff Record.
BERSHADSKI: If we go to page 23, "Welcome event for Lucy Letby". Is that the sort of document you
would see in an HR record, a document from HR support services welcoming her to her position at
the Countess of Chester Hospital?
APPLETON-CAIRNS: This is -- this is a document we would send out to anybody who was starting, yes.
BERSHADSKI: Yes. So you wouldn't be surprised to find that within her HR documents then; is that
fair?
APPLETON-CAIRNS: No, I don't think we would. This is the letter we would send out and then we
would have -- and again this is in the Education Centre, I was across the campus at the HR
Business Partners Department which is pretty much at the other side. They would keep a record of
who had attended and what courses they had done. They would then input that into the Electronic
Staff Record because then there would be a mechanism for if there was any reviews or updates or
whatever, then that would trigger through their system. But it wouldn't necessarily come down to
HR no, that letter.
BERSHADSKI: Okay. By this point, there was clearly a particular concern about Lucy Letby. Would
you agree that it was important for you to carefully scrutinise all records that the Trust had in
relation to her, either yourself or if you didn't understand all the documents relating to her
because they had a clinical element, to make sure that somebody who did understand them reviewed
them with you?
APPLETON-CAIRNS: Yes. That would have been Sian Williams or Karen Rees, but they wouldn't
necessarily do it with me. They would bring something to me potentially.
BERSHADSKI: Now, if we go back to the Silver Control document, please, INQ0004319.
APPLETON-CAIRNS: Can I just say that says "HR Support Services" at the bottom.
BERSHADSKI: Yes.
APPLETON-CAIRNS: That is that shared service that I talked about. So that would have been
generated by that shared service which is autonomous from both Trusts, but shared.
BERSHADSKI: Yes. So if we go to INQ0004319, page 5, we can see your name there towards the top. "Dee
Appleton-Cairns: we have been looking at data, gone through every personal file for everyone on
the unit. As expected we have not really found anything."
APPLETON-CAIRNS: Mm-hm.
BERSHADSKI: Why was it you who said that as expected you hadn't really found anything?
APPLETON-CAIRNS: It -- it was a shot in the dark going through there. You know, you rarely, what I
have found in personal files in the past has been things like a reference that says: we have got
some concerns about this person's practice or whatever and it's been overlooked or it's -- well,
there was nobody else and they were better than -- better than having nobody. But it's rare. But
it's still worth checking which is why I did that. I didn't have anything else to do in
Silver Control that day so that's why I did it but as expected, I didn't really find anything.
BERSHADSKI: Yes. Well, would it be fair to say that you weren't expecting to find anything in the
personal records because you personally didn't believe that there was foul play involved?
APPLETON-CAIRNS: I am very open-minded but I wanted to see some evidence. I wanted to hear
something like we have heard you know, after that about somebody's got an eye witness account or
something. Something that I can then start an investigation about.
BERSHADSKI: Well, why can't you start an investigation if a Consultant or a number of Consultants
have come to you to say that they have got real concerns about a particular individual, they think
that they are deliberately harming babies? Why isn't that enough for you to begin an investigation
to see whether you can find any evidence?
APPLETON-CAIRNS: No Consultant or anybody else ever came to me and said that.
BERSHADSKI: Yes, but you knew by this point that the Consultants did have those concerns, albeit
you didn't speak to them directly yourself but you knew that they did have that concern, didn't
you?
APPLETON-CAIRNS: No. They were speaking to the Executives.
I was hearing it second-hand and so I said, okay, if they have got concerns what are those
concerns? And they were vague.
BERSHADSKI: Now, you explain in your statement at paragraphs 39 and 41 that you worked with Sian
Williams to look at shift patterns and, in particular, whether there was a particular correlation
with Lucy Letby; is that right?
APPLETON-CAIRNS: No, I don't think I said that. Sian was looking at the patterns.
BERSHADSKI: Yes. Okay. So at paragraph 39 you say that: "Sian had been analysing the staffing
rotas to identify any commonalities [that can come down off the screen now, thank you] between the
staff on duty and the time of the neonatal deaths." Were you -- did you speak to Sian Williams
about the exercise that she had conducted?
APPLETON-CAIRNS: Just to say, you know, have you completed it or, you know, have you got any
concerns? I had a very brief look at it and it was quite -- and I just remember it being quite
large, quite comprehensive. There was a lot of data on there and there was Lucy -- the commonality
was definitely that Lucy Letby had been on more shifts than anybody else but there was also
another nurse and there was a doctor that
had -- there was quite a lot of commonality there. If you then factored in the fact that Lucy was
the only full-timer and she had been doing extra shifts it then -- it then -- it then didn't give
you such a clear picture for me.
BERSHADSKI: Well --
APPLETON-CAIRNS: But that wasn't my decision to make, I just had a look at it and I just said, you
know: have you found anything? And she went "not really" and then she went off to speak to Alison
Kelly but it wasn't -- it wasn't my decision to make.
BERSHADSKI: Sorry, so you are saying that Sian Williams told you that she hadn't really found
anything as a result of her analysis?
APPLETON-CAIRNS: I think she said there was a cluster -- there was a cluster of three days/nights
or babies that she may have a concern about and that was -- but then she said she wanted to go and
speak to Alison about it so that was it. It was a passing comment.
BERSHADSKI: The Inquiry has heard evidence from Sian Williams this morning who has explained that
after she had conducted her analysis, she had real concerns about the amount of time that Lucy
Letby was on shift when babies were collapsing and dying and that she recommended that the police
be called in on a number of occasions; that was her evidence to the Inquiry this morning?
APPLETON-CAIRNS: (Nods)
BERSHADSKI: Now, is it possible that you are misremembering what Sian Williams told you about her
concerns following her analysis?
APPLETON-CAIRNS: It was a passing comment so she probably didn't want to confide in me before she
had spoken to Alison, potentially. But I will accept it's eight years ago, I can't remember.
BERSHADSKI: Okay. I am just going to ask you about a different topic, Ms Cairns. So you were
aware that Lucy Letby submitted a grievance in September 2016; is that right?
APPLETON-CAIRNS: Yes.
BERSHADSKI: If we just bring that up on screen, it's INQ0002879. If we look at page 3, this is the Letby's actual grievance
document. She was asking why she had been redeployed essentially as part of her grievance; is that
right?
APPLETON-CAIRNS: Yes.
BERSHADSKI: Now, if we look at the grievance policy, INQ -- if we go to page 99 within that
document, you would have been familiar with this policy at the time presumably?
APPLETON-CAIRNS: If this is the policy, yes. But it's -- the -- my only concern is it's -- it's
signed there by Susan Young and she was -- she actually left the Trust in 2011. So I have just got
some concerns. I know it says January 2013 but she did leave the Trust.
BERSHADSKI: Yes, well, it says January 13 there --
APPLETON-CAIRNS: Okay.
BERSHADSKI: -- and this again was a policy that was to be reviewed every three years, wasn't
it?
APPLETON-CAIRNS: Yes, okay.
BERSHADSKI: So it would appear that it would be in force, unless something else intervened, until
November 2016?
APPLETON-CAIRNS: Mm-hm.
BERSHADSKI: Is that right? Now if we go over the page to page 100 the policy provided, in the
middle of the "Grievances" paragraph: "If a grievance can be more appropriately dealt with under a
different procedure, staff will be advised that this is the case. The examples below indicate
where it is inappropriate to follow the grievance procedure as other mechanisms or Trust
procedures are in place". Can you see that? It's been highlighted in yellow on the screen?
APPLETON-CAIRNS: Yes.
BERSHADSKI: So the policy provided that actually there can be circumstances where rather than
dealing with the grievance as a grievance it's more appropriate to follow other policies of the
Trust such as disciplinary or the whistleblowing policy in the last bullet point?
APPLETON-CAIRNS: Mmm mm.
BERSHADSKI: Did you consider that the situation that you were faced with in September 2016 was
precisely the kind of situation where it would be better rather than dealing with the grievance
about the redeployment to consider the substance of the matter which was concerns that had been
raised about Letby under the whistleblowing policy or potentially even to investigate it under the
disciplinary policy and doing it that way rather than dealing with the grievance itself?
APPLETON-CAIRNS: Okay. So this was Lucy Letby's grievance.
BERSHADSKI: Yes.
APPLETON-CAIRNS: So it wouldn't be appropriate to -- for her to -- the whole point of a grievance
which is, which is partly terms and conditions, it is contractual that you are entitled to have a
grievance if you are not happy about something, is the fact that you are looking for a way to move
things forward. Somebody is unhappy with something, they want it to move forward. So I didn't
think that -- I think you -- so,
forgive me, are you implying that instead I should have said: well, I'm sorry, Lucy, you can't --
I am actually going to discipline you under this?
BERSHADSKI: Well --
APPLETON-CAIRNS: Or the fact that, but she wasn't -- she wasn't whistleblowing, so this is about
Lucy Letby and it was her grievance, it wasn't what am I disciplining her about? And what, what is
she whistleblowing about? I don't understand I think you are saying: well, shouldn't you follow
the policy for somebody else? But somebody else didn't raise it. Lucy Letby raised it.
BERSHADSKI: Well, they did raise it, didn't they, because a number of Consultants, or on your
evidence as far as you knew just Dr Brearey had raised a serious concern about her and that should
have been dealt with under the Speak Out Safely policy, shouldn't it?
APPLETON-CAIRNS: Well, that -- but we are talking which one -- which policy are we talking about
now. Somebody has raised a grievance? This is a grievance policy.
BERSHADSKI: Yes.
APPLETON-CAIRNS: And that is their grievance, that is who we are looking at, that is who's in the
box. You can't turn round and say: well, you have raised a grievance so I am going to discipline
you over it. That -- that doesn't follow. And in the same instance she hadn't whistleblown. So it
is about her, it's not about then saying: you have raised this grievance so I am going to --
because it is about you, it's not about somebody else.
BERSHADSKI: Yes, what I am suggesting is that when a grievance came in about the situation from
Letby, what ought to have happened is that using this section of the policy, the actual underlying
concern that had been raised should have been dealt with under the Speak Out Safely Policy?
APPLETON-CAIRNS: Well, you could have done that before the grievance came in, if that is what --
if that's what Sue Hodkinson, Alison Kelly, the Executives who were dealing with that, if that is
what they wanted to do, then that is what they should have done. But when we come down to the
grievance then those -- those are not appropriate, no.
BERSHADSKI: Did you consider that the Speak Out Safely policy should have been applied to the
concerns raised by the Consultants?
APPLETON-CAIRNS: Well, I did suggest that it should be done in tandem. I -- I spoke to Sue
Hodkinson about that and she said she was going to raise it with Ian Harvey, the Medical Director,
but whether that happened or not, I don't know. But it would have been good to have that
in tandem from Dr Brearey and Dr Jayaram.
BERSHADSKI: Well, why?
APPLETON-CAIRNS: But they didn't.
BERSHADSKI: Why didn't you ensure that that happened given that you had said it should be done,
but then you say you simply don't know whether it was done --
APPLETON-CAIRNS: No, I escalated it to Sue Hodkinson, who is my HRD, who -- and I said, you know,
you need to pass this on to Ian Harvey and I understand that's what she did and they chose not to.
BERSHADSKI: It's right that you had operational conduct of these HR processes at the time; is
that right?
APPLETON-CAIRNS: Yes, yes.
BERSHADSKI: Well, why didn't you -- rather than just escalating it if they didn't do it, why
didn't you just make sure it was done yourself?
APPLETON-CAIRNS: I had done what I thought was appropriate. I raised -- I escalated it to my HR
Director because they were -- the Executive Team were dealing with the Consultants and suggested
that Ian Harvey speak to the two Consultants about it.
BERSHADSKI: Now, I am not going to ask you about the grievance investigation itself, that was
conducted by Dr Chris Green; is that right?
APPLETON-CAIRNS: That is correct.
BERSHADSKI: Were you involved with his appointment?
APPLETON-CAIRNS: Yes, I made that suggestion along with a couple of others.
BERSHADSKI: Now, I think it was raised with you by Sue Hodkinson that it would be more in line
with policy to have an independent person, somebody external to the Trust investigate the
grievance; is that right?
APPLETON-CAIRNS: No, I don't recall that. We said about the hearing being an independent person,
the person, the chair, the person who would -- who would hear it.
BERSHADSKI: Well, did you give any consideration to whether Chris Green was sufficiently
independent to act as the investigating officer for the grievance?
APPLETON-CAIRNS: I have always known Dr Chris Green to be an extremely honest and honourable man
who had a lot of experience with grievance investigation -- in fact disciplinary investigations.
So there was -- there was himself and there was a couple of other people that I put forward as
suggestions but it was again up to the Executive Team who they chose.
BERSHADSKI: Did you know that Chris Green had had a disagreement with Dr Brearey about a
pharmaceutical error in relation to one of the babies prior to this grievance?
APPLETON-CAIRNS: I did not know that prior to him conducting the investigation. However, it is in
the notes of the grievance and I did read them during the -- when I got the bundle and read the
hearing notes and it seemed to me that that Dr Brearey was supported by his BMA rep and the BMA
rep had actually come to the conclusion that there was no conflict of interest and therefore it
wasn't an issue.
BERSHADSKI: Do you think now, looking back on it, that given the particular importance of the
issues that were being investigated as part of the grievance that it wasn't best practice to have
as the investigating officer somebody who had had a disagreement to do with one of the babies with
the person raising the concern?
APPLETON-CAIRNS: I can only reiterate what I have said. I have only ever known Dr Chris Green to
be an honest and honourable person and the fact that I didn't know that going -- when I
recommended him, and it seemed that it was dealt with by Dr Brearey's BMA rep during the interview
for the investigation and they were happy that it wasn't a conflict of interest and that's all I
can say on it.
BERSHADSKI: That can come down now off the screen, thank you. Now, it's right, isn't it, that you
had a meeting with the chair of the grievance hearing on 1 December prior to the grievance hearing
itself?
APPLETON-CAIRNS: Yes.
BERSHADSKI: The chair was Annette Weatherley, I think she was the Deputy Chief Nurse at South
Manchester; is that right?
APPLETON-CAIRNS: Annette?
BERSHADSKI: Annette Weatherley. She was the person who heard the actual grievance; is that
right?
APPLETON-CAIRNS: I don't know.
BERSHADSKI: You don't know.
APPLETON-CAIRNS: I can't remember now. She was -- that was the first time I had met her.
BERSHADSKI: Okay. Well, if we could just put up on screen INQ0054483. We can see that a pre-meeting was arranged for you to meet with
Annette who was the chair who heard the grievance, a pre-meet was held with you before the
grievance hearing took place?
APPLETON-CAIRNS: Yes.
BERSHADSKI: Now, did you discuss at that pre-meeting that you and Annette Weatherley thought that
there had been a witch hunt against Lucy Letby?
APPLETON-CAIRNS: No. Not, not to my recollection. The pre-meet was exactly like I have had today,
been invited to this Inquiry. I am invited to come here at a certain
time, I am shown the room, we meet each other, we chat. That's it. There's nothing more sinister
about it than that.
BERSHADSKI: I am going to suggest that you discussed your views about whether the allegations
against Lucy Letby had any merit or not at that pre-meeting prior to the grievance hearing taking
place?
APPLETON-CAIRNS: I have absolutely no recollection of that.
BERSHADSKI: Okay. I am just going to take you to a few emails about -- concerning the grievance outcome. Could we put up on screen, please, INQ0056138. Sorry, Ms Cairns, unfortunately the system can get a little bit sluggish at times. There is an issue with that INQ reference. I think if we could have instead INQ0056150.
LADY JUSTICE THIRLWALL: Is there a hard copy we could use?
MR BERSHADSKI: Yes, we seem to have an issue with some of the INQ references. Okay.
LADY JUSTICE THIRLWALL: I know the one this morning did actually materialise when we thought that wasn't there either. Can we ...
MR BERSHADSKI: Okay let's try a third one and see if it will improve things. INQ0056173. We have struck lucky, Ms Cairns. You can see there is an email
from
you to Annette Weatherley on 2 December: "Hi Annette, sorry for the delay. I have also added in
about LL's mentor."
APPLETON-CAIRNS: Yes.
BERSHADSKI: Now, it appears that you had a hand in drafting the grievance outcome?
APPLETON-CAIRNS: Yes.
BERSHADSKI: Why is that, considering that it was supposed to be the independent chair who was
coming who was determining the grievance?
APPLETON-CAIRNS: Well, you just write what they want. You know, you are like a secretary to them.
They tell you what they -- what they want you to -- to write and you do that. Normally you can't
get anybody to chair a grievance or a disciplinary unless somebody is prepared to do that for
them, so it would be standard practice.
BERSHADSKI: Okay. Well, you have --
APPLETON-CAIRNS: But it wouldn't be -- it is not for me, so what happened was the -- you have got
to answer every question from the grievance, that's part of the template. So there would have been
somebody in HR who's got the template and then you fill in all the bits and then you send it to
the chair and the chair will then, you know, make any changes, do whatever they want to do,
say what they want to say and then it usually goes back two or three times and I remember when I
saw the in the first bundle there was the outcome letter and it was dated 1 December which was the
date of the hearing and I said I am really sure that that is not the final version because I
rarely manage to complete it on a day because you usually are exhausted and by the time
everybody's sort of, you know, gone through what -- what, you know, the Chair's telling you what
they want in it and the bits not to miss and you are making all the notes and then it's the
following day that you finally get to the letter and then the letter goes backwards and forwards
and then there is final version and then that's the one that goes to the person with the
grievance.
BERSHADSKI: Now, it's unfortunately in one of the documents that we are not able to put up on
screen but you have seen them, I know?
APPLETON-CAIRNS: Yes.
BERSHADSKI: My Lady, they are behind tab 16 in the bundle. You had actually sent a draft of the
grievance outcome to Sue Hodkinson and Alison Kelly --
APPLETON-CAIRNS: Yes.
BERSHADSKI: -- at the Trust as part of the drafting?
APPLETON-CAIRNS: Yes.
BERSHADSKI: That's right, isn't it?
APPLETON-CAIRNS: Yes.
BERSHADSKI: Alison Kelly then replied to you with some suggestions to add in a section of
conclusions into the draft which you then added in in the version that you sent along with the
email that we have got here; that's right, isn't it?
APPLETON-CAIRNS: Well, I think we should -- it's a shame we can't see it because I think that the
Inquiry needs to know exactly what that was. So basically it was obviously a hot topic, Sue
Hodkinson, who was my HRD, had asked to see a copy of the draft, I said: this is the draft but,
you know, it's not -- it's not complete and it had also gone to Alison Kelly. Alison Kelly had
asked me -- had put into that document that are we going to see Chris Green's conclusion here,
which we always were, because I had put it's not complete. That conclusion was going to go in
anyway and then there was a bit where she had tried to suggest we took something out and Annette
was really clear that no, that was not coming out and that stayed in. So there was no change to it
The only other words, because it came back from Mary Crocombe, who is Alison Kelly's secretary,
and she
is a bit of a -- of a grammar police and there was a couple of words that she was suggesting that
I took out which I remember being a bit sort of -- well, a bit sort of frustrated about but
actually she was right with regard to the grammar. So they -- those words that said Lucy or
whatever came out. But there was only two things, one was Chris Green's conclusion which was going
in anyway and the bit that Alison was suggesting that she didn't want there but Annette insisted
that it went in anyway so there was nothing.
BERSHADSKI: Well, do you agree that it's not appropriate when you have appointed an independent
chair to hear a grievance to start involving Executives at the Trust and yourself in drafting the
outcome?
APPLETON-CAIRNS: It would be absolutely usual for me to draft, so that is the first thing. To
include Alison and Sue, they wanted a copy of the draft. They weren't being involved, they weren't
being invited to make any comments and certainly that was curtailed. Should I have sent it on
reflection? No probably I shouldn't of, because I think you are right, I think that they thought
oh -- well, certainly Alison, Sue wouldn't of, but Alison thought: oh, here's -- you know, I think
I can add something in and it was like, well, no, you
can't. So I think you are right on that point.
BERSHADSKI: You added a whole section as part of your input into the draft. If we can go to INQ0056174 -- unfortunately that document's not working either so I am going
to have to read out the relevant section?
APPLETON-CAIRNS: Okay.
BERSHADSKI: You added in a section under question 7 where you wrote: "I acknowledge that these
concerns [ie the Consultants' concerns] were raised through the appropriate channels in line with
both the Trust's Speak Out Safely policy and the guidance proffered by the GMC. However, I do not
find that the consultants' concerns when reiterated to the Executive Team were 'Clear, honest and
objective'. (GMC guidance)." You added that section in; is that right?
APPLETON-CAIRNS: No, I don't believe I did. I would have to see it. I don't believe I did. I
didn't add anything in. It was all Annette's work. She signed off the final copy.
BERSHADSKI: Yes, well she signed it off but that was the section that was added by you in
response to a suggestion by Alison Kelly that section 7 be expanded; that's right, isn't it?
APPLETON-CAIRNS: Well, no, I can't -- I'm sorry, I need to see
it. Can I see a paper copy?
BERSHADSKI: I think you have been -- you have been sent all of these documents so you would have
seen it. Unfortunately we can't bring it up on screen.
APPLETON-CAIRNS: Well, I think it's unfair to ask me the question if I can't see it. I need to see
it.
LADY JUSTICE THIRLWALL: It may be something that we will have to bring you back to ask you about
when we are able to show it to you more clearly. It is not in the file you have been provided
with, I presume.
APPLETON-CAIRNS: It is downstairs, if somebody wants to go and get it.
LADY JUSTICE THIRLWALL: So you have got it? All right. Perhaps that might that be the way ahead
to get the --
APPLETON-CAIRNS: I don't believe I added anything into -- into that, that grievance letter.
Anything.
MR BERSHADSKI: My Lady, I am in your hands about how to deal with it. We could get a copy or I am happy to hand up my copy to the witness to simply expedite.
LADY JUSTICE THIRLWALL: That might be the quickest way of dealing with it.
MR BERSHADSKI: Yes, it is marked up, I am afraid.
LADY JUSTICE THIRLWALL: It has got highlighter on but you can ignore that. (Document handed to
witness).
APPLETON-CAIRNS: Why would you think I have done that?
MR BERSHADSKI: Well if you look back, from the bit I have given you, if you look at the previous
draft, that was annotated by Alison Kelly, wasn't it, to say, whereas previously section 7 was
simply one sentence.
APPLETON-CAIRNS: Section 7 said about adding in -- Alison Kelly had put: are we adding in Chris's
conclusions?
BERSHADSKI: Yes.
APPLETON-CAIRNS: Yes, we were always going to add in Chris's conclusions. We didn't have it at the
time, that was the first draft that she had had. So that went in.
BERSHADSKI: You then typed up and added all of that in?
APPLETON-CAIRNS: I typed it all up.
BERSHADSKI: Yes, so in response to Alison Kelly's suggestion you added in that whole page-long
section under section 7; is that right?
APPLETON-CAIRNS: No, no, not according to Alison Kelly, not on her direction. That, Chris's --
Chris Green's conclusions was always going to be added in and -- and that is the -- that's what
went to Annette who signed it all off.
BERSHADSKI: Yes, so you added in those conclusions?
APPLETON-CAIRNS: I added it all in, I added it all in.
BERSHADSKI: And then it went off to Annette Weatherley?
APPLETON-CAIRNS: Yes, but --
BERSHADSKI: That's right, isn't it?
APPLETON-CAIRNS: I wrote all of it, you know, I typed all of it.
BERSHADSKI: Yes, and I think you have agreed already that on reflection, getting the input in
--
APPLETON-CAIRNS: I didn't add that in on the direction of Alison Kelly. She had put that in but it
was always going to be in anyway.
BERSHADSKI: Right.
APPLETON-CAIRNS: So I wasn't being directed by Alison Kelly. I want to make that really clear.
BERSHADSKI: Yes. So even though in the previous email Alison Kelly suggested adding in a section
and then in the next version you have added it in, you're saying it wasn't because Alison had made
that suggestion?
APPLETON-CAIRNS: That's exactly what I am saying.
BERSHADSKI: Okay.
LADY JUSTICE THIRLWALL: We got that.
APPLETON-CAIRNS: Okay. Sorry.
MR BERSHADSKI: I will get it, don't worry. It's right, isn't it, that you attended a meeting with
the Local Authority Safeguarding Board in 2018, is that right?
APPLETON-CAIRNS: Yes. The LADO?
BERSHADSKI: The LADO.
APPLETON-CAIRNS: Yes.
BERSHADSKI: And that was in July 2018, yes?
APPLETON-CAIRNS: Yes.
BERSHADSKI: Now, on reflection, do you think that that is a meeting that you should have attended
and made the referral to attend that meeting two years previously when you first heard about
concerns about Letby harming babies?
APPLETON-CAIRNS: No. The only reason I attended that meeting is because Sue Hodkinson was off sick
and I had stepped up into her role at that time and I was asked by Alison Kelly to accompany her.
That's the first and only LADO meeting I've ever been to.
BERSHADSKI: You had never previously been to any LADO meetings?
APPLETON-CAIRNS: No.
BERSHADSKI: Had you ever made any LADO referrals before?
APPLETON-CAIRNS: No. Sorry, no.
BERSHADSKI: Do you think that that might explain why you didn't make a referral in this case,
because you just weren't familiar enough with the necessity of doing it because you hadn't done it
before?
APPLETON-CAIRNS: Possibly. If I had wanted to make a LADO
referral, I absolutely would have gone through Alison Kelly because she was the LADO lead. I
wouldn't have known how to do it because I have never done it before. So I would have gone to her
and said: Look, you know, I think you need to do this. I didn't. But then that was -- she was in
the inner circle, the thick -- you know, she could have made that decision.
BERSHADSKI: Do you agree that you should have suggested that the referral be made if you had
taken concerns about babies being harmed seriously?
APPLETON-CAIRNS: If I had seen or I truly believed there was evidence then yes, I would have of.
But at that point I was not -- I was too far on the periphery to have that kind of information.
MR BERSHADSKI: Thank you very much, Ms Cairns. My Lady, I don't have any further questions. I don't know, there may be some from a Core Participant.
LADY JUSTICE THIRLWALL: Mr Baker.
MR BAKER: Ms Appleton-Cairns, my name is Richard Baker. Can I begin by offering a space at the
start of my questions for reflection. I represent a number of Families whose children were
murdered or attacked by Lucy Letby. Do you feel, on reflection, that the HR process and the way in
which you managed it contributed to a delay in bringing Letby to justice?
APPLETON-CAIRNS: No, I do not.
BAKER: Even with the benefit of all that you have seen and heard, you don't think that your
actions contributed at all to a delay in bringing Letby to justice?
APPLETON-CAIRNS: No, I do not. I think that the grievance procedure was an opportunity for the
Consultants to bring forward and explain in more detail what their concerns were and any evidence
that they had. And there was nothing in that grievance that they brought, that they brought to the
attention of somebody who was independent, an independent chair.
BAKER: Well, I think you have already been asked questions about how independent that process
was. But can I say this: this was a process that was designed to pander to the whims of a serial
killer, wasn't it, the grievance process, with the benefit of hindsight?
APPLETON-CAIRNS: I don't believe that.
BAKER: Do you have any skills or experience at all that permitted you to understand or interpret
the clinical issues in this case?
APPLETON-CAIRNS: The what, sorry?
BAKER: Did you have any skills or experience that permitted you to interpret the clinical issues
in this case?
APPLETON-CAIRNS: No.
BAKER: Would you agree you were entirely ill equipped and unqualified to investigate murder in a
healthcare setting?
APPLETON-CAIRNS: Yes.
BAKER: Can we look at your witness statement, please, and to paragraph 17, which I think sets out
your first involvement. You should have a copy of it in front of you I think, it won't appear on
the screens. It's a reference to a meeting on 30 June 2016, which you attended two neonatal unit
action planning meetings and in attendance to both meetings were Alison Kelly, Jill Galt, Sue
Hodkinson, Sian Williams, Ruth Millward, Julie Fogarty and Karen Rees?
APPLETON-CAIRNS: Yes.
BAKER: And they were meetings arranged to provide assurance to the Executives as to how the
situation on the NNU was being handled in light of the increase in neonatal deaths?
APPLETON-CAIRNS: Yes.
BAKER: So that was a meeting that was attended only
by yourself and the nursing staff?
APPLETON-CAIRNS: Okay.
BAKER: Well, that's "yes", isn't it?
APPLETON-CAIRNS: Yes.
BAKER: You have already said in evidence that you at no time went to speak to any of the
Consultants who were making allegations against Lucy Letby?
APPLETON-CAIRNS: (Nods)
BAKER: That's correct, isn't it? That's what you say in your witness statement?
APPLETON-CAIRNS: Yes.
BAKER: So you approached this issue by having a meeting on the face of it about these issues with
the nursing staff, but didn't seek to balance that by speaking to any of the Consultants. Why was
that?
APPLETON-CAIRNS: I was -- I was asked to attend this meeting. It wasn't my meeting.
BAKER: Well, no, that's, I'm sorry, not a very good answer because you have made various
assertions in this Inquiry about the evidence that was being presented to you as to the quality of
the allegations that were being made by the Consultants?
APPLETON-CAIRNS: Yes.
BAKER: Now, if you say before the Inquiry that the evidence was never presented to your
satisfaction, then
I think it's important that you justify your approach. So you spoke to the nurses. You never spoke
to the doctors?
APPLETON-CAIRNS: There was no evidence presented to me at all.
BAKER: Well --
APPLETON-CAIRNS: By anybody.
BAKER: I'm sorry. We are going to come on to a note in a moment where you make assertions about
the quality of evidence that was available. I think it's quite a simple point. You spoke to the
nurses, but you never spoke to the doctors. Why not?
APPLETON-CAIRNS: Because the doctors would only speak to the Executives.
BAKER: So you are saying that the doctors --
APPLETON-CAIRNS: And I knew Ravi. I knew Ravi quite well.
BAKER: Are you saying the doctors refused to speak to you?
APPLETON-CAIRNS: The doctors didn't speak to me. You would have to ask them why they didn't speak
to me.
BAKER: No. Are you saying that you sought to speak to the doctors and they refused to speak to
you?
APPLETON-CAIRNS: No.
BAKER: Okay. So the answer is you didn't seek to speak to the doctors, did you?
APPLETON-CAIRNS: No.
BAKER: No. Now if we go on, please, to INQ0101934. This document has worked in the past, so I am reassured to see
that it's worked again.
APPLETON-CAIRNS: That's Ian.
BAKER: This is Mr Pace's note of a conversation with you.
APPLETON-CAIRNS: Mm-hm.
BAKER: Now, you have been taken already to a section that says: "Dee is satisfied that there are
no malicious issues involved." This is 5 July 2016 and I think in response to questions from my
learned friend, you appeared to question whether you used those words by saying, "This is Mr
Pace's note."
APPLETON-CAIRNS: That's correct.
BAKER: Can you look, please, at paragraph 30 of your witness statement?
APPLETON-CAIRNS: 30?
BAKER: Yes, paragraph 30. Would you like to read that out, please?
APPLETON-CAIRNS: Yes: "At this stage I was satisfied that there was no malicious issues involved."
I was copying it from Ian's note.
BAKER: Right.
APPLETON-CAIRNS: "My understanding was that there was only one person pointing the finger at Letby
and that was Stephen Brearey."
BAKER: Okay. So if you could stop there.
APPLETON-CAIRNS: "However, he had not provided any evidence to support ..."
BAKER: If you could stop there, please.
APPLETON-CAIRNS: Sorry.
BAKER: So in quoting "no malicious issues involved", you don't seek there, do you, to say: Those
weren't the words that I used?
APPLETON-CAIRNS: I was -- I was -- it's in italics, so I was quoting those words.
BAKER: Yes. But where in this paragraph does it say that: Those are Mr Pace's words and I didn't
use them? It doesn't.
APPLETON-CAIRNS: Well, if it carries on, if I could continue to read that paragraph.
BAKER: Does it say in that paragraph that those weren't your words?
APPLETON-CAIRNS: No.
BAKER: No. If we could go on, please, to read the next sentence.
APPLETON-CAIRNS: "My understanding that there was only one person pointing the finger..."
BAKER: No, sorry. We are going back to the telephone note.
APPLETON-CAIRNS: Okay.
BAKER: If we could go on please to read the next sentence of the telephone note.
APPLETON-CAIRNS: "I asked Dee how ..."
BAKER: I'll read it: "I asked Dee how she can be sure and she said that she did not think there
would be any such issues." Now, what does that mean?
APPLETON-CAIRNS: This is Ian's note. I don't -- I don't know. I can't remember.
BAKER: "I explained that really the employment aspects of the matter pale into insignificance
taking into account potential issues involved, especially if those who are working on the ward and
including Consultants are pointing the finger at each other and the suspicions that the death rate
could be attributable to one in particular individual." Now, isn't that describing a conversation
between you and Mr Pace wherein you are reassuring him that you are satisfied that there's no
substance in these allegations and him saying: Well, whether there are
employment issues in this case or not pale into insignificance if there's any reality to the
suggestion that there is a murderer in this unit. Isn't that the interpretation?
APPLETON-CAIRNS: Well, I think the interpretation is that he explains that: "... the employment
aspects of the matter pale into insignificance taking into account potential issues involved
especially if those who are working on the ward and including Consultants are pointing the finger
at each other and the suspicions [that the death] that the death rate could be attributed to one
in particular individual."
BAKER: Well, doesn't this bring us to a key issue in your interactions with this case; that
employment issues are of nothing compared to the seriousness of a potential murderer on this
ward?
APPLETON-CAIRNS: I would agree.
BAKER: So in permitting this grievance process to proceed, you would accept, wouldn't you, that
you did so based upon incomplete and un-investigated facts?
APPLETON-CAIRNS: No because we had -- there had been the Coroner who had looked at each of the
deaths and the Chief Executive had brought in the Royal College of Paediatricians.
BAKER: Sorry, which -- which --
APPLETON-CAIRNS: We had had that --
BAKER: Which Coroner?
APPLETON-CAIRNS: -- we had had that report --
BAKER: Sorry, you keep saying things in your evidence that I'm afraid don't appear to have any
reality to the facts of the case. Which Coroner made a determination in which case?
APPLETON-CAIRNS: The Coroners had gone -- I was told that the Coroner had gone through each of the
baby deaths.
BAKER: That's untrue.
APPLETON-CAIRNS: Oh, okay. That's what I was told.
BAKER: Who told you that?
APPLETON-CAIRNS: I was told by the Chief Executive and also by Alison Kelly.
BAKER: So Ian Harvey and Alison Kelly reassured you that the Coroner had investigated all of the
deaths?
APPLETON-CAIRNS: Yes.
BAKER: And that there was nothing to be concerned about?
APPLETON-CAIRNS: Yes -- well, no. They said that there was only -- there was two where they
couldn't be very specific about what the cause of death had been.
BAKER: Right.
APPLETON-CAIRNS: But they couldn't identify that there was foul
play either is what they told me.
BAKER: And that's information that had come from the Coroner?
APPLETON-CAIRNS: Sorry?
BAKER: That is information that had come to you, obviously via Ian Harvey, but from the
Coroner?
APPLETON-CAIRNS: It wasn't Ian Harvey. It was Alison Kelly and Tony Chambers.
BAKER: Yes, but they were referring to determinations by a Coroner?
APPLETON-CAIRNS: Yes, but they had also instigated the Royal College of Paediatricians to come in
who had already completed their investigation and I -- again I was told verbally that there was
nothing untoward within that report and that's the only reason that the grievance went ahead when
it did.
BAKER: But you hadn't been told that by the date of your conversation with Mr Pace in July 2016,
had you?
APPLETON-CAIRNS: I don't recall.
BAKER: Well, no because the investigation hadn't been concluded by then.
APPLETON-CAIRNS: Okay.
BAKER: Again, throughout the grievance process, Letby via her Royal College of Nursing
representative, advocated strongly that the Consultants should be
disciplined, didn't she?
APPLETON-CAIRNS: He. Yes.
BAKER: No. But it was Letby's representative, wasn't it?
APPLETON-CAIRNS: Yes.
BAKER: Finally, and I am conscious of the time --
APPLETON-CAIRNS: But there was -- but there was no chance that that was ever going to happen.
BAKER: No, but that was what was -- what Letby's representative was pushing hard for; that they
should be disciplined?
APPLETON-CAIRNS: There was no -- there was nothing to discipline them on.
BAKER: If you look at paragraph 75 of your witness statement: "Letby was concerned that the
Consultants thought she was lying and said, 'I have nothing to hide.' I then said we need to
compromise as if you go down the disciplinary route with the Consultants --
APPLETON-CAIRNS: Yes.
BAKER: "I think I was interrupted at this point."
APPLETON-CAIRNS: Yes.
BAKER: Yes: "I did not think the disciplinary route in relation to the Consultants would be in
any way helpful in
resolving ..."
APPLETON-CAIRNS: Yes.
BAKER: That is a reference because Letby was pushing for them to be disciplined, wasn't she?
APPLETON-CAIRNS: It was her representative that was pushing. She -- she wasn't pushing at that
point. But there was -- you know, with a grievance you are trying to find a way forward, for
everybody to move forward. Going down disciplinary route to me was just unimaginable because it
would just be making things a hundred times worse. So I would not ever have supported that, but I
don't think she could have done anyway because there was no grounds.
BAKER: No. But just to be absolutely clear. Tony Millea?
APPLETON-CAIRNS: Millea.
BAKER: Millea was the advocate, the RCN advocate for Letby?
APPLETON-CAIRNS: (Nods)
BAKER: And he was pushing very hard for the Consultants to be disciplined on Letby's behalf,
correct?
APPLETON-CAIRNS: That's what he said at the end, yes.
BAKER: Yes.
APPLETON-CAIRNS: Can I also just make a point because I think this is important? It wasn't just
Lucy Letby's grievance that came in. We also got an almost identical grievance in from the RCN
separately, but they were both together and so we were getting -- it was like a pincer movement to
try and get this, her grievance heard. So one of the things that I did was to look at the
commonalities between the two so that we only had one process. So we were under -- I was under
pressure to hear the grievance. The grievance came in in July and it wasn't heard until December.
But at that point we had -- we did know about the Royal College of Paediatricians report and so it
felt we couldn't hold it back any longer that then it went, it went ahead. But I wouldn't
necessarily disagree with you and your learned friend that we could maybe have, have pushed it
back further. But it's how far do you keep pushing it down the road? It was -- there was a lot of
pressure from the RCN.
BAKER: Well, what somebody needed to do was call the police if allegations like this were being
made because they are the people who are equipped to investigate it, aren't they?
APPLETON-CAIRNS: Do you know what? I couldn't agree with you more. But I think the people who had
all of the
concerns and all of the evidence, they were the people who should have called the police and
there's no reason why they shouldn't of.
BAKER: Well, that's a very judgmental thing to say --
APPLETON-CAIRNS: Yes, it is.
BAKER: -- because you didn't interact with them and you didn't obtain their side of the
story.
APPLETON-CAIRNS: (Nods)
BAKER: Finally, and I want to clarify something Mr Bershadski asked you because I think he asked
you two questions in one and I just wanted to make sure that you answered both of them. Did you
know that Lucy Letby was visiting Alder Hey Children's Hospital in 2017?
APPLETON-CAIRNS: No.
MR BAKER: Okay. Thank you, my Lady, I've got nothing further.
LADY JUSTICE THIRLWALL: Thank you very much, Mr Baker. I have no questions. Thank you very much,
Ms Appleton-Cairns, you are free to go.
APPLETON-CAIRNS: Thank you.
LADY JUSTICE THIRLWALL: So we will start again tomorrow morning at 10 o'clock.
(5.04 pm) (The Inquiry adjourned until 10 o'clock on Wednesday, 6 November 2024)
MS LANGDALE: My Lady, may I call Mrs Griffiths and may she be sworn.
LADY JUSTICE THIRLWALL: Take the oath please, Mr Griffiths.
MRS HAYLEY GRIFFITHS (sworn)
MS LANGDALE: Mrs Griffiths, you have provided a statement to the Inquiry dated 14 June 2024. Do
you have that with you?
GRIFFITHS: I do, yes.
LANGDALE: Can you confirm for us that the contents are true and accurate as far as you are
concerned?
GRIFFITHS: I can confirm, yes.
LANGDALE: I am going to take you through that statement if I may and we are also going to get
some documents on screen. If you can't hear me at any point or there is a problem, just let me
know although I will likely pick that up. If we look first of all at your professional background,
we see that you qualified as a registered adult nurse in 1997?
GRIFFITHS: That's correct.
LANGDALE: You worked at a couple of hospitals before
moving to the Countess of Chester in 1999?
GRIFFITHS: Yes.
LANGDALE: You worked on the High Dependency Unit until 2014?
GRIFFITHS: Yes.
LANGDALE: You became an RCN rep in 2012?
GRIFFITHS: Yes.
LANGDALE: Voted Staff-Side Chair in 2013?
GRIFFITHS: Yes, that's correct.
LANGDALE: Can you just, before I move to your next job in the Risk and Patient Safety department,
tell us about what attracted you to the RCN rep role and a bit more about the Staff-Side Chair,
what that role was?
GRIFFITHS: Yes. So I think there was event going on in the hospital where all the different trade
unions were there and I think somebody had come round to the areas to say, you know, you can go
and visit the stalls, the stands in your breaks and that -- and that's what I did and I happened
to speak to the RCN on their stand and I think they were just talking to me about possibly
becoming a representative. And there is three different types of representative: you can become a
steward, a learning representative and a health and safety representative. So I took the leaflets
away and then I did some
research and I think it was over the course of a few weeks I started to read a bit more and I
thought it might be something I was interested in, advocating for staff on their behalf and so I
applied and did the training possibly six months or so after I first applied.
LANGDALE: Was that for the steward role?
GRIFFITHS: Yes, that was for the steward role.
LANGDALE: That is the one that supports the member of staff, is it?
GRIFFITHS: Yes, yes.
LANGDALE: And is involved in their rights and their --
GRIFFITHS: Yes.
LANGDALE: -- concerns and looking at it from that perspective?
GRIFFITHS: Yes, that's correct.
LANGDALE: In that training, as a matter of interest, did you get any training around where
safeguarding of children might fit into that? I am not going to broaden it to patient safety; I am
just going to ask you about child protection?
GRIFFITHS: I don't think so, no. I don't -- I don't recall -- I mean, obviously it was 12 years or
so ago but it doesn't stand out for me, no.
LANGDALE: Because on one view we have heard from
an expert, Professor Dixon-Woods, who talks about HR processes can become very employee/individual
employer issues rather than a broader context perhaps?
GRIFFITHS: Yes.
LANGDALE: Of where the patients, or in the case we are examining, babies fall within that. Do you
think that's fair that there is not much consideration at the outset in that role from your
perspective about where children feature and what the competing interests might be and how you
have to take that into account?
GRIFFITHS: Yes, I think that would be correct, yes.
LANGDALE: Is that something you may have reflected on or may not since dealing with this that you
can get very partisan in that role and perhaps not think of the broader picture?
GRIFFITHS: Yes -- I have reflected a lot obviously, you know, since being given my Rule 9 Request
and the evidence and, you know, I think that is safe to say you can, you know, become --
narrow-minded -- not be the right word, but you can become focused.
LANGDALE: On your member?
GRIFFITHS: Yes, on your member.
LANGDALE: Their rights, their position?
GRIFFITHS: On your member, yes.
LANGDALE: You moved 2014, paragraph 4, into the Risk and Safety Team at the hospital. We have
heard evidence from Ruth Millward and others about that?
GRIFFITHS: Yes.
LANGDALE: But what's your overview about what a Risk and Patient Safety Team does; what's it
supposed to be doing, this team?
GRIFFITHS: So at the time when I applied for the -- for the role, I didn't know an awful lot about
it. I had seen the role advertised, I had looked at the job description, it did interest me and at
the time the role was advertised as for three days a week and that had also interested me because
working in intensive care we were doing a lot of shift work and I didn't always have a lot of time
to do RCN steward work, so by applying for this job I thought if I was successful, the Trust might
allow me to then do two days' trade union work, which they did later on. So when I applied for the
job I did speak to a couple of members the team and, you know, my understanding from what the
roles I was covering is, you know, it would be looking at incidences and risks and the Risk
Register, managing the day-to-day risk work that, you know, there could be some investigation
work, but you are there as support to the investigating officers.
And as I say in my statement I think to begin with I covered pathology and pharmacy and then later
on radiology.
LANGDALE: In terms of in your area, how are you in that assessment or risk management taking the
load off the people -- I mean, we have all got day jobs but in their day job of dealing with
clinical care or patients? Nurses and doctors who are with patients, if they raise anything with
you, where does the responsibility lie for following through on concerns or you say
investigations?
GRIFFITHS: Well, I would say the responsibility lies with all of us. I wouldn't have just heard or
taken something and then not acted on it and if any concern was ever raised to me I would talk to
the individuals involved about, you know, what it is, you know, they wanted to do with the
information and, you know, if I felt even in my Union role, you know, something was said to me
that was serious enough that I had to breach somebody's confidence, in a matter of patient safety,
then I would have done. But the areas I covered I didn't have an awful lot to do with clinical
areas because they were more what they call back office functions, pathology and radiology and
that's whilst they dealt with patients.
LANGDALE: You moved more into your union work, didn't
you, the two days --
GRIFFITHS: Yes, over time, yes, I started to pick up because I was the only representative in the
Trust I was as far as I could remember. So I started to pick up more and more work.
LANGDALE: When you say "pick up work", did members of staff find you or the RCN allocate you to
people; how did it work?
GRIFFITHS: Both, to be honest. So you know certainly in the latter years more members would come
to me directly, you know, I have been in the Trust a long time so a lot of people --
LANGDALE: Knew who you were?
GRIFFITHS: -- knew me now. Obviously at the start most -- most people would ring what RCN direct
and there was a freephone telephone number that they could ring between core hours and I think now
they can also ask for advice online. I'm not sure if they could at the time. So often, you know, a
member of staff would ring the RCN, they will explain the situation, what they might or might not
want support with. Sometimes the RCN team who have took that call might be able to assist in the
beginning and if -- if it warrants, they refer -- they put the referral through to the region, so
in our my case it would have been the North-West region, and
then as far as I am aware, one of the officers who would have covered Cheshire and Merseyside,
that was the patch we were under.
LANGDALE: Did you ever end up doing more than two days a week in that kind of work or ...
GRIFFITHS: Pardon?
LANGDALE: Did you -- I know you moved to two days a week doing your Union work, did you go to
increase that over time as well?
GRIFFITHS: Yes, I did.
LANGDALE: What did it go up to eventually?
GRIFFITHS: It eventually went up to full-time work.
LANGDALE: Right, full-time. Okay.
GRIFFITHS: Yes.
LANGDALE: You chaired the informal Staff-Side quarterly meetings; what were they?
GRIFFITHS: Yes. So I was elected the Staff-Side Chair so the Staff-Side Chair position you can
only hold if you are already an elected trade union representative but it doesn't have to be a
specific trade union. So I was elected so you are kind of like the spokesperson on behalf of the
trade unions, you don't oversee their day-to-day work because that is for the individual trade
unions. But we would have meetings, I mean over time they went to monthly meetings but I think at
the time they were probably quarterly meetings, so we would meet with the trade unions and discuss
general Trust business, to be honest, and we -- our -- every quarter we would meet formally as the
partnership forum with -- there would be one or two Exec members on there and different managers
and I would just -- I would be the spokesperson and others would be able to contribute but I would
set the agenda and obviously help review policies, if there was wider employment issues in the
organisation, so perhaps a consultation which would involve a change to people's terms and
conditions. They might notify me first but, you know, and we discuss a plan on how we are going to
communicate and support the staff and what other unions might be involved.
LANGDALE: In terms of policies can we go please to INQ0014165, page 1. It will come up on the screen. It's a safeguarding and
promoting the welfare of children policy, Mrs Griffiths. That's page 1. If we go to page 3 there
is an email from -- an Executive introduction, sorry, from Alison Kelly, setting out: "As a
statutory partner of the local Safeguarding Board, the Countess of Chester recognise it has clear
responsibility to identify and respond to issues of safeguarding promoting the welfare of all
children. Every adult has a responsibility to protect children. As employees of the Trust we are
duty-bound to act in the best interests of a child." Did this ever get discussed at a Staff-Side
meeting, this policy?
GRIFFITHS: No.
LANGDALE: If we go overleaf, to the next page, section 5 I am looking for actually, so it's INQ0014165, page 30. We see there Speak Out Safely raising concerns about
patient care, take your time to have a read about that. (Pause) "Staff may have concerns about the
care or treatment given to any patients and may wish to discuss these with managers. All concerns
raised by staff about patient care will be dealt with seriously, promptly and be subject to a
thorough and impartial investigation where necessary." Was that discussed?
GRIFFITHS: No.
LANGDALE: You were somebody who also had a role as a Speak Out Safely person, didn't you?
GRIFFITHS: That's correct.
LANGDALE: If we go to INQ0098554, page 1, we see there
this is 2017, you are sending it to a Clare Jones, the new RCN guidance on raising concerns to be
circulated as one of the actions. There is Freedom to Speak Up meetings, isn't there, or Speak Out
Safely meetings?
GRIFFITHS: Yes.
LANGDALE: You attend those and it looks like you have all agreed this needs to be sent out in
2017. If we go to INQ0102688, page 2, we see there a section on raising concerns or
whistleblowing: are you raising a concern, are you blowing the whistle, are they the same thing?
Often difficult to understand they can be the same thing depending on what you are concerned
about, seriousness, how you make concerns known. It sets out about whistleblowing being a popular
phrase, et cetera. Did you understand this, these distinctions?
GRIFFITHS: Pardon?
LANGDALE: Did you understand these distinctions, was that ever discussed in these groups, the
Freedom to Speak Up safely --
GRIFFITHS: No, I don't recall it ever being discussed.
LANGDALE: There was earlier guidance in relation to this, in 2015, in fact I have just taken you
to the earlier guidance in 2015 at page 2, so that would have been in play around 2015/16.
If you look at INQ009855 [not found] page 4, that is the one that was the most recent. It sets
out: "Concern must be based on a reasonable belief that you can justify but you do not need hard
evidence that wrongdoing is happening." Did you understand that that's the purpose of speak up
safely, speak up, you just need to be worried?
GRIFFITHS: Yes.
LANGDALE: You need to be concerned but you don't need hard evidence? Was that something you think
was actively spoken about at the Trust at the time of events we are concerned about, 2015 to 2016;
you don't need hard evidence, you need suspicion, concern, worried about patients?
GRIFFITHS: No, I don't think it was something that was --
LANGDALE: Looking back, do you think it would have been helpful to have reminders of this, what
speak up safely means in terms of you don't -- a gut instinct is relevant here, you know, it
doesn't mean you have to have hard evidence?
GRIFFITHS: Yes, I think it would be helpful.
LANGDALE: I'm not going to take you to the Speak Out Safely meetings but an example is INQ0098375, page 1. This is one in 2017. We see it's a member of the
governing body, isn't it, who chairs these. Non-Executive director Mr Andrew Higgins, you have Mrs
Kelly, Mrs Hodkinson, yourself and Stephen Cross. So a high-powered group in terms of the Trust,
isn't it, sitting at those meetings?
GRIFFITHS: Yes.
LANGDALE: Representative, you are Staff-Side Chair, Governor, Director of Corporate and Legal.
You know you are all sitting there discussing these issues. There appears to be on page 3 at this
meeting box 6?
GRIFFITHS: (Nods)
LANGDALE: Ms Kelly raising whether we need to consider concerns raised by paediatricians need to
be formally logged. I am not going to take you to this issue about whether they were logged or
not, the minutes; there was obviously retrospective gaze on that one, wasn't there, about whether
you logged them what they were saying and how they should be logged?
GRIFFITHS: Mmm.
LANGDALE: What was your understanding at the time they were raising concerns and when you were
involved -- we will to when you were involved -- about the avenue with which the paediatricians'
concerns were being raised?
GRIFFITHS: So my recollection is nothing was ever really discussed in those meetings about the
neonatal unit. It
was like it was glossed over. Now, I don't know whether that was because I was in the room or
anything else but, you know, I obviously mention at times they have a spreadsheet where cases are
logged. I never had access to that spreadsheet, so whilst we have the action log, one of the
points I had raised was that I was never informed -- you know, people would raise concerns to
another designated officer but we would be sat in these meetings talking about it but we didn't
all have the background and knowledge about it. So as far as I can recall whilst it says after
discussion, I don't recall a discussion because I don't believe it was ever properly discussed in
there.
LANGDALE: In your mind, who was responsible for setting how these concerns should be raised, was
it HR, was it the Execs? Presumably not you as a Staff-Side Chair?
GRIFFITHS: I -- I don't know to be honest. I could only presume it would have been the Execs. They
used to alternate the chair between Alison Kelly and Sue Hodkinson.
LANGDALE: So you understood that across the Trust they would know under the Speak Out Safely who
was raising concerns whether it was that or whistleblowing, Sue Hodkinson was Director of People
wasn't she, would
she be expected to know, do you think?
GRIFFITHS: Well, I would have expected so because I would imagine if somebody was raising a
concern to one of us, you know, that is exactly where it would have come to, whether it be that
meeting or outside of that meeting. So more often than not it appeared Sue Hodkinson and Alison
Kelly did know about most of the concerns raised.
LANGDALE: Who set the agenda for those meetings?
GRIFFITHS: I think it was -- it alternated between Sue Hodkinson and Alison Kelly's personal
assistant, from what I recall either.
LANGDALE: So you weren't setting those agendas?
GRIFFITHS: No.
LANGDALE: You did that for the Staff-Side and partnership meetings?
GRIFFITHS: Yes.
LANGDALE: Where it was very much ask your members what they felt about things but you didn't set
this one?
GRIFFITHS: No.
LANGDALE: So that can go down, thank you. We know therefore you have got a number of hats,
haven't you, you have got the Staff-Side member, you are working on Risk and Patient Safety. You
get invited, if we go to INQ0004884, page 1,
this is a mortality review?
GRIFFITHS: Yes.
LANGDALE: If we go to page 3, you know the one, you have seen it. You get invited to this meeting
where we know two babies have died in rapid succession in suspicious circumstances and at this
meeting the suspicions are being discussed, aren't they? You say you don't remember Letby being
mentioned by name but the suspicions that there is foul play?
GRIFFITHS: I don't recall that at the time. I was asked to attend the meeting with -- as support
with Sian Williams to take some notes. I -- I remember sitting towards the back of the room
although it was quite a small room but I don't remember anybody saying anything about foul play or
having suspicions and I didn't know anything at that time.
LANGDALE: Dr ZA has given evidence that Letby's presence was referred to in the meeting of 5 July
and her having something to do with the deaths, her continued association, it had gone beyond a
coincidence and she must have been involved in some way, either deliberately or incompetently,
that that is why they were having this meeting. We know that the doctors, Dr Brearey was going to
Karen Townsend -- sorry, speaking with Karen Townsend on the phone in the evening the doctors were
really worried, weren't they, that was the purpose of the meeting and the review?
GRIFFITHS: I thought the purpose of the review was what happened. After any death they have a
review. That's what I was led to believe that review was, was they would look at the care and
other things to do with it. As I say, I don't recall anything, anybody saying anything about
suspicions to do with an individual.
LANGDALE: Do you recall, as we know was discussed, the fact that the bags -- bags, samples were
being kept, Dr Green was being asked to keep samples in relation to the two babies for testing, so
they were stored at the hospital; do you remember that being said?
GRIFFITHS: No, I don't recall that.
LANGDALE: If that was said, is that the sort of thing you would think: well, why are you keeping
those if you are not suspicious about something? You wouldn't keep samples for testing, would you,
unless you thought they needed testing for something?
GRIFFITHS: I would only be speculating but yes, you might think that. But as I say, I don't recall
that being said.
LANGDALE: Did you, if you don't recall it, look back at that meeting when you were subsequently
dealing with
Letby and remember that meeting? You say you don't remember these concerns. But assume for a
moment they were being discussed and for whatever reason you are not taking them on board at the
time, did you look back and think about that meeting and what it represented?
GRIFFITHS: No. I thought it was a -- a mortality review, a peer review that they do.
LANGDALE: What did you think the circumstances were of those deaths, when did you think they had
happened, what did you think was learned in that discussion then?
GRIFFITHS: I don't know, to be honest.
LANGDALE: No memory? I mean, two babies we have heard evidence from many people, in writing and
orally, how shocked to the core they were with those two healthy -- two of three Triplets dying in
rapid succession unexpectedly. Can you not now remember anything about what you thought that was
about? That meeting?
GRIFFITHS: No. I can't recall anything. I hadn't recalled going to the meeting until I had got the
evidence.
LANGDALE: I don't suppose you have been to many meetings where deaths of babies and concerns that
someone from the staff has been involved are going to be discussed?
GRIFFITHS: No, that is the only meeting but, as I say, I didn't hear that discussed.
LANGDALE: So are you saying they are wrong when they tell us that is what they discussed or you
just weren't listening, or I am at odds with whether other people have said with what you are now
saying, Mrs Griffiths; I am just trying to understand what you are saying?
GRIFFITHS: That is their recollection. My recollection is I went with Sian, I sat in a corner of
the room to take some notes and I don't even think I could probably hear what they were in another
part of the room discussing.
LANGDALE: So you think you were too far away to hear it?
GRIFFITHS: That's possible.
LANGDALE: What notes did you take?
GRIFFITHS: I can't remember what notes I took, to be honest. I know they were very brief because I
was asked to take some notes and I handed them over to Sian the next day.
LANGDALE: You tell us that you gave the notes to Sian and never looked at them again so were they
handwritten notes?
GRIFFITHS: Yes.
LANGDALE: Did you know the purpose of you taking the notes?
GRIFFITHS: I just -- I think I was just asked by Sian or by Ruth in the absence of the Women's and
Children's
Risk Lead to -- as I say, to go and support Sian and take some notes of what was discussed but as
I say as far as I was aware it was a review that they undertook after any death so having not been
involved in any before, it -- I thought that was normal.
LANGDALE: Thank you, that can go down now. You tell us that you assisted Letby submitting her
grievance and you set out briefly in your statement in July how you were asked to attend a meeting
with Alison Kelly in your role as the representative and asked, were you, by her to support her;
was that the position?
GRIFFITHS: What date was that again, sorry?
LANGDALE: If you go to your statement paragraph 19, so Friday, 15 July, asked to attend a meeting
by Alison Kelly in your role as representative?
GRIFFITHS: (Nods) Yes, that's correct.
LANGDALE: You were informed that there were concerns raised about an individual nurse who was
working on the neonatal unit?
GRIFFITHS: That's correct.
LANGDALE: So that's 15 July, just a week after the meeting we have just looked at?
GRIFFITHS: Yes.
LANGDALE: So by then did it fall into place the meeting or not, the one that you had been at the
week before?
GRIFFITHS: It could well have done.
LANGDALE: So you must have realised if they are right, Letby being mentioned at that point, this
was the nurse that there were concerns about who needed support and you were being asked to
support her, so the gravity of it from that meeting that you attended with O and P must have been
in your mind? Yes, you are nodding?
GRIFFITHS: Yes.
LANGDALE: Serious, isn't it?
GRIFFITHS: Yes.
LANGDALE: You have been asked to support somebody where there is concerns that babies have died
or deteriorated unexpectedly and she is linked to it for deliberate harm or otherwise; yes?
GRIFFITHS: Yes.
LANGDALE: So I don't suppose before or since you have ever had a case like that?
GRIFFITHS: No.
LANGDALE: You were to subsequently accompany Lucy Letby in her interview with the Royal College,
weren't you?
GRIFFITHS: Yes, that's correct.
LANGDALE: What did you understand that was about, the Royal College report, the review that they
were undertaking?
GRIFFITHS: So one of the first times I met Lucy Letby was when Karen Rees came down to our office
and she said she needed to meet with Lucy and would I be able to, you know, sit in on the meeting?
So I did do and it was at that meeting that it was talked about this Royal College review and it
was just -- the Royal College was -- I understood it to be they were going to look at lots of
different factors and they were going to be interviewing lots of staff, that it was an external
review. I didn't know any more than that.
LANGDALE: You say in your statement at paragraph 41 as you have said now: "... the purpose was to
undertake a review into the increased mortality rate within the neonatal unit centred around
culture, procedure and staffing levels." You knew at that time yourself, as you said earlier, that
there were suspicions that Lucy Letby was involved which isn't to do with staffing levels, it is
to do with an individual, right, so how did that sit with you when you understood the review
wasn't looking at whether she was involved and had done something?
GRIFFITHS: It was uncomfortable and it didn't feel right.
LANGDALE: Why not?
GRIFFITHS: Because we had been made aware that an individual may be, you know, potentially harming
babies
and, you know, I think Lucy Letby was led to believe that this once this review will be done this
will solve everything and it was quite evident in the interview it wasn't going to solve anything.
I didn't know what to expect when I went into the meeting to support her, I was asked last minute
and Lucy didn't trust anybody in the organisation to go with her. So I went with her but it --
within five minutes of being in the interview it was evident they were just asking very generic
questions.
LANGDALE: Shall we go to the notes of it, INQ0014602, page 1., more for others' reference than yours, Mrs Griffiths.
You were there but this is where we get page 1. Give people time to scan that and then page 2 and
3. We know, Mrs Griffiths, this interview was undertaken with Alex Mancini and a Claire
MacLaughlan from the RCPCH. What was the nature and the tone of the interview? You have just given
us a sense of it.
GRIFFITHS: It seemed inquisitive but not out of the ordinary. They really just seemed to be asking
generic questions of an individual.
LANGDALE: Were you at all times with Letby when she was with the reviewers MacLaughlan and
Mancini? You know, was she ever with them on her own away from you?
GRIFFITHS: I don't recall that she was, no.
LANGDALE: So you had gone to accompany her, you stayed with her?
GRIFFITHS: Yes.
LANGDALE: We know because she messaged Dr U about this that she said afterwards the two members
were nice, they didn't ask much about the babies, it was more about the unit as a whole. In brief
it looks as though there is the potential for this to go further over a long period of time. H --
that is presumably you -- thinks we need to look at taking out a grievance. Then she says: "They
off the record tell me they think an investigation into the deaths will be a recommendation and I
need to prepare myself for that as I need to prepare myself that as I would play a big part in
that over due to being a common factor". It is not clear if she is saying, they, the two members,
but it appears to be, had said there may be an investigation. But she wouldn't have had any time
to speak with them when you were there?
GRIFFITHS: I don't recall that being said.
LANGDALE: No, so there was nothing in that?
GRIFFITHS: I don't, yes.
LANGDALE: Did you mean -- would you have said that on leaving that meeting?
GRIFFITHS: No.
LANGDALE: That it could go further over a long period of time?
GRIFFITHS: No.
LANGDALE: Because at that point you have just gone for the interview and you haven't seen the
report; right?
GRIFFITHS: Yes.
LANGDALE: The grievance we know if we go to INQ0002746, page 3.
LADY JUSTICE THIRLWALL: Sorry, Ms Langdale, just before you get to that, I wonder if I might just ask a question.
MS LANGDALE: Of course. Sorry.
LADY JUSTICE THIRLWALL: Did the WhatsApp -- the message says that "H says I should look at taking
out a grievance"; is that something that you had said?
GRIFFITHS: That's possible, yes.
LADY JUSTICE THIRLWALL: At the end of the interview or some time after it?
GRIFFITHS: That is possible that I could have had a conversation with her after the interview
walking back knowing that that review, that interview wasn't ...
MS LANGDALE: Fit for purpose from your perspective, because it wasn't investigating her?
GRIFFITHS: Yes, it wasn't going to do anything for our
member.
LANGDALE: From your point of view there needed to be investigation into her and that wasn't
happening through this, is that what you were thinking and that someone was going to do it?
GRIFFITHS: Sorry, can you repeat that?
LANGDALE: From your point of view did you think, given the seriousness of the allegations, there
needed to be an investigation into her and this review wasn't doing that?
GRIFFITHS: Yes.
LANGDALE: Because they were serious allegations and you can't tiptoe round the outside of those,
can you?
GRIFFITHS: They were serious allegations.
LANGDALE: The letter on screen now is a letter that you were cc'd into to your colleague Tony
Millea?
GRIFFITHS: Tony Millea.
LANGDALE: Tony Millea, so he is also supporting her and if we read that, we see in that bottom
paragraph: "I am now aware the independent external review has commenced, Lucy was interviewed.
Lucy was accompanied by Hayley Cooper. It is following this meeting that my concerns have
deepened. This is due to the fact the Terms of Reference does not seem to address the initial
Trust concerns that they have in relation to the
unacceptable high mortality rate and our member's involvement." I will let you finish reading
that. So the grievance is launched with this in mind?
GRIFFITHS: Well, it was Lucy's decision to submit a grievance.
LANGDALE: We see INQ0002859, page 1. We see there: "Many thanks for meeting ... explain the
current situation ... discuss the grievance and the letter ... she wishes for it to be dealt with
formally." So you are having conversations with her about it; yes?
GRIFFITHS: Correct.
LANGDALE: The grievance itself, give me one moment. That can come down, thank you. Who puts
together the points of the grievance?
GRIFFITHS: More often than not, the member. I have had cases, not necessarily Lucy's, where I
might have sat and helped the member type it up. But it's their words at the end of the day and I
always make that clear to a member. It's their right to submit a grievance as an employee if they
feel they have got grounds, sometimes it is not always something I might or might not agree with
but in my role that it's entirely down to the member.
I do more often than not ask for the members to then send it to me so sometimes we can, we can
check it or if there's a date that needs adding and also I like more often than not to submit the
grievances to the organisation on my member's behalf so that we have got a record of it.
LANGDALE: We see it at INQ0002879, page 3. Look for page 3, if we can. There we see that. Is that
the grievance?
GRIFFITHS: Yes.
LANGDALE: You tell us, as you touched upon earlier, you tell us at paragraph 56 of your statement
-- you don't need to turn it up -- that you told Alison Kelly and Sue Hodkinson that they had a
duty to investigate Letby. Did you email that or was that a conversation?
GRIFFITHS: I think it was a conversation, to be honest.
LANGDALE: And when did you have that conversation, can you remember, was it around this time,
before? After?
GRIFFITHS: I can't remember. Sorry, I can't remember because it's quite possible that I said it on
more than one occasion. I know very early on I took some advice from the RCN and again had said it
to Alison Kelly and Sue Hodkinson that, you know, they had a duty to investigate this and, you
know, from the RCN point of view it was, you know, you either need to investigate our member or
you need to allow her back on the unit because nothing was happening. You know, this was made into
an employment issue and it was never an employment issue and it shouldn't have been.
LANGDALE: Paragraph 49 of your statement, you don't need to turn it up, you say before issuing
this you met Lucy Letby in the Countess Country Park to discuss that she was being accused of
deliberately harming babies?
GRIFFITHS: Yes.
LANGDALE: Tell us about that.
GRIFFITHS: So I think we were due to have a weekly meeting that had been set up with Sue
Hodkinson, Alison Kelly, Karen Rees and myself and that for support and I think it was the meeting
that was cancelled at short notice. I just wasn't -- I wasn't sure in myself that Lucy understood
the gravity of what was potentially happening and what was potentially being said and, you know,
with -- any member has a right to know what they are potentially being accused of and nothing was
happening in the Trust. She had been removed, she had been put into my office and that was it.
Nothing else was happening.
LANGDALE: What did she have access to when she was in
your office in the Risk and Patient Safety team?
GRIFFITHS: So I think in the first instance she moved there was a wider part of the team, we were
in the same building but different offices. I think she was in there with the admin support,
health and safety, maybe I think somebody from safeguarding was based in that office and I think
she did low level concerns and complaints and compliments, I think. Then later on in time she
moved into the Risk Team and was starting to pick up some risk work.
LANGDALE: Can you access any risk work when you are in the Risk Team, could she have accessed
material about babies in the hospital or the babies on the indictment or the investigations
because there was a lot of documentation flying around at this point?
GRIFFITHS: Yes, if she had been given access to the Datix system, which I believe she would have
done, I don't know if she ever had access to what we call the S drive on the computer which is
where you have lots -- people in the hospital have lots of different folders but you have to ask
for access to that and that's normally via your manager to the IT department. But I know one of
the text messages references her sort of moving desks and she hadn't got access to the S drive and
H drive and that. So I would imagine in
time that she did have. But I don't know for certain.
LANGDALE: Sure. But that was something you had raised as a concern, didn't you, you were
concerned that -- perhaps you are saying that with a retrospective lens -- that she had access to
material that really given the position wasn't potentially appropriate, was it?
GRIFFITHS: Well, it was never appropriate to have put her in our office in the first place.
LANGDALE: Why's that?
GRIFFITHS: I just didn't think it was appropriate, given we were, you know, risk and governance.
Everybody was aware that there was an internal review or had been an internal review. There was
starting to be the rumour mill everywhere of, you know, what's going on there, is -- is somebody
involved, is somebody not.
LANGDALE: Of course when someone is moved, aren't they, from a clinical-facing role, the whole
hospital must have been talking about it, mustn't they? It is hard to keep that secret, however
hard you try, isn't it?
GRIFFITHS: Yes.
LANGDALE: People are people everywhere?
GRIFFITHS: Yes, and absolutely people talk across different departments, people have friends
everywhere. It wasn't necessarily something I talked about but I had a different role in it but I
didn't think it was right
that she came into the office and I did raise that and none more so because I was potentially
going to be officially representing her at that time and that would have caused a conflict and,
you know, I also made the RCN aware to say also given I had been involved in a review on the --
you know.
LANGDALE: On the Triplets O and P?
GRIFFITHS: On the Triplets, then I would have a conflict. So my role was more a support. She had
other officers who were officially representing her but, you know, going back to the question, I
don't know what she had access to or what she would have accessed, there would be an audit trail,
but I didn't think it was right, no.
LANGDALE: When you say you spoke to the RCN about a conflict did you go back to them to discuss
that at all in your -- because you are wearing a number of hats now, aren't you: Risk and Patient
Safety, Speak Out Safely and supporting somebody who's the most serious allegation you have ever
dealt with?
GRIFFITHS: Yes. I don't think I necessarily spoke to them and reported it as a conflict because by
then, you know, Tony Millea and then later on Colm Byrne took over her representation. So like I
explained in my statement I never had access to what we call her case file in the RCN so therefore
I could never be officially representing her because I didn't have access to her documents or
anything which I would do normally for members. So anything I -- I sent or needed to be reviewed I
would send up to the RCN to review but obviously we did have a lot of verbal conversations, but I
don't know that I particularly raised it because I just seen that I was giving her support.
LANGDALE: If we look at the question of support, look at the document on the screen, the bottom
paragraph. This is from Letby in her grievance: "Eight weeks ago I was made aware that I was going
to review. I agreed to be redeployed. I now feel completely victimised, feel I am being made a
scapegoat of. I feel completely isolated from my friends and colleagues having been told not to
contact the NNU." If we go look at what she says there about being isolated and not to contact the
NNU, if we can go please to INQ00024580001 and it is a letter, 18 July, from Karen Rees to Lucy Letby.
If we go to the second page, second paragraph: "You raised the issue of personal support, your
friends are work colleagues. I advise you the purpose of the redeployment was not to stop the
usual social contact ... be mindful of discussing matters which may
be sensitive relating to the review". So collapse of babies, review, et cetera. Karen Rees had
never said she couldn't have social contact and she did have social contact, didn't she, with a
number of people, including yourself, over WhatsApp groups, Dr U, others. The Inquiry has heard
evidence from Nurse T who was also communicating with her. Plenty of support from other people,
she just couldn't be in the NNU; is that the position?
GRIFFITHS: Yes, I wasn't aware, I wasn't in that meeting, so I wasn't aware that she had been told
she couldn't have contact.
LANGDALE: Right.
GRIFFITHS: And I -- had that been raised with me, had she said to me when I first met her "I have
been told I can't have contact" I know I would have asked -- said to her I would ask on her behalf
if she could have contact because that wouldn't be normal to say to an individual that you can't
have contact.
LANGDALE: Well, they hadn't, had they?
GRIFFITHS: No.
LANGDALE: She states that in the grievance you said, you are careful it is their words, the words
used, no one had said that. Karen Rees was someone on a WhatsApp group supporting her. She hadn't
prevented her from
having contact and wasn't trying to see that she was isolated, was she; quite the reverse?
GRIFFITHS: But that wasn't my grievance, I didn't write the grievance, so that is Lucy's words in
the grievance, not mine.
LANGDALE: I understand. Did you understand at the time the level of support she was getting from
a number of people or did you think there was just a few of you?
GRIFFITHS: If I am honest I thought there was just a few of us. I just thought the ones were
certainly -- within the Trust myself, Karen and Kathryn, I thought were --
LANGDALE: Just the three of you, no other?
GRIFFITHS: I thought it was just the three of us. I knew she had contact with her friends on the
neonatal unit but I don't --
LANGDALE: Did you know about her messaging with Dr U? I don't want to ask you more about Dr U,
just the level of communication?
GRIFFITHS: No.
LANGDALE: Right. INQ0002748 0001, please. When you send the grievance you copy in Sir Duncan
Nichol?
GRIFFITHS: (Nods) Yes.
LANGDALE: "I appreciate you feel you can't get involved
... you should know how a member of staff is feeling. This has now dragged on for several weeks.
My member has been left with no other alternative." Have you ever before or since copied in the
chair of the governing body to a grievance?
GRIFFITHS: I have done once. However, that was a collective Staff-Side trade union grievance so
sometimes that would be the route to go when submitting a grievance on behalf of all the trade
unions. However, it is -- I accept it is unusual.
LANGDALE: What did you want him to do, if anything, about that? Were you just letting him know
she was upset or she had got no other alternative or what?
GRIFFITHS: I wanted to them to know what an individual member of staff was going through and how
they were feeling and I wanted them to know that she was still there.
LANGDALE: Did you ever --
GRIFFITHS: She hadn't gone anywhere.
LANGDALE: -- share with them in that email you thought she needed investigating or in any other
email because that is an important point, isn't it? You had seen that there should be an
investigation and the grievance didn't fit the bill, really, for that part of it, whether she had
harmed babies?
GRIFFITHS: I don't think I ever did put it in an email, no.
LANGDALE: Was that because you were acting on behalf of her by that time? You know, you are doing
the best for her and you thought it was better not to have an investigation?
GRIFFITHS: No. I was supporting her but, as I say, you know, she had RCN officers representing
her. So she would have needed to have a conversation with them about that. I -- it wasn't because
I didn't think there needed to be an investigation because clearly there did need to be an
investigation.
LANGDALE: You discussed with Lucy Letby about going to the police and suggesting that she would
be prepared to go to the police but she didn't want that, did she, she didn't want you to say
that?
GRIFFITHS: I asked her if she wanted to go to the police station herself. I said to her she was
quite within her rights to go to the police station herself and make -- make -- you know, inform
the police that these allegations were happening and she didn't want that.
LANGDALE: No. Did you make anything of that at the time?
GRIFFITHS: No.
LANGDALE: By connecting that she might go to the police
or the police should be involved, you were very sighted on the fact this needed proper
investigation, sudden unexpected baby deaths and somebody is always there and suspicion about her
and you didn't even know the material that the police then gathered or indeed some that the
Inquiry has heard about concerns or complaints about her? But you even then thought the police are
likely to be involved, is that what you thought?
GRIFFITHS: I did feel there needed to be an investigation and, as I say, I raised that with the
Trust. But every week we were meeting with members of the Executive Team and every week we were
being told: we support you, Lucy, we are behind you, Lucy, the board are behind you, we are going
to get you back on the neonatal unit. So I wasn't aware of any evidence.
LANGDALE: Let's go to INQ0002879 0017, please, and this is your interview with Dr Green. While we
are calling that up, you emailed Dr Green and said: look, I have been involved for a while, I
think I need to meet you, is that right, you asked to be interviewed by him?
GRIFFITHS: So I don't recollect that. However, having seen the evidence obviously --
LANGDALE: You have seen the email?
GRIFFITHS: -- I accept I have -- I have sent the email.
LANGDALE: You emailed him?
GRIFFITHS: Yes.
LANGDALE: Again, was there a reason you felt the need to email to ask to speak with him?
GRIFFITHS: I don't recall it, to be honest, so I can only surmise that whatever I put in the email
I have actually spoken about as part of my grievance interview.
LANGDALE: Yes. So you email him and you get a meeting with him. If we go to page 18, you say at
the top of there: "External review people came in told Lucy she would be interviewed and I
attended with her. [that is the RCPCH] I think that the penny started to drop and that there was
more to it than what she had been told. Both reviewers expressed their concern following this
regarding her health and well-being. At this point she was very distressed." So is that -- who are
you referring to there, expressing concern for her health and well-being?
GRIFFITHS: I think the people who had interviewed her.
LANGDALE: Pardon?
GRIFFITHS: I think the people who had interviewed her.
LANGDALE: In the interview when you were both there?
GRIFFITHS: Yes.
LANGDALE: So they were taking a welfare view for her, as it were?
GRIFFITHS: Yes.
LANGDALE: So that is Mr Mancini and Ms MacLaughlan when they were interviewing her. Can you
remember what they said expressing that concern?
GRIFFITHS: I vaguely recall and I think I have mentioned it in my statement, I think I had to go
back into the room for something. I don't know whether I had forgotten my coat, bag, something and
they just asked me. It was, you know, obviously it's not word for word but, you know, it was along
the lines of: is she okay? Does, does -- does she know what's happening? And I was like: no, I
don't -- because we didn't need to speak about it but it was evident to me that -- I thought they
knew that she was, you know, potentially a person of interest but that didn't come across in that
interview.
LANGDALE: A couple of paragraphs down. LL didn't want some things in the grievance in regards to
the police. She didn't want to say she was happy to go to the police or the police should be
called, is that the position?
GRIFFITHS: Yes.
LANGDALE: Yes. Because you have said she decides what's finally in the grievance. For you an
option was to say: go to the police, get them to investigate, she will go herself if needs be.
That is something you appear to have discussed with her?
GRIFFITHS: I asked -- yes, I discussed with her if she wanted to go to the police herself.
LANGDALE: To get on with an investigation, in your mind presumably to suggest that she might be
exonerated like that, they would clear it up?
GRIFFITHS: Possibly.
LANGDALE: Or possibly not. You didn't know?
GRIFFITHS: No.
LANGDALE: So when you suggested that to her you didn't give her any reassurance what would
happen, you didn't know, you just said they need to investigate it, why don't you go?
GRIFFITHS: I wouldn't know what was going to happen. I was just giving her the option of another
avenue because nobody seemed to be doing anything in the organisation.
LANGDALE: We see there you tell him at the end of that paragraph: "I informed the Trust of a duty
to investigate and felt they were citing her welfare as an excuse. It was intimated not to see her
on Friday pms in case cause upset over the weekend. I was a little insulted by this." Who was
really worried about her welfare; Alison Kelly, was it?
GRIFFITHS: Yes, I think both Alison Kelly and Sue Hodkinson were worried about her welfare once
they started meeting with her.
LANGDALE: Karen Rees -- I mean you and Karen Rees and others do send messages reminding them of
the distress she is in and how upset she is and that puts pressure on, doesn't it, if you think
they are concerned about the welfare already?
GRIFFITHS: Yes.
LANGDALE: Do you think looking back you may have added to the pressures by referring to her
distress as often as you did in various emails?
GRIFFITHS: No, I don't think I did add to the pressure.
LANGDALE: Okay. Well, do you think they did feel pressured about her welfare?
GRIFFITHS: Yes, I think they did.
LANGDALE: So the more people referred to it do you think that does add to that pressure?
GRIFFITHS: I'm not sure, I don't understand.
LANGDALE: Let's have a look. Shall we look at INQ0057497, page 1. This is your letter setting out Lucy asking Karen Rees
to read something.
GRIFFITHS: Yes.
LANGDALE: Attached we have it at INQ0057493 0001. When people have had a chance to read that one,
57493, page 1 is the next one. We know this is the statement that was read out at a meeting and Dr
Tighe gave evidence to the Inquiry was that the last thing this meeting needed discussing concerns
about the baby deaths, unexpected deaths, was this missive from Letby herself read by Karen Rees.
If we go to page 2 and it continues in the tone we know "hurt and disappointed", et cetera, et
cetera. Who drafted this?
GRIFFITHS: Lucy herself.
LANGDALE: With input from you, a bit of help from you and Karen we see various messages about you
supporting or helping or looking at emails, what about this?
GRIFFITHS: No, absolutely not.
LANGDALE: The next document if we can go to INQ0057494, page 1. This is in red, the comments that have been pulled
together. As her member were you taking and getting the statement from the parents?
GRIFFITHS: So until I had seen the evidence outline the other day I hadn't realised I had even
seen her parents' statement because that's not something I would be involved in. However, I accept
Lucy has obviously sent it to me and I have sent it into the Trust on their behalf but in no way
did I contribute to it or make any comment on it
because that's a personal statement from her parents and I wasn't ... the RCN weren't supporting
or representing her parents.
LANGDALE: Over the page, it continues. "We believe that certain Consultants have a personal
grudge against Lucy. We are at a loss to understand why." We know Karen Rees in her police
statement, indeed she told the Inquiry very early on she asked Lucy Letby -- she asked, not anyone
else at this point, her -- whether there had been a relationship or any issues with Dr Jayaram and
Dr Brearey and Lucy Letby said no in fact she got on really quite well with one of them, I can't
remember which one, but basically she had no reason whatever to doubt their personal approach to
her. It didn't really feature. Was that your understanding: that there wasn't anything in fact
that pointed to a personal grudge or pre-existing issues between either of those doctors and
Letby?
GRIFFITHS: Yes, there was nothing that I was aware of.
LANGDALE: Indeed we see some of them, even those who were strongly supportive, like Yvonne
Griffiths, of Lucy Letby and her innocence at that time, was even she was saying Dr Brearey was a
nice guy, a nice doctor?
GRIFFITHS: (Nods)
LANGDALE: Yes, there was no sense that any of the nurses aside from this issue had a problem with
either of those doctors; is that your understanding?
GRIFFITHS: That's my understanding, yes.
LANGDALE: Indeed relationships with Eirian Powell may have been very good until this issue when
it really was a very difference of opinion, wasn't it, and she was very supportive of Letby?
GRIFFITHS: Yes. I mean, I hadn't had anything to do with the neonatal unit or really the staff on
there before all of this had happened. So I wouldn't know about the Consultants.
LANGDALE: You attach INQ0102244, page 3. This is after the grievance conclusions. You send to
Alison and Sue a statement that Lucy wishes to be read out and sent out to the nursing team. We
see that at INQ0058365, page 1. So that -- she writes that again. Does she get support
writing that?
GRIFFITHS: No.
LANGDALE: Did you think it could safely be suggested that the allegations were unfounded and
untrue at this point?
GRIFFITHS: Well, like I said before, we were -- we were told near enough on a weekly basis, if not
more, that there was no evidence, that nobody had produced any
evidence, they weren't calling the police in. She had had her grievance, it had been upheld.
LANGDALE: If we go over to INQ0058646, page 1. This is Mrs Hodkinson asking you and Lucy would you be
able to share with me the final copy of wording if sent out today. So she's obviously asking you
what messaging or what needs to be sent out. Do you remember what that was about?
GRIFFITHS: So I'm not sure, this is about the email that she was sending out to the staff, the one
we have just looked at before. I don't know where that was agreed that Lucy Letby was allowed --
you know, it was agreed that she could write an email out to staff, that wasn't a meeting I was
in, whether that was in the grievance meeting or another meeting. And by this point there was
another a senior RCN officer who was supporting or representing Lucy. So as far as I am aware, you
know, the Trust knew this -- Lucy had asked to send this email out and Sue was just asking me.
LANGDALE: Sue was communicating a lot with you in her messages, wasn't she?
GRIFFITHS: Yes.
LANGDALE: She was asking for help, for support, so it
wouldn't be surprising if she was saying: shall I write this, shall I do that in her discussions
with you?
GRIFFITHS: It's possible but I don't -- I wouldn't have commented on that, like I wouldn't have
commented on the statement that was read out on her behalf because that's...
LANGDALE: Can we go please to INQ0002796, page 1. This is about Alder Hey. So third paragraph: "Karen Rees
has informed Lucy of both advice ... Lucy doesn't go to Alder Hey for the time being. We would
like to know why it's the case, is this a management instruction?" She wants to know why it wasn't
raised in the meeting. She's upset and disappointed, lack of openness and honesty. So they have
made a decision she can't go to Alder Hey. Did you think that was a sensible, if not late,
decision, that she couldn't go to Alder Hey?
GRIFFITHS: I think in hindsight yes. But at the time, you know, in 2017, we had been planning for
her return to the neonatal unit and thinking April. So they had known that she had been going to
Alder Hey, that is not my decision to make, whether she should go or not go. But they were fully
aware of it, of it.
LANGDALE: Remember where we started in this this morning
about where to babies fit in and responsibilities to patients? When you say that wasn't your
business, them having made that decision, you knew there should be an investigation into serious
allegations and that the RCPCH didn't deal with those allegations against her. You must have known
the grievance certainly didn't deal with those allegations against her. So with a different hat
on, for the safety of babies and patients and any baby you would want your family or friends to
have looked after in a hospital, would you at that stage have wanted her to be there pending an
investigation?
GRIFFITHS: Like I said earlier, this wasn't -- this wasn't an employment issue and it should never
have been an employment issue and they should have -- you know, they should have called the police
in straight away. Absolutely. But we were being told, as I say, on a weekly basis: there is no
evidence, we support you, we are going to get you back on to the unit, every week.
LANGDALE: With that in mind INQ0067360 0001. We asked Ms Powell and Ms Rees about this, they couldn't
remember this course, but fact if you look at, if we go to page 2, it looks as though Lucy Letby
has emailed having looked at a course, Glan Clwyd, spaces on the neonatal life-support course for
September, need to apply ASAP. If we go back to page 1 she sends that to Karen Rees and if we look
up, that is sanctioned. There is a concern because she is coming back on the ward you say, the
expectation to keep her -- the reference is "competencies up"; is that the position?
GRIFFITHS: Yes.
LANGDALE: So she's able to go on a course, a structured course, presumably, with people there.
Did you think there were proper checks being made about where she was working and when or what she
should be doing at this point; did any of that worry you?
GRIFFITHS: I don't know what checks they were doing or not. I -- I don't think I really thought
about it, to be honest, at the time.
LANGDALE: Looking back, what do you think about it?
GRIFFITHS: Looking back and on reflection, you know, they should have done -- you know, the Trust
Executives should have done something moment they heard about it. And if that was excluding an
individual then that would be excluding an individual.
LANGDALE: You say in your reflections you were a fairly new and inexperienced representative at
the time of your involvement and had not dealt with a lot of cases within the workplace and it was
an unprecedented case.
You also say you were never aware of any evidence being produced. You had been in that mortality
review meeting, hadn't you, and discussions about mortality reviews, extra work being undertaken,
staffing analysis being done by Eirian Powell. Did you become aware of those things?
GRIFFITHS: But I didn't recall all of that being said in that review meeting and maybe that's my
naivety or my memory in the meeting, I was going to a meeting that I was completely unfamiliar
with. But yes, on reflection, it's very different. But at the time, no, and as I say, every week
it was the same: we are going to get you back on the unit. We are going to get you back on the
unit. You have done nothing wrong. And everybody was saying that to her.
LANGDALE: We will go, if we may, to a few messages between you and Lucy Letby. If we can go
please to INQ0108368, page 3. The first message 168: "I am currently [this is you]
watching a programme called How To Get Away With Murder. I am learning some good tips." Next but
one message from her, 170: "I could have given you some tips." This is a really serious situation,
you have said that. What did you make of that at the time, that level
of exchange?
GRIFFITHS: You know, I have thought about this a lot and obviously I have read it in my evidence
and it was nothing more than a conversation. However, I truly and deeply regret having started
that conversation entering into text messages with Lucy. You know, this is completely
unprofessional and poor judgment on my behalf and completely insensitive and for that, I can only
apologise from the bottom of my heart, I can only apologise to say I have -- I have reflected on
that and that was eight years ago. But there is nothing else I can say.
LANGDALE: And she says at message 174 -- sorry, no, you say sending out, 174 you are saying: "I
need someone to practice on to see if I can get away with it." She says: "I can think of two
people [176] you could practice on and will help you cover it up." "Deal, I will get thinking of a
plan, get the cruise booked and getaway." Part of a sequence you say you deeply regret. Knowing
what you know about her now, how do you find all of that?
GRIFFITHS: I just think it's really insensitive and I --
you know, I started the conversation. I didn't think it was anything more than a conversation,
maybe, you know, I didn't think she was telling me anything. I just know that is not something we
should have been having a conversation about.
LANGDALE: You were keen, like others the Inquiry has heard from, to give her support. If we look
at 346, you refer here to: "Karen's friend has texted, she's no signal, she sends her love
thinking of you ... she is so lovely." Even friends, you know, this is conversation, isn't it,
what's going on?
GRIFFITHS: (Nods)
LANGDALE: You fairly said earlier on people speak across hospitals, across departments; people
knew what this was about, is that the reality?
GRIFFITHS: Yes, I think that is the reality.
LANGDALE: Somebody else who she's met briefly is sending a message of support via Karen on this
WhatsApp group; yes, is that fair?
GRIFFITHS: Yes.
LANGDALE: So people wouldn't have known anything about the facts, the concerns, the babies, the
trauma, the pain, the distress, commenting, offering support, they don't really know anything
about the details that since you have had this evidence pack and if you were following some of the
details of the Inquiry they did not know about?
GRIFFITHS: Mm-hm.
LADY JUSTICE THIRLWALL: Ms Langdale we still have 176 on the screen, I think you asked for a number over 300, I think.
MS LANGDALE: Yes, I did. 346 -- sorry, page 7. That was the penultimate one from the friend. Then
if we go to page 9. Message 459 and 460, have a look at those. So that is incoming to you.
GRIFFITHS: Mmm.
LANGDALE: "She's been told 100% getting back on to the unit." As you said earlier, did you ever
doubt that?
GRIFFITHS: I started to doubt it towards the end of the year, I think. But not at that time, no.
LANGDALE: 461: "Dad said Sue was very supportive of me going back." So Mr Letby has obviously
spoken to Sue Hodkinson as well. "She says I am happy that she's spoken with Dad rather than it
all coming via me." And then you say 464:
"I think the email yesterday did the trick. It will have made them feel guilty and your dad would
have given them what for. So proud of you right now. I will have extra cake later for you." Was
that something to be proud of before, that she had made people feel guilty, given what she was
accused of?
GRIFFITHS: You know, not what I know now, but at the time, you know, we were giving her support.
Telling her she was -- she was doing well because she wasn't under investigation. However, she
still wasn't back on the neonatal unit. Nothing, you know, had been happening. I think this is
possibly March, isn't it, you know, this is probably round the time when, you know, the police get
involved. But she -- we felt or she felt she needed to put pressure on them and you need -- she
needed to put pressure on her employer because she couldn't stay working where she was working
when nothing -- nothing was happening.
LANGDALE: She wanted apologies from four of them, didn't she: Dr Jayaram, Dr Brearey, Dr
McCormack and Dr V? What was Dr V supposed to have done?
GRIFFITHS: I don't know, to be honest. You know, I wasn't, I wasn't in the grievance outcome
hearing so
I don't know what was discussed and agreed there and I had only got told snippets from Lucy
afterwards.
LANGDALE: Yes, well if you look at 688 and 689?
LADY JUSTICE THIRLWALL: Page number?
MS LANGDALE: Page 11, you get a message from her: "I went to term admission with Annemarie, saw
Dr V, it went really well. "That is good. Did she apologise? "No, she didn't, but she was
completely normal. So it looks like you were sighted at the time on what that was about but you
can't remember now what she needed to apologise for?
GRIFFITHS: No.
LANGDALE: 695 at the bottom: "See you next Wednesday when back ... OMG I think I might cry about
the fact that you will be leaving me." So that means leaving the Risk Department yes?
GRIFFITHS: Yes. So that was round the time when we were planning, I think she was due to go back
something like 3 April and it was only stopped, or put on hold, shall I say, I don't think it was
stopped, a day, maybe a day or two before.
LANGDALE: Page 12, message 717. You talk about assurances that: "... they support your return and
that there are no
restrictions on your practice and you preferably want that in writing before you return properly,
if that makes sense." No restrictions on your practice. Again, wearing multiple hats, did that
seem a sensible request?
GRIFFITHS: I think it did seem a sensible request.
LANGDALE: At this time?
GRIFFITHS: At the time because I go back to we weren't being told anything different other than we
are going to get you back on the unit and everything, you know, is going to be fine. We tried to
put provisions for place to say well, actually, this can't -- if she does go back on to the unit
it can't -- she can't keep getting removed potentially every time somebody raises an allegation
because, as I say, we weren't being told there was any evidence.
LANGDALE: So if she went back, a baby died unexpectedly and she was around and there was a
suspicion that she was again around, you wanted to make sure you weren't back in the same
position; she should be able to carry on?
GRIFFITHS: No, I didn't mean it like that. What I meant was, you know, we had been informed
concerns had been raised but that there was no evidence, you know. The Trust themselves were the
ones saying: you know, we are potentially going to discipline these Consultants, you can have
mediation and that. So I think what I meant was, you know, you needed -- if she was going to go
back, having not been investigated and this is put to bed and nothing has come of it, then it
can't keep happening all the time.
LANGDALE: Page 13, message 795 and 796. "Was the meeting okay? [This is from you] Did they say if
they are going to discipline SB? "They are having further discussions and will tell me on
Tuesday." How did this fit at this point with your Speak Out Safely role? Here you are discussing
and approving, it would seem, the disciplinary process with her. What do you think about that?
GRIFFITHS: Well, I just asked her a question from whatever meeting she had been in: had they said
they were going to discipline SB? I'm not sure it had -- that particular text had anything to do
with my Speak Out Safely role. You know, as I said before, nothing was ever brought it that
meeting. You know, I have read elsewhere about a possible letter that the Consultants have written
and they wanted it logged under Speak Out
Safely, if that was logged under Speak Out Safely then I never had access to that and I never knew
about that.
LANGDALE: Let's go, please, to page 17, messages 1621 through to 1625. Then the next one as well.
1625. What's going on there about Letby's parents ringing you and then you being worried -- well,
just tell us what are the dynamics there?
GRIFFITHS: I think they -- they did ring me, I think, any of us who, you know, supported Lucy
Letby may at some point have had a conversation with her parents. I know I did on a couple of
occasions and I know other members of the RCN did as well. I would never have had a conversation
with somebody without the permission of the member. Is it usual? No, it's not usual but this was
an unusual situation. I have, you know, spoken to people's partners, their wives, their
girlfriends, their mother, you know, if the members asked but it's not routine. But we were
providing them with a lot of support.
LANGDALE: 1623, you say "I was caught by surprise", so you weren't expecting a call from the
parents?
GRIFFITHS: Yes, she must have rung me out of the blue.
LANGDALE: But they had your number --
GRIFFITHS: Yes.
LANGDALE: -- and knew they could phone you, presumably, if they did?
GRIFFITHS: Yes.
LANGDALE: So your main concern was they shouldn't say anything different than your member was. It
wasn't that you minded taking calls from them or did you mind it, did that become an issue for
you?
GRIFFITHS: I don't recall it being an issue. But I don't think I spoke to them very often. Had it
become an issue, I would have raised it.
LANGDALE: Page 19, message 1732 and actually 1730 and 1732. This is about Alder Hey in May 2017.
We have seen you sent the message saying: is it a management instruction, she is disappointed? But
here at 1732 you say to her: "I am thinking of the news coverage and don't want people asking you
questions generally about it"?
GRIFFITHS: Yes.
LANGDALE: Yes?
GRIFFITHS: So as I have said in my statement this was about, I think, the police. Police had just
got involved then. However, there was nobody under suspicion, nobody had been interviewed, so it
was more around if you are going to Alder Hey, you know, if
anybody says to you, you know: what's going on over there at the Countess, what's going on on the
unit?, or they make any reference or comment to quite frankly gossip, then the advice was you just
need to not tell them anything.
LANGDALE: If we go over to 1749, you appear to have discussed that with another union rep, is
Colm another union rep?
GRIFFITHS: Yes, Colm was the senior office who ended up --
LADY JUSTICE THIRLWALL: Colm Byrne, is it?
GRIFFITHS: Yes.
MS LANGDALE: "He says not to change your plans [that is in relation to Alder Hey]. If anyone
asks, you can just say the hospital has given you strict instructions not to say anything ..."
GRIFFITHS: Yes, that's correct.
LANGDALE: Her work is being discussed, isn't it, at 2453, page 28. What clinical work did you
think that referred to?
GRIFFITHS: So after -- after a while Lucy must have mentioned to me that -- and I think it may be
referenced in a text message that she felt she had minimal work and that she was bored working in
the PALS and Complaints Team because she was literally dealing with low level concerns and
compliments. So I said I would ask if she could come and do some work in the Risk Team. Excuse me.
So I had a conversation with Julie Fogarty who was the Associate Director of Risk and Safety at
the time and I will have put it in an email. That in itself wouldn't be unusual for me to do as an
RCN representative for a member, you know, I have done that on many occasion where people have
been redeployed into an area that maybe doesn't suit them or they don't feel they are being
challenged -- challenged enough or it's a little bit too quiet for them. So I asked I think if she
could do some risk -- risk work and then obviously you can see from the text messages she did
indeed do some risk work. The only risk work I know she did is what she's put in the text messages
to me because I kept that very -- tried to keep it very separate because whilst I was in the
office or my base was in the office I often was in and out at meetings which was the nature of my
other role is I could be gone from 9 through to 5 at meetings.
LANGDALE: Page 29, please. Message 2597. She's quizzing you about what people know about your
situation. This is in August 2017. "Ruth told everyone I was removed and that I am not
to have anything to do with Women's and Children's which I've never heard?" Your response, message
2958: "I don't think that is quite true, people have been redeployed at the same time we were
conducting an internal review." You said before people were discussing it. It was more than
internal review; there were discussions across the hospital about suspicion, wasn't there, we
heard Dr Lambie talk about it as early as 2005, nurses thinking who was present; people were
suspicious and she had been linked to the suspicions widely, hadn't she?
GRIFFITHS: I think there was suspicions and people talked about it once she came into our office
in 2016. Before then I had never heard anything, I had never had anything to do with her, I never
had anything to do with the neonatal unit. So I think it was and was it discussed in the office?
Quite possibly.
LANGDALE: Page 31, please, message 2711. "Flowers and fizz for me, how kind? "Yes, we will get
her some bits." And then: "You are worth it, my lovely criminal mastermind", from you. So can you
remember what you were getting flowers
for?
GRIFFITHS: No, I don't, to be honest.
LANGDALE: Sounds celebration doesn't it, and fizz?
GRIFFITHS: Yes, I know Karen Rees I think retired around that -- whether it was round that time,
but as I say I would only be guessing, to be honest, but it is likely it --
LANGDALE: Discussion following a meal?
GRIFFITHS: -- could have been something like that.
LANGDALE: Yes, was it linked in to having a meal somewhere with her retirement or not?
GRIFFITHS: It might have been.
LANGDALE: Finally 5259, which is on page 39. It looks as though at 5259 she is referring to the safeguarding referral, she understands now there is going to be a safeguarding referral, asking you about whether it will stay on her record at 5261. If you go please to 5269, 5273. That is you saying you will check the website. 5275. 5279 5280 and 5871.
LADY JUSTICE THIRLWALL: Sorry, which page is that one?
MS LANGDALE: 5871 is page 42.
So she is worried about safeguarding and asking you to provide support, help, knowledge of the
system, what it means?
GRIFFITHS: (Nods) So it had been mentioned in the weekly meeting, I think, about the C -- Alison
referring to the -- the doing a CDOP referral, from what I recall, and, you know, obviously Lucy
wanted more information about it. That wasn't information I could give her because I didn't know
an awful lot about it, but as I said I would find out and I think Lucy was just asking did I know
-- are you able to see the referrals and that's not something I would have known.
LANGDALE: The referral was made in fact on 27 March 2018 but you didn't see it, did you, or
not?
GRIFFITHS: No, no.
LANGDALE: And finally the last message, please, page 43. Message 6250. You had been to the
mortality review of those two boys, O and P, what did you make of that text?
GRIFFITHS: I don't think I did make anything of it. I -- I probably -- I don't know, I would just
be surmising that maybe she was just thinking about the Families and what they must be going
through.
MS LANGDALE: I have no further questions, Mrs Griffiths. My Lady, there may be five or ten minutes.
LADY JUSTICE THIRLWALL: Thank you, Ms Langdale. Mr Sharghy.
MR SHARGHY: Mrs Griffiths, I ask questions predominantly on behalf of the Family of [Child I] but
I also ask questions on behalf of additional Families of Children A, B, L, M, N and Q. You were
asked by Counsel to the Inquiry a number of questions as regards your initial involvement from
being a notetaker at the meeting on 5 July 2016 to being called into a meeting by Ms Kelly and Ms
Hodkinson about a week later on the 15th and your recollection was abundantly clear, that not only
did you not add it into your notes but you don't recall anybody raising serious concerns of
deliberate harm and indeed one of the participants at that meeting mentioning Lucy Letby's name;
is that correct?
GRIFFITHS: That's correct.
SHARGHY: But by 15 July, this is the meeting with Ms Kelly and Ms Hodkinson, when you are
informed that there had been concerns that had been formally raised, they must have surely told
you at least the broad outlines of the nature of those concerns?
GRIFFITHS: From what I recall in the meeting, they were just, I think it was, you know, along the
lines of, you
know, there's concerns being raised about an individual who may come to you for support. I don't
think there was anything more than that from what I can recall.
SHARGHY: Okay. So again your recollection is at that meeting the concept and the notion of
deliberate harm being caused to babies on the neonatal unit was not part of the discussion?
GRIFFITHS: No, I think afterwards I -- that's exactly what I thought. That -- there could
potentially be an investigation into somebody for harming babies but I can't tell you how I -- how
I thought about it.
SHARGHY: Your next substantive involvement was when you accompanied Lucy Letby to her RCPCH
interview on 1 September?
GRIFFITHS: Yes.
SHARGHY: You have given quite a lot of evidence about it, so I am not going to recap. But the
essence from what I understood of your experience of being in that meeting was that the
allegations, in particular regarding serious harm, or indeed any connection with Lucy Letby, did
not form part of any questions that the interviewers asked; is that correct?
GRIFFITHS: That's correct.
SHARGHY: So how did the conversation come about and you
deal with this at paragraph 43 of your witness statement, if you would like, you can turn up that
paragraph?
GRIFFITHS: Yes, I have got it, yes.
SHARGHY: Where you say: "I recall one of them saying to me something along the lines of 'does she
know what is going on here and what she is potentially being accused of?'" [You] replied that I
didn't think that she did." Now that seems to indicate, doesn't it, that at least by this meeting
you were aware of the serious concerns of deliberate harm and the connection to Lucy Letby?
GRIFFITHS: Yes.
SHARGHY: How then, between 15 July and 1 September, did you become familiar with those
allegations?
GRIFFITHS: I don't know if anything was said in the risk office. But I know by then I had met Lucy
Letby with Karen Rees. I probably would have had a conversation with Karen or somebody, it's quite
possible somebody's made me aware of the allegations. I did know, but I can't tell you how or when
I knew but I can tell you I did know.
SHARGHY: Were you having separate conversations with members of staff regarding these concerns
and then
separate conversations with Lucy Letby regarding these conversations?
GRIFFITHS: I didn't have any conversations with Lucy Letby about the concerns apart from when I
spoke to her in the Country Park and spoke to her about the allegations. We never really discussed
it again.
SHARGHY: Lucy Letby's reaction at this meeting, when no issues around concerns of serious harm or
indeed any association with her was raised, was to get very upset and to leave the room and you
followed shortly thereafter?
GRIFFITHS: Yes.
SHARGHY: When you then decide that you need to have a very frank discussion with her, on 7
September, so just under a week later, you go to the Country Park, it's just the two of you, and
you have that frank discussion that I suspect went something along the lines of: do you know what
they are accusing you of?
GRIFFITHS: (Nods)
SHARGHY: Multiple occasions of harm being caused deliberately to babies on the unit. Is that fair
in terms of how frankly you spoke with her?
GRIFFITHS: I do believe I was quite frank to her.
SHARGHY: Her reaction was to calmly stand up, say she wanted to be alone, walk away and at some
point go on her phone?
GRIFFITHS: (Nods)
SHARGHY: Do I take and understand by that that she didn't seem surprised that those serious
allegations are being made, she didn't burst out crying, did she?
GRIFFITHS: No.
SHARGHY: She didn't ask reasonable questions such as: well, who's making those allegation? Why
are they saying this? How do you think I have done it? Or anything like that, did she?
GRIFFITHS: She never said anything to me.
SHARGHY: How strange was that to you as a reaction given that the week before, when no such
discussions are had, she became so upset?
GRIFFITHS: I -- I thought it was a little strange and I put that in my statement but everybody
deals with things differently and maybe I might have viewed as to how I would be if somebody said
that to me. I don't know. I did think it was strange at the time but ...
SHARGHY: Again I am not going to go through the messages that you have been taken to already. But
it seems from the totality of those messages, that you became extremely close to Lucy Letby; is
that fair?
GRIFFITHS: That's correct.
SHARGHY: You became so close that it actually clouded
your professional judgment as regards patient safety and indeed how appropriate you should be
acting as an RCN representative?
GRIFFITHS: No, I don't believe that that's correct, I don't believe it did cloud my judgment and
as I said before, I was there to support her. I wasn't her representative. I can see how it looks
but I never had access to her case and she had two other officers that were representing her at
more formal meetings like the grievance meeting and that it was probably because more I was a
local rep however I accept I became close to her. The girl was put in my office, she had more
access to me than any other member would and quite a lot of us became friends with her in the
office and we supported each other. It was a difficult time for me personally, but I accept that.
SHARGHY: Would you go so far as to say that you loved her as a friend?
GRIFFITHS: She was a friend and she was a very good friend at the time.
SHARGHY: The reason, Mrs Griffiths, to be entirely fair to you, is that is exactly one of the
messages that you sent to her. Would you like to see that message?
GRIFFITHS: I don't need to see the message. But that's the kind of message I would possibly send
any of my
friends.
SHARGHY: Okay. Given the severity of the allegations that were made, and would you agree that
they are possibly the most serious allegations that anybody could make against a healthcare
professional?
GRIFFITHS: Yes, absolutely.
SHARGHY: Were you making light of those allegations when you were referring to "potentially
committing a crime"?
GRIFFITHS: No.
SHARGHY: Can you even begin to imagine or put yourself in the position of the families of the
babies who were harmed when they see those messages?
GRIFFITHS: I know. And as I have said before, I'm -- I am so remorseful. I've seen -- as soon as I
seen them myself, I was, I was upset and I can't begin to imagine and I can only apologise and say
I've learnt. I can't go back in time, but I have reflected absolutely on it.
SHARGHY: There is one document though I would like you to have a look at and it is at INQ0006346. Mrs Griffiths, this is an email that you sent to Alison Kelly
and others on the Executive Board on 23 November of 2016 and it's essentially raising a concern,
and probably even a complaint, that Dr Brearey had already seen a copy of the RCPCH report.
What you say, if we can go just to the bottom of the paragraph: "On behalf of my member we would
like to know why this is happening as we were given assurances not two weeks ago that a
confidential meeting would take place with the Medical Director and key people regarding the draft
report and that it would be kept confidential until the report [I think it should say 'was']
finalised and that nothing would be discussed as yet." Who gave you or indeed Lucy Letby those
assurances?
GRIFFITHS: I would imagine it was members of the Executive Team. I --
SHARGHY: Just to help you if it does, the people who you had sent that to were Alison Kelly, Tony
Chambers, the Chief Executive, Alison Kelly, being the Director of Nursing, Ian Harvey, the
Medical Director, and Sue Hodkinson, who was head of HR on the Executive Committee. Were at least
some of those the ones that had given you the assurance, hence why you have included them?
GRIFFITHS: Yes. I would imagine at that point, because it's November 2016, that it would have been
Alison Kelly and Sue Hodkinson in one of the many weekly meetings that we had. I can't recall any
other meeting taking place where others might have been present then. She hadn't had a grievance
meeting or anything, so that's what I would presume, but I can't say for certain.
SHARGHY: At these meetings, would anyone take a note of it or would any note of it be produced
later on?
GRIFFITHS: Of the weekly meetings?
SHARGHY: Yes.
GRIFFITHS: Yes. Sue Hodkinson took very comprehensive notes, so much so that none of us -- we just
felt it was more of a supportive meeting but Sue took very comprehensive notes.
SHARGHY: Thank you. Can we go to the following page, just quickly and what you say there,
penultimate paragraph: "I find this completely unacceptable when we have been given reassurance
after reassurance over the reports, et cetera, and I am disappointed that we had to email again."
So that again indicates that there had been other discussions, first of all, regarding when you
would get to see or Lucy Letby would get to see the report --
GRIFFITHS: (Nods)
SHARGHY: -- as opposed to others and, secondly, that it had been mentioned on more than one
occasion. Can you help the Inquiry with that, please?
GRIFFITHS: I think from what I recall, it probably was mentioned quite regularly that, you know:
Don't worry, you'll get to see the report along with everybody else, we'll share their findings
with everybody else.
SHARGHY: But that is not, Mrs Griffiths, if I may, what you are saying in this email. Your
complaint is directly that there would be a draft report seen by you and Lucy Letby, or the RCN
representatives and Lucy Letby, there would follow a meeting before the report is finalised and we
can look at that again on page 1, if you would like. So this --
GRIFFITHS: Ah.
SHARGHY: So this is specifically about Lucy Letby and/or you having an input into a draft report
that is supposed to be independent.
GRIFFITHS: Right. Apologies. I misunderstood. I certainly didn't see any draft report, but I just
thought that we would be getting to see the final report, not the draft report.
MR SHARGHY: Thank you, Mrs Griffiths. Those are my questions, my Lady.
LADY JUSTICE THIRLWALL: Okay, thank you very much, Mr Sharghy.
May I just ask you one question. You were asked some questions by Counsel to the Inquiry about
your interview with Dr Green.
GRIFFITHS: Yes.
LADY JUSTICE THIRLWALL: There was a sentence which we did look at. I just wanted to check
something with you. You were talking about Lucy Letby and the note says: "She didn't want some
things in the grievance in regards to the police." I just wondered what that meant?
GRIFFITHS: I can't really recall, to be honest. I just knew she, she was -- she was a very private
person and I'd be surmising if I could remember. Whether it was to do with the Consultants or
whether there had been suggestions of any personal relationships, I can't really recall to be
honest.
LADY JUSTICE THIRLWALL: I was asking you about it in regards to the police.
GRIFFITHS: In her going --
LADY JUSTICE THIRLWALL: Yes. She didn't want some things in the grievance in regards to the
police. You have told us that you had a discussion with her about going to the police.
GRIFFITHS: Okay, yes, sorry.
LADY JUSTICE THIRLWALL: So I mean, I just wondered if this was a reference in that context.
GRIFFITHS: Yes. Apologies, my Lady. That may well have been a reference to she hadn't wanted to
ask the question of why hadn't the police been called. I'm not sure to be honest.
LADY JUSTICE THIRLWALL: No. But do you think that seems quite a likely --
GRIFFITHS: It's likely, yes.
LADY JUSTICE THIRLWALL: Yes. Yes, thank you. That is my only question. Anything else, Ms Langdale?
MS LANGDALE: No more questions. Thank you, Mrs Griffiths.
LADY JUSTICE THIRLWALL: So thank you very much indeed, Mrs Griffiths. We are going to break now
in any event but in due course you will be free to go.
GRIFFITHS: Thank you.
LADY JUSTICE THIRLWALL: Thank you for coming. We will start again at 5 past 12.
(11.49 am) (A short break)
(12.05 pm)
LADY JUSTICE THIRLWALL: Mr Bershadski.
MR BERSHADSKI: Yes, thank you, my Lady. I think Ms Sementa is our next witness.
LADY JUSTICE THIRLWALL: Ms Sementa, would you like to come up to the table.
MS LUCY SEMENTA (sworn)
LADY JUSTICE THIRLWALL: Do sit down.
MR BERSHADSKI: Could you confirm your name for the Inquiry, please?
SEMENTA: Yes, it is Lucy Jane Sementa.
BERSHADSKI: Thank you Ms Sementa, I think you have made a statement for the Inquiry that is dated
22 May 2024. Have you had an opportunity to read through that statement in preparation for your
evidence today?
SEMENTA: I have, yes.
BERSHADSKI: Now, I think it's been pointed out to me there is one date error at paragraph 8 which
is pretty clear, it says 2014 rather than 2016. Apart from that, is that statement true and
accurate to the best of your knowledge and belief?
SEMENTA: It is, yes.
BERSHADSKI: Thank you. Ms Sementa, if we could just start please with a little bit of background.
You worked in the NHS I think since 2015 but you had some HR experience in the retail sector prior
to that, can you just tell us for
how long you've worked in the HR sphere?
SEMENTA: So my experience in retail involved employee management for the last 20 years and as part
of that, I suppose it grew, I became an HR supporter for the East Anglia region for the
organisation I work for, which is a multi-national organisation that operated with clothing,
accessories and homeware. So I trained other managers in employee relations matters, I dealt with
investigations, disciplinaries, grievances, flexible working, appeals, all that kind of thing, not
exclusively but certainly for a large part of my role for probably up to five years before I
joined the NHS.
BERSHADSKI: You joined the NHS in 2015 and was that at the Countess of Chester Hospital --
SEMENTA: It was, yes.
BERSHADSKI: -- straight away? So could you just describe your level of familiarity with the HR
policies in place at the Countess by the time that you dealt with the grievance that Letby had
submitted, so her grievance was submitted in September 2016, you had been there for a little bit
under two years by that point?
SEMENTA: (Nods)
BERSHADSKI: How familiar were you with policies such as
the grievance policy, disciplinary and Speak Out Safely policy?
SEMENTA: So far more familiar with disciplinary and grievance than Speak Out Safely, attendance
disciplinary and grievance were the most commonly used policies in the role that I was in. They
would be very frequent, multiple cases at any one time; anything up to 20 different cases from an
employee relations perspective at any one time for the whole of my employment with the Countess.
Speak Out Safely-wise I don't know that I had many cases that involved Speak Out Safely aspects, I
am certainly familiar with it as a document, it's not one that was commonly used in my role.
BERSHADSKI: Obviously the facts relating to the Letby case that you dealt with and her grievance
were extremely serious?
SEMENTA: (Nods)
BERSHADSKI: Had you dealt with cases, of the 20 cases or so that you would have on at any one
time before that, had you dealt with cases that were anything approaching that level of potential
seriousness, in terms of the underlying allegations?
SEMENTA: No. But I had dealt with many cases that involved clinical staff and patient care
aspects. So
from that perspective some of it was not that unusual. Obviously the nature of those concerns was
very unusual, not something I have thankfully come across before or since. But I think for me the
role that I was asked to do was to support the grievance and the grievance is raised by the
employee and the employee's issue was the removal of her from her place of usual work into a
non-clinical role and not to do with the allegations that had been made about what she may have
done at that time.
BERSHADSKI: The reasons for Letby's redeployment were obviously an important part of her
grievance; is that fair?
SEMENTA: Yes.
BERSHADSKI: So what did you know about the problem of a spike in mortality on the neonatal unit
at the time that you dealt with the grievance?
SEMENTA: Prior to starting with the grievance, very little. Only that it had been mentioned within
our HR team at one or two points but nothing specific. So it wasn't until we sat down with the
people that we interviewed that I gained any real knowledge of that. I am not a clinician by
background, I have got no clinical training at all so in those kinds of situations you are very
reliant on what clinical staff are telling you and it was not my take-away from any of those
meetings that the spike was perhaps as significant as I now see that it was.
BERSHADSKI: You mentioned that there had been some discussions in the HR Department prior to you
taking on the grievance, could you just tell us a little bit more about those discussions, what
was the nature of them and who was involved with them?
SEMENTA: I recall at some point and I am not quite clear if I have got that in the right order
now, I'm sorry, because it was a while ago, when the Silver Control was brought together and I
know that Dee Appleton-Cairns was part of those conversations, I know she came into the office on
one of those days and was talking to us about the collation of personal files and it was mentioned
then that there had been an increase in deaths in the neonatal unit and that some Consultants had
concerns about a particular member of staff. I don't recall Lucy Letby being named in that
conversation, I recall that specifically.
BERSHADSKI: Were you involved in the task of reviewing personal files for that Silver Control
exercise?
SEMENTA: No.
BERSHADSKI: Did you see Dee Appleton-Cairns undertaking
that task --
SEMENTA: No.
BERSHADSKI: -- herself. Okay. Now, you say in your statement that you had some involvement, as
you typically would do, in preparing the questions that would be asked as part of grievance
interviews; is that right?
SEMENTA: Yes.
BERSHADSKI: So can you just tell us a little bit about your role in preparing with Chris Green
for dealing with the grievance that Letby had submitted in 2016, what role did you play in that
process?
SEMENTA: It's difficult to be precise now. I can tell you my usual practice and I see no reason to
recall that my usual practice wasn't applied in this case and my usual practice would be to have a
conversation with the investigating manager to make sure they understood the ask of them, that
they understood the policy that the investigation was relating to, to talk to them about who they
might want to interview and in what order because that varied case to case. And then as each
interview approached, to discuss with them what questions they may ask. It would be usual for the
manager to provide me with a list of questions. I would review them.
Sometimes I would make comments on questions that did not feel appropriate or were misplaced or
perhaps needed rephrasing or if I felt that they hadn't present -- prepared a question about a
particular aspect that I thought would be important I would include that when I -- when I sent
that feedback back. I don't remember anything different about this case. I expect it was that, but
I can't be precise.
BERSHADSKI: Presumably this case would have been significantly more serious in terms of the
allegations that were involved, I think you have already said, than anything you had dealt with
before. Would it not stick in your memory to some extent somewhat more than perhaps more
run-of-the-mill disciplinary cases that you may have been involved with?
SEMENTA: Not necessarily because I think what you are trying to establish with a grievance is
whether or not the employee has got a point, that what's been done to them or not done for them is
against any process or policy that we might have in place as an employer. So I think though I
don't recall there being any questions specifically prepared about the nature of the allegations
against her, it was more to do with what process had been followed or not followed, what
information had been given or not given and in what
order.
BERSHADSKI: So were you involved with deciding who would be interviewed as part of the grievance
process?
SEMENTA: I would have discussed it with Chris Green. It would ultimately be his decision. My role
is to advise. So often with a case somebody might not think that a particular witness might be
important or might have anything to contribute and I might disagree and put forward my thoughts
about why I feel they should be included.
BERSHADSKI: Now, I think Lucy Letby was the first person that you spoke to and the first person
you conducted a grievance interview with; is that right?
SEMENTA: That's correct.
BERSHADSKI: Presumably that would be quite normal because you would tend to speak to the person
who's made the grievance in the first instance to understand precisely what it was that their
grievance related to; is that fair?
SEMENTA: That's correct, yes.
BERSHADSKI: Now, you mention in your statement that Lucy Letby's parents called Chris Green and
spoke to him on more than one occasion?
SEMENTA: (Nods)
BERSHADSKI: Can you just give us a little bit more detail about that, how many times do you think
they spoke to him and what was the purpose of those conversations?
SEMENTA: I think it was twice. I'm not sure. I never spoke to them. I know that I spoke to Chris
Green a number of times, you know, during and following this investigation which is not unusual
but perhaps more so with this one than any other investigation because I think emotionally it was
taxing for Chris Green and he mentioned to me during one of those conversations that Lucy Letby's
parents had called him, that they were quite distressed and I believe that that happened a second
time at the -- after the investigation had concluded and the grievance had been heard. I may be
wrong but that's my recollection.
BERSHADSKI: Is that the sort of thing that would be normal to happen, that somebody's -- the
parents of a person who makes a grievance directly phone up the investigating officer for the
grievance and speak to them?
SEMENTA: No. I have never known that happen in any other case.
BERSHADSKI: What did you think about the appropriateness of conversations taking place between
the investigating officer and the parents of the person bringing the grievance when you heard
about them?
SEMENTA: I didn't have any concerns about what Chris Green may have said because I have always
found him ethically unquestionable. I didn't have any concerns that he would have disclosed any
information that was inappropriate or related to that case. I took from that from what he said to
me that he had listened to their concerns and their distress at what was happening. But I don't
recall feeling that he had given any information to them. So it probably wasn't appropriate that
they called him, but I think I struggle to see necessarily what else he might have done in that
situation. You know, when somebody calls you to speak to you, it used to happen to me in my role
all the time. Somebody would call and they would want to share with you how they were feeling,
particularly if they were distressed, and I would listen.
BERSHADSKI: Do you know how it was that they even came to call him, how they even had his phone
number?
SEMENTA: No, I don't know, but it would be very usual and I believe that was the case with this --
this investigation that his number would be in the documentation that went to the aggrieved, so
Lucy Letby in this case. His phone number, his email address would be on that documentation as a
matter of course for that
person to contact if they had queries, questions or needed to re-arrange a meeting, that kind of
thing. So I expect that she passed on that information to her parents, but I don't know.
BERSHADSKI: Did you consider suggesting to Chris Green that, you know, if they call again, that
it would be best to say to them that it's not really right to speak to them because there's an
investigation going on into a grievance and until that's concluded it's best not to speak to
people about it?
SEMENTA: I don't recall doing so. But I think if that's the case that would either have been
because I didn't think it was necessary because I trusted him implicitly about how he had
undertaken this process or because I wasn't expecting that that would happen a second time. I was,
you know, surprised it happened the first time. As I say, I have never known that happen before.
BERSHADSKI: Do you think that there's a chance that a person investigating a grievance might be
influenced by the fact that they are receiving these distressed phone calls from the parents of
the person bringing the grievance?
SEMENTA: I don't know that I see it as any different to sitting in a room with a person that's
distressed, which
is part of the process. Very often in grievance cases, particularly bullying and harassment cases,
occasionally with disciplinary somebody is very distressed. It can be really hard to hear that to
hear the impact that any situation is having on somebody's life. I don't know that it's any
different to that.
BERSHADSKI: Now, I am just going to ask you some questions about that initial grievance interview
that you had with Lucy Letby. I think you have said within your statement that no questions were
asked of Letby in that grievance interview relating to the underlying allegations that had been
made against her; is that right?
SEMENTA: That's correct.
BERSHADSKI: Now, was that a conscious decision by you and Chris Green when discussing the
questioning of her in advance to not ask any questions about harm to babies that she may have
caused?
SEMENTA: I don't recall whether or not we had that conversation but I think it's likely. It's
often very difficult with grievances and with disciplinaries to stay within the scope of what you
have been asked to do and not to drift outside of that, where there would be a different process
and to me questions about that would very much have been a disciplinary process and not a
grievance.
BERSHADSKI: So to be clear, what was your rationale for being careful to avoid any questions
relating to possible harm by Letby to babies?
SEMENTA: Can you repeat the question, please?
BERSHADSKI: What was it that motivated you to make sure that you didn't ask any questions about
the underlying allegations?
SEMENTA: Probably professional etiquette, I think, in terms of making sure that we are following
the policy that's related to the matter in hand and that was the grievance process we were looking
into, why she had been redeployed from her role and not into what might have happened from a
clinical perspective. I think if -- if there had been clinical questions to ask, Chris Green would
not have been the right person to ask them.
BERSHADSKI: Yes. And it's right, isn't it, that you didn't speak to any possible witnesses to the
deaths that Lucy Letby had been accused of causing?
SEMENTA: That's correct.
BERSHADSKI: So you didn't approach, for example, the nurses who were on duty at the time --
SEMENTA: No.
BERSHADSKI: -- is that right?
SEMENTA: That's correct.
BERSHADSKI: You didn't approach the parents of the babies who may have been around at the time
that Letby was alleged to have harmed them; is that right?
SEMENTA: That's correct. That would not in my view have been appropriate.
BERSHADSKI: No. So would it be fair to say that when coming to draft the report outlining your
findings, that it would be appropriate to avoid any discussion of the underlying allegations and
the evidence relating to the underlying allegations, because you hadn't spoken to any relevant
witnesses about those allegations?
SEMENTA: To a point. It is difficult though because, as you pointed out earlier, the reason for
the redeployment is related to those allegations. So there was always going to be a bit of a
crossover, I suppose for me it was about limiting that crossover as far as it was possible to do.
BERSHADSKI: Did you consider at any point when dealing with the grievance, suggesting that the
grievance should be put on hold and a more appropriate process put in place to actually deal with
the underlying allegations first to avoid any spillover risk?
SEMENTA: I didn't but I think I might have done if when we had met with the Consultants
particularly or any of the witnesses that we met but specifically the
Consultants, if there had been more information imparted than there was, if I had felt that there
was anything there that hadn't already been looked at that should be looked at under a different
process then I would have done.
BERSHADSKI: Okay. Well, I am going to ask you some questions about the Consultants and in
particular their interviews. But before I do that, can I just ask you to look at some of the
correspondence that went with the Consultants before they actually came on to have their grievance
interviews. If we could please have up INQ0068308. Thank you. Now, this is an email -- if we look at the bottom, it
is an email from Ravi Jayaram who is obviously one of the two Consultants that you spoke to as
part of the grievance process?
SEMENTA: (Nods)
BERSHADSKI: He asks you if you would be able to give an agenda for the meeting and information as
to what the grievance relates to and you reply on the same day, 24 October, with what we see
there: "Chris ..." And that is a reference to Chris Green, I assume who's copied in?
SEMENTA: (Nods)
BERSHADSKI: "... is investigating a grievance submitted by an employee which relates to
redeployment. He is required to interview any individual who may have some knowledge of the
surrounding events. In light of this, there is no formal agenda. However, the process will be that
Chris will ask you some questions and if you can provide any details or information this will be
noted. Any information within the grievance that is relevant to you will be discussed." Then you
have got a sentence below that saying: "I must emphasise that at this stage you have been invited
as a witness who may have some pertinent information and you are not being investigated yourself."
Can I just ask you, what led you to write that sentence to Ravi Jayaram and in particular the
words that at this stage he was being invited as a witness and not being investigated himself?
SEMENTA: I think if I was going to include that sentence I would probably always include the
phrase at this stage because I suppose with any case you never know what's going to happen because
he haven't met with everybody and you don't what information might come out. I am surprised that
that sentence is there. I think from memory, but I cannot be sure, that it may be that I had been
told there was some reluctance for Ravi Jayaram particularly to attend and that he was concerned
he was being investigated. I think that's why that sentence is there. I can't be sure.
BERSHADSKI: I mean, do you think you included sentences like this for any of the other people you
were speaking to other than Stephen Brearey; so, for example, Ian Harvey, you spoke to Alison
Kelly, you spoke to Sue Hodkinson. Would you have had that sort of sentence in any correspondence
with them prior to their grievance interviews?
SEMENTA: I don't believe that anybody else corresponded with me ahead of their meeting. I believe
everybody else just confirmed their attendance which would be usual to do that with Chris Green
rather than myself and attended. I'm not sure that I had email correspondence with anybody else in
relation to this case.
BERSHADSKI: Do you see that somebody who's been invited in to be interviewed for a grievance who
gets an email saying that at this stage they "are being invited as a witness and not being
investigated", that that might cause some degree of concern on their part because the implication
is that there may well be at some point an investigation into them, where they are not merely a
witness?
SEMENTA: I think it's possible. But I think it's important that people are aware of what might
happen next in any process and I think it's often appropriate to make people aware that different
things might happen depending on what information is forthcoming. At this point we had already met
with Lucy Letby and I believe a number of the other witnesses, so a picture starts to emerge. I
don't think it was unreasonable if I had concluded at that point it was possible that that might
happen at the end of that process but you never know what's going to happen until you have met
with everybody that's relevant to a case.
BERSHADSKI: Because you say in your statement that you were surprised and disappointed by the
attitudes and behaviours of Ravi Jayaram and Stephen Brearey in your interviews with them as part
of the grievance.
SEMENTA: (Nods)
BERSHADSKI: Do you think that if they had received this sort of correspondence from you before,
that that might have some impact on the degree to which they felt comfortable in being open with
you during the grievance process?
SEMENTA: I suppose it's possible. They were both represented by regional trade union reps who I
believe were very experienced and knowledgeable. I was
surprised -- I would be surprised if they hadn't given them any reassurance on the point that I
don't feel that that sentence in that email is inappropriate. I think it's accurate and I think
it's fair.
BERSHADSKI: Now, I am just going to ask you to turn up the interviews that you conducted with
Ravi Jayaram and Stephen Brearey, so if we could go please on screen to INQ0002879 at page 47. So these are the notes of the interview with Ravi
Jayaram and we can see that very early on in his interview, he explains that there was a rise in
mortality and they were not the babies you would have predicted and that none of these babies
responded to timely resuscitation manoeuvres; can you see that?
SEMENTA: Yes.
BERSHADSKI: Now, at this stage, did you know how much of a rise in mortality there had been?
SEMENTA: In terms of figures?
BERSHADSKI: Yes.
SEMENTA: No, I don't believe so, no.
BERSHADSKI: Well, did you consider questioning Ravi Jayaram about how much of a rise in mortality
there had been?
SEMENTA: I think I did ask him towards the end of this conversation, I think I asked him about
percentages.
BERSHADSKI: Okay and what's your recollection of what he said?
SEMENTA: Can I see it on the screen, please?
BERSHADSKI: Yes. So the whole interview is that page through to page 48 and 49. But I don't think
there is a note within here of any discussion of percentages or figures. Or in the middle of the
page, sorry, on page 49 on average two or three in a year, the number has increased to nine in a
year?
SEMENTA: Yes, that is the first time I recall being aware of the numbers.
BERSHADSKI: Did it concern you that Ravi Jayaram was telling you that there had been a rise in
mortality from two or three in a year to nine and that they were not babies that one would have
predicted to die?
SEMENTA: It did concern me. But we had spoken with other witnesses previously who had provided I
suppose a different take on that. I think it was Eirian Powell who had talked about the rise in
congenital defects and changes in lifestyle and I don't have a clinical background, as I have
said.
BERSHADSKI: Yes. But was Ravi Jayaram the first doctor who had actually been caring for these
babies who was giving you this information that you spoke to?
SEMENTA: Yes.
BERSHADSKI: And did you speak to Stephen Brearey after you spoke to Ravi Jayaram? I know they
were both interviewed on 11 November.
SEMENTA: They were the same date, I think so.
BERSHADSKI: Yes, okay. Well, let's go if we can go forward to Stephen Brearey's interview, it is
page 51 of the same document. So that is the interview with Stephen Brearey. Just over the page on
page 52, we can see that he says in his grievance interview that from memory there were no issues
in terms of clinical care, six of nine died between midnight and 4 am. Eirian Powell looked at
staff present looking after the babies involved in the review, this is part of the review. Stephen
Brearey looked at both junior and senior medical staff involved in looking after the babies, no
common cause. Eirian Powell identified that Lucy Letby was on shift around the time of the deaths
but was not necessarily the named nurse. That is towards the top of the page.
SEMENTA: Yes.
BERSHADSKI: Chris Green then asks about two of the Triplets dying, what happened around then. And
Stephen Brearey responds that: "In a three-month period following the meeting with Ian Harvey and
Alison Kelly starting to arrange the
review meeting prior to Lucy going back on nights there had been no episodes of sudden collapse or
deaths at night". So what you had heard between Ravi Jayaram and Stephen Brearey on 11 November is
that there had been a spike in deaths from two to three to nine so a threefold spike in deaths of
babies that weren't expected to deteriorate, that Lucy Letby was on shift around the time of the
deaths, and that after she had been moved off nights, there had been no collapses or deaths at
night and you had all of that information on 11 November; is that right?
SEMENTA: Yes.
BERSHADSKI: How much did all of that information in totality concern you?
SEMENTA: I think Chris and I were both surprised that there wasn't more from both the Consultants.
I think prior to meeting them with them we had been expecting that they would be more forthcoming
with why they had concerns about Lucy Letby beyond just her presence on the unit. In neither of
those interviews did either of them sort of articulate why they felt that that was such a concern
beyond the fact that there was a commonality and when we had met with some of the other people
that
we had interviewed, they had given a different explanation for why there was -- why that
commonality was there and they talked about sort of Lucy Letby undertaking additional shifts and
being very willing to work nights which some staff are not. So it was perhaps that aspect was less
of a concern, I think, to me than it might have done if it had just been these interviews in
isolation.
BERSHADSKI: But the other people you spoke to, none of them were medical doctors looking after
the babies, were they?
SEMENTA: They weren't medical doctors, no, that to me does not mean that they don't have valuable
knowledge, insight and experience in that unit, the nature of those cases.
BERSHADSKI: Why do you say that you felt that Stephen Brearey and Ravi Jayaram weren't
forthcoming when they have just told you all of this information and that this was leading them to
be so concerned about Letby that they weren't sure that they would have her back on the unit?
SEMENTA: Because I don't feel that that's what they said. I think they were explaining why some
conversations had taken place. I don't believe either of them said that they specifically had
concerns,
I think they talked generally about those concerns. They weren't forthcoming about saying that
they individually held those concerns.
BERSHADSKI: Well, Stephen Brearey was asked about whether he thought there was deliberate harm by
Letby and he was saying that it's not for him to say; is that right?
SEMENTA: Correct.
BERSHADSKI: He told you in the interview that he wasn't a forensic scientist or investigator; is
that right?
SEMENTA: Correct.
BERSHADSKI: Now, that's not him not being forthcoming, that's just him relaying the facts that he
can't know whether somebody is doing something deliberately or not because he's not a forensic
investigator. Is that in any way not forthcoming by him or is that him being open about the
limitations of how far he is able to go?
SEMENTA: I can only tell you how I took that information at the time.
BERSHADSKI: Yes.
SEMENTA: That is how I took that information at the time.
BERSHADSKI: Now, were you familiar, at the time, with the safeguarding provisions in the
disciplinary and Speak Out Safely policies?
SEMENTA: Yes.
BERSHADSKI: So is it fair to say that the basic point in those safeguarding provisions is that if
there is any concern that somebody may be harming children, that a safeguarding referral needs to
be made?
SEMENTA: Yes. I think what's difficult about interpreting those policies and I think the concern
is not quantified. So what we would ordinarily look for is some substance to those concerns. I sit
in a lot of meetings with a lot of people where they say a lot of things and often that's
somebody's perspective or somebody's perception of a situation. It isn't necessarily always
appropriate to just take what somebody tells you and take action on it. In all of the cases that I
have had where there have been safeguarding concerns there has been some substance to them beyond
I suppose a commonality, this is a unique case I think on a number of fronts. But for me, there
had never been anything else where somebody's presence alone had resulted in a safeguarding
concern being raised.
BERSHADSKI: But what you were being told is it wasn't just presence alone, was it, there were
many additional factors, that for example it was unexplained, unexpected deaths, that they stopped
occurring on night shifts when
Letby was taken off night shifts. You were given a whole host of reasons for why there was a
particular concern about Letby. So why was that insufficient for you to take the precautionary
step of suggesting a safeguarding referral?
SEMENTA: I don't feel that we were given any different information than had already been examined
by other people with far more clinical knowledge than myself, that that had been looked at by
people such as Alison Kelly who has a lot more knowledge about safeguarding referrals, what to
look for in clinical cases than me. If we had been given new information we absolutely would have
done something with that. I don't feel that that happened during the course of the grievance
investigation.
BERSHADSKI: Well, I think you told us that you had very little knowledge of the allegations
against Lucy Letby prior to dealing with this grievance. Why didn't you apply your own independent
knowledge of the policies and when safeguarding referrals needed to be made to make a
recommendation?
SEMENTA: I think I did apply that knowledge. I just -- I didn't see that there was a need to do
that based on the information that was available to us at the time.
BERSHADSKI: Do you think with the benefit of hindsight, if you were in this situation again, and
you had received information like this from two Consultant doctors, that you would take a
different approach and recommend a safeguarding referral?
SEMENTA: I would hope so, but I think it's -- it's very difficult to accept one group of people's
opinion over another. You know, everybody we spoke to had knowledge and experience in that area
and knew the person concerned very well and we had four of five people that all said they didn't
see a concern and two people that did and there wasn't anything tangible to rely on in that
instance.
BERSHADSKI: But isn't the point of the safeguarding provisions that if there is a risk then you
make a referral, does it really matter if there are some people who disagree whether there's a
risk or not?
SEMENTA: No and I don't disagree, you know, that is the purpose of that process, isn't it, that
they will explore it and look at it in far more detail. But I think you need to have something to
go on and I don't -- I don't feel that at that point in time that was necessarily there because --
and I absolutely take your point about what you are saying about there was, you know, a spike and
then it changed when she came off
nights but we had been told that other things were also in place, that the rest of the nursing
staff were reviewing their competencies, you know, there were other things happening at the same
time that might have accounted for that.
BERSHADSKI: You say in your statement that you thought the Consultants should have called the
police. Paragraph 40.
SEMENTA: (Nods)
BERSHADSKI: Did you ask them why they didn't call the police?
SEMENTA: No, we didn't, because the conversation as it went the interview if you like, didn't lead
there because we were expecting them to give more information than they gave. I think potentially
that would have been a question that we were planning to ask and that is not where it went because
neither of them said that they had those specific concerns about that specific person.
BERSHADSKI: If you thought that the Consultants should have called the police, then why didn't
you recommend that the police be called yourself?
SEMENTA: Sorry, can you repeat the question?
BERSHADSKI: If you thought that the Consultants should have called the police, why didn't you
recommend that somebody call the police or call them yourself?
SEMENTA: I suppose what I was trying to say in my statement there is that now when I reflect on
that situation that's what I think they should have done. I think if they held those beliefs at
the time, they should have done that. I don't -- I didn't feel there was cause for me to do that
at that point in time.
BERSHADSKI: You say in your statement that you thought that Ravi Jayaram and Stephen Brearey held
a genuine belief that Letby had harmed babies but that no party was able to provide evidence. Did
you think that you needed hard evidence in order to call the police or make a safeguarding
referral?
SEMENTA: No, but again I think that's my reflection of looking at it now. I think that's what I
was asked about, whether now do I think they held that belief generally, yes, I do.
BERSHADSKI: Well, are you saying that at the time you didn't think that they had a genuine
belief?
SEMENTA: I don't know now. It's -- it's difficult to say. Before we met with them I think I was
expecting that that is what they would present and it's not what they presented and so we were
left very much with the feeling that things had been said and blame had been attributed with no
substance. That's how it felt at the time.
BERSHADSKI: Was there anything in your interviews with them that caused you to think that they
didn't have a genuine belief that Letby had harmed babies?
SEMENTA: Yes, because they didn't -- they didn't say that to us and because they hadn't taken that
action of calling the police themselves, I think if they had and they had said: we feel so
strongly about this that we have done -- we have made the following steps, I absolutely would have
seen that. But they didn't.
BERSHADSKI: Well, you knew that they had raised their concerns with Executives at the Trust; is
that right?
SEMENTA: That's correct.
BERSHADSKI: You knew as part of the grievance that they had insisted that Letby be removed from
the unit; is that right?
SEMENTA: That's correct.
BERSHADSKI: Part of the issues that you were considering within the grievance was whether in fact
they threatened to call the police if Letby wasn't removed from the unit; is that right?
SEMENTA: Yes.
BERSHADSKI: So surely that would have all left you with the impression that they did have a
genuine concern here?
SEMENTA: Not necessarily. I think there's been plenty
of other cases that I have been involved with where one or more people have not wanted to work
with somebody for any one of a number of reasons and so it's not beyond the realms of possibility
to me that there was other reasons why they didn't want to work with her on that unit.
BERSHADSKI: Was there anything in their interviews that suggested that they had some ulterior
motive for not wanting to work with Letby?
SEMENTA: Only that they didn't -- in my view, they weren't open about -- about the reasons that I
now believe they genuinely held. That did not come across to me at that point in time at all from
either of them.
BERSHADSKI: Right. There was a part of Stephen Brearey's interview where you say that there was
in effect a tense conversation between him and Dr Green about a prescribing error that had
occurred with one of the babies; is that right?
SEMENTA: That's correct.
BERSHADSKI: Was that the first time that you were aware that Chris Green had had some involvement
with the events surrounding one of the babies?
SEMENTA: Yes.
BERSHADSKI: What did you think about the appropriateness of Chris Green hearing a grievance when
there had been
that interaction between him and Stephen Brearey, in relation to one of the cases?
SEMENTA: So he wasn't hearing it, he was investigating it, so his role was to gather the
information. I wasn't concerned from that perspective. I would have been concerned if he had been
hearing it and been a decision-maker but he wasn't. His role was to pull together all the
available information and present it and offer some conclusions but it's always for the hearing
chair to decide whether or not to accept those conclusions, to decide something else.
BERSHADSKI: I mean, you would have been aware, surely, that the policies required independence on
the part of the investigating officer and not just the chair of the grievance?
SEMENTA: I still think he was independent. I think in a Trust of that size, very often people have
come across different people as -- as part of the course of their role, so I don't think it's that
unusual from that perspective. I don't think it had any bearing on the questions that he asked,
the information that he received or the way in which he pulled that report together and if I had
done, I would have raised it. It wouldn't be the first time we have changed investigating manager
partway through, we could have done that. I didn't think it was necessary.
BERSHADSKI: Well, why not there was a tense exchange with one of the Consultants relating to the
facts that were underlying this whole grievance, why was that not enough for you to think: hang on
there isn't sufficient independence here?
SEMENTA: I -- I don't know that I see that as relevant necessarily. So that conversation as I took
it to be was about what had happened to one of the babies, not about why Lucy Letby had been moved
from that unit. I don't see them as the same thing.
BERSHADSKI: I am going to ask you a few questions about the investigation report that came out of
your interviews. Can you just explain what your role was in the drafting of that report? That can
come down off the screen now, thank you.
SEMENTA: So once the report was drafted, I believe it came to me, which would be usual for me to
look it over, provide a second pair of eyes, to pass comment on anything that might not be clear,
necessarily, anything that might not be well-presented, anything that might have been missed from
the body of the report but referenced in the appendices, grammatical adjustments, that sort of
thing. I would usually comment on that in track changes
and comments and send it back before the draft was finalised. Some managers take on board all the
comments that you give them, some take on board none.
BERSHADSKI: If we just turn up, please, the draft report first, that's INQ0002879 at page 178. So this is the draft report. Would you have been
sent that by Chris Green?
SEMENTA: Yes.
BERSHADSKI: So are all the changes between the draft version of the report and the final report,
were they all changes that you would have made yourself?
SEMENTA: I wouldn't have thought so. So I would -- I might make recommendations about changes, I
might have changed it in track changes and sent it back. But then it would be for Chris Green to
accept or not accept them and I believe he made some other changes anyway, which would be usual
when you review a document for the second, third or more times and think about how you have
presented something and whether or not it expresses what you are trying to express.
BERSHADSKI: If we go to the final report, please. I am just going to ask you a few questions
about particular aspects of that. So if we go to page 221. I'm just going to ask you
about that section underneath the bullet points, which reads: "No party refutes that concerns were
raised by Consultants, in particular SB, to the Executive Team around a perceived commonality
between LL's presence on the NNU and the collapses/deaths. I acknowledge that these concerns were
raised through the appropriate channels in line with both the Trust Speak Out Safely policy and
the guidance proffered by the GMC. However, I do not find that the Consultants' concerns when
reiterated to the Executive Team were 'clear, honest and objective' (GMC guidance)." Now that
passage, I think, was added to the final report. Do you recall whether it was you who added that
or what involvement, if any, you had in that passage being added?
SEMENTA: I think it's likely. I do recall looking in some detail at the GMC guidance and I know
that I provided some comments to Chris Green about that aspect. So I think it's likely, but I
can't be sure.
BERSHADSKI: Well, why did you think that the Consultants' concerns, when reiterated to the
Executive Team, were not clear, honest and objective?
SEMENTA: I don't necessarily know that that's my opinion. I think what I'm trying to say is part
of my
role is to speak to the investigating manager and to help them articulate in their report their
feelings, findings and conclusions, and I think that that sentence reflected Chris' findings and
conclusions.
BERSHADSKI: Well, what was it that Chris Green told you about his views which led you to add that
into the report?
SEMENTA: I don't know that I can be precise about that at this point. I know that we had
conversations in which we both agreed that we didn't feel that the information we'd necessarily
been expecting had been given in the way that we were expecting it to be given. Neither of us
felt, I don't feel, that the two Consultants we spoke to were open and honest about the strength
of their concerns and the basis of those concerns.
BERSHADSKI: But why is that? They had said to you that there had been a spike in deaths, that
Letby was on shift during those deaths, that they stopped happening when she was -- at night when
she was shifted away from night duties. They told you all of that?
SEMENTA: (Nods)
BERSHADSKI: Why did that lead you to the conclusion that they weren't being open, clear, honest
and objective?
SEMENTA: I think because of what I have already said; that there were other -- there was other
information that was given to us and there was no account, accounting for that. So the review of
competencies I think by the nursing team, we had been told by other members of the nursing team
that the document that had been produced, the table if you like, in which different staff were
recorded and it was referenced who was on shift, that there had been a doctor on that list that
had been removed before that information was shared. Those things hadn't been accounted for. And I
still don't feel, when I re-read the information that they had given, that they were as
forthcoming as I was expecting them to be and perhaps that's unreasonable, but, at the time,
that's how I felt about it.
BERSHADSKI: Well, did you suggest to them in the interviews that they weren't being clear or
honest or objective?
SEMENTA: No.
BERSHADSKI: Why did you consider it fair to include that finding within the investigation report
if you hadn't even suggested to them in their interviews that they hadn't been clear, honest and
objective with you?
SEMENTA: I think they were asked reasonable questions
in the grievance interviews and they gave the information that they gave. They didn't give other
information that I think they could have given. You know, there was a lot of reference to private
conversations, never officially discussed, you know, there was very much an undertone there that
those conversations had taken place and they weren't prepared to share them in that setting, and
the report is a pulling together of all of the information that's available.
MR BERSHADSKI: My Lady, I see the time. There are going to be a few more questions for Ms Sementa.
LADY JUSTICE THIRLWALL: Yes, thank you. May I just ask one in relation to this topic --
MR BERSHADSKI: Certainly.
LADY JUSTICE THIRLWALL: -- before we break. The highlighted part of the document on page 14: "I
do not find that the Consultants' concerns when reiterated to the Executive Team were clear,
honest and objective." I had rather assumed that's a reference to speaking to the Executives
rather than to Mr Green?
SEMENTA: Yes.
LADY JUSTICE THIRLWALL: But you also say, I think, that when they were talking to you, they
weren't clear,
honest and objective either?
SEMENTA: Correct. I think if they had expressed to us: This is what we said to the Executive Team,
I think that might have satisfied that point. Does that answer your question?
LADY JUSTICE THIRLWALL: No, it answers a different one, but it's helpful. So you think if they
had said to you what they said to the Executives that would have been clear, honest and
objective?
SEMENTA: It might have been. I suppose it depends what they said.
LADY JUSTICE THIRLWALL: Yes. It's just that you seem to be making a finding here about what they
had said to the Executive Team.
SEMENTA: I suppose the two points align to some degree. When we spoke with the Executive Team they
didn't, I suppose, relay to us that there had been specific evidence or support for what had been
said; only that -- the commonality at the time. That didn't, to me personally, feel objective and
there had been other information that had been given from some of the other witnesses that also
did not feel honest and objective. I can't quite recall which witness it was now, but somebody had
mentioned that I think Stephen Brearey had
discounted somebody else's commonality because they were nice; that did not feel objective and
honest, certainly to me, and I don't feel to Chris Green.
LADY JUSTICE THIRLWALL: Did you follow that up?
SEMENTA: Pardon?
LADY JUSTICE THIRLWALL: Did you follow up that point?
SEMENTA: I don't think we asked Stephen Brearey about it, no.
LADY JUSTICE THIRLWALL: I see. Thank you. I think then we will stop. Perhaps we ought to take a shorter lunch break, if that doesn't inconvenience too many people, so we will start again at quarter to 2.
(1.02 pm) (The luncheon adjournment)
(1.45 pm)
MR BERSHADSKI: Ms Sementa, before we go back to the report, I just wanted to pick up one of the
topics on which you answered questions before the break. You said that you felt that it was
acceptable for Chris Green to remain the investigating officer because the Chair, Annette
Weatherley, was independent and, in your view, in effect, that was a sufficient level of
independence within the process. Is that a fair summary of your views?
SEMENTA: Yes.
BERSHADSKI: Now, as far as you were concerned, there was no plan for Annette Weatherley to hear
directly from Stephen Brearey as part of the grievance hearing, is that fair?
SEMENTA: That's fair. It was possible. I suppose it's for the hearing chair to decide if they want
to call people.
BERSHADSKI: Realistically it was going to be, therefore, Chris Green's decision in his
investigation report about Stephen Brearey and his credibility that was going to be the evidence
before Annette Weatherley?
SEMENTA: To a point. So the role of the investigating manager is to pull together all of the
information that's presented to them, however that comes. So sometimes that's verbal from the
meetings that we had, sometimes it's emails or written documents and there is an obligation on
that person to include all of that information in -- in the pack that they present to the hearing
chair.
BERSHADSKI: Yes. So she wasn't going -- Annette Weatherley wasn't likely to be receiving any
other information about Stephen Brearey and his credibility other than that which was contained
within
the report from yourself and Chris Green and all the material that went with it; is that
right?
SEMENTA: Not unless she asked for it, no.
BERSHADSKI: No. So if it was Chris Green rather than Annette Weatherley who was going to be
making direct comment on Stephen Brearey's credibility, wasn't it particularly essential that it
was Chris Green who was independent and wasn't clouded by any professional disagreement that he
may have had with Stephen Brearey?
SEMENTA: My position on that is still that I don't think he was clouded at all -- that is, that is
not my impression of it then, it's not my impression of it now. Part of my role would have been to
identify if I felt he was presenting information that was not an accurate reflection of what had
been gathered and also I feel as the hearing chair, it would have been Annette's role to pick
through that. You know, the role of the chair is to evaluate the information that's presented to
you and ask probing questions if that's appropriate to do. I would expect that she would be
sufficiently knowledgeable and experienced to be able to do that if it was required.
BERSHADSKI: It wasn't fair, was it, for you to be including within the investigation report a
comment about Stephen Brearey's honesty and integrity in
circumstances where there was a direct professional tense disagreement between the investigating
officer and Stephen Brearey about the fact?
SEMENTA: Sorry, can you repeat the question?
BERSHADSKI: It wasn't fair to include comment from somebody who had had a significant
professional disagreement with Stephen Brearey about his integrity within the report, was it?
SEMENTA: I don't know that I would consider the exchange that I witnessed to be a significant
professional disagreement.
BERSHADSKI: If we can turn up the report again, please, it is INQ0002879 and page 218, please. Sorry, Ms Sementa the system can
occasionally become a little bit sluggish. I just want to ask you about the middle portion of
this. The heading in the middle of the page is "I wish to be informed of any evidence the Trust
may have and the process which they have followed". This section of the report, do you recall
whether this was -- the next section, whether this is something that Chris Green wrote or was it
something that you had written?
SEMENTA: I don't recall but for clarity, I wouldn't describe my contribution to the report as me
writing
anything necessarily, but I -- I don't recall with this section, no.
BERSHADSKI: Okay. So it reads that: During the course of this investigation I have not been made
aware, nor has there been any allusion to, any evidence relating to any alleged wrongdoing by Lucy
Letby." In your -- at the start of your evidence to the Inquiry, you said that it was important as
part of this process not to have strayed into making any findings about the underlying allegations
against Lucy Letby because that wasn't what you were investigating; is that correct?
SEMENTA: That's correct.
BERSHADSKI: You hadn't heard from any witnesses that were relevant to any of the underlying
allegations; is that right?
SEMENTA: That's correct.
BERSHADSKI: So would you agree then that this section of the report and making a finding that
there had been no allusion to any evidence relating to any alleged wrongdoing by Lucy Letby, that
that strayed into making a comment on the actual allegations against her?
SEMENTA: No. I think she asked a question and Chris has provided a response but I think he's clear
there that he's talking about during the course of the investigation that he's carried out which
was in line with the grievance policy and in scope of the questions that she asked. That is not to
say there was no evidence. None was provided.
BERSHADSKI: Well, there was a danger, wasn't there, of including a finding that there's been no
allusion to any evidence relating to any alleged wrongdoing by Lucy Letby, that that would then
give the impression that that was the view of the investigating officer, that there's not been any
evidence relating to any alleged wrongdoing by Lucy Letby?
SEMENTA: I don't think I agree. I think that sentence doesn't say that to me. I think if it had
said there was no evidence, I didn't find any evidence, I don't think that's what that says.
BERSHADSKI: Well, you said earlier that you were very concerned by the matters that Ravi Jayaram
and Stephen Brearey had set out to you: the spike in deaths, the timing, the fact that they had
stopped at night; all of those matters we discussed. I think you say in your statement that you
were deeply concerned about those matters?
SEMENTA: (Nods)
BERSHADSKI: Why doesn't that appear in this section when making a finding about the evidence of
wrongdoing by
Lucy Letby?
SEMENTA: Well, firstly, this isn't my report, it's Chris' so it wouldn't be reasonable for it to
reflect my feelings. It's only reasonable that it reflects his and I would always be concerned
about deaths in, in any setting.
BERSHADSKI: Well, are you saying that you personally wouldn't have come to that conclusion in the
report?
SEMENTA: No. That's not what I'm saying.
BERSHADSKI: So did you disagree with Chris Green when you were interacting with him in finalising
this report --
SEMENTA: No.
BERSHADSKI: -- with his characterisation of the evidence against Lucy Letby?
SEMENTA: No.
BERSHADSKI: Do you think on reflection looking back on it, that it was an omission on your part
and his part not to include the matters that you were deeply concerned about from Ravi Jayaram and
Stephen Brearey when coming to these findings in your report?
SEMENTA: I don't know if I consider it to be an omission. I think on reflection, and knowing what
we know now, I think the report would have benefited from -- from that as well. But that
information was there, all of those appendices were included. There was
no information held back. Annette Weatherley as the hearing chair had access to the whole pack,
all of the information. So those comments made by Stephen Brearey and Ravi Jayaram were presented
to her as part of that pack.
BERSHADSKI: What you should have done is not made any comment at all about the evidence of
alleged wrongdoing by Lucy Letby because it simply wasn't something that you were in a position to
investigate; would you agree with that?
SEMENTA: I don't know if I agree with that because the question that she's posed is: "I wish to be
informed of any evidence the Trust may have", and what Chris is presenting there is that we
weren't provided with any evidence during the course of this investigation. So he can't answer
that question and I think that's accurate.
BERSHADSKI: Well, given the deeply concerning matters that you had heard from Ravi Jayaram and
Stephen Brearey, why wasn't the answer to Lucy Letby's question: well, the evidence of alleged
wrongdoing is the unexpected and unexplained spike in deaths, the fact that she's on duty more
than anybody else, the fact that the deaths stopped at night when she was taken off night shift,
all of those matters that Ravi Jayaram and Stephen Brearey had set out to you in their interviews
for their concern
about Lucy Letby, why wasn't that the answer as to the evidence against Lucy Letby?
SEMENTA: I wouldn't have described those things as evidence. So perhaps that's just an
interpretation of the term.
BERSHADSKI: So why not include those deeply concerning matters in your report?
SEMENTA: So it wasn't my report, it was Chris' and I think those -- they are there because they
are included in the appendices as part of the pack.
BERSHADSKI: Do you think that's good enough; that not setting those matters out in a 19-page
investigation report and asking the reader to find those deeply concerning matters within the
appendices to the report, do you think that's an adequate way of dealing with these deeply
concerning matters?
SEMENTA: No. But I think that when we met with Ravi Jayaram and Stephen Brearey, and we've looked
at those documents again today, I don't think at the time it was as clear as it appears today;
that when they were talking about the fact that there was this -- the commonality and the spike
that it was attributed to her in quite the way that it looks now. I don't feel that that was clear
at the time.
BERSHADSKI: Well, you say in your statement that you were deeply concerned about the points
raised by Ravi Jayaram. Presumably you mean that you were deeply concerned at the time?
SEMENTA: I suppose I was trying to answer the question. The question posed to me was: was I deeply
concerned about the fact that a disproportionate number of babies had died on that unit and the
answer to that is always going to be yes.
BERSHADSKI: Well, in your statement one of the matters that you say you were deeply concerned
about was the association with Letby, not just the fact that there were the deaths?
SEMENTA: And that -- that is -- was a concern and is a concern.
BERSHADSKI: The fact is that making any comment within the report about the evidence of alleged
wrongdoing created a risk, didn't it, of this report being seen as exoneration of Lucy Letby, if
it was accepted by the chair?
SEMENTA: I think that's possible, yes. But I do think the role of the chair as I have said is to
read and evaluate the information that's presented and I believe it was clear to the chair that
her role was to examine the grievance and the reasons for the redeployment and that this was not a
clinical investigation.
BERSHADSKI: Well, let's go now, if we may, to the grievance hearing conducted by the chair. If we
could have, please, on screen INQ0003155. You were present at the grievance hearing conducted by Annette
Weatherley; is that right?
SEMENTA: Yes.
BERSHADSKI: You are listed there at the top. Now, were you involved with compiling and sending
the material to Annette Weatherley in order for her to prepare for this hearing?
SEMENTA: I don't recall being so.
BERSHADSKI: We can see that one of the first comments or the first comment that Annette
Weatherley makes is she introduced herself and advised that she had only received the full pack 48
hours ago. Do you know why it was that she only received the full pack 48 hours prior to the
hearing?
SEMENTA: No, I don't know.
BERSHADSKI: Given how serious the matters were that were part of this grievance, did it cause you
any concern that Annette Weatherley had only had 48 hours to familiarise herself with all the
material?
SEMENTA: Not particularly because with a grievance quite often there isn't an investigation report
to review ahead of time; often you just as a chair sit in
the room and listen to the information and it's presented on the day. And I think again this was
not an investigation into anything that might have happened clinically. It was about why Lucy
Letby had been redeployed. So I don't think the information contained within the report was
particularly complex and there wasn't an enormous amount of it and I think, you know, she had been
asked to hear this as an experienced professional. If she didn't feel prepared to do that because
she hadn't had the materials for long enough I would have expected her to raise that herself.
BERSHADSKI: If we go over the page, please, to page 3, we can see towards the bottom that Annette
Weatherley seems to have not known that there was an external panel that was looking into the
allegations against Lucy Letby. Was that your impression in the hearing, that Annette Weatherley
seemed not to know that until it was mentioned in the hearing?
SEMENTA: I don't recall that being my impression, no.
BERSHADSKI: Well, what did you understand that to be a reference to, Annette Weatherley saying
"panel?"
SEMENTA: So when I have read it now --
BERSHADSKI: Yes.
SEMENTA: -- to me it's the use of the term "panel"
I think that might have been where the confusion came from. But that's my interpretation of these
notes.
BERSHADSKI: Okay, so you don't -- is it your evidence you don't recall either way --
SEMENTA: No.
BERSHADSKI: -- yourself what was said about that? Okay. If we go over the page to page 5, Chris
Green, about two-thirds of the three quarters of the page down, is recorded as saying: "Regards
the terms of allegations on Lucy Letby there isn't any other than the deaths of the babies
involved, no investigation for Lucy Letby and there is no answer as there is no evidence at all."
Did it concern you at all that Chris Green was telling Annette Weatherley that there was no
evidence at all against Lucy Letby despite all of the matters that you say you had found very
concerning that Ravi Jayaram and Stephen Brearey had told you?
SEMENTA: So firstly I don't -- these notes are not verbatim and I don't know that they are
accurate in terms of everything that was said. But secondly, I -- I imagine something similar to
that was said, but as I think I have explained, my interpretation of the term "evidence" might be
different to your own. I would have taken that to mean something more concrete, so a witness or
some documentation, that sort of thing, that would be what we would usually expect to see in a
case where we were talking about evidence as an employer.
BERSHADSKI: How were you in a position to evaluate what you would expect to see by way of
evidence of a nurse murdering babies?
SEMENTA: I wasn't in a position. But I think that's what I was talking about before when we were
talking about the Consultants, that is not the information that they presented to us.
BERSHADSKI: Did you at any point during this hearing, bring up all of the matters that Ravi
Jayaram and Stephen Brearey had said to you that you say you were deeply concerned about?
SEMENTA: No.
BERSHADSKI: Why not?
SEMENTA: It wasn't my role. My role there is to support the investigating manager, which was Chris
Green.
BERSHADSKI: Well, you are recorded as having contributed to this grievance hearing on a number of
occasions; is that right?
SEMENTA: I am recorded as doing so, yes.
BERSHADSKI: So it's not as if you felt that you weren't
able to say what you thought in the hearing; is that right?
SEMENTA: If I was asked, I would have said so.
BERSHADSKI: Well, there was clearly a discussion at this hearing of the evidence of wrongdoing by
Lucy Letby?
SEMENTA: (Nods)
BERSHADSKI: So there was an opportunity for you to say: Well, these are all the very concerning
matters that were relayed to us ... So why didn't you do that?
SEMENTA: Because I didn't disagree with the report. That isn't what I'm saying. You were asking me
whether or not I was concerned about the fact there was a rise in deaths on that unit and the
answer to that is absolutely, yes. Then, was I concerned about the fact that some people thought
there was a correlation between those deaths and a member of staff? Yes, I am concerned about
that. That doesn't mean that I felt there was evidence. I didn't. I'm not saying I was right.
That's just how I felt at the time.
BERSHADSKI: But why didn't you set out the matters that you say deeply concerned you from Stephen
Brearey and Ravi Jayaram given that you have accepted that they weren't set out in the report
itself, that they were
buried away in an annex to the report?
SEMENTA: I don't --
BERSHADSKI: Why not communicate them?
SEMENTA: I don't know that I would say they were buried away. I think when I was referencing the
appendices I am saying that those comments were clearly identifiable in those appendices. I do
think the body of the report references the fact that there was an increase in deaths on the unit
and there was a commonality, which are the -- is the information that was given to us by all of
the witnesses.
BERSHADSKI: Do you think, on reflection, that you should have raised the matters that had deeply
concerned you at the grievance hearing?
SEMENTA: I think the report would have benefited from having reflected that more thoroughly. I
don't know that it was my place to raise that at the hearing.
BERSHADSKI: I have got just one final topic, please -- that can come down off the screen now,
thank you -- for you. I just want to pick up on something that you say in your statement at
paragraph 45 as regards calling the police. You say towards the end: "I also recognise the need to
balance the reputations of the Trust and Lucy Letby and with the
feelings of the families of the babies who had sadly died against taking any action that might not
have been appropriate (such as calling the police in this situation) and appreciate that this was
a difficult position to be in." Is that what you were doing in your mind when considering the
question of calling the police; balancing the reputations of the Trust and Lucy Letby?
SEMENTA: No. I think what I'm trying to explain there is that that's how I think the Executive
Board presented to us that that's what they were doing.
BERSHADSKI: Well, do you think that that was a correct thing for them to have done; to have
balanced the reputation of the Trust and Lucy Letby against the need to call the police?
SEMENTA: I think all those things needed consideration.
BERSHADSKI: Well, I am going to suggest to you that it is completely wrong and contrary to all
the safeguarding aspects or policies to balance the reputations of the Trust and a possible
killer, against the need to call the police; that would go completely contrary to all the guidance
within your own HR policies. If there is a risk, the police should be called, notwithstanding the
effect it may have on the reputation of the Trust or the potential murderer; would you agree with
that?
SEMENTA: I would agree with that. Perhaps I have not explained that quite in the way that I wanted
because I don't agree with that at all. I think where I am what I was trying to articulate is I
think when the board were talking to us they did not feel with all the information that they had
available that there was grounds to believe that Lucy Letby had done those things. So what they
were explaining to us or how I interpreted what they were explaining to us was that if they had
contacted the police and there was no substance, no reason to do so that that would be damaging to
an individual's career, to the reputation of the Trust and potentially cause a great deal of upset
for the Families of the babies, not that that was the right thing to do because they were worried
about the reputation of the Trust.
BERSHADSKI: With your knowledge of safeguarding principles within the HR policies, you should
have recommended that the police be called, shouldn't you, notwithstanding any effect it may have
on the reputation of the Trust or Lucy Letby because it's the safe thing to do? Do you agree with
that?
SEMENTA: Yes.
MR BERSHADSKI: Thank you, I have no further questions, my Lady. I don't think there are any further questions from Core Participants.
LADY JUSTICE THIRLWALL: No. Thank you very much indeed. I know it's taken slightly longer than
expected but you are now free to go.
SEMENTA: Thank you.
LADY JUSTICE THIRLWALL: So we are going to take a break now and start again at 2.30 pm and then we will run through.
(2.11 pm) (A short break)
(2.29 pm)
MS LANGDALE: My Lady, may I call Dr Green, please.
LADY JUSTICE THIRLWALL: Dr Green, please come forward.
DR CHRIS GREEN (sworn)
LADY JUSTICE THIRLWALL: Thanks, Dr Green, do sit down.
GREEN: Thank you.
MS LANGDALE: Dr Green, you have provided the Inquiry with a statement dated 9 June 2024. Can you
confirm the statement is true and accurate as far as you are concerned?
GREEN: I can, yes.
LANGDALE: Do you have it with you?
GREEN: Yes, thank you.
LANGDALE: We see, Dr Green, from the beginning of your statement that you qualified with a BSc
Honours in Pharmacy in 1992. Between June 2005 and March 2023, you were the Director of Pharmacy
and Medicines Management at the Countess of Chester?
GREEN: That's correct.
LANGDALE: You were or are registered with the Royal Pharmaceutical Society of Great Britain until
the split to form the General Pharmaceutical Council and Royal Pharmaceutical Society?
GREEN: That's correct.
LANGDALE: Along with another number of memberships of various professional associations?
GREEN: Yes.
LANGDALE: But for our purposes you in 2013 took up a place on the NHS Leadership Academy Nye
Bevan Programme?
GREEN: I did, yes.
LANGDALE: Can you tell us about that course?
GREEN: That course was designed to prepare senior managers for potential executive leadership
positions, so there was a wide range of sort of theoretical learning and experiential learning,
some finance, some
dealing with the public, dealing with the press, MPs, sort of the softer side of leadership maybe.
And then there were some assignments to do around various leadership models and that sort of
thing.
LANGDALE: How long was the course?
GREEN: From my recollection about 18 months, maybe, two years.
LANGDALE: It's part-time presumably, was it?
GREEN: Yes, kind of a day release, kind of.
LANGDALE: Day release?
GREEN: Yes, yes.
LANGDALE: Did safeguarding -- and I don't just mean patient safety, I mean safeguarding of
children, babies, feature in that course?
GREEN: Not to my recollection, no.
LANGDALE: Did patient safety more generally feature in it?
GREEN: Not as a specific topic, I don't think. I mean, the idea of being an executive leader is to
make sure that your organisation delivers good quality care. So it might have been implicit in the
learning but I don't recall there being a specific module about patient safety or safeguarding for
that matter.
LANGDALE: You say at paragraph 13 your biggest achievement at the Trust was successfully leading
and managing the introduction of electronic prescribing at the hospital and you were awarded the
hospital's Outstanding Team Achievement of the Year for that. When was that?
GREEN: I think that was 2011, 11/12, maybe.
LANGDALE: We asked you about following -- about various policies and the like within the
hospital. You are also our first and I think our only pharmacist to give evidence. So can I ask
you to have a look first of all, the Standards for Pharmacy Professionals, so that we understand
them, INQ0108367, page 1. Just while we are getting that, does the General
Pharmaceutical Council provide advice or assistance or helplines, what is the role of that
organisation, as far as you are concerned, as somebody who is a pharmacist, Director of
Pharmacy?
GREEN: The General Pharmaceutical Council looks after my registration. As a professional I am
required to provide them with evidence of ongoing continuing professional development each year.
LANGDALE: Right.
GREEN: And they are also responsible for the registration of the pharmacy premises I am
responsible for and the standards that that service delivers.
LANGDALE: Okay, I don't think we can get that on the
screen so I am going to discuss it with you, if I may. You have seen it before presumably?
GREEN: Yes.
LANGDALE: Thank you. So I will -- I don't know if it's possible to get it on the screen in the
next few minutes while I am talking people through so they can see it. I am sure Mr Suter, if it
can happen, he will make it happen and we will be able to see it for other people to follow. But
the Standards for Pharmacy Professionals, there's basically as I see it nine, isn't there, there
is nine requirements for pharmacy professionals?
GREEN: That's correct, yes.
LANGDALE: 1, provide person-centred care. 2, to work in partnership with others. 3, to
communicate effectively. 4, maintain development and use their professional knowledge and skills.
5, use professional judgement. 6, behave in a professional manner. 7, respect and maintain the
person's confidentiality and privacy. 8, speak up when they have concerns or when things go wrong.
And 9, demonstrate leadership.
This document breaks down those various standards and explains them a bit further, doesn't it? And
under the "Pharmacy professionals must work in partnership with others", there is a reference to
"take action to safeguard people, particularly children and vulnerable adults". I wanted to ask,
the guidance Working Together 2015 and the like, were you aware of that when you were at Countess
of Chester, that it's everyone's responsibility to protect children and to safeguard children?
GREEN: At -- at some point safeguarding mandatory training was introduced and I would have done
that every year or two years, so -- and I am fairly sure I attended a face-to-face education
session about that. But I couldn't be specific about when that was.
LANGDALE: Because it is not the case, is it, it would be wrong to think it is just paediatricians
and nurses and the doctors involved in day-to-day clinical care that have that responsibility; we
all have that responsibility?
GREEN: Yes.
LANGDALE: Looking at the standards for your profession, it is the same. Under "Pharmacy
professionals must communicate effectively" which is page 10 of this guidance, it says
this: "Communication can take many forms and happens in different ways. Effective communication is
essential to the delivery of person-centred care and to working in partnership with others. It
helps people to be involved in decisions about their health, safety and well-being. Communication
is more than giving a person information, asking questions and listening. It is the exchange of
information between people, body language, tone of voice and the words pharmacy professionals use
all contribute to effective communication. There are a number of ways to meet this standard and
below are examples." It speaks about listening actively and responding to information etc, etc. So
soft skills, really, you use that in terms of the course. Soft skills: you are expected to
communicate and pick up what people might not be saying, what they are saying, why, the underlying
thinking; is that fair.
GREEN: Yes, it is.
LANGDALE: One of the experts that's given evidence to the Inquiry, Professor Dixon-Woods, spoke
very eloquently about psychological safety and the need for when people are speaking up or
concerned about matters, psychological safety, that there's no immediate risk or threat if -- if
they do so.
GREEN: (Nods)
LANGDALE: Is that a concept you are familiar with, psychological --
GREEN: It is, yes.
LANGDALE: -- safety? So how would you define that? Sorry, before you do, miraculously Mr Suter
has it there and it is page 10. Thank you, Mrs Killingback. Sorry, so what would you say about
psychological safety?
GREEN: It's providing -- my own version of the definition would be it's providing a safe space for
individuals to speak up about their concerns in a way that doesn't leave them feeling judged or at
risk of punitive treatment and that their contribution to the subject matter at hand is valued and
-- and means something.
LANGDALE: When we use concerns, we mean just concerns, suspicion, concerns, gut feeling; it
doesn't mean concrete proof of a criminal act, does it?
GREEN: No.
LANGDALE: It means concerns, particularly when we are dealing with children. If I am worried
about something, I should tell someone, share that?
GREEN: Yes.
LANGDALE: Yes. So we are agreed that it's important not only to recognise the concept but to
actively think about the skills required to ensure people tell you what really matters and they
are worrying about?
GREEN: (Nods). Yes
LANGDALE: Yes. Did you have any training or discussion within the Trust about that as an
issue?
GREEN: Psychological safety specifically?
LANGDALE: Yes and directed particularly to people sharing worries about patients, the people you
are there for?
GREEN: No, I think it is a term that's grown in use over the last few years rather than 10 years
ago.
LANGDALE: So you -- if I asked you that question in 2015 would you have answered it in the same
way?
GREEN: I'm not sure I might have known what psychological safety was as a concept then.
LANGDALE: How would you have ranked your soft skills, if I can use the language of the definition
there in your General Council guidance? Are you good at picking those things up, the reasons are
for why people might be doing things or saying things in the way they are?
GREEN: I know where this is going, so --
LANGDALE: Of course, you are a bright man.
GREEN: Yes, but I would like to think so, yes. You
know, if -- if I notice that members of my team are not themselves or I feel there's something
they are not really sharing or -- I coach a girls' rugby team and sometimes I ask them if they are
okay, I can see that they are not their normal self, so yes, I think I have got reasonably good
soft skills, yes.
LANGDALE: Page 12 of this guidance: pharmacy professionals must use their professional judgement.
One of the penultimate bullet points there: recognise the limits of their competence. Does that
mean in relation simply to giving prescriptions or drawing up prescriptions, supervising others or
does it mean more broadly that as professionals we are all required to say: this isn't my bag
really or I am out of my depth, it is not for me. Does this cover the wider category, you just say
when it's outside your area, not really my thing?
GREEN: I think that would be fair to say.
LANGDALE: So we should all be saying: I am not a commercial lawyer, that is not the case for me.
Or you might be saying if you are asked to do something that it's not within your area of
expertise or competence, not for me?
GREEN: (Nods)
LANGDALE: Page 13, standard for lots of professionals.
Treat people with respect and safeguard their dignity. I suppose how would we manifest that?
GREEN: It's through our patients, isn't it, I think rather than colleagues in this context?
LANGDALE: Okay.
GREEN: But we would expect to respect people's personal beliefs, be they religious or, you know,
just general sort of perceptions of how life should be.
LANGDALE: Understanding?
GREEN: Yes.
LANGDALE: At page 15: must speak up when they have concerns or when things go wrong. We see in
the bullet points there: raise a concern even when it's not easy to do so, open and honest when
things go wrong. Say sorry, provide an explanation, put things right when things go wrong. So
really duty of candour is referred to, isn't it, so at the top, usually called the duty of
candour. So you have the same again as those doctors, nurses and medical professions around being
candid?
GREEN: Yes, it is something that's drummed into us from a very early part of our career, is to be
honest about anything that goes wrong. So, yes.
LANGDALE: That's that guidance on speaking up generally. Would you ever have looked at the
speaking up policy at the Countess of Chester?
GREEN: Yes.
LANGDALE: Speak Up Safely I think it's called, isn't it?
GREEN: At one point in my career I did begin to look at whether I might take up a Speaking Out
Safely kind of approach to concerns I had about the way the hospital was being run.
LANGDALE: What year was that?
GREEN: It was between Covid and my departure, so I would say 21/22 maybe.
LANGDALE: Okay. But before then it's not something you had asked for or been shown?
GREEN: Not particularly, no.
LANGDALE: Not particularly?
GREEN: I don't think I had ever really encountered a situation in which it would have been
applied, not that I can recall anyway.
LANGDALE: Grievances now, the grievance policy. That can come down now, thank you. The next
policy is INQ0002879 0100. There we have it. Look at the box immediately under the
heading "Grievances"?
GREEN: Yes.
LANGDALE: It says: "If a grievance can be more appropriately dealt
with under a different procedure, staff will be advised. The examples below indicate where it's
inappropriate to follow the grievance procedures as other mechanisms or Trust procedures are in
place. "Dismissal or any disciplinary matters." There are a number listed and we see there:
"Complaints of harassment and bullying. "Disclosures made under the Trust's whistleblowing Public
Interest Disclosure Act policy." Dealing with those last two, were you aware of this policy first
of all saying it's inappropriate to deal with complaints of harassment and bullying under this
policy?
GREEN: At the time I will have read the policy.
LANGDALE: You didn't --
GREEN: I will have read the policy --
LANGDALE: Right, okay.
GREEN: -- to try and get some understanding what the grievance procedure was and to make sure I
followed it as best I could.
LANGDALE: Yes.
GREEN: So I will have read this and thought about its contents.
LANGDALE: Disclosures made under the Trust whistleblowing. Did you understand what that even
meant, protected disclosures or what that involved?
GREEN: Yes, but I wasn't aware at that time of any disclosures made to the Trust under the
whistleblowing policy.
LANGDALE: Right. You were aware I think we will come to the documents that Letby was making a
complaint of bullying, wasn't she?
GREEN: Was she?
LANGDALE: Let's go to the documents.
GREEN: Okay.
LANGDALE: If that appears to be the case it didn't cross your mind at the time to go back to the
policy?
GREEN: No.
LANGDALE: Okay. Because it looks as though this policy, like lots of policies, gives a discretion
to just allow the person who's been asked to do something to stand back and say: does this fit the
bill?
GREEN: So I think Lucy Letby raised this grievance herself.
LANGDALE: Yes.
GREEN: If she felt she was being bullied and harassed, I would have expected her perhaps to have
raised that concern under that policy under the guidance of her trade union.
LANGDALE: So I don't know what the policy was for that
was, it very different for harassment and bullying?
GREEN: I couldn't say, sorry.
LANGDALE: So that can go down, thank you. We asked you in your Rule 9 about what you knew at
various times about the mortality rate, deaths, unexpected deaths, so I am going to take you
through a few documents now to ask you --
GREEN: Okay.
LANGDALE: -- if you would, to set out what you did or didn't glean from those, okay. So the first
one please is INQ0003114, page 1. And this is an email from Dr Brearey to a number of
people, including you, saying: "I have brought together all the summaries of the reviews of care
into this Thematic Review Report." It's dated 2 March 2016. Then if we look at the report, can we
please go to INQ0003251, page 1. The Inquiry is familiar with this document now. Dr
Green, I think you are as well?
GREEN: Yes.
LANGDALE: You have seen it through us certainly. If you look at page 2, refresh your memory of
what it sets out at the beginning. Higher than expected mortality rate. Then, please, if we go to
page 7, themes identified during discussions of all cases and we see there Dr Brearey setting out
themes. "Some of the babies suddenly and unexpectedly deteriorated and there was no clear cause
for the deterioration or death identified at postmortem. Timing of arrest, six babies for nine
deaths reviewed had arrests between midnight and 4 am. "Action: Dr Brearey and Eirian Powell to
review all these cases focusing on nursing observations in the four hours before the arrests. Aim
to identify phone while babies could have identified earlier. Identify any medical or nursing
staff associated with these cases." What did you think when you received that?
GREEN: I honestly don't remember receiving the report.
LANGDALE: So when you were cc'd back in March, you don't remember -- clearly you are not
disputing you got it but you didn't open it, didn't read it; is that the position?
GREEN: I don't remember seeing it. I get hundreds of -- literally hundreds of emails every week.
LANGDALE: Like many professionals?
GREEN: Yes.
LANGDALE: So how do you sift what matters to read? Did you get many from Dr Brearey of this
nature?
GREEN: No.
LANGDALE: It says "NNU Mortality Thematic Review". I mean, "mortality"; what did you think that
meant as a headline?
GREEN: Well, exactly what it says.
LANGDALE: Yes.
GREEN: But I honestly can't remember seeing the document.
LANGDALE: Just looking at that page 7 now.
GREEN: Yes.
LANGDALE: Another piece of evidence Professor Dixon-Woods gave us was that when people sometimes
sense things aren't wrong, they don't know why, it is sense-checking, they just think it's not
right. You nod, you agree. So she described Dr Reynolds, who was one of the first to be suspicious
of Dr Shipman, and she had noticed her patients were dying in the afternoon, sat up in a chair in
their armchair at home and the pattern was something she just didn't know at that point what Dr
Shipman had done, but that it didn't sit with her.
GREEN: (Nods)
LANGDALE: Reading this pattern now that is being described to you, Dr Brearey has chosen at this
stage without linking the pattern but he is saying six -- on
the documents: six babies had arrests between midnight and 4 am. He has bothered to point that
out, hasn't he, it is a pattern he's picked up?
GREEN: Yes.
LANGDALE: When you look at that now, sense-checking, what do you think about that?
GREEN: That distributed over 24 hours, that is statistically unlikely to be chance.
LANGDALE: Is the hospital quieter -- avoiding statistics for a moment, is it quieter at midnight
4 am generally around the hospital, might it be?
GREEN: Yes, absolutely. There is no outpatient activity, the vast majority of staff have gone
home. Yes.
LANGDALE: So he's picked something up there but you say you didn't see that at the time. Did you
ever go back to that email? We know Dr Brearey offered in his grievance interview to send you the
mortality review. But you didn't take him up on that. You didn't ask for that or get it later?
GREEN: No.
LANGDALE: Right. Is there a reason you didn't? You had been sent it before, we will have known
that, but when he offered to send it to you as part of the grievance process, were you interested
to see it or not?
GREEN: Honestly no because I was aware that there were two formal investigations going on into
these cases. So what -- what's what Dr Brearey might have found in his mortality report we had
seen. But actually this was a specific investigation looking at the deaths and that was being
carried out by people who were eminently qualified to do so, from my perspective. So I was aware
that these investigations were ongoing and that they would look at was there a case to answer
about any potential foul play or wrongdoing or poor practice.
LANGDALE: Next document, please INQ0005701, page 1. Just going through the chronology, so that is why this
one comes up next, Dr Green, because this one is 13 April 2016. This is an email to Janet McMahon
cc'ing you and we see there Dr Brearey is not happy about a response you have given around
pharmacist involvement in a particular case and he needs to meet to discuss it because he has go a
duty of candour with the parents until the issues regarding the Gentamicin advice had been
resolved. That is not an indictment baby, I am not asking you for the details of that baby or the
issue but we see there was an issue between you and him at that time over email.
GREEN: This had cropped up a number of times over the course of the Inquiry and my personal view
is that it's been blown out of all proportion.
LANGDALE: Okay.
GREEN: We have disagreements about things all the time.
LANGDALE: Okay.
GREEN: And usually it is done in a professional manner, usually it's resolved. But yes, we
disagreed about this but I didn't walk away from it with any grudge or malice towards Dr Brearey
as a result of that. It was just a professional disagreement and I didn't have a problem with
that.
LANGDALE: So if we can go to the next document, please INQ0003174, page 1. This is taking us forward, Dr Green to July, 8 July,
page 2 --
GREEN: Yes.
LANGDALE: -- would be even more helpful, thank you, Mrs Killingback. So this is 8 July and it's
the set-up, as you tell the police, of the Silver Control Room. You tell the police it was a major
incident kind of alert around deaths on the NNU and whether there could be foul play, can you
remember saying that, that is what the Silver Control Room was about?
GREEN: I did say that.
LANGDALE: Yes.
GREEN: At the time, was it -- was it billed as foul play? I am not -- I am not entirely sure I can
remember that it was.
LANGDALE: It was your expression to the police, wasn't it?
GREEN: It was yes, not disputing that but I maybe that was with the benefit of hindsight. I can't
remember.
LANGDALE: There were 36 people there looking at that list, a serious list of people?
GREEN: Yes.
LANGDALE: So who summoned you all to the boardroom or got everybody to go there?
GREEN: It will have been an Executive decision to call Silver Control together. I can't
specifically remember which member of the Executive Team it was but I think it was the Chief
Executive.
LANGDALE: You think it was, sorry?
GREEN: The Chief Executive.
LANGDALE: That is Mr Chambers?
GREEN: Yes.
LANGDALE: You said again to the police you were all
called to the board meeting and we set up a kind of incident room, if you like. Some people went
through notes to identify anything that would be a concern.
GREEN: Yes.
LANGDALE: If we look --
GREEN: That was definitely the case.
LANGDALE: That's correct, yes. So if we look at the actions underneath. We see for example Sian
Williams looking at staffing at the time of identified incident. She was doing that with Julie
Fogarty and she was tasked with looking at sudden and unexpected deaths or deteriorations and
looking at the staff who were present there or thereabouts; is that what you understood to be the
case?
GREEN: I really can't remember.
LANGDALE: Well, it must be a one-off in a lifetime, this?
GREEN: No.
LANGDALE: Mustn't it?
GREEN: Sorry, the subject matter absolutely.
LANGDALE: Yes, so having a Silver Control, 36 of you -- literally were you in the same room?
GREEN: Yes. I think personally I have been through Covid, a very challenging time in the hospital,
which
led to my potential exploration of whistleblowing, things that happened eight or nine years ago
have been superseded in many cases by some things that no one else should have to go through.
LANGDALE: Okay. But in terms of at the time it was a highly unusual set-up and looks like you are
all being allocated things to do; is that the situation?
GREEN: Yes.
LANGDALE: I think you say you were allocated to handling helplines if we go to page 35 and 36,
looking at both in sequence, if we could. Media enquiries, key messages for parents or patients
have been drafted and over at 36 we see you are one of the people named to take calls on the
contact number. What -- who were you anticipating would be calling, what was the issue?
GREEN: I think -- and again I am struggling to remember, but I think it was around any kind of
press awareness of what was going on in the Silver Control sort of set-up and whether that
resulted in concerned calls from family members or the press or ...
LANGDALE: Did family members -- we know there was the downgrade on 7 July, we know there was an
announcement. Were family members discussed as much as press interest in that meeting, can you
remember?
GREEN: I can't remember now, sorry.
LANGDALE: Because we are aware that there was a lack of communication with family members and
parents affected. Yet here you all are, everyone's got a chance to think: what do we do next? It
seems quite a programme that is being put in place here; is that a fair assessment?
GREEN: I'm not sure that I saw it that way at the time.
LANGDALE: What did you see it as at the time?
GREEN: I saw it as a response to a spike in deaths on the neonatal unit and a sort of assessment
of whether there was anything in there that would cause concern that might require further action.
LANGDALE: Since the March thematic review Dr Brearey had been at pains to say they were
unexpected, unexpected with no medical cause. The doctors were at a loss. So it wasn't simply
about deaths, was it, it was that these were unexpected deaths?
GREEN: Yes. I think so. I think that would be fair.
LANGDALE: There is an important distinction there, though, isn't there?
GREEN: Yes, yes.
LANGDALE: Sometimes it gets lost, doesn't it, in the emails --
GREEN: Yes.
LANGDALE: -- and certainly some of the comments that you are given in the grievance process?
GREEN: Yes.
LANGDALE: They were unexpected with experienced paediatricians having no explanation for
them?
GREEN: Yes.
LANGDALE: So it is --
GREEN: But in that summary there seemed to be things that could have contributed to that.
LANGDALE: In the mortality --
GREEN: Yes, yes. So it wasn't that there was no possible explanation, but it was that there was --
they were unexpected despite those things.
LANGDALE: You were aware, were you, at the time of this meeting, or subsequently, of the death of
two baby boys, two of three Triplets?
GREEN: Yes.
LANGDALE: If we go to INQ0006890 0112, we see an email from Mr Harvey to you. You see: "We
discussed the issue of the retained TPN at Execs this morning ... felt at this time we continue to
store in as safe and non-degrading (in a chemical, not an E&D way) possible." That was sent to
you and you understood, what, from
that?
GREEN: At some point I had gone to the neonatal unit and retrieved some TPN, I don't know if you
know TPN is, so intravenous feed that's given to the neonatal patients. I retrieved the bags and
stored them in the pharmacy cold store.
LANGDALE: You were aware that there was a suspicion of foul play to be taking those bags and
storing them, weren't you?
GREEN: Yes.
LANGDALE: Indeed you tell the police that. We knew there was an issue. "I am fairly sure because
otherwise I wouldn't have been sure about why we were collecting the bags, so I was aware there
was something going on that perhaps shouldn't be." Is what you said to the police; yes?
GREEN: Yes.
LANGDALE: The request came from Sian Williams, is that right, to you?
GREEN: Possibly.
LANGDALE: To go and collect the bags?
GREEN: (Nods)
LANGDALE: You also speak to Eirian Powell, if we go to INQ0014568, page 11. Thank you.
We see the police ask you, you see halfway down: "Eirian handed the bags to you and you have gone
over to get them. Did you have any conversations surrounding why you were taking them?" You say:
"I can't really remember, I think there was a kind of -- I think there was a kind of, you know,
got to pick these up, we hope it's not the reason that we think we have to, but I can't remember
any particular conversation." They continue down the page: "For what purpose did you retain the
bags?" Go to the next page, please, Mrs Killingback at the top: "I was advised to keep hold of the
bags by Sian Williams ... didn't really question it. Under the circumstances it seemed like a
reasonable request." The circumstances were there was suspicion that someone had deliberately
harmed those Babies O and P and that these samples might be relevant to that, to understanding
what had happened?
GREEN: (Nods)
LANGDALE: You nod?
GREEN: Yes.
LANGDALE: But there was no doubt about that. From that point that was very clear to you having
been asked to go over and get them?
GREEN: Yes. Yes.
LANGDALE: As a Director of Pharmacy, have you ever been asked to do anything like that before or
since, I don't need to know the details if you have, but to go and take samples that might be
needed for an investigation of foul play, and to keep them in the hospital?
GREEN: I think once, one other occasion.
LANGDALE: One occasion?
GREEN: I think.
LANGDALE: You think. Or you know?
GREEN: I don't know for sure.
LANGDALE: What was the suspicion? You don't have to tell me which hospital or who, what was the
suspicion, of what act?
GREEN: So we had discrepancies in the volumes of methadone on a ward and we sent the contents of
the bottle off to see if it had been diluted so it wasn't foul play necessarily.
LANGDALE: So it was dosage?
GREEN: No, the suspicion might have been that someone had taken out the methadone which is a
controlled drug and replaced it with water.
LANGDALE: Right.
GREEN: To make it look like there was more in the bottle, so we sent the bottle off for analysis
to check that that wasn't the case.
LANGDALE: Okay. So nothing like being suspicious of --
GREEN: No.
LANGDALE: -- whether somebody has injected, put something into a bag, put something -- a poison
or anything else into a child, nothing like that --
GREEN: No.
LANGDALE: -- before or since? It must be really rare that you --
GREEN: Yes.
LANGDALE: -- you get a request like that and that is what you are telling us?
GREEN: Yes.
LANGDALE: So it would presumably stay in your mind and you would have some curiosity about:
what's happened with that, what's that about?
GREEN: Yes.
LANGDALE: The next document, going back to what you were aware of before the grievance INQ0004335. It's a Quality Safety and Patient Experience Committee meeting,
Monday, 15 August at 12 noon. If we can go, please, to page 6. You are listed as an attendee, you
tell us you are
on that committee QSPEC and we see an NNU briefing paper: "Action Plan: Mrs Millward reported that
pages 12, 13 of the paper details have reached while waiting an independent review plan for 1 and
2 September 2016. "Mrs Rees advised it could take up to six months for the report to come from the
RCPCH. "Mrs Hodkinson replied this was discussed with the Execs team. "Mrs Williams agreed to
check timescales." So this was coming back to this meeting at this point for discussion about what
was happening with that review?
GREEN: (Nods)
LANGDALE: What did you understand that review was about?
GREEN: I understood that the -- that some of the paediatricians had raised concerns about the
deaths on the unit and that as a result of that, the Executive Team had commissioned an
investigation to be delivered by the RCPCH and they were waiting for that to come back.
LANGDALE: Did you ever -- it is a relatively small hospital, isn't it -- reach out or go and chat
to one of your paediatrician colleagues and say: what's going on, you know, how are you doing?
What are you worried
about? Did you have professional relationships that were supportive in that sense before you were
involved in the grievance? I mean, just reaching out to someone saying: this must be really
worrying?
GREEN: No. No.
LANGDALE: Why was that?
GREEN: It didn't occur to me to do that.
LANGDALE: Again you had done that leadership course. Part of that leadership is it's everybody's
responsibility, isn't it, within an organisation with leadership roles? Do you think looking back
that might have been helpful, you are at meetings, you are hearing about it, might have felt quite
an isolated space, mightn't it, for doctors trying to deal with that this situation?
GREEN: Yes, in retrospect, yes, but I didn't really have a particularly close relationship with
any of the paediatricians.
LANGDALE: Right.
GREEN: I am not -- I am not a particularly outgoing kind of person. I am more of an introvert, I
think, so that wouldn't naturally be my style. Unless I could see that somebody was distressed or
struggling or suspected that that was the case and then I might reach out to them to say: hope
you're doing ok?
LANGDALE: It is not always visible, that kind of thing, is it?
GREEN: No.
LANGDALE: Sometimes the people who appear the most distressed may be less distressed than the
introverts who don't demonstrate it?
GREEN: Yes.
LANGDALE: The next document, please, INQ0002879 0083. This is something that came to you as part of the grievance
process. It appears Eirian Powell sent it to you on 28 October 2016. We see if we can start at
page 84 [not found] first, please, Mrs Killingback. Thank you. We see it is an old article that Dr
Jayaram sent his consultant colleagues and Eirian Lloyd Powell. Then if we go back to page 83, Dr
Gibbs commenting on case cause of air embolus and thinking about it and at the top we see Eirian
Powell says: "This is the article and email I was alluding to in our discussion". This exchange
between the doctors shows very clearly that they are thinking about air embolus, doesn't it?
GREEN: Yes.
LANGDALE: When you read that, and all that you knew before about the samples being taken, were
you worried for those babies and think about that?
GREEN: Yes. But as I have mentioned already there were two investigations commissioned by the
Executive Team to look into this in a structured and sort of forensic way. So for me, some of this
was kind of going on at the side of those two things, so everyone could have an opinion about what
was going on.
LANGDALE: Everyone had an opinion, did you say, or would have an opinion?
GREEN: Everyone could have an opinion about what was going on.
LANGDALE: Could have?
GREEN: But there were two separate teams or two separate investigations actually looking at the
detail because that's where the real sort of evidence would be, in my view.
LANGDALE: What, the RCPCH review?
GREEN: Yes, and the there was a forensic review as well.
LANGDALE: Yes, what did you understand that meant, a forensic review?
GREEN: That there would be an investigation into bloods and postmortem results and histology, that
kind
of thing.
LANGDALE: Who did you think was doing that?
GREEN: I'm not sure I was ever aware of who it was specifically but I was led to believe it was
some leading paediatricians from somewhere in the country had been brought in to do an external
review.
LANGDALE: Who did you rely on? Eirian Powell has obviously sent you this, but who did you rely on
for that information?
GREEN: About the external investigations?
LANGDALE: No, the reviews or what was happening?
GREEN: They were mentioned in meetings, so it was mentioned in QSPEC, as we have just seen.
LANGDALE: Mmm.
GREEN: I had a conversation with Ian Harvey about it as well, I put that in my statement.
LANGDALE: When did you have a conversation with him?
GREEN: Around the time of the grievance -- before the grievance, I think. Because he was -- as I
said in my statement, he gave me some insights into what the report might be finding.
LANGDALE: What did he say to you about that?
GREEN: As I recall --
LANGDALE: Do you want to direct us to where it is in your statement, that conversation? Can you
remember
now?
GREEN: Yes. INQ0101359 [not found] --
LANGDALE: Sorry, which paragraph of your statement?
GREEN: Sorry, it is number 37.
LANGDALE: Right. So you say: "I am recorded to have said 'I was led to believe it was not out of
the normal range but it was high'." When are you having this conversation, in his office?
GREEN: Yes, I think so.
LANGDALE: There is no reference to the document of that on that paragraph. I am going to go to a
conversation you had with Mr Cross and maybe there is somewhere. But what -- was it before the
grievance or during the grievance? Who appointed you to do the grievance?
GREEN: So just before I answer that can I just say -- it is the last sentence: "I also recall
being informed there had been a review of the unit which found some concerns around medical
leadership on the unit and around clinical decision-making and the care of individual babies." So
that was from the report that Ian Harvey told me those things were potential findings.
LANGDALE: Right, so he was telling you what the review said or something?
GREEN: That is my understanding of what happened, yes.
LANGDALE: Okay. Who appointed you to do the grievance?
GREEN: I am pretty sure I was approached by Sue Hodkinson, the Director of HR.
LANGDALE: What did she ask you to do?
GREEN: She explained some of the background and said that Lucy Letby had raised a grievance and
they would like a senior manager to investigate it and that they would ask me to do it.
LANGDALE: One more document before we go to the details of the grievance. If you can have a look,
please, at INQ0002879, page 59. This is later in time, it doesn't have a date on this
but I can tell you it is 9 September. When it comes up, Dr Green, it is an email that's contained
within the grievance file but I'm not sure whether you saw it or not. Can you tell us if you saw
that?
GREEN: I recognise the smoking gun reference so I think I have seen that.
LANGDALE: Okay. So this is Dr Jayaram saying when he has had a meeting with Mr Harvey he did
acknowledge that concerns were raised over foul play and recommended a forensic detailed
independent review of all the cases.
That is what you said, you understood that was happening. Did you rely on Mr Harvey for
information then in that conversation about what was happening with that?
GREEN: I would have had some information from Mr Harvey but I think I would have heard those
things being mentioned elsewhere like QSPEC or perhaps other meetings. I don't know, but --
LANGDALE: The QSPEC meetings are not like emails, are they, they don't really tell you what's
going on sometimes. They certainly don't use expressions like "foul play" "smoking guns" and
things like that?
GREEN: No, there was never any mention of that sort of thing in QSPEC meeting.
LANGDALE: Why is that when we get minutes of those sorts of meetings, they are written in a very
neutralised way, when you read them as an attendee do you sometimes think: it is a bit more florid
than that, or do you think they are accurate?
GREEN: I think sometimes they are written in a way to soften the -- soften the truth maybe.
LANGDALE: Conceal the truth is another way of saying it. Potentially sometimes if you have got a
very difficult discussion and it's conveyed in very neutralised language or doesn't really say how
people spoke which
often communicates how strongly we feel about things?
GREEN: Yes.
LANGDALE: They are certainly not helpful, are they, when you go back to them?
GREEN: No.
LANGDALE: And there is a lot of meetings, aren't there, a lot of meetings, a lot of minutes?
GREEN: Yes.
LANGDALE: When you all get sent them to read them and approve them, do you do that?
GREEN: Not always, since I have taken an oath to tell the truth. I think -- I mean, yes, there
are, there are too many meetings and in my view they are too broad in terms of their content and
too little time to actually get to the bottom of a number of things. That would be my criticism of
many meetings that I have gone to over the last 20 years.
LANGDALE: Interestingly in the Silver Control meeting board meeting boardroom, names were put
next to tasks. That is a very effective way of seeing what gets done, isn't it?
GREEN: Yes.
LANGDALE: You have someone who's accountable for that task?
GREEN: Yes. In my current Trust there's always an action plan at the end of every set of meeting
notes, so it's transparent about who should do what and when it's expected to be done by.
LANGDALE: Sian Williams incidentally gave evidence yesterday that when she had finished that --
the document can go down, thank you, Mrs Killingback, when she finished that staffing review, she
and Julie Fogarty thought they should have gone to the police?
GREEN: Yes.
LANGDALE: Did she ever say that to you?
GREEN: She did, yes.
LANGDALE: When did she say that to you?
GREEN: I couldn't tell you an exact date but I would say that Sian and I discussed it or more than
one occasion and both felt the same about that.
LANGDALE: What did you say to her when she said that?
GREEN: I can't remember the exact words but I would -- my recollection is that I agreed with her
because if there had been doubt about it, then the easiest way to address that will have been to
call the police in but I have said in my statement I don't know that the police weren't ever
contacted about this.
LANGDALE: Say that again?
GREEN: I don't know for sure that the police weren't ever contacted about this. I am not privy to
that information. I surmised that Stephen Cross as an ex-senior policeman may well have had some
informal conversations with former colleagues to say, you know: this is the situation we have got,
what do you think we should do? Or, you know, have we got this right? Or is it too early to call
the police in? So.
LANGDALE: You had a meeting with Mr Cross since you mention him, INQ0003373, page 1. This is his handwriting, I believe, 16 November 2016. An
8 o'clock meeting with you about the grievance: "Pressure on Execs. 'Threatened' to go to police
by Consultants? Consultants say no issue re police being called. Denied any knowledge they would
want police. Accusations that Lucy had harmed babies, disputed emails from Eirian marked
confidential, [something] to refer to foul play." Can you remember an 8 o'clock meeting with him
and what this was about?
GREEN: I have been asked that in my Rule 9 pack and I was asked that by the police as well -- no,
no, sorry, Facere Melius.
LANGDALE: Facere Melius, that company that did interviews with you all?
GREEN: Yes, yes. So I had no recollection of that meeting at the time. I have since looked through
my email calendar and it is in my diary, so --
LANGDALE: It must have happened?
GREEN: It must have happened, yes. But I don't really remember anything and I have tried in my
mind to recollect the meeting but I can't now decide what was -- what I am sort of imagining
happened and what actually happened. But I think --
LANGDALE: I know -- sorry.
GREEN: I think there was -- there was -- there was nothing that happened at that meeting that was
a red flag to me or crossed any lines, red lines in terms of, you know, how the grievance was
being conducted or the outcome or anything like that.
LANGDALE: But it is apparent, isn't it, looking at that the way forward, do you see the next
paragraph: "The way forward to be discussed at Execs when final version received." It's pretty
clear reading that, and as is the case, the police hadn't been called at that time in November
2016. When you say you weren't sure whether they had or they hadn't, this meeting demonstrates,
doesn't it, that they hadn't because that is what you
were both discussing?
GREEN: Does that demonstrate it?
LANGDALE: Well, why would there be pressure on Execs, threatened to go to police, if the police
had already been contacted and gone to them?
GREEN: I think he is making a note of what I said rather than --
LANGDALE: Oh, so it is recording what you say?
GREEN: Perhaps, yes, but I can't remember the conversation.
LANGDALE: It seems unlikely you would have that conversation without saying: have they been
called, do you want them called? Or -- rather than just -- you don't just sit and take notes of
what someone says, you are trying to say what they mean, aren't you, write down what they
mean?
GREEN: So this is -- this is saying, so it says: the Consultants saying no issue re police being
called. But I didn't ask him: have you called the police? I don't think I asked him that question,
no. I could have -- in retrospect I could have done.
LANGDALE: I am just asking -- focus on Mr Cross.
GREEN: Yes.
LANGDALE: You and Mr Cross are having this conversation and suggesting within the conversation
you both had in
November, whatever he's written down --
GREEN: Yes.
LANGDALE: -- about what you had said or got from the grievance interview, you would have been
clear that the police were not already involved because he says: way forward is to be discussed at
Execs. If the police were involved, that's the way forward, isn't it, the police are involved?
GREEN: My understanding is that forms part of his notes from the next meeting. See where it says
Part 1, 9.30 Execs?
LANGDALE: Yes, yes.
GREEN: That is an Executive meeting.
LANGDALE: Looks like that, you are right. So do you think he didn't share that with you at all
and you didn't ask him about that?
GREEN: No. I think I would have been careful not to stray too far off general "how's it going"
kind of conversation.
LANGDALE: Weren't you curious? You have been asked to get those samples, suspicion of foul play,
babies had died, people are talking about it?
GREEN: Yes, I was. And -- and it was a topic of, you know, as I say I have discussed this with
Sian Williams on a few occasions, but again I come back to curiosity isn't going to find anything
out that leads to Lucy Letby's arrest or an explanation of why those babies died, that was -- that
was the responsibility of those two qualified investigations. So, I mean, I'm not sure that
speculation or gossip or kind of "what if" is that helpful when those things are going on at the
same time.
LANGDALE: If we can go now to the grievance interviews and the notes of them. If we start with
the one you had with Letby INQ0002879, page 5. 14 October. So before you have taken the time to do all
the other interviews this is the first one you get, page 5: "... and her representative TM goes
bang in with 'the issue been raised under the grievance policy but we also wish to raise under the
Dignity at Work policy as fell LL has been bullied and harassed by Consultant Stephen Brearey'."
So his opening line to you is they want to raise that as well which wasn't in the original
grievance, was it?
GREEN: No, it wasn't.
LANGDALE: If you -- well, we have seen that document, but if you want to see it again, INQ0002879 0069, that is where we see Sue Hodkinson summarising the
grievance
and the questions that Letby wanted answering. If you look at that now to focus everyone's mind on
that?
GREEN: I am familiar with the document.
LANGDALE: You have got the document?
GREEN: I am familiar with it, yes.
LANGDALE: Okay. Well, basically I can read it Mrs Killingback, don't worry: "What are the issues
the Consultants have raised?" There we are. "Professional responsibilities. What is the Trust
doing about it? What evidence does the Trust have? Is there to be an investigation into a
practice? What are the grounds? Does she have to undertake supervised practice? Who else has to
undertake it? No one else, why not? Why she's been singled out? When can she return?" So no
mention of being bullied and harassed by the one Consultant as it happens, however minor, you have
had an issue over email a short while ago. Did you think at that point: this isn't for me, this is
something completely different?
GREEN: No.
LANGDALE: Do you think you might have done?
GREEN: I -- I did go away and think about it after Sue Hodkinson had asked me to do it but I had
had some
experience of grievance investigations. There wasn't anything in there that was technically or
clinically sort of challenging or complex. It was more about process and I felt I was able to do
that with HR support which I did get.
LANGDALE: Let's go to INQ -- back to the interview with Letby -- 0002879, page 6, at the bottom of page 6. Letby asks: "How have the Trust
values [the penultimate entry on that page] been adhered to in my situation? I would like to know
what I am being accused of." TM says: "There is serious allegations. Why hasn't this been reported
to the police? Why is the organisation sitting on something like this? Has the organisation
challenged this evidence?" Did you think when you said that: why haven't they been to the police?
Let's just go to the police. That is the people who should be looking at it. You have been sent to
save samples, other people are doing staff rotas and looking at things. That is not what a
hospital is set up for, is it, that kind of --
GREEN: No, no. Whether I thought about it in that moment I'm not sure but I thought about it on a
number of occasions before and after the grievance process and
came back to the same conclusion that at the very least the police should have been called to at
least assess the situation. But -- but again I wasn't -- I wasn't in -- in possession of the
knowledge that that hadn't happened and I am surprised that it didn't.
LANGDALE: At an early stage, Karen Rees told the police that she had asked Letby if there was any
reason or personal issue between her and either of the Consultants, including a relationship or
anything that could lead them to do this or say these things. Letby said no, there wasn't, as far
as she was aware, a personal issue. Early stages, that is what she said and I think it was Dr
Jayaram in particular, it could have been the other way round, but one of them that she got on
with and always got on with relatively well?
GREEN: Mmm.
LANGDALE: You never asked her that question, did you, Karen Rees did but you didn't say: well,
why would Dr Brearey bully you?
GREEN: Well, at that stage, we didn't have any evidence that Dr Brearey was bullying her because
we hadn't done any interviews.
LANGDALE: You are doing one with her?
GREEN: Yes.
LANGDALE: So she's the person who can tell you if she thinks she is being bullied by him so isn't
she the one to ask: why would he do that and what's he done?
GREEN: But the RCN rep had already sort of intimated that was the case.
LANGDALE: Sorry?
GREEN: If we go back to paragraph 1 of the --
LANGDALE: Yes. Just the paragraph that says "she feels as though she's been bullied and
harassed"?
GREEN: Yes.
LANGDALE: But that doesn't tell you why or what he has done or how; did you just accept that as a
fact?
GREEN: Well, I think the next action was to give Lucy no I think Lucy Sementa said in response
that they would be investigated in the same way. So ...
LANGDALE: So how were you going to investigate it? What did you need to ask Letby to investigate
that?
GREEN: Yes, okay. I guess we could have or should have -- should have asked her questions around
how that bullying had been manifest.
LANGDALE: Well, look --
GREEN: But then -- then we kind of knew that because she had been removed from the unit, so --
LANGDALE: Look what she says at page 7 in the third box
up. She says: "Out of all the Consultants worked with Stephen Brearey the least and unaware of any
issues." Unaware of any issues with him. It's Hayley Cooper believed Brearey was influencing the
rest of the team. So Letby herself says: I am unaware of any issues?
GREEN: Okay.
LANGDALE: Did you make that distinction, did you appreciate what was being said there, that
Hayley Cooper seemed to believe he was influencing the rest of the team? That is what Letby tells
you that is right, that's what she tells you?
GREEN: Are they the same thing? I'm not sure that they are.
LANGDALE: Of course they are not, are they, Hayley Cooper --
GREEN: No.
LANGDALE: -- is acting for her as her representative and saying she believed that and Letby's
saying Hayley Cooper believes that but she herself didn't know that. Do you see?
GREEN: No, sorry, I don't.
LANGDALE: Let's move to the next box. TM says: "SB has a right to raise concerns but failed to
provide any evidence so the conclusion is that he has
set out to professionally discredit LL." You knew from the Silver Control times and taking the bag
that they were wrestling with this and a number of people were given tasks to look at and they
hadn't gone to the police to see what explained these sudden and unexpected deaths, who was there
and the suspicions that they had?
GREEN: (Nods)
LANGDALE: When he said that to you, when they failed to provide any evidence so he must have set
out to professionally discredit LL, you knew yourself many people were involved in looking at
evidence or material that might help with how these deaths had occurred, these unexpected deaths;
yes?
GREEN: Mm-hm.
LANGDALE: So you already had knowledge of some of the facts. Did you bring that to bear when you
listened to what TM said?
GREEN: I'm not sure I understand the question, sorry.
LANGDALE: Well, it wasn't just Stephen Brearey, was it? Here it is being suggested he set out to
professionally discredit LL with no evidence?
GREEN: Yes.
LANGDALE: You knew many people were involved, Executives, other people gathering, looking at
material --
GREEN: Yes.
LANGDALE: -- including Eirian Powell who did that first table with Letby's name in red?
GREEN: Yes.
LANGDALE: So it wasn't just about Stephen Brearey, was it? You knew that because you worked at
the hospital and you had that evidence and material?
GREEN: I'm not sure that is true. I -- I think the impression I got that it was being largely
driven by Stephen Brearey, you know, the drawer of doom thing, the table that he had drawn up. I'm
not sure that other people actively believed that Lucy Letby had deliberately harmed patients.
LANGDALE: That is not the question. The question was what Dr Brearey had done. Here he's being
accused of bullying her for putting that material together. You knew he wasn't alone putting
material together Eirian Powell had put material together?
GREEN: Possibly, but in the interview situation, that didn't cross my mind.
LANGDALE: Let's go to the next interview, if I may. 17 October, Yvonne Griffiths. That reference
is INQ0002879, page 43. Here Yvonne Griffiths is telling you, if we go to page
44 in the penultimate box, she appears to say here: "It's not like Steve Brearey to cause trouble
but we have looked at the information. The only thing seems to be she was on duty. SB had voiced
concerns prior to the loss of two triplets. They said that if they didn't go to the Chief Exec,
they would be going straight to the police. We were very uncomfortable. We told them to take their
concerns to Lucy but they were adamant they wanted her fired immediately. I find it very difficult
to act on something I didn't believe in. It was a witch hunt". Did you test anything that Yvonne
Griffiths told you there, by asking the doctors: did you want her fired immediately? Were you
engaging in a witch hunt?
GREEN: Repeat the question, please.
LANGDALE: Did you ask the doctors what you were being told by Yvonne Griffiths there?
GREEN: No.
LANGDALE: To see if they -- why not?
GREEN: We asked them about going to the police, I think. I'm not sure we used the word "witch
hunt" but I think we did ask them about Lucy.
LANGDALE: If we go to page 45 in the middle of the page: "I have worked on the unit for 10 years.
I feel we have had equivalent deaths in previous years but now we
have more older mothers, increases in fertility treatment and less termination of care some
outcomes are not fantastic." When you are looking at sudden and unexpected deaths, every medical
professional view is important, but this was a nurse giving you that view. Would you be more
interested in what the doctors said a medical cause might be for a sudden unexpected death than a
nurse. The specific deaths, I am not talking about generalities, specific deaths?
GREEN: It depends because, you know, if you look at one of the things that sparks human factors
training in healthcare it was the death of an airline pilot's wife and there were two Consultants
in the theatre and two nurses, as I recall it. The patient passed away despite the nurses telling
the Consultants what they were doing was wrong, so the idea that Consultants are infallible is not
--
LANGDALE: Absolutely not my question.
GREEN: No.
LANGDALE: Here you have got a nurse describing to you that she's worked for 10 years and feel we
have had equivalent deaths in previous years?
GREEN: Yes.
LANGDALE: But now we have older mothers, basically more
death rates might be explicable for these reasons, would you want to test that with the
Consultants who were concerned about specific sudden and unexpected deaths; for example, were they
older mothers, any of them?
GREEN: So --
LANGDALE: It's easy to say generalisations, isn't it: older mothers, premature babies?
GREEN: Yes.
LANGDALE: Looking at each baby as an individual child is key, isn't it?
GREEN: It is, yes and that was the role of the two external reviews. So that was not our role as
-- in my mind, and perhaps given some of the questions I have been given in the Rule 9 and we have
heard today, perhaps I got that wrong, but in my mind I was there to focus on the -- the grievance
issues raised by Lucy Letby, not to stray into trying to solve all the other issues were that were
investigated.
LANGDALE: Yvonne Griffiths strays into this, doesn't she, by commenting on the death rates?
GREEN: She does.
LANGDALE: You let her do that. Let's go to the next page, 46. You say: "Is there a culture for SB
to come on to the unit
and say things? He is a nice guy. We haven't been able to see what he feels, gut feeling. He is
responsible for all neonates. What are we doing wrong?" Nice guy, you are not getting anything,
are you, about him targeting Lucy Letby?
GREEN: Not from that paragraph, no.
LANGDALE: No. Let's keep going to the next interview. If we go to INQ0053104, page 1, taking you, Dr Green, to an email sent to you by Hayley
Cooper asking she couldn't remember sending it, but accepted it this morning that she recognised
it was sent from her and she met you. But she's looking to ask to meet you first, or early on,
isn't she? "You interview myself separately as I have been involved in this situation right from
the start and I need to make you aware of some issues." I think you told the police you had done a
couple, two or three grievances before this one. Two, this was your third, is that that is my
reading of what you said? You had done two or three and that sounded like you were including this
one but tell us what it was?
GREEN: It's something in that ballpark I can't honestly remember how many I have done.
LANGDALE: Hardly any, really?
GREEN: Not that many.
LANGDALE: Two or three is not very much, is it, if this was your third and one of this type?
GREEN: Yes.
LANGDALE: So my question: did you think that was typical that you would have somebody saying
"interview me separately as the member supporting the person making the grievance first"? She was
wearing a number of hats, as she explained to us this morning?
GREEN: Yes.
LANGDALE: She worked as a Freedom to Speak Up designated officer, Risk and Safety Patient and
also RCN rep.
GREEN: Sorry, did you say she asked to be interviewed first?
LANGDALE: She asked to meet you, didn't she?
GREEN: Yes, separately. Well, from that email I took it to read as is it possible to interview her
as part of the grievance process separately, which -- as opposed to accompanying Lucy.
LANGDALE: Yes, so you did meet her on INQ0002879, page 17. So you have interviewed Letby, Griffiths, now you are
interviewing Ms Cooper. I am taking you through the interviews chronologically, Dr Green, if that
assists you as we go through, because you will know what you knew before and afterwards.
GREEN: Okay.
LANGDALE: So this is Hayley Cooper and if we go to page 18. At the bottom of the page, she says:
"I don't feel that the Trust has supported Lucy at all. Met with her and her parents after her
interview meeting and I can honestly say it was one of the most distressing conversations I have
ever had to have." Pausing there, her parents feature as well as Letby when she's dealing with
members of staff at the hospital. Did you have any contact with her parents?
GREEN: Yes. I think I met them in person on the day of the hearing. I think they were on site.
LANGDALE: What did they say to you?
GREEN: I can't remember. I think they thanked me for investigating the grievance on -- on behalf
of their daughter.
LANGDALE: They thanked you?
GREEN: Yes, I think so.
LANGDALE: Right. So we see there it says: "Having to explain to parents what is being alleged
about their daughter I feel was unacceptable. It is a conversation I will never forget." That is
what Hayley Cooper says: "The Trust should have had this conversation with Lucy. I am disgusted at
the Trust and how they have
treated her. Letby told me others had been questioned re relationship with SB/LL. LL reported this
to me and I emailed for clarification. The effect on that girl cannot be understood." Pausing
there. As I have said Karen Rees in fact asked Letby that directly but at this point, are you
getting -- well, what impression are you getting about the emotions of Letby and her family?
GREEN: I didn't get a lot of emotion from Lucy Letby. Even to the point where we had a follow-up
meeting that wasn't documented anywhere, there was no -- there were no minutes of it to explain
the outcome of the grievance and when I explained to her that other people had said that she had
potentially been murdering babies, which was a difficult thing to say to somebody if you didn't
know that it was actually true. If someone had said that to me I would have reacted very strongly
and been angry about it and, you know, indignant about it. But she didn't really react at all from
my recollection and that's the one thing that I took away from that meeting; that that reaction
wasn't quite normal, I didn't think. However, her union rep, if I recall correctly, did jump in to
sort of take over the conversation about that being outrageous and that sort of thing.
But -- and I think I put that down to potentially she knew there was allegations already; it
wasn't like it was a shock. So -- but -- but I was struck by how coolly she took it. So I didn't
get a lot of emotion from Lucy Letby at all.
LANGDALE: Okay. Yet here was Hayley Cooper describing how distressed she was and upset she was
and that was fed back?
GREEN: Yes.
LANGDALE: But that's not your experience when you were speaking yourself with Letby?
GREEN: No.
LANGDALE: Okay. So the next interview then, please -- that can go down -- is INQ0002879, page 21. Dr Green, this is your interview with Ms Kelly. We see
here in the top box: "Eirian Powell was confident there were no issues with the individual nurse.
She was a competent nurse and had a good network of friends on the unit and there were no concerns
about her behaviours. In the meantime SB conducted his own mini review of the cases and an
analysis of staff on duty at the time of deaths." Did you accept that as fact from Alison Kelly
that there had been no concerns about her behaviours?
GREEN: I did in the context that it was triangulated with other members of the nursing leadership
team and there were no pieces of information to suggest otherwise, except perhaps the -- I hadn't
appreciated this at the time, but I have seen it in the Inquiry documentation; that Lucy was
visiting other nurses' babies which apparently was not the done thing.
LANGDALE: That's right.
GREEN: But I'm not sure I knew that at the time or appreciated that it was an issue.
LANGDALE: Over the next page, page 22, you ask Ms Kelly at the top: "Why do you think LL was
being singled out?" She says: "I have no idea." Then further down you ask about: was there a
threat from the Consultants, talking about the police. Ms Kelly says: "The Consultants were very
anxious about it. There was talk about whistleblowing and going to the police, it was talked about
at the board if we needed to go to the police, but in the absence of any evidence, what was there
to say? We needed to understand the external review and wait for the final report." Dealing with
the point that you were examining,
Ms Kelly says to you the Consultants were very anxious, not bullying and discriminating, they were
anxious; that is how she describes them?
GREEN: Yes.
LANGDALE: Did you listen -- did you hear that? I will us Professor Dixon-Woods' expression here
"hearer courage", did you hear something that went against what you were looking for here, which
was whether there had been bullying and discrimination when Ms Kelly says they were very anxious,
the very reverse of someone being bullying?
GREEN: Yes, I think this has turned into a Consultants v nurses v managers v me perhaps kind of
situation and it's a shame because that's not going to deliver effective healthcare. And at the
time I did not set out to investigate the Consultants. That was not the intention about it. So --
LANGDALE: But that is what you ended up doing, that is what the report ends up saying when we get
there.
GREEN: Well, I -- I would disagree, I think it touches on that but -- but there were several
questions set out by the complainant that I was set out to investigate so I answered them and
there were some other issues that I picked up that I thought were worthy of further investigation.
I didn't -- so, for example,
I said the Trust might want to consider disciplinary action about some of the things the
Consultants may have said, but I didn't present any evidence necessarily that they should be
disciplined, if that makes sense.
LANGDALE: Well, we will get to that.
GREEN: Okay.
LANGDALE: Sue Hodkinson you interviewed, I won't take you to hers. Sian Williams INQ0002879, page 29. We see here you interview Sian Williams and on page 30,
in the top box, she's repeating the type of material you have heard from Yvonne Griffiths she is
saying: "No red flags. Sudden deteriorations in neonatal babies is apparently common. Although I
am not neonatally trained, I didn't find anything more than that. I asked how the sudden
deterioration could happen and was told they are more unstable than adults. Met Lucy ..." Et
cetera. She didn't tell you in this grievance interview that when she had completed the staff
analysis, she thought she should have gone to the police, did she, and her answer to that was you
never asked her that?
GREEN: No.
LANGDALE: Did you think of saying to any of these
grievance witnesses: what did you make of the allegation? Have you been sighted on any of the
material because that is what she would have told you: I wanted to go to the police?
GREEN: Possibly, but I will come back to it, again we were very clear to stay on the Terms of
Reference of the grievance. So -- and again as I have said before, we could have gone down that
route of trying to investigate the allegations a bit more. But again there were two separate
properly structured qualified reviews going on into -- into the deaths of the babies. So for me, I
was quite happy to stay in my lane, as it were, and allow that process to continue alongside.
LANGDALE: Karen Rees, one more before we take a break, if I may, INQ0002879, page 33. If we go to page 35 of that interview. You asked: you
believe the intention is to return LL to the unit?
GREEN: Where's this, sorry?
LANGDALE: Page 35, can you see? There we are.
GREEN: Yes, yes.
LANGDALE: Yes. Karen Rees tells you: "I feel very strongly we need to get her back on the unit. I
raised or questioned why they hadn't brought the police in. Karen Rees said she hasn't because of
LL. Would we like our daughter to be treated like this? I don't think so. In a meeting with
Stephen Cross it was mentioned about if we call the police the unit will be shut down and people
may be arrested." That is what she said to you, didn't she?
GREEN: Yes.
LANGDALE: Making it clear the police hadn't been called and at least in her case, and it suggests
others here, there was a worry she might be arrested?
GREEN: But again did Karen Rees know for sure that no one had ever had a conversation with the
police? I don't know.
LANGDALE: Were you concerned if a reason for not phoning them was just a worry that she would be
arrested?
GREEN: No. If the police were called and they had grounds to arrest Lucy Letby then she should
have been arrested.
LANGDALE: You then meet with Eirian Powell, INQ0002879, page 37 and if we can go to page 38, please. We have halfway
down: "Ravi Jayaram was heard by a nurse, Nurse T, in outpatients, when asked if anything had come
from the review to say 'somebody's causing these deaths on the unit'. Nurse T is now anxious to
return to the unit
after RJ's statement." Then she says to you: "I said to SB 'what if LL goes home, kills herself?'
... said I don't care." She gives you information about Mr McCormack, suggesting to her you are
harbouring a murderer so she is giving you the information about comments here and I am not going
to respond now with the evidence we have heard about those, but she's given you that information.
Did you think to interrogate with any of those people whether those things were right, if this is
what you were doing? I mean, in the scheme of things it seems a lot less important than the
underlying allegations in terms of the babies, but in terms of what you were looking at, did you
think about addressing this with any of these people that were named to see if they had said
anything? In other words, this might not be right?
GREEN: Not really. Because as I said before we weren't investigating the Consultants and there was
a lot of "he said/she said" kind of stuff going on. And again, my view was very firmly to let the
process find out whether anything had gone on on the unit that needed.
LANGDALE: The process wasn't going to find anything out
if you didn't test what you were being told. You just accepted what people said to you and in Ms
Powell's case, if we can go to INQ0002879, page 63?
GREEN: I would challenge the view that I accepted everything people told me.
LANGDALE: Okay.
GREEN: I think that we tried to triangulate what people told us with other people's evidence. So,
for example, where Ravi Jayaram was heard to say something in clinic, Ian Harvey told us that he
had had a conversation about it with Ravi Jayaram. So, you know, I had no reason to disbelieve Ian
Harvey and you know, I think there --
LANGDALE: So you believed what he said. So that is what I have just suggested: you believed what
he said, who did you not believe?
GREEN: Well, there were -- there were two other or three different people who said that over the
course of the interviews and I wasn't out to get Ravi Jayaram for saying something on the unit,
you know, that -- that -- for me, again I made a recommendation that maybe consideration for
disciplinary actions against the Consultants if they had said these things --
LANGDALE: We will come to that.
GREEN: Yes.
LANGDALE: Let's look at INQ on the screen now. Eirian Powell sends you this document, doesn't
she, you have had time to read it, I just want to be clear that other people have the opportunity
to do so. It's a six-page document giving you information. You don't accept Dr Brearey's
invitation to send you his mortality reviews but you receive this information from Eirian Powell.
Is there a reason for the difference?
GREEN: I'm sorry, I don't understand which information I accepted and which I rejected?
LANGDALE: This document has been sent to you. Do you remember seeing it?
GREEN: It has because it's got my handwriting on it but I don't -- I don't really remember seeing
it.
LANGDALE: Say that again? It has got your handwriting on it, you say?
GREEN: Yes.
LANGDALE: So you will have seen it if it has got your handwriting on. So Eirian Powell has sent
you this, so she's given you written evidence as well as her oral interview; is that right?
GREEN: Yes.
MS LANGDALE: My Lady, I see the time. I don't need to go into the details of that document, and it may be that the shorthand writer and others need a break at this point.
LADY JUSTICE THIRLWALL: Yes. Shall we take a 10-minute break? So we will come back in just after 5 past 4.
(3.57 pm) (A short break)
(4.04 pm)
LADY JUSTICE THIRLWALL: Ms Langdale.
MS LANGDALE: Dr Green, Mr Harvey's interview next so INQ0002879, page 9. We see at the body of the interview in the last paragraph, he says to you Executives were uncomfortable in assigning blame without every other cause being included. There was a threat -- sorry.
LADY JUSTICE THIRLWALL: Excluded.
MS LANGDALE: Excluded, sorry, I thought I said there. "There was a threat to go to the police
when the cause being excluded. Execs considered do we go to the police? How do we take this
forward? How do we protect LL from allegations whilst carrying out the investigation work? Going
forwards to protect Lucy from the allegations we felt this redeployment was the best cause of
action." So to be clear this note, Mr Harvey is telling you
every other cause needs to be excluded before we would be investigating Letby; is that the
point?
GREEN: Yes. But I took that in context of the investigation as they were ongoing at the time.
LANGDALE: So you thought that the RCPCH and the other investigation would be able to exclude or
include?
GREEN: My expectation from those external reviews was that they would be able to establish or to a
degree of probability that either foul play or not foul play was the most likely cause of the
deaths.
LANGDALE: Did you ever ask Mr Harvey how that was going to be done in those reviews or not?
GREEN: No.
LANGDALE: We see at page 10 four boxes up he tells you there had been a number of behaviours that
do not reflect too well: "I had to go and speak to RJ that some of the trainees had been making
reference to 'angel of death' but no specific person was named. There was behaviour in the clinic
being heard talking about killing babies on the unit. I had to speak to Ravi about comments. RJ
did accept that it was inappropriate." And you asked: "Did you hear about Jim McCormack telling
Eirian Powell she was harbouring a murderer?
"No, I hadn't heard that." So he who you relied on, is it, for those comments?
GREEN: So somebody had said that a nurse had heard it in the outpatient clinic and then Ian Harvey
is saying that he spoke to Ravi about it and Ravi accepted it. So I didn't have any grounds to
think that Ian Harvey would lie about it. So I did accept it, yes.
LANGDALE: You said earlier in your evidence when you were talking about Letby's reaction that if
someone accused you of doing that, it would be so upsetting, assuming it wasn't true and it's a
hard thing to say about somebody if you don't know it's true, yes?
GREEN: Mm-hm.
LANGDALE: If these nurses and doctors were saying comments like that, did it enter your mind that
they might have been worried that was true?
GREEN: Yes. Yes, I think.
LANGDALE: Did that influence how you viewed those comments, inappropriate as they were, did it
influence you if someone really thinks you might be doing that?
GREEN: Yes, I wasn't -- I didn't sort of ignore those comments but -- sorry, I have lost my train
of thought. The question again, please?
LANGDALE: Yes. If these nurses -- and you said it did enter your mind -- were saying something
like -- or
doctor -- "angel of death" they may have thought she was suspicious in her work and was involved
in foul play?
GREEN: Yes.
LANGDALE: That is why they are saying it?
GREEN: Yes.
LANGDALE: Did you think about that?
GREEN: I did, yes. So comments, comments made in clinic or in passing, you know, I'm not sure they
add in isolation a huge amount of value to what I was doing as regards to grievance. But, you
know, is that an appropriate way to raise concerns about somebody, to make a comment in public in
a clinic or to refer to somebody as the "angel of death"? I didn't believe so. So, you know -- and
again, this was being -- so everyone can have an opinion about what was going on but there was
some focused pieces of work looking at the evidence, the actual evidence.
LANGDALE: You say you didn't think the comments were very important but you know in the hearing
itself Annette Weatherley did think they were important, didn't she; they were important to
her?
GREEN: I can't recall Annette Weatherley actually saying anything about it. It might have been in
the transcript, but I don't remember.
LANGDALE: We will go to that later, thank you. INQ0002879, page 165, please and this is a letter that Dr Jayaram and also
Dr Brearey received from you before their interviews and they come last in this chronology of
interviews. You see what you state at paragraph 2: "Any information you provide me will form part
of my investigation into this matter and ultimately may be presented in a disciplinary hearing.
You are entitled to be accompanied by a staff organisation trade union representative." Over the
page, 166, Dr Brearey gets the same letter and unsurprisingly they both do come with a trade union
representative, don't they?
GREEN: They did. Everybody else got that same letter and nobody else brought a trade union
representative.
LANGDALE: What did that tell you about their differences in approach to what this grievance might
have been about, the fact that these are the only two, if they all got the same letter, but
thought they needed to come with a representative? Using your soft skills, what does that tell
you?
GREEN: It tells me that they might think that they have a problem that they need support with in
terms of their behaviour, maybe.
LANGDALE: Rather than they have got a problem with why
the grievance is happening and who's being investigated?
GREEN: They weren't being investigated. The subject that was being investigated was the list of
grievance issues that Lucy Letby had raised. We were not investigating the Consultants?
LANGDALE: They didn't know that, did they? If we go to INQ0068308. So it's 0068308, page 1. I will read it out -- there we have it.
See at the bottom, Dr Jayaram asks Lucy Sementa: "Would you be able to give me an agenda for the
meeting and information as to what the grievance relates to?" And he gets told: "No formal agenda.
Chris will ask you some questions and if you can provide any details and information, this will be
noted. Any information that's relevant to you will be discussed with you in more detail in the
meeting. You are invited as a witness, you may have pertinent information. You are not being
investigated yourself."
GREEN: (Nods)
LANGDALE: If we go over to page 2 we see Dr Jayaram emails: "You have been in contact with the
BMA. They have advise me until you have provided me with a copy of the
grievance policy that I can share unless representation can be provided at such short notice, then
the meeting should be deferred." So they have gone to get assistance and to have someone come with
them, yes?
GREEN: (Nods)
LANGDALE: If we go to Dr Jayaram's interview with you, INQ0002879, page 47. If we could highlight, please, that first paragraph
from Dr Jayaram. He sets out very clearly a rise in mortality and they were not the babies you
would have predicted. None of the babies responded to timely resuscitation manoeuvres. What
clinically did you understand from that?
GREEN: Exactly what it said.
LANGDALE: That is suspicious, unexpected as well, that they are not responding in a way that you
expect babies when they require resuscitation from natural causes do?
GREEN: I -- I wouldn't be able to make a judgement on that.
LANGDALE: "We were concerned they were deteriorating and needed to look at why. It was raised to
the Executive Board about the increase in death rates. Also reviewed individual cases internally
... didn't seem to be anything in terms of clinical practice, equipment or environment. There did
appear to be an association with
Letby either looking after or being present at the time of the deaths. "Discuss with obstetricians
who were all concerned we were potentially putting babies at risk when there was something that
there might have been a factor. Executives took further decisions. Outcome was to downgrade the
status of the unit only looking after babies at 32 weeks." Next but one paragraph, reference to
the two Triplets. "These were babies who were getting better and were stable who suddenly
collapsed. This led to a review sooner than the three months." That is the ones that you knew the
TPN bag had been taken --
GREEN: (Nods)
LANGDALE: -- and stored in your department. He was clearly setting out there, wasn't he, why foul
play was suspected?
GREEN: Perhaps. But he did not say at any point we suspect foul play, does he?
LANGDALE: You have had the background, I have been through all the documents that you have
had?
GREEN: Yes.
LANGDALE: You sat in Silver Control, you have told the police: we were thinking as we took it,
let's hope we haven't to got to take it for the reasons we think we have. You said to Sian
Williams: it is reasonable in the circumstances. Setting out clearly that they were suspicious of
foul play.
GREEN: Yes, but he didn't actually say it, did he?
LANGDALE: So you are suggesting you didn't understand that? Just look at that and with all that I
have been through with you that you knew. What is Dr Jayaram telling you first and foremost in
that extensive paragraph?
GREEN: He's given me some factual information about why they were concerned. But at no point in
the interview does he say: We think Lucy Letby is guilty of foul play.
LANGDALE: You said earlier: "That's a really difficult thing to say, I suspect you of murdering
babies, unless you think it's true."
GREEN: Yes.
LANGDALE: You said that earlier?
GREEN: Yes.
LANGDALE: They couldn't come before there was a proper investigation forensically with the
resources it
requires to you and say: she's been murdering babies, they could say: we are concerned?
GREEN: Yes.
LANGDALE: We think she's associated with this, infer she's involved in deaths and deteriorations
and let other people pick up the work. They are not forensic investigators, are they, the hospital
aren't equipped to forensically investigate what was required in this case, are they?
GREEN: No, no which is why I keep saying that there were two ongoing reviews into the deaths that
were doing that job. But this wasn't new information that Ravi was giving us on the day. As you
say, it had cropped up in other -- other forums so -- but, you know, if you read the trial report
of Lucy Letby and Baby K [Child K], Ravi Jayaram clearly describes seeing Lucy Letby in proximity
to the tube that he thinks she's tampered with.
LANGDALE: Let's --
GREEN: That doesn't come out in this interview.
LANGDALE: Let's look at page 48. "So to clarify, was there any suggestion from any of the
Consultant team that Lucy had been deliberately harming babies? "Ravi Jayaram: we discussed a lot
of possibilities
in private. "You: so that is not a yes or no. "We discussed a lot of possibilities in private and
took our concerns to the Executive Board." He wasn't telling you what they discussed in private,
was he, that was obvious?
GREEN: Well, if I had said -- if I had taken that as what might be obvious, then I would be at
risk of being criticised for making an assumption, wouldn't I?
LANGDALE: Why would you? Just look at it. He says "we discussed a lot of possibilities in
private" and you say "yes or no"?
GREEN: Well, a lot of possibilities.
LANGDALE: I have taken the concerns to the Executive Board but I am not taking them to you; that
is the answer, isn't it?
GREEN: A lot of possibilities suggests there is more than one explanation for what's gone on.
LANGDALE: You had already had from Eirian Powell the air embolus email, hadn't you?
GREEN: Yes.
LANGDALE: So that was what they were discussing in private but you didn't tell him you had seen
that?
GREEN: No.
LANGDALE: You didn't say: I have seen an email. You
were discussing air embolus, weren't you, Dr Jayaram?
GREEN: No.
LANGDALE: So why didn't you ask him that?
GREEN: I'm not sure that is the case.
LANGDALE: This is 11 November --
GREEN: Yes.
LANGDALE: -- with that interview and the document I took you earlier that was sent to you by
Eirian Powell was 28 October? Call it up again, if you --
GREEN: Yes, I need to refer to my statement, please.
LANGDALE: Shall we go to the document? The document is INQ0002879 0083.
GREEN: So I have got a different reference number here for the document but it says --
LANGDALE: Let's put the document back on screen. This one can go down, we have got that one and
it will come in a moment, 00002879 0083?
GREEN: Sorry. If you go back to the previous page, please.
LANGDALE: Before we do, just look at the date on this one so we don't have to get the other one
back up. Can you see Eirian Powell sent it to you on 28 October?
GREEN: Yes.
LANGDALE: Right, so now we can go back to Dr Jayaram's interview, which is in November, INQ0002879, page 48.
GREEN: So around a third of the way down I ask: "Was deliberate intent by Lucy suggested that she
might have been doing something to the babies? Air embolism was mentioned."
LANGDALE: Yes.
GREEN: So I did ask him about that directly. "I am not here to speculate things ... can only say
that the Consultants had concerns and they escalated these to the Executive Board."
LANGDALE: Yes.
GREEN: That is not a straight answer, is it?
LANGDALE: "I am not here to speculate on things. I am not here to discuss whether there's been an
air embolus or not." You are not investigating, you say, the actual events, are you?
GREEN: No, no.
LANGDALE: And he certainly doesn't say: no, we didn't discuss air embolism. On the contrary, he
just says "we are having discussions in private". You knew the Consultants were having those
discussions because you had been sent them?
GREEN: Yes.
LANGDALE: So why didn't you say -- not "air embolism was mentioned", when he said "I am having
discussions in
private", "yes, I have seen an email between you and the Consultants and Dr Gibbs. You were all
worrying about air embolism", if you wanted to go down that line? That would have been open,
wouldn't it?
GREEN: It would have been yes, but --
LANGDALE: You have been sent every document that we might go to; that is open, isn't it?
GREEN: Yes.
LANGDALE: You have got material there that you don't tell him about or show him that you have
already got?
GREEN: Yes.
LANGDALE: Why not?
GREEN: Because it's not -- it doesn't come across from the transcript necessarily that those two
interviews -- all the other interviews that I did I felt that the people who attended were being
open and honest with their answers. These two interviews were different, considerably different to
that. I felt that in both cases, the answers were evasive, non-committal.
LANGDALE: Circumspect. We have had discussions in private but we are not going to discuss them in
a grievance process with you. Circumspect maybe. What is wrong with that? You weren't
investigating whether they were being open with you, were you? You weren't
being open with Dr Jayaram. You didn't show him the email you had got?
GREEN: No.
LANGDALE: So you engaged in a process that made you perhaps behave in a different way. Would you
normally do that with someone, read something that you know they had written and not mention it in
your conversation?
GREEN: I think I was frustrated during these interviews that I wasn't getting open and honest
answers to some of the questions I was asking and --
LANGDALE: But you recognise today how difficult it is to say, "You are murdering babies, I have
got evidence I have walked in", it's difficult?
GREEN: But that's directly to the individual concerned.
LANGDALE: What about them, it is difficult, isn't it?
GREEN: Yes, yes, I guess. But --
LANGDALE: "I guess?" It is, isn't it? It's really hard to say.
GREEN: But the things that the Consultants disclosed in the court proceedings against Lucy Letby.
LANGDALE: You didn't know about that then?
GREEN: No.
LANGDALE: When you did this interview -- let's focus on the timeline, okay?
GREEN: Yes.
LANGDALE: If we go to Dr Brearey, can we go to INQ0002879, page 51. You didn't ask Dr Brearey, did you, whether he had been
honest and open with the Executives or generally, you didn't ask him that, you didn't ask Dr
Jayaram that, whether he had been honest and open with you or the Executives. You didn't ask
either of them, did you?
GREEN: No.
LANGDALE: I go through all of this, I see no reference to "honest" and "open" about anything. If
you talk about what was being said, if you go to page 53 here, you say: "There was a view that
Lucy was possibly deliberately harming babies. Do you know why that was? Was there anything
suspicion about her behaviour?" You knew in that Silver Command room that people were looking at
links and what may or may not be suspicious; it wasn't just these two, was it?
GREEN: And yet the answer to the question was: no.
LANGDALE: He says -- no, he says "not really for me to say" and the rep says "the answer is
no".
GREEN: And then --
LANGDALE: What do you take from that?
GREEN: Then he says "no, not my position to speculate".
LANGDALE: So what do you take from that? If someone is saying -- both of them have used the same
phrase, they are sat with their reps "not for me to speculate, not for me to comment on the detail
about her". What do you take from that when they both have reps? I know you have only done two or
three grievances?
GREEN: Yes.
LANGDALE: What do you think happening's there?
GREEN: What I thought was happening there was that the Consultants didn't really believe what they
were alleging about Lucy Letby.
LANGDALE: Right. So --
GREEN: Or at least weren't sure.
LANGDALE: You have just said something else. really think about what you mean there, Dr Green.
What did you think "not sure". Sure, certainty, you need a police investigation for that and a lot
of experts and resources, don't you?
GREEN: Which was --
LANGDALE: You just said -- so what did you mean?
GREEN: If -- one, one of the possibilities of what was going on in this meeting is that when it
came to the crunch, when they had the opportunity to say: we think there is foul play going on
here, they didn't take that
opportunity. Now, why didn't they take that opportunity was the question that I was asking myself.
Was it because they didn't believe it? Was it because they were worried about the consequences to
themselves? Was it because there was no evidence? I don't know the answer to that. But -- but
again come back to: there were two separate reviews looking at that, we were investigating their
bullet point list of Lucy Letby's grievances.
LANGDALE: That can come down now, thank you. If we go back to your police interview, INQ0014568, page 33: "As regards Lucy I did ask myself a few times: am I
helping out somebody here who has done something horrific? But then it wasn't my job to decide
whether she had or hadn't done anything. My job was to do the investigation into the grievance and
that was it. I wasn't there to draw any sort of conclusions about what had gone on, so I kind of
parked that aside. "And, you know, across this table looking at her thinking 'that won't show up
on the tape, will it', but thinking, you know, are you a monster or are you the fall guy in all of
this?" You remember saying that to the police?
GREEN: Yes.
LANGDALE: There was no evidence at that point built up
collectively, was there, by experts or elsewhere to say categorically Lucy Letby has murdered
these children, that wasn't -- that wasn't -- so how could you ever have expected Dr Jayaram and
Dr Brearey to tell you that in the meetings? They had told you they were suspicious but you are
saying you want more, you wanted to know what the proof is that were they certain, were they
clear?
GREEN: So -- but that -- that was the problem at the time, wasn't it, that there was, there was no
objective evidence, there was no CCTV footage, there was no abnormal results, there was no
abnormal pathological investigations. So --
LANGDALE: Do you understand that suspicion and what Dr Jayaram had set out at the beginning of
his interview was more than enough to justify the referral to the police immediately? Do you
understand that? Just what he said in that one paragraph I have taken you to, they should have
gone to the police?
GREEN: Yes, I have already said that I agree that the police should have been called.
LANGDALE: Can we go now to the actual report that you did and there is two versions of this. Just
so people have the opportunity to see the difference, I am going
to ask that the first is put up but we will concentrate on the second. The first one is INQ0002879, page 178. 12 November 2016. If we go to page 183 [not found],
you see this looks like a first draft. This is in July, question marks about dates, and we go
through it and we see at page 187 [not found]: "During the course of this investigation I have not
been made aware, nor has there been any allusion to, any evidence relating to any wrongdoing --
alleged wrongdoing by LL. Repeated reference to a commonality between the dates and times that LL
was on duty and collapse/deaths of a significant number of babies. Nothing to support additional
information or data beyond this that has not been shared with LL." You wrote that?
GREEN: Yes.
LANGDALE: That was your view on what we have gone through?
GREEN: Yes.
LANGDALE: If we go over the page, 188 [not found]: "The drive to remove LL from the neonatal unit
appears to have come from the Consultant SB and to a lesser extent RJ. The concept of air embolism
also appears to have originated from the Consultant body although this is denied." They hadn't
denied it, they said they weren't going to speculate, did they, they didn't deny that at all? They
didn't, did they, we had no denial about air embolism at all?
GREEN: So in my interview with Steve Brearey, I asked him: "It's been said there is a suggestion
of air embolism and twisting of tubes that led to babies' deaths. Was that on the table as a cause
of death? "SB: I have never come across a case of air embolism before. "JB [which is the union
rep]: no, in this particular case he's asked you a specific question as requested. In this
particular case, was that suggested by you?" And Steve Brearey says "no". Now --
LANGDALE: That was Dr Gibbs and Dr Jayaram, wasn't it?
GREEN: In retrospect it was but --
LANGDALE: So that is the answer, no, not by him but by others; you knew that?
GREEN: But there had been some discussion of it.
LANGDALE: Yes, and you knew that?
GREEN: Yes.
LANGDALE: But "denied" isn't right, is it?
GREEN: Yes. I guess, looking back, I could have said or should have said: the Consultants refuse
to confirm or deny whether this was the case.
LANGDALE: Could you have said: I have been sent an email by Eirian Powell that set out the
position. I had it in full, they didn't and might have felt able to comment if they knew that I
already had it. That might be an accurate summary. Let's look at what else is in this box: "I find
it a concern, these concerns are based on gut feel and do not accept this provides a basis on
which to make the accusations that appear to have been made." We spoke earlier about Dr Reynolds
and her observation of patterns and you agreed sense-checking and patterns are relevant?
GREEN: Yes.
LANGDALE: So why here are you condemning gut feel as not being a basis to be suspicious once
somebody investigated and need an explanation for their role or part in events?
GREEN: I think gut feel is a reasonable basis on which to speak out safely to raise -- raise a
concern. But to accuse somebody of murder without supporting evidence I think is a different thing
in my view.
LANGDALE: Can we go to page 190, please. Third box up from the bottom: "I have found that the
Trust Executive Team and Nurse Management Team have showed significant empathy for LL's situation.
They have all been deeply affected by it. I also believe that the Executive Team have reflected on
their initial handling of this situation and taken action to address this in their fortnightly
meetings." Do you set out anywhere the anxieties or difficulties the Consultants have had and as
you have expressed now how difficult it is to clarify or articulate that you think someone is
murdering babies?
GREEN: I -- so I am describing there what I found during the course of my investigatory meetings
and some of the interviewees were very visibly upset by the situation that they were answering
questions about and some of them weren't.
LANGDALE: What did you deduce from that? We spoke before about being visibly upset and privately
upset. I mean, what do you take from that?
GREEN: That some people handled it differently to others.
LANGDALE: You might not always know what some people are feeling?
GREEN: No.
LANGDALE: If we look at the conclusions at page 192. Last paragraph: "Trust Executive Team and
the Board in the absence of firm objective evidence to identify the true situation on the unit
clearly found themselves in a situation where it's conceivable, if unthinkable, that to leave LL
on the NNU may have exposed patients to harm. "Secondly, LL may have been left in a position where
ultimately she may have been subject to adverse treatment from Consultant staff and ultimately she
may have been arrested which one would imagine to be infinitely more damaging than redeployment."
So was that your view, certainly a view that had been expressed by Karen Rees to you, that
avoiding arrest was important for her?
GREEN: This is eight years ago so it's difficult to be clear about exactly what I was thinking
when I wrote this. But I think what I am trying to say here is that -- so take the first sentence,
you know, I think that -- is there any issue with the first sentence -- it is the second sentence
that we want to pick up, is it?
LANGDALE: Say that again?
GREEN: Sorry. You read out two sentences there.
LANGDALE: Yes.
GREEN: The question is specifically about sentence two, is that correct?
LANGDALE: Yes, that is right.
GREEN: Okay, thank you. Yes. So I think what I am trying to say there is that if Lucy had gone
back on the unit, the Consultants may have called the police because of that, not because of
evidence to confirm or -- the trigger for calling the police would be the fact that she was on the
unit, not the fact that there was evidence or new evidence or that sort of thing.
LANGDALE: There can only be the trigger they were worried she was going to do something to kill
or harm a baby?
GREEN: Yes.
LANGDALE: That would be the right thing to do, wouldn't it, if someone was on unit and you
thought they were going to kill or harm a baby?
GREEN: Yes, which is why she was removed.
LANGDALE: So what are you saying, that that would be better for her to be removed than to be
arrested?
GREEN: Well, at this point in time, there was no clear -- I mean, we have heard and we have read
all the data behind the increase in deaths and the reviews but the fact is the police weren't
called.
LANGDALE: I am not interested in increase in deaths, Dr Green, and that is not what they are
talking about. We are talking about sudden, unexpected specific babies not expected to deteriorate
or die and who didn't respond to resuscitation?
GREEN: Yes.
LANGDALE: So let's remove generalities of an increase in deaths. That is a general picture. This
is not a general picture. These are babies with parents who loved them and lost them, so let's
focus on those babies.
GREEN: Yes.
LANGDALE: So what are you saying: you didn't have any evidence around sudden and unexpected
deaths and what Dr Jayaram had said to you in that grievance interview?
GREEN: Well, at the time if -- if there had been enough evidence to call the police, if it was
really obvious for example that something -- if there had been CCTV footage, if there had been
evidence that bags had been tampered with, that sort of thing, then that clearly would have led to
the arrest of Lucy Letby.
LANGDALE: You say at page 193, the recommendations, that the grievance should be upheld and Letby
given the opportunity to return to the NNU?
GREEN: Yes.
LANGDALE: You say: "In that context I believe her return should be managed in tandem with the
final reports regarding the neonatal unit's mortality figures"?
GREEN: (Nods)
LANGDALE: What do you mean by that second sentence?
GREEN: That -- as I have said several times, there were two ongoing investigations being
independently carried out into the forensic detail of what happened on the unit and that Lucy
shouldn't go back to the unit without them confirming or -- or clarifying that there was no sort
of case to answer.
LANGDALE: If you go to page 194, the last recommendation. As a result of your investigation you
believe: "... the elements of the events leading to the suspension which were mediated by SB and
RJ warrant further investigation, possibly under the Trust disciplinary policy and under the Trust
bullying and harassment policy. "The fact that LL has been subject to the ordeal of the last four
to five months based on a gut feeling and the subsequent behaviour of SB is not compatible with
the Trust values and behaviours." Do you reflect on that now?
GREEN: Yes.
LANGDALE: What would you say now sitting today looking at that?
GREEN: I think -- I think that conclusion was -- was arrived at on the basis of the investigatory
interviews, but obviously more and more information has come to light since then. I have had
access to information as part of this Inquiry that I didn't have at the time and also Speak Out
Safely was -- I'm not sure how aware I was of -- of it at the time in terms of the basis on which
concerns could be raised. But at the same time, I don't feel that we -- I don't feel the situation
was handled correctly by the Trust in terms of they should have called the police from the outset.
LANGDALE: There's a second version of the report, 22 November 2016. If we can go to that, it's
INQ0002879, page 208 [not found] is where it starts. I am going to just take you to bits that have
been added. So your draft goes to, who?
GREEN: Nobody. Lucy. Lucy Sementa, maybe.
LANGDALE: Yes, Lucy Sementa.
GREEN: Yes.
LANGDALE: Well, this next version has other bits in it. So tell me if you are the author of the
extra bits or who, okay. So if we look at this next copy, INQ002879, page 221. We spoke earlier, didn't we, about Speak Out Safely
policy and you said that wasn't as refined and you don't remember looking at that before. Look
what this section says at 221: "No party refutes that concerns ..." That middle section
paragraph.
GREEN: Yes.
LANGDALE: "... were raised by the Consultants in particular SB to the Executive Team around a
perceived commonality between LL's presence on the NNU and the collapse/deaths of babies. I
acknowledge [that's you as the report writer] that these concerns were raised through the
appropriate channels in line with both the Trust's Speak Out Safely policy and the guidance
proffered by the GMC through the Executive Team. I do not find that the Consultants' concerns when
reiterated to the executive team were clear, honest and objective." So here we have got a section
that includes a policy you told us earlier you hadn't looked at and also GMC guidance and
reference to "clear, honest and objective". How did that get added?
GREEN: This is probably one of the key parts of the document that I look back on now with some
regret maybe.
I -- I can't remember specifically thinking about this document in terms of what was my thought
process, why did I add it, what drove me to include those comments?
LANGDALE: Did you write that? Who did the research for that?
GREEN: I can't remember exactly, but it was either myself or Lucy, but my name's on the document
so I'm responsible for it.
LANGDALE: You take responsibility for it --
GREEN: Yes.
LANGDALE: -- but did you look up the Trust's Speak Out Safely policy and clear, honest and
objective from GMC guidance? I notice in the statements to the Inquiry you don't remember writing
"clear, honest and objective"?
GREEN: No.
LANGDALE: Might it be because it was written and you just adapted or adopted that?
GREEN: It -- it may have. I'm not saying it did. It may have been Lucy Sementa's suggestion, but I
can't remember.
LANGDALE: So we should follow that up where this has come from because you are not clear now, are
you, sitting there where you -- did you look up the guidance or not? Do you have a memory of
that?
GREEN: I would have done. I'm pretty sure I would have done.
LANGDALE: You think you would have looked at GMC guidance?
GREEN: Yes. Yes, I don't think I'd include something in a document like that without looking at it
at least.
LANGDALE: So you either got someone to look it up for you or -- why did it come at this stage?
Why not in your first draft if that's the case?
GREEN: I -- I honestly can't remember, I'm sorry.
LANGDALE: The next page please 224, 0224, paragraph 3: "I conclude that the decision to redeploy
Lucy was fundamentally due to the impracticality of supervising..." If you go further down: "I
find on the balance of probability Consultants as a group, and specifically SB, asserted they
would call the police if she wasn't removed and this was something the Executive Board wished to
avoid. In the interests of both Lucy and the Trust conflicting statements were provided. You both
deny that this unwritten threat took place. I have found no evidence to support that this did not
occur and furthermore no reasonable explanation for why it would be suggested it had not."
Isn't it the other way round? You have to find that it did happen and they have to say they did
say that? Are you saying you didn't believe them that they hadn't threatened that?
GREEN: Yes. Again, I can't remember specifically writing that sentence, but it's mine. I --
LANGDALE: I just want to break that down. When you say "it's mine", you take responsibility for
it.
GREEN: Yes.
LANGDALE: It's your report, I understand that.
GREEN: Yes.
LANGDALE: But I'm interested in who holds the pen with you to get you to your report. We all get
input and assistance with documents and ultimately we take responsibility for them. So, did you
get, apart from Lucy Sementa, any input from anyone?
GREEN: No. No.
LANGDALE: So it was Lucy Sementa or you?
GREEN: I got the impression from the Rule 9 questions that there was concern that perhaps the
Executives might have had some involvement in the writing of the report. But I can categorically
state that that was not the case.
LANGDALE: So it was you. So if we go to page 225, unless you want to comment on that section any
more, do you, the findings that you make there?
GREEN: I think it's badly -- I think, I -- I knew what I wanted to say, but I phrased it badly.
LANGDALE: Okay?
GREEN: Yes.
LANGDALE: 225, so we have that. The one that's been added is: "Due to the nature of the unit and
its patients it is unfortunately probable that a further death will occur on the unit and that LL
may be associated with that event. I consider that it would be prudent to acknowledge this prior
to Lucy's return to the unit and to agree an outline plan as to how this might be managed." Again,
do you remember writing that?
GREEN: Yes.
LANGDALE: Right, and what was the thinking behind that?
GREEN: If, if the external reports found no suggestion of foul play and there was no evidence that
any foul play had taken place and Lucy Letby was returned to the unit then, if anything were to
happen unfortunately, if there was another baby death on the unit, then the Trust needs to think
carefully about how
it would manage that situation in terms of the response, in terms of supporting the Consultants'
concerns and Lucy Letby and the effective functioning of the unit when there was clearly conflict
around the safety of patients on the unit.
LANGDALE: The next page, please, 226. This end bit has been toned down considerably from the
first draft. In the first draft you said that you thought there should be an investigation
possibly under the Trust's disciplinary policy and/or the Trust's bullying and harassment policy
and you made reference to "gut feeling" as we discussed earlier. This conclusion now says: "The
evidence gathered has raised significant concerns around the behaviours reported to have been
exhibited by SB and RJ. Further exploration of details surrounding their suggesting accusations
regarding Lucy and comments that are reported to have been said was not undertaken as it was
beyond the scope of this investigation. I recommend that the Trust takes action to explore this in
more detail and to investigate if required in line with the policy." Did you change your tone
deliberately about "gut feeling" or did Lucy Sementa suggest you might want to think about "gut
feeling"?
GREEN: I can't remember specifically. But, yes, perhaps in the cold light of day when I read the
draft maybe a week later or something I thought that's a bit strong or inappropriate, so...
LANGDALE: So the --
GREEN: Lucy might have said -- sorry -- Lucy might have said: I think that's a bit inappropriate,
Chris. Lucy Sementa that is, obviously.
LANGDALE: Yes. We now go to the hearing -- that can go down -- the hearing with Annette
Weatherley and it's INQ0003155, page 1. A number of comments made you have seen the transcript,
Dr Green. Just a couple of questions please. From page 0011 you say at the top fourth box, the
fifth box: "If the Consultants had called the police it would have been declared a crime scene and
LL would have been arrested." Annette Weatherley says: "Who said this would happen?" "Ian Harvey,
that's what he said would have happened." Lucy Sementa says that. And Letby says: "I was happy for
the police to come. I had nothing
to hide." We know from Hayley Cooper's evidence that actually -- sorry, Hayley Griffiths' evidence
that that wasn't the position. Lucy Letby wasn't inviting the police or wanting to go to see the
police actively. Did you have that discussion with Hayley Cooper or not about whether that was
going to be included in the grievance or not the question of the police?
GREEN: I don't -- I don't recall any discussions about the police as part of the grievance
process.
LANGDALE: If we go to page 0015. At the top, the third box: "I believe that the Exec Team wanted
that but I don't know about the Consultants. I would like to say it would be managed." Further
down Dee Appleton-Cairns says: "Mediation." Annette Weatherley to Letby: "Do you feel strong
enough to discuss this with them?" "I want to go back to work, so yes." Further down. Annette
Weatherley: "Have apology from senior nurses. Would you like apologies from the Exec Team? We will
meet them and get this in writing." Over the next page, page 17. This is the hearing investigator.
You have handed your notes, your report at the top of the page: "Am I right in thinking that you
both think that two Consultants have caused this?" That's Annette Weatherley. Further down, three
lines up, you say: "I was disgusted by their behaviour. It's likely that they lied."
GREEN: I'm not disputing that I said that because it's recorded in the notes. I don't recall
saying it, but I am deeply embarrassed that I said that. I really wish I hadn't. That said, I was
very frustrated with their behaviour during the investigative interviews.
LANGDALE: We have red the transcripts, Dr Green.
GREEN: Yes.
LANGDALE: Assuming for a moment not everyone shares a sense of frustration when you read that
transcript given the situation they're in with a Union rep there and what they do actually say
--
GREEN: No, but --
LANGDALE: What --
GREEN: -- if you were -- if you were the investigating officer and you were in the room and their
body language and the tone of some of the answers and
don't forget they are not verbatim transcripts. I was really frustrated after those meetings
because I thought we are not really getting to the truth of the issue here.
LANGDALE: Did you think as you reflected on this and looking at this hearing, it was absurd the
position that you ended up in, this grievance and the outcome that there was going to be mediation
between Dr Jayaram, Dr Brearey, a managed return to the unit, while there was the huge task of
investigation into the allegations themselves outstanding?
GREEN: I suppose it could be described as absurd, yes. Regardless of the outcome of this grievance
process, I was absolutely clear that Lucy Letby was not going back on the unit unless there was
compelling evidence there was no case to answer. So in that respect it was almost tokenism in some
respect, except that you know, that if you look at the individual bullet points of Lucy Letby's
grievance we did answer some of those in -- well, I think we answered pretty much all of them in a
really honest and supportable way, supportable by the evidence. But in some respects it might be
described as, I don't know, I don't know what the right phrase is, maybe window dressing in that
whatever the grievance
found Lucy Letby was not going back on that unit any time soon.
LANGDALE: You said that depending on the reviews that were produced, didn't you?
GREEN: Yes.
LANGDALE: You said see what the reviews say?
GREEN: Yes.
LANGDALE: But this is a different question. You get to this point and at the conclusion the
absurdity is that it's the Consultants that you are commenting on as being untruthful, not honest
and open with you as though that was what was ever part of the grievance. How they worked in the
grievance with you was not the question for the grievance procedure itself, was it?
GREEN: Sorry, could you repeat that?
LANGDALE: You weren't being asked as part of Lucy Letby's grievance to say whether the
Consultants were honest and open with you --
GREEN: No.
LANGDALE: -- in their meetings with you?
GREEN: No.
LANGDALE: So what's the point of that finding or observation?
GREEN: As I said, I'm deeply embarrassed that I said that. I think that was an off-the-cuff
comment at the
end of the meeting borne out of some frustration at the process and not part of the actual
evidence, discussion of the hearing. So, you know, had I seen the meeting notes I would have asked
for that to be taken out because that wasn't part of the actual, you know, presentation of the
grievance case.
LANGDALE: Wait a minute. That's where the person who is the decider is having the conversation
with you, isn't she?
GREEN: Yes.
LANGDALE: Annette Weatherley?
GREEN: Yes.
LANGDALE: So you would have asked to take out something that you said to the decision maker?
GREEN: Well, in -- in -- in the sense that it was an off-the-cuff comment and it wasn't a
evidential piece of discussion sort of thing.
LANGDALE: Well, the strength of the rest of the evidence will be scrutinised I'm sure. But the
reality is in that conversation with her, presumably you were presenting your report and your
findings. It should have been a formal conversation, not an off-the-cuff question and answer with
--
GREEN: Yes.
LANGDALE: -- something you now regret and would say was wrong. Would you say that was wrong?
GREEN: Yes. Yes, absolutely. And, and, you know, it was a difficult and emotive meeting. You know,
yes, I -- I really wish I'd said -- and I've reflected on that in my statements to the Inquiry as
well.
LANGDALE: You say: We answered the questions to the grievance. You were doing the investigation
report and it was Annette Weatherley who was supposed to make the findings one way or the other.
Is that how you understood it or did you think you were doing it together, the investigator and
decision maker were the same. Tell me how you thought the structure of that was?
GREEN: I thought the structure was that Lucy Letby posed some questions about experience and my
job was to gather the evidence and come up with some suggestions as to whether those grievances
could be upheld and it was Annette Weatherley's decision whether the argument that I presented was
reasonable or not.
LANGDALE: That can be taken down. The last document from me please, Dr Green, INQ0058624, page 1. The grievance has happened. The review has happened.
This is an email from Letby to her colleagues on the NNU:
"After a thorough investigation established that all the allegations were unfounded and true I
have been fully exonerated. I have received a full apology from the Trust. This whole episode has
been extremely distressing. I will begin my return to the unit in the coming weeks. I will need
colleagues to be sensitive and supportive at this time." So the reviews that you were relying on
to examine the conduct and the impact of Letby's care of the babies had come back and this was the
conclusion?
GREEN: (Nods)
LANGDALE: It's quite clear those reviews were not tackling the issues of her involvement or the
suspicion around her involvement at all. When did you become aware of that?
GREEN: I was never informed of the outcome of those reviews. I never got to see the actual
documents. They were never tabled to my knowledge at any of the meetings I went to.
LANGDALE: When did you know that the hospital did go to the police?
GREEN: I'm not sure I was ever in possession of that detail of who went to the police and on which
date and what triggered that in terms of what changed from where we were at the time of the
grievance investigation maybe
to when the police were called. Oh, it was the -- there was an insulin result, wasn't there, that
hadn't been picked up I think that might have triggered the police.
LANGDALE: Finally, one of the issues that Professor Dixon-Woods raised was that in an HR process
it becomes very focused on the individual --
GREEN: Yes.
LANGDALE: -- the individual, the employer, the individual backwards and forwards and that within
the NHS it can take a long time, there can be defensiveness and it's not effective for patient
safety or for child safety?
GREEN: No.
LANGDALE: Reflecting on all of this now, and now with all that you know, what would you say about
this grievance process in terms of the time it took, the way it was conducted, the conclusions?
What do you say about it as a reflection on an HR process in a difficult situation where all of
those people in Silver Command knew foul play was suspected even if they didn't have the concrete
evidence that you say you wanted to see at that point? What do you say about the process?
GREEN: (Pause).
I did what I thought was right at the time in terms of conducting the grievance and the
conclusions that I came to, but there are certain things that I wish I had done differently. I do
wish I had probed the -- Ravi, Ravi Jayaram and Steve Brearey around why they weren't sharing
their real concerns with me and that was partly because of the trade union reps being very
controlling about what was discussed at the meeting in terms of their responses, you know, for
example: This is an answer we agreed on or something. So I think perhaps I should not have been
asked to do that grievance; perhaps it should have been someone external to the Trust. But I
thought I was doing the right thing at that time by focusing solely on the grievance allegation --
the grievance issues raised by Lucy Letby. But clearly there was a lot of other stuff going on at
the same time in there, but I'm not sure I would have been equipped to deal with that. In terms of
the process and why she was removed and what was being said about her, I was fine with that, but
the other part of it I don't think I was equipped to deal with that. So I think I've said in my
statement, you know, if ever this situation arises again there should be some specialist input to
deal with it, not, not a local manager who thinks he's doing the right thing.
LANGDALE: And so was your access for support Lucy Sementa in the process and nobody else?
GREEN: No. No.
LANGDALE: Sorry, you looked like you wanted to say something else.
GREEN: I'm just trying to think if anyone else spoke to me. In terms of day-to-day support and
actual input into the process of the documentation, I think Lucy Sementa was the only support that
I had. I think people might have asked me how I was doing personally because it was a very
stressful and emotive kind of thing to go through.
LANGDALE: Who asked you how you are getting on and how is it?
GREEN: I think Sue Hodkinson might have asked me that in passing in a meeting. I think Dee
Appleton-Cairns might have done the same. Maybe my line manager might have asked me how I was
doing, seeing how I was doing with the grievance. So just general kind of supportive comments or
just checking in that I was doing okay sort of thing.
MS LANGDALE: Thank you, those are my questions. Mr Baker has some questions.
LADY JUSTICE THIRLWALL: Mr Baker.
MR BAKER: Dr Green, I ask questions on behalf of 12 or The Families of 12 children. Lucy Letby
was convicted of murdering five of those and attacking a number of others.
GREEN: (Nods)
BAKER: I want to take a step back and begin by saying how they would perceive this episode; that
they would say that the grievance process delayed Lucy Letby being brought to justice, that there
was a sense the process was centred around meeting the needs of someone who turned out to be a
serial killer and that it became a process that effectively put on trial the people who were
trying to draw that to the attention of the appropriate authorities and it nearly led to her being
returned to the unit and those people being disciplined or losing their jobs. Now, that is a fair
observation for them to have about this, isn't it, on reflection?
GREEN: From -- from The Families' position I can completely understand how they might see it like
that. Did it delay Lucy's arrest? I don't think it did. I think the arrest was triggered by the
discovery of a -- of a blood result.
BAKER: Well, if I put it this way: your approach to this investigation, this grievance could have
begun by you saying, "This is entirely inappropriate, it's not an employment matter. Let's call
the police", couldn't it?
GREEN: It -- it's possible that could have been an approach.
BAKER: Well, I mean that was the observation made by Hayley Griffiths in evidence this morning;
was that she couldn't see why it was an employment route, why the employment route was being
taken, that the police should have just been called?
GREEN: Yes and I have -- I've said that I agree with that.
BAKER: Yes. Now, if you look at paragraph 108 of your witness statement, please.
GREEN: Yes.
BAKER: You say here: I do not hold a particularly strong view about the Consultants or: "I did
not hold a particularly strong view about the Consultants. I felt there was enough to warrant a
mention in the report about their behaviour in the context we were dealing with either a serial
killer or terminating someone's career." And that's a binary categorisation that you use
throughout the witness statement. It's either a serial
killer or we are ending somebody's career. Do you accept that's completely the wrong approach in
this scenario? It isn't an approach where the Consultants have to prove that Lucy Letby is a
serial killer in order for this grievance process to function?
GREEN: I don't recall suggesting that the Consultants had to prove that Lucy Letby was a serial
killer.
BAKER: But the exercise of a grievance process can never get to the bottom of whether Lucy Letby
is a serial killer or not, can it?
GREEN: No and it was never intended to.
BAKER: Well, in that case, I think it proceeds on a completely false premise, doesn't it, because
the correct thing to do is to call the police?
GREEN: Yes. That -- that conversation had been had within the Trust by a number of people on a
number of occasions and the decision by the Executive Team had been that they weren't going to
call the police. So I think under employment law or contract, Lucy Letby is allowed to raise a
grievance as part of her working sort of terms and conditions. So that was the sort of take I got
on it from HR, I think.
BAKER: But the way that's handled is that it's upheld and you recommend at the end of it that the
Consultants who blew the whistle should be disciplined?
GREEN: That's not what I said in my final report. I said it warrants further investigation. I
didn't say they should be.
BAKER: Well, your original position was that they should be disciplined?
GREEN: Well, in the draft report, do you mean?
BAKER: Your original position you took was that they should be disciplined?
GREEN: But not the final position.
BAKER: Can I also look at some aspects of your statement where you deal with points that you make
against the Consultants within your statement and if you could go first of all please to paragraph
89.
GREEN: Yes.
BAKER: You refer here, and in a very judgmental way, to the suggestion that there may be some
evidence that Stephen Brearey did not like Letby?
GREEN: Yes.
BAKER: And you say there is a reference to Mel Taylor, that Stephen Brearey was told that Mel
Taylor was also common to the incidents and Stephen Brearey's response is, "But Mel is nice." Now,
the source of that information was Eirian Powell, wasn't it?
GREEN: Yes.
BAKER: The next comment about, "How would everybody feel if Lucy Letby went home and killed
herself?" Steve Brearey's response was, "I don't care." Again that was -- the source of that
information was Eirian Powell?
GREEN: Yes.
BAKER: Again the next point: "Eirian Powell highlighted that Stephen Brearey removed a column
containing doctors' names from the analysis as stated." Source of information: Eirian Powell?
GREEN: Yes.
BAKER: And d): If Lucy Letby had done something that we hadn't been able to see what he feels is
happening it all seems to be on a gut feeling. Yvonne Griffiths?
GREEN: Yes.
BAKER: And if you go on then to paragraph 175, you quote here: "... interviews members of staff
who were much closer to the situation than me gave me a consistent story." And the quotes are
Yvonne Griffiths, Yvonne Griffiths, Sue Hodkinson, Sian Williams, Yvonne Griffiths, Eirian Powell
and then
Yvonne Griffiths and finally Dr Jayaram. Do you think you were being influenced by the accounts
that were being given by the nurses and ignoring any other perspective?
GREEN: I felt at the time that the evidence given to me by the nursing staff was done so in a more
open and honest spirit than I felt the Consultants gave their evidence.
BAKER: But they were giving -- they were advocating for Lucy Letby and advocating against the
Consultants, weren't they, the nursing staff?
GREEN: Not necessarily. They were perhaps providing an alternative explanation for some of the
Consultants' concerns. That's not necessarily advocating against the Consultants.
BAKER: Well every -- and you list these as criticisms of the Consultants in your witness
statement. Every one of those criticisms is lifted from a source who is a nurse?
GREEN: I -- I'm not sure I understand why you think they are criticisms of the Consultants.
BAKER: Because the first set of things going through were all points being made against the
Consultants. B) Steve Brearey said he had concerns but never found any evidence. Points here again
Lucy Letby being
responsible or there being no evidence and the previous sections, comments about Stephen Brearey
or Ravi Jayaram. Again, the source of information were all the nurses?
GREEN: Yes, but I would say that the nurses were more forthcoming in giving evidence to the
investigative process.
BAKER: Do you understand why a whistleblower might find this grievance process intimidating?
GREEN: Yes.
BAKER: Do you understand why, if they are being asked to provide evidence, that they might feel
that if they accuse Lucy Letby of being a serial killer they will lose their jobs?
GREEN: At the time of the -- of the investigative meetings it did not -- it did not cross my mind
that if they said in those meetings that they had concerns about Lucy Letby they would lose their
jobs. That was not a connection that I made or a conclusion that I came to at all.
BAKER: But part of this grievance was about bullying and harassment, part of the complaint, and
that bullying and harassment related to derogatory comments about Lucy Letby being a serial
killer. Can you not understand how if those Consultants had done as you had been asking them to do
and say: We think she might be a serial killer, that that could have been held against them?
GREEN: Potentially, but if it -- if -- if they had said those things and it had led to Lucy
Letby's arrest, then they would have got what they...
BAKER: This was an adversarial process in effect. They were being accused as part of a grievance
process. What they did was they were reflective and circumspect which is an entirely normal
response to that sort of pressure, isn't it?
GREEN: Yes. I did not enter into the grievance process with a view this was an adversarial
process. Now, the Consultants because of things that had -- must have gone on in the background
that I wasn't privy to the Consultants may have felt that way, but I wasn't aware of that at the
time.
BAKER: Yes. Well, it culminated in you recommending, initially at least, they be disciplined. So
it was a fairly adversarial scenario, wasn't it?
GREEN: No. I would say that I came to that conclusion because I thought some of the things that
had been said in public places were inappropriate and not, not particularly professional in their
sort of manner.
BAKER: Well, they didn't say anything to you. That was your problem with them. It wasn't that
they were saying things that were inappropriate. It was that they didn't open up and require or
provide a level of commitment you were wanting them to?
GREEN: Yes. I was frustrated that -- I didn't feel after the interviews with the Consultants that
they had given me what they really thought and their Union reps were quite controlling in that, I
thought.
BAKER: Yes. But do you not understand another reason as to why that might be that they felt
threatened?
GREEN: I do now, but at the time I had not even anything within the Trust to make me think that
people couldn't raise concerns. I had not seen any particularly bullying behaviour or behaviour in
meetings where people were raising issues that, that was intimidating or...
BAKER: Can you not see how being interviewed as part of a grievance process that names you as a
source of a grievance might be slightly intimidating?
GREEN: Yes, but they got the same letter as everybody else and there was no -- and that's a
standard letter the Trust sends out.
BAKER: Okay. Finally, did it occur to you, at any point given what was being said, that somebody
should
check that the parents were aware of the concerns that were being raised?
GREEN: Again that was -- I didn't feel that was in the scope of my involvement in the grievance
process. That was something that the Trust needed to deal with at a much higher level than me, in
my view.
BAKER: But you didn't check?
GREEN: I didn't check, no.
MR BAKER: Thank you, my Lady. No more questions.
MS LANGDALE: My Lady, Mr Kennedy has a couple of questions.
LADY JUSTICE THIRLWALL: Mr Kennedy.
MR KENNEDY: My Lady, I am very grateful. There's just one point where perhaps Dr Green should be offered the opportunity to say more if he wishes to.
LADY JUSTICE THIRLWALL: Certainly.
MR KENNEDY: It was a point in the [draft] transcript at page 213, line 2. Perhaps if I can just
read it out and offer him the opportunity. If he declines to take it up, then we know where we
stand. Dr Green, you gave an answer, and this was in the context of what was said or not said to
you by the
Consultants.
GREEN: (Nods)
KENNEDY: You gave an answer to this effect: "But the things that the Consultants disclosed in the
court proceedings against Lucy Letby ..." And then my learned friend said to you, "Well, you
didn't know about that then?" And you said, "No." I just want to offer you the opportunity through
my Lady to provide any further detail in relation into point. If as I say, if you decline to take
it up then we know where we stand.
GREEN: I'm not sure I understand by what you mean by where I stand.
LADY JUSTICE THIRLWALL: Do you want to say anything about it?
MR KENNEDY: Well, I'm just affording you the opportunity --
GREEN: Right.
KENNEDY: Forgive me. I am affording you the opportunity to say something if you wish to,
appreciating that of course I act on behalf of the Trust.
GREEN: Yes.
KENNEDY: Therefore you and also the Consultants. So I'm just doing this out of fairness to
you.
GREEN: Right. When I read the BBC report of the retrial of Lucy Letby and Baby K [Child K], when I
read what Ravi had said --
LADY JUSTICE THIRLWALL: I think we have heard your evidence about that.
GREEN: Yes.
LADY JUSTICE THIRLWALL: Was that what you were referring to?
GREEN: Yes, in particular.
LADY JUSTICE THIRLWALL: Yes. Is there anything else apart from that?
GREEN: No, thank you.
LADY JUSTICE THIRLWALL: I'm not rushing you, but just if there is something else please do say
it.
GREEN: I -- I think -- I think I'm disappointed that I wasn't able as investigating officer to
draw the information from Dr Brearey and Dr Jayaram that was elicited in court is where I think I
stand on that.
MR KENNEDY: Very well. My Lady, I am very grateful.
LADY JUSTICE THIRLWALL: Thank you very much, Mr Kennedy. But, of course, it wasn't your role to
investigate that which was elicited in court, was it?
GREEN: No.
LADY JUSTICE THIRLWALL: No. One of the things that was said by Lucy Sementa, I know you were in
for part of her evidence but I can't remember at which stage you arrived, but one of the things
that she expressed frustration about as you have was the fact that there wasn't anything more.
There was nothing more than they had already given the Executives.
GREEN: Yes.
LADY JUSTICE THIRLWALL: Was that something that you felt frustrated by?
GREEN: Absolutely, yes.
LADY JUSTICE THIRLWALL: Yes.
GREEN: Yes.
LADY JUSTICE THIRLWALL: So although they had said what they had to say to the Executives, you
felt they would be able to say more?
GREEN: Yes. Like I -- I'd known Ravi for 10, 12 years by this point and I felt I had a good
working relationship with him and I was kind of disappointed that he felt he couldn't trust me to
give me the information that maybe he felt he could have done. So I kind of felt a bit frustrated
and a bit sad about that to be honest.
LADY JUSTICE THIRLWALL: Yes. Yes, I understand
that. But again that information was information that was pertinent to whether or not Lucy Letby
had killed babies or injured babies.
GREEN: Yes.
LADY JUSTICE THIRLWALL: Which wasn't what you were investigating?
GREEN: No.
LADY JUSTICE THIRLWALL: So I suppose there may have been perhaps just a mismatch between the
things that you were looking at -- I just want to give you a chance to think about this --
investigate and being frustrated about and actually what you needed to look at which were the
details of the grievance which you did also look at.
GREEN: Yes. Yes, I think that's a fair comment.
LADY JUSTICE THIRLWALL: Thank you. Now, can I just turn to something completely different. You
mentioned that you had met Lucy Letby's parents?
GREEN: Yes.
LADY JUSTICE THIRLWALL: And they had thanked you for taking on the grievance or something like
that and again we heard from Ms Sementa this morning that you had had at least one or possibly two
telephone calls from
her parents.
GREEN: Yes.
LADY JUSTICE THIRLWALL: Was that something that you were surprised by, had you expected?
GREEN: To be honest when -- when Lucy Sementa said that I had had two calls I was surprised. I
don't remember the first one. I'm not saying it didn't happen, but I don't -- I didn't really
remember them until it was --
LADY JUSTICE THIRLWALL: Did you remember a call?
GREEN: Now, that she mentions it --
LADY JUSTICE THIRLWALL: I think she wasn't sure there were two. I think she thought there might
have been two, but she thought there was one.
GREEN: Now that it's been brought up it does, it does bring back some memories. But so -- so if --
it's not the first time that a family member of a member of staff has contacted me.
LADY JUSTICE THIRLWALL: No, Ms Sementa said that.
GREEN: Yes. And in those situations the line to take I felt was to listen to what that person had
to say and that's, rightly or wrongly, largely driven out of trying to be kind to them and listen
to their concerns.
LADY JUSTICE THIRLWALL: Understood.
GREEN: But then to say that I can't really talk about that member of staff with you, you are not
their trade union rep or work colleague and our policies are very clear around that. So I always
have a very firm line around, you know, trying to be kind and supportive to the person who has,
obviously has genuine concerns about what they are ringing me about, but not disclosing anything
that, you know, shouldn't be disclosed to them in terms of process or evidence or anything like
that.
LADY JUSTICE THIRLWALL: But you don't have a particular memory of that conversation, but that's
what you would have done in usual circumstances? It doesn't matter --
GREEN: Yes, I think I do but I don't really remember it and I'm surprised at that because I would
have thought that would be quite an emotive discussion. So -- but it was a long time ago and a
lot's happened since then.
LADY JUSTICE THIRLWALL: Finally, there was one thing which I did want to ask you about. It was in
respect of the fact that the doctors came with their Union representatives and I appreciate how
frustrated you got by the interventions, I do understand that. But it's rather what your view was
as to why they had come with their Union representatives and I have
just got a rough note, but I think you said: I thought they must have a problem that they need
support with in respect of their behaviour. And then you did say "maybe". I mean, is that what you
would usually think, that someone brings a representative along with them because they think
they've got a problem or just because they are entitled to bring one?
GREEN: I think in that context, I think they brought a Union rep because they were concerned about
the process and the content of that process. Ordinarily if someone brings a Union rep along, I
don't take a particular view on that. Some staff like to bring a Union rep, some staff don't.
LADY JUSTICE THIRLWALL: But on this occasion, you have just given us the answer --
GREEN: Yes, yes, I felt that they were concerned about what was happening.
LADY JUSTICE THIRLWALL: Yes.
GREEN: Yes.
LADY JUSTICE THIRLWALL: Yes. Thank you. Does anybody want to ask anything arising out of that? I am not saying anybody should.
MS LANGDALE: No, thank you.
LADY JUSTICE THIRLWALL: Thank you, Ms Langdale.
Dr Green, thank you very much indeed. It's been a very long session, it's been very helpful. Thank
you for coming.
GREEN: Thank you very much.
LADY JUSTICE THIRLWALL: You are now released, as they say, and we will rise now until 10 o'clock tomorrow morning.
(5.28 pm) (The Inquiry was adjourned until 10.00, on Thursday, 7 November 2024)
LADY JUSTICE THIRLWALL: Ms Langdale.
MS LANGDALE: My Lady, may I call Ms Weatherley.
MS ANNETTE WEATHERLEY (sworn)
LADY JUSTICE THIRLWALL: Thank you very much, do sit down.
WEATHERLEY: Thank you.
MS LANGDALE: Ms Weatherley, you provided a statement to the Inquiry dated 21 June 2024. Can you
confirm the contents are true and accurate as far as you are concerned?
WEATHERLEY: They are, yes.
LANGDALE: You have got it in front of you if we go to it, but in fact you will find documents
will come up on the screen in front of you. We can go back to the statement where we wish to, and
if at any point you are not following it, do say so?
WEATHERLEY: (Nods)
LANGDALE: If we look at your statement you tell us at paragraph 2 you qualified in 1991, a Member
of the Royal College of Nursing, and you have a BSc in Nursing Practice and an MSc in Health and
Social Care Leadership and Management.
When did you undertake the MSc?
WEATHERLEY: 2012.
LANGDALE: Was that helpful in terms of leadership and management, that course?
WEATHERLEY: Yes.
LANGDALE: Was it a part-time course?
WEATHERLEY: Yes.
LANGDALE: Did safeguarding crop up in that course or child protection?
WEATHERLEY: No.
LANGDALE: Not even in -- I am just asking about different courses where people have done them --
the context of leadership, the importance of having patient safety first, particularly children
and vulnerable adults; anything like that?
WEATHERLEY: No, it didn't. It was more focused particularly on sort of the key aspects of
leadership and management. It wasn't specific to clinical care.
LANGDALE: No.
WEATHERLEY: It was more a higher sort of broader overview of leadership.
LANGDALE: So if you had to summarise management priorities as a learning from that course, what
would they be?
WEATHERLEY: How to build and lead effective teams.
LANGDALE: So team building, morale building?
WEATHERLEY: Yes, to a degree. But also around aspects of service delivery and sort of excellence
and encouraging and empowering teams to work towards that in the services that they provide.
LANGDALE: Much discussion about HR and processes?
WEATHERLEY: Not really, no.
LANGDALE: You say in autumn 2016 you were the Deputy Chief Nurse at the University Hospital in
South Manchester. Tell us how you were asked by your line manager to chair a grievance or the
grievance that you are here to talk about?
WEATHERLEY: I don't recall the exact details of whether it was in a specific one-to-one meeting. I
imagine that it was. And he just asked whether I would be prepared to chair a hearing, a grievance
panel hearing, in relation to a nurse who had a grievance against her Executive colleagues.
LANGDALE: You have explained you didn't know the nurses at the Countess of Chester, you didn't
know Alison Kelly yourself, you didn't know --
WEATHERLEY: No, I didn't.
LANGDALE: -- any of the people that you came across when you chaired that hearing? But you know
that Alison Kelly had worked in your
role before, had she, or knew your boss; that was the link?
WEATHERLEY: She did.
LANGDALE: One of the matters that Sir Duncan Nichol raised in an interview with a company called
Facere Melius after the events he said this: "Surely Alison or Sue wouldn't have gone to the
Senior Nurse in South Manchester, that could have created a perception of not being entirely,
entirely fair." Do you think the fact that it was a nurse from a unit or somewhere Alison Kelly
had worked might create a perception that it was bringing someone in where the complaint was made
by a nurse and there were some issues between nurses and doctors, that choosing you as a nurse
wasn't the best choice or not, what would you comment on that? You wouldn't have known that
background, but now I am asking you, what do you think about that in terms of you being
independent?
WEATHERLEY: I don't think that's something I could comment on, I wasn't involved in sort of the
discussions at that time. Like I said, I didn't know anybody.
LANGDALE: Okay, no. But when you look back now, do you think having a nurse hear that grievance
in particular was the best choice?
WEATHERLEY: I think it's unfair to ask me to look back now. I think at the time I was asked a
question as to whether I would be prepared to listen to a grievance hearing and that's something I
had done many, many times throughout my career.
LANGDALE: Of course, so you say for others to comment who knew the bigger picture whether the
perception of that may have been fair or unfair, from your point of view you didn't know that
background; you have just been asked to do it before?
WEATHERLEY: Yes.
LANGDALE: You tell the police I think you have done about 20 to 30 grievance -- was that
grievance or disciplinaries?
WEATHERLEY: Probably a mixture of both but I would say certainly over 20 in terms of grievances.
LANGDALE: Over 20. And had you always done them in the same Trust?
WEATHERLEY: Yes, this was the first one that had been outside of the organisation I was working.
LANGDALE: And what was the process in the Trust you were working in, when would you get the
papers, when did you get involved as the chair of the grievance, just talk
through the process as you understood it broadly to be in your other Trust?
WEATHERLEY: So you would ordinarily get the papers at least a week in advance. Obviously the
grievance from a process perspective is a very limited procedure. It's not -- it's almost you
could describe it as a tabletop exercise, so you are not investigating anything that has occurred;
you are sitting almost in adjudication having heard representation from both the person with the
grievance and the person who investigated the grievance to be able to come to a conclusion and a
decision in respect of the outcome.
LANGDALE: And when you do that in your other process in the other Trust, do you have the person
who's making the grievance and their Union member present, the investigator but not the people
about whom the grievance complaint is made, potentially?
WEATHERLEY: Sorry, just say that --
LANGDALE: In that hearing setting you have described having the person who's made the grievance
and the investigating officer?
WEATHERLEY: Yes.
LANGDALE: Do you have the people who have responded to the grievance?
WEATHERLEY: You wouldn't, no, unless the either party had
specifically asked to bring witnesses to that hearing.
LANGDALE: Right. So the investigating officer and the person raising the grievance have an input
or choice around who's at that hearing with you or the panel overview with you?
WEATHERLEY: They -- they would do.
LANGDALE: Right. So in this case, moving to this grievance, did you have a discussion with either
Dr Green or Lucy Letby's representative about who was going to be present at the hearing?
WEATHERLEY: No, I didn't.
LANGDALE: So you turned up and that was sorted as far as you were concerned?
WEATHERLEY: Yes.
LANGDALE: In the same way did you have any input about who was going to be interviewed or was
that sorted by Dr Green and supported by Lucy Sementa?
WEATHERLEY: Yes, that was -- that was nothing to do with me.
LANGDALE: Nothing to do with you?
WEATHERLEY: Yes.
LANGDALE: So have you ever come in to any of the grievances -- I don't need details -- and
commented on the picture that has been presented and said: well, I don't know this from this
person or: I haven't got
this, or do you just take what you are given and that is the job?
WEATHERLEY: You just work with the information that's presented to you at the time.
LANGDALE: Being trained as you were to do grievances, that's what your understanding is: you are
just told what -- deal with what's there, don't look around if you think there's a bigger picture
or something missing?
WEATHERLEY: Yes. You would work within the confines of the process of the grievance. If there was
something specifically that had alarmed me in any grievance, that might be something you would say
back to the investigator there needs to be further investigative work in respect of that, or you
may have a question that you feel has been unanswered within the investigation, so you may -- you
know, that that may come up during the grievance.
LANGDALE: You were sent a grievance pack and you tell us you think policies were included in that
and you saw those. Can I just ask if we go to INQ0002879 0100, which is the grievance procedure from the Countess of
Chester. Page 0100. Here at the top we see grievance is a problem or concern that an employee has
about their working conditions et cetera and it says: "If a grievance can be more appropriately
dealt with under a different procedure, staff will be advised this is the case." Then there is a
list of various mechanism and procedures in place. My question is: you are presumably you say sent
this because it's a grievance but you are not presumably sent all these other policies as well,
are you?
WEATHERLEY: No.
LANGDALE: Do you find, as somebody who's listened to grievances, that a particular helpful
description of when a grievance might be more appropriately dealt with under a different
procedure, just a list of policies; does that help you in any way as somebody who's coming in to
look at a grievance when you might think of using a different process or not even having the
grievance?
WEATHERLEY: I don't believe that that would be something that the manager hearing the grievance
would be -- would have an opinion about.
LANGDALE: It certainly would look complicated to find out what that meant, wouldn't it, that some
of these -- look at it -- suggest other procedures are in place for example in relation to
harassment and bullying, other procedures. Is that something you picked up on? Of course in
the complaint we come to deal with that is what Lucy Letby does complain about, but it's not
something you would pick up or go and look for, is it?
WEATHERLEY: No, sorry I am not clear on the question?
LANGDALE: So you are told in this grievance policy that you did see if it can be more
appropriately dealt with under a different procedure, staff will be advised this is the case. Who
would you look to check, and maybe you didn't check, whether this was the right procedure for what
you were being asked to look at?
WEATHERLEY: This procedure was followed because a grievance had been raised, so if a grievance has
been raised, you follow the grievance policy.
LANGDALE: But look at this policy. It tells you there are examples when it's inappropriate to
follow the policy, doesn't it, and one of them is complaints of harassment and bullying. Did you
at any time understand that Lucy Letby complained that she was being bullied by Dr Brearey?
WEATHERLEY: It was mentioned by her RCN representative within both his grievance to the -- or
letter of grievance to the Trust on Lucy's behalf and also then in Lucy's actual grievance that
she wanted the grievance to be heard under the grievance policy as well as the
harassment and bullying policy. But at that time, as I understood it, the investigating manager,
Dr Green, had said obviously that was a separate policy to follow the harassment and bullying and
he sent that policy to Lucy and suggested that that would be something she would need to look
through and then raise a concern in respect of that thereafter.
LANGDALE: Did you look at that policy?
WEATHERLEY: The harassment and bullying policy?
LANGDALE: Yes?
WEATHERLEY: No, I didn't.
LANGDALE: Can we go to another policy, INQ0003012, page 1. This, you tell us, was also sent at the time to you, the
Speak Out Safely raising concerns about patient care and whistleblowing policy. We look at that
top box and it says halfway down: "Above all, the Trust encourages a culture whereby staff and all
levels of management fully understand that it is safe and accepted to raise such matters
internally. Staff will be supported in these circumstances at high level." It continues: "The
policy has an aim in supporting staff in
fostering an open culture to raise concerns in the workplace and also to provide clarity around
existing legal rights for staff to raise concerns about safety, malpractice or other wrongdoing
without suffering any detriment." Had you read and understood this policy?
WEATHERLEY: Yes.
LANGDALE: Broadly what do you think the effect of this is? This policy, what does it say, what
does it mean?
WEATHERLEY: This is a policy to support people who are concerned to follow a process to raise
those concerns.
LANGDALE: You say "follow a process". Is it also just to feel able to raise concerns, to be able
to articulate concerns about patients?
WEATHERLEY: Well, all staff should be able to raise concerns anyway. This is the process in order
to do it, it just outlines a clear responsibility of the organisation and also staff that would
want to raise concerns.
LANGDALE: We see on page 2 of that policy in the third paragraph, 0002, we see: "Managers have a
particular responsibility to protect patients, to handle concerns about their care in a way that
will encourage the voicing of genuine misgivings whilst at the same time protecting staff against
unfounded allegations." So to encourage people in the interests of all those who use the NHS and
patients, babies, vulnerable adults to say when they are worried that something's not right or
doesn't look right?
WEATHERLEY: That's right, yes.
LANGDALE: In the disciplinary policy finally, INQ0108329, page 15, we see that includes -- you will be familiar with this
no doubt -- safeguarding requirements, where there is a concern raised or an allegation made and
there's concerns that they may have behaved in a way that's harmed a child or possibly committed a
criminal offence. The level for referral is "concern and suspicion", it is not concrete proof, is
it? It's some concerns, suspicion that children are being harmed or babies are being harmed?
WEATHERLEY: Yes.
LANGDALE: That would be something that you think would be widely known or should be widely
known?
WEATHERLEY: It should be widely known. I think it's certainly -- be more widely known for people
that are working with children certainly from a safeguarding training perspective.
LANGDALE: So do you think less widely known for managers
or people that aren't working with children on a day-to-day basis, is it something front line
workers with children would think about more?
WEATHERLEY: There is different levels of safeguarding training. I think the more senior you are in
terms of the management structure, you would -- this is covered in sort of Level 2, 3, 4. Level 1,
which is safeguarding training for most staff, for all staff, I don't think that -- well, I am not
sure but I'm not sure that people would know what the LADO was there to do and how you would make
a referral.
LANGDALE: Let's -- we can take the policies down, thank you. When you first spoke to the police
about this grievance, investigation generally, you said this, if we can go to INQ0017846, page 28. We see they said, the second answer, they said -- this
is you: "He has said no party refutes that concerns were raised by the Consultants, in particular
[that should be SB, I think] SB to the Executive Team around a perceived commonality." You say
further down: "What were your thoughts, that she should have been allowed to remain on the unit
supervised or was that
just something that could have been considered as well or ..." You said: "Well, what I would have
done at that if -- you know, if I would have been any part of that Executive Team would have been
to say: right, well clearly that's a significant concern and if you are raising that with us then
we do this properly. "Yeah." Over the page: "She will be suspended for her own protection and we
will investigate and we will alert the police. Then she would have been brought in by whoever,
probably her line manager, to say: have to be open and honest with you in respect of the Trust
policy, a concern has been raised that suggests X, Y and Z. In order to protect you we are going
to now suspend you on full pay whilst we investigate. We will assign you somebody to support your
psychological well-being throughout this process to keep you in touch with how things are going,
we will take it from there. And that is what should have happened." You tell the police when you
were first interviewed that?
WEATHERLEY: Yes.
LANGDALE: Is that what you think should have happened?
WEATHERLEY: That should have happened in 2015, yes, when the first concern was ever raised.
LANGDALE: You say very clearly on the first page that commonality, just the perceived
commonality, was a significant concern that demanded that?
WEATHERLEY: Sorry, I say where?
LANGDALE: If you go back to the previous page, they put to you concerns were raised around a
perceived commonality. So you don't put it any higher than a perceived commonality and you say
that is a significant concern.
WEATHERLEY: That's what I remember at the time when I spoke to the police around perceived
commonality, without having obviously any information in front of me.
LANGDALE: No, I think we will go to that. You had in fact seen that table with her name next -- a
perceived commonality between deaths and you are saying that is a concern that should have
required this?
WEATHERLEY: It, yes, but it wasn't -- the statement that I gave to the police there in respect to
what I would have done was on the basis that the concern was not about the commonality, the
concern was that the consultants had said that there is an allegation that somebody is -- a
colleague is murdering babies on the unit.
LANGDALE: That's not what you say here. You don't refer to the fact that a colleague has said
murdering babies on the unit. You just say there is a commonality around, a perceived commonality.
We will come on to what you say the Consultants said but I am giving you the opportunity to say is
that what you understood should have happened?
WEATHERLEY: Perceived common -- what the Consultants were saying around a perceived commonality of
one particular nurse on duty at the time that they felt babies were being murdered.
LANGDALE: Exactly.
WEATHERLEY: That is what I meant by "perceived commonality".
LANGDALE: Yes, yes. So perceived commonality and they should have gone to the police. We know
obviously that they didn't then and you were then investigating this grievance. Was there any time
when you were investigating the grievance you thought to suggest that or were you focused on the
grievance and as you said before you are just looking at what's in front of you?
WEATHERLEY: I was focused on the grievance. I didn't have anything within the investigation that
suggested to me
WEATHERLEY: that time that I would call the police in at that point or suggest that the police be
called in at that time. This is 12 months later from when I am saying I would have said the right
thing to do is as part of that Executive Team would have been to suspend her and call the police,
and in that 12 months I think there had been four reviews, all of which had shown no concern in
respect of Lucy. And therefore, that was a different situation in 2016 in December when I was
hearing this.
LANGDALE: Let's have a look, go back to page 12 in this police interview INQ0017846, page 12. You set out when we get to page 12: "The Consultants
were doing their own kind of investigation, whatever it was that they were doing. Whether they
liked or disliked her, there were lots of rumours around. They decided it was her. She was the
baby killer, they were openly talking about her as the baby killer. They went to the Trust, they
said 'she is the baby killer we don't want her on the unit'." If we go over the page to page 13,
the officer says: "You felt that it was a witch hunt, I felt it was a witch hunt." Over the page:
"It's a rumour -- I can't remember who said it, but there was rumour that she have had rebuffed I
think -- I don't know, I think a Consultant had made it clear that he had an interest in her and
she had rebuffed it." The officer says: "What, physically? "Yeah, physically." Overleaf, if we go
over the page to 15, officer at the bottom the page: "You say there was some rumour although you
don't know where it had come from that she had rebuffed one the Consultants? "Yes, it was someone
told me that, I can't remember who it was when I was there that there was a rumour." Over the page
again, page 16, and you say, page 16: "When I got to the actual hearing I went a little bit early
and I met I think it was the head of HR or deputy. It was in fact the deputy HR, Mrs Dee
Appleton-Cairns. "Yes. "And she said to me 'what are your thoughts?' I said 'I think it is a witch
hunt'. She said 'that is what we all think'." When you went to -- you obviously relied on what
people told you at different points, you did meet with her before the hearing?
WEATHERLEY: Yes.
LANGDALE: What do you remember about that conversation using that to help you, if it does?
WEATHERLEY: It wasn't a detailed conversation, we didn't have long, she asked me whether I had had
the opportunity to fully read the pack, cover to cover and absorb it. I said I had. She asked me
what my thoughts were. I said it felt like a witch hunt. She said yes, we all feel the same. It's
very sad.
LANGDALE: When she gave evidence, she told the Inquiry that it was exactly -- that meeting was
exactly like giving evidence at this Inquiry, she came, was shown the room, meet each other, they
had a chat, nothing more sinister. She said she didn't recollect saying that about a witch hunt.
You say that is wrong and she did have that conversation with you?
WEATHERLEY: She did.
LANGDALE: On the point of the Consultants, were you aware that a nurse one of the ones who was
interviewed Karen Rees told this Inquiry and told the police she was the person who asked Letby
directly if she had any reason to believe that the Consultants, Dr Jayaram and Dr Brearey, had a
personal issue with her or anything of that nature and she said no and she had had good working
relationships, certainly with one of them?
WEATHERLEY: (Nods)
LANGDALE: So again, were you relying on others telling you that rumour when you tell the
officers, as you do, that you understood she might have rebuffed a Consultant, where did you get
that from?
WEATHERLEY: That was said to me during the investigation hearing, I think --
LANGDALE: We will go to the notes of that and of course Letby was at that hearing as well so we
will see but you can't remember if it was a conversation out of the hearing?
WEATHERLEY: No, it was in the hearing.
LANGDALE: How many conversations did you have out of the hearing, you have obviously had one with
Mrs Appleton-Cairns. Any others?
WEATHERLEY: No and it wasn't so much a conversation; it was a -- I had not met any of them before
I hadn't met her, it was having a coffee. Yes, she was right in that she said: this is the venue,
this is where, obviously, the hearing will take place and these are the people that are involved.
We didn't discuss the case any further beyond that
one sentence where I said it felt like a witch hunt and she agreed.
LANGDALE: There is a line that is crossed there, though, isn't it? When we meet and we meet
witnesses, we don't say: what did you think of this, then? There is no suggestion that we would
discuss anything that goes on in this hearing room and you are asked questions about. So there was
a different line when she said: what do you think? And she said "We think it is a witch hunt too,
that is sad". That is giving you evidence of her view and what they think, isn't it, before you
have even got in there?
WEATHERLEY: I would disagree with that in respect of a grievance. The panel was myself and Dee. So
the panel would discuss what was contained within the pack, if they felt they needed to, in
respect to anything that was about to be -- obviously before we go into the hearing, anything that
she might want to say, anything I might want to say. We collectively were the panel.
LANGDALE: Oh, so Dee Appleton-Cairns was a decision-maker as well, as far as you are
concerned?
WEATHERLEY: She is -- she is the support to -- this other HR person normally in a grievance
hearing is the support to the hearing manager and they collectively can ask questions of the
representatives that are presenting the
grievance and those who are presenting the investigation into the grievance. So therefore they
make up the panel who are hearing it.
LANGDALE: But that panel ceases to be anything like an independent panel, doesn't it, when you
have got someone from HR knowing all the people, listening to what they want about what they want,
there is no independence in that panel any more, is there?
WEATHERLEY: The independence I suppose is when you come to the decision-making in respect of
outcome which was my decision.
LANGDALE: But it's influenced by someone who's got close access to you and is having a
conversation with you that goes on outside the hearing room?
WEATHERLEY: I guess it's influenced if the hearing manager is prepared to be influenced.
LANGDALE: You repeat that you think it's a witch hunt when you get into the hearing room and we
will come to the basis for you saying that, but you saying you would be able at that stand back
from her telling you things like that in an informed way?
WEATHERLEY: I had said it first, that was my -- that was my gut feeling when I read the initial
investigation report.
LANGDALE: Let's go to the pack that you were sent and we
know what the documents were, you say they were shredded after that. Is that normal, you just
shred grievance process material, that is what happens in the NHS?
WEATHERLEY: You would -- yes, you would delete the information that you have.
LANGDALE: How quickly does that happen? Is that just you as the hearing manager, not everybody
else, presumably?
WEATHERLEY: I can't speak for anybody else but the information that I have if you, if you have
that information you would either hand that back or you would discard of that information
appropriately.
LANGDALE: We have got INQ0002879, page 3. And here's the grievance, that's how it came to you; is
that right?
WEATHERLEY: Yes, so the grievance was contained within the pack.
LANGDALE: Yes. So these were the questions that you were asked to answer?
WEATHERLEY: No, I wasn't asked to answer them. The investigating manager was asked to investigate
these. The role of the chair of the hearing, yes, the hearing chair of the panel, is to consider
whether the investigation has sufficiently answered the points of grievance enough that you can
come to an outcome.
LANGDALE: I accept that because when we get to your letters you do deal with the points and
answer or respond to them. So either way you agree those are the questions and when we get to it,
you are responding to them?
WEATHERLEY: Yes.
LANGDALE: You also have sent to you INQ0003189, page 1. The Inquiry is very familiar with that document now, Ms
Weatherley, of course you will only have seen it when it was sent to you, so just have a look at
the front page. We see it's this document with Letby's name in red and around a number of babies,
some ciphered for the purposes of the Inquiry. Do you remember seeing this and these links being
made and if you did, who did you understand had prepared this?
WEATHERLEY: I had -- I didn't see this.
LANGDALE: It was -- you refer to the mortality review and you refer to common staff and it is in
the pack but you say you didn't see that?
WEATHERLEY: No I hadn't seen this and there was something -- and I can't remember what it was --
that was in there in respect to commonality because that prompted a question that I put to the
investigating manager in respect to there only being nurses on the list. It wasn't this.
LANGDALE: Well, we know another nurse, Sian Williams, who was also interviewed, and Julie
Fogarty, did another staffing analysis she was interviewed and she said that when she completed it
she thought she should have gone to the police. Do you know if it was hers or you don't know now,
you just saw something?
WEATHERLEY: I don't know, I can't remember what was in the pack, but it was just something that
had some commonality on it. There was nurses on it but there was no other members of staff on it.
LANGDALE: So you did see the commonality, it was either this one or another one that showed Lucy
Letby's name linked to babies as a nurse?
WEATHERLEY: It wasn't -- it was who was on shift at the time. There weren't red crosses, it wasn't
what I have seen in the media.
LANGDALE: I am not interested in the media. I am interested in that, the one that was prepared
--
WEATHERLEY: The only two that I have ever seen was the one that was in the media and this that had
red pen or any red on it.
LANGDALE: Fine. So you have seen this one and the one that's been produced and this is something
that's been put together by Eirian Powell but you didn't find out who had done it. You just saw
nurses only and Letby's
name and no doctors on it; you didn't see a list of doctors?
WEATHERLEY: No.
LANGDALE: But when you looked at that, if you looked at that, what did you think?
WEATHERLEY: I -- I don't recall looking at this.
LANGDALE: Because you do say to the police about significant perceived commonality, it is a
concern that should go to the police. We have just been to that. Was that something thought when
you saw this or would you say now you don't remember looking at it?
WEATHERLEY: I didn't see this.
LANGDALE: Can we go to INQ0009618, page 9. Did you see this? This is an RCPCH report and part of
the report?
WEATHERLEY: No, I didn't see this.
LANGDALE: Can I just say just to refresh your memory about the chart of commonality. At paragraph
12 in your statement, if you have a look at it, Ms Weatherley, when you tell us here what you had
been sent, you say at the bottom of paragraph 12: "I had not seen any information at all prior to
receiving the pack, neither can I recall the exact contents of it save the investigation and
interview transcripts and several appendices that are not all
included in the Rule 9 information ..." So maybe more than we sent you from the pack here but:
"... such as the nursing rotas and I believe the chart of commonality was also included." That is
the chart of commonality I have just taken you to. So when you wrote this statement you thought
you had got that?
WEATHERLEY: I had seen something that was, that had some degree of commonality on it. What it
looked like I can't recall but it definitely wasn't that.
LANGDALE: Well, we don't have any other one that looks like that.
WEATHERLEY: I can't -- I'm sorry, I can't answer you .
LANGDALE: But you took the point that she was linked with the baby deaths, the association, you
took the point --
WEATHERLEY: Yes.
LANGDALE: -- the chart of commonality. So you had that point?
WEATHERLEY: Yes. But as I said with there not being anybody else on that, it was just nurses, I
had questioned in the investigation if --
LANGDALE: You also say -- sorry, go on?
WEATHERLEY: No go on.
LANGDALE: Paragraph 16, you say: "I became aware of a completed external review by the Royal
College of Paediatricians looking into neonatal deaths when I received the grievance pack two days
before the hearing. Contained within was information referencing the reviewing which had concluded
in October 2016 and had found nothing of concern but had recommended a further forensic review of
the case notes. That forensic review was ongoing at the time of the hearing but was not
investigating Letby and therefore I did not feel there was a need to wait for the outcome of that
review." So if we look at the second page of this, this is the review you refer to in your
statement. Look at the conclusion on the next page, page 10, 0010. You see there that is the
recommendation you refer to in your statement to the Inquiry: "Conduct a thorough external
independent review of each neonatal death to determine any factors which could have changed the
outcome." So it looks like this -- either you see the whole report or these two pages because you
refer to this in your statement. Can you remember now what it was, the whole report or?
WEATHERLEY: I hadn't seen any of the report.
LANGDALE: So how did you know then about the recommendation for a further forensic review of the
case notes?
WEATHERLEY: Because -- sorry.
LANGDALE: Go on.
WEATHERLEY: That was in the Executive statements that they provided to Dr Green in this
investigation.
LANGDALE: We have seen the interview transcripts, and we will go to those, of Dr Green's
interviews. But I am just trying to understand what you had seen in writing first and this is from
the pack and these are the things he had, okay? So you are saying not this?
WEATHERLEY: No.
LANGDALE: Did you have the document from Eirian Powell, a six-page document giving various
concerns, a written document?
WEATHERLEY: Can you show me that?
LANGDALE: It's INQ0002879, page 63. You have been sent these with your Rule 9 but let's
have it on the screen so you can see. This document; remember that?
WEATHERLEY: Yes, I have seen this.
LANGDALE: So we don't need to go through all the pages so you had seen that. Had you seen an
email that was referred to in the hearings about air embolus that was
forwarded to Dr Green from Eirian Powell? It was an email that --
WEATHERLEY: Yes, I have.
LANGDALE: Yes, you saw that?
WEATHERLEY: Yes.
LANGDALE: Then there was another one from Dr Ravi Jayaram to a group of people 9 September; had
you seen that? INQ0002879 0059. It's the smoking gun email. This one, see: "There was ...
no smoking gun to explain the increase in death rate identified. They did acknowledge the concerns
we raised over foul play."
WEATHERLEY: I have seen this, yes.
LANGDALE: You have. So you had seen the emails, you had seen something about staff commonality
and you knew about the review and that being recommended, the forensic review by the RCPCH. Then
you had interview transcripts, didn't you, from a number of people. Did you find them very useful
in terms of answering the grievance or dealing with the grievance?
WEATHERLEY: Sorry, in what way?
LANGDALE: Did you find them very informative and useful the way it had been put together if you
were looking at answering those questions?
WEATHERLEY: I found that Chris or -- sorry, Dr Green, put
the questions, the relevant questions, the pertinent questions of Lucy's grievance to each member
that he interviewed and they answered. Some in terms of my decision-making were definitely more
helpful than others. Some were evasive and clearly not engaging in the process.
LANGDALE: What did you think the questions were that the doctors, Dr Jayaram and Dr Brearey,
needed to be asked to answer that grievance?
WEATHERLEY: In respect of Dr Jayaram and Dr Brearey, they -- they were unclear. They clearly
didn't engage with Dr Green during his investigation and the questions that he put to them were
very different, their responses were very different than the responses as witnessed by other
people's testimonies. They were making accusations that one nurse was responsible for harming --
deliberately harming babies on their unit and, yet, on the other hand in their statements to Dr
Green they said that it was conceivable that the Royal College report could alleviate their
concerns. Now to me, if you are convinced that you have somebody harming babies, how could
anything alleviate your concerns? So what they were saying in those statements was confusing.
LANGDALE: Did you think to ask the Executives that or think to yourself: what is that report
about? The Execs have commissioned it, Alison Kelly was also interviewed. Was that a question that
she should have been asked about, what is that doing?
WEATHERLEY: That is outside the remit of the grievance.
LANGDALE: Right, okay. So let's go to Dr Jayaram interview INQ0002879, page 47. What do you think he is saying in that first paragraph?
We can see it, take your time to read it. What's the level of concern, how would you describe
that?
WEATHERLEY: (Pause) So what he is saying in that paragraph there is that there had been an
increase in the rate of babies dying and they felt that that was outwith the norm. They were
concerned about that. He had clearly been discussing it with other people, there had been some
review undertaken by Dr Brearey. They couldn't see from that review anything in terms of clinical
practice or equipment or other factors that could be relevant to those babies, the increase in
those babies who had died. But there was an association with Lucy either being present at the time
of deaths there or thereafter. Again they discussed it as a group and they were concerned and they
took the
concerns to the Executives.
LANGDALE: He is saying there, isn't he, at the beginning: "The rise in mortality were not the
babies you would have predicted, none of them responded to any resuscitation manoeuvres either."
In other words, these were unexpected and unexplained deaths and when they were resuscitating them
they were doing things you wouldn't expect with a naturally collapsing or dying baby?
WEATHERLEY: He did say that, yes.
LANGDALE: So that is a significant concern, as you said to the police at the beginning one that
you would have said "suspend her, investigate it" if you had seen that early on?
WEATHERLEY: Yes.
LANGDALE: Over the page, at page 48, Dr Green says at the bottom of the page: "So to clarify, was
there any suggestion from any of the Consultant team that Lucy had been deliberately harming
babies? "We discussed a lot of possibilities in private, so that is not a yes or no, we discussed
a lot of possibilities in private and took our concerns to the Executive Board."
You had seen the emails had been forwarded to you by Eirian Powell, she was on that group of
emails as the only nurse, as the ward manager. Their concerns were being discussed in private,
weren't they, between them about air embolus, what was the cause of these deaths, and they were
discussing it, they tell you there, with the Executives. There was no doubt you knew that was
being discussed within the hospital?
WEATHERLEY: They were discussing it in private. (Nods)
LANGDALE: Well, a group of Consultants and Eirian Powell and also the Executives, within the
hospital a number of professionals were involved in that communication and you knew that because
you had seen the email that had been forwarded to you?
WEATHERLEY: Yes.
LANGDALE: Let's go to Dr Brearey's interview, if we can. INQ0002879, page 51. If we go to page 52, to the top of the page. He is
being asked about the redeployment. He says: "It wasn't my decision." It was clearly an HR or
Executive decision, wasn't it, a redeployment eventually? He said: "It wasn't my decision" Did you
understand that the Consultants aren't
responsible for making the redeployment decision, are they? That is an HR decision, an Executive
management decision?
WEATHERLEY: The making of the decision is, yes.
LANGDALE: Then he says: "We had undertaken a thematic review of deaths in 2015 and one that
occurred in January 2016. We wanted to identify common themes linking the deaths." He offered to
send Dr Green a copy of the report. Dr Green didn't take him up on it although he had in fact been
cc'd into it some time before. When you read that, did you think: well, I would like to see what
they have done or what they have got, these doctors who are worried about these things, or not?
Did you rely on Dr Green for that?
WEATHERLEY: Yes, yes. The -- the -- the remit of the confined process, which is a grievance
hearing, is based on the information of the investigation that's before you.
LANGDALE: Here he says: "From memory there were no issues in terms of clinical care. Six of nine
died between midnight and 4 am." For your information, you may know already, Dr Reynolds, a GP,
noticed her patients or those that were looked after by Dr Shipman, there was an increased pattern
that elderly women at home were dying when they had seen by him, didn't know what had happened
when he got there, didn't have any evidence to say what happened when he got there. But she
noticed a pattern that wasn't right and she reported it to the police, there wasn't an
investigation or effective investigation at that time, but there was later when someone else came
forward and had a motive in terms of a will being altered and a death and that was investigated
and so it was Dr Shipman was brought to justice. When you look at this, and he says there is a
pattern, did anything -- did you think anything or was it just another line in a series of
comments? Just think what is he trying to say there, what does that mean or not?
WEATHERLEY: I think in a healthcare environment there are often lots and lots of patterns, there
is lots of things that can contribute to illness and significant deterioration. So in reading
that, he has found a pattern. That's what it said to me, he's found a pattern, one person's view
of a pattern.
LANGDALE: Then if we go to page 54, Dr Green says: "Any discussions between Consultants about air
embolism or twisting of tubes ... no efficient
discussions ... privately, not my place to say." Then the Union rep: "You can answer specifically
only for yourself, you cannot comment on colleagues, only yourself." Does this usually happen
people come with Union reps presumably to grievance procedures when they have been advised?
WEATHERLEY: Yes, that that's normal.
LANGDALE: So you would see that straight away; you have got the soft skills to see that is a
Union rep with them, they are not supposed to be saying things about other people, they are not
going to say that in this situation?
WEATHERLEY: Sorry, say that again.
LANGDALE: Do you pick that up what the Union rep is doing there, tell me what you think is
happening there?
WEATHERLEY: She is just clarifying for him what he can answer.
LANGDALE: What is the impact on what he's saying? What do you think the impact on what he's been
advised on what's going on is there?
WEATHERLEY: Can we -- can we just highlight where the Union rep says that --
LANGDALE: The Union person says you can answer specifically?
WEATHERLEY: Okay, it's just been highlighted, thank you.
LANGDALE: There you go, have a look at that. He is talking constantly just about himself, isn't
he, not anybody else, not speculating about Letby, just answering the questions about himself. Is
that something you recognised when people are in a grievance procedure?
WEATHERLEY: I'm not sure why that person said that other than clarity to him. The question was any
discussions between Consultants and therefore the Union rep was saying: you can only answer for
yourself so not for the Consultants, the group. To me it just read that that was she was
clarifying for him you can only answer for yourself. This is your -- this is your interview.
LANGDALE: Thank you, that can go down now. You get sent the investigation report from Dr Green.
Do you get sent one report or two because we know there is a draft and a second one, presumably
you just get the second final report?
WEATHERLEY: Yes, I just had one.
LANGDALE: So if we can go, please, to INQ0002879, page 221. This has been added since the draft report so this is
his final report. "No party refutes ..."
Can you have a look at that paragraph: "... concerns were raised by the Consultants to the
Executive Team around a perceived commonality between LL's presence on the NNU and the
collapse/deaths of babies. "I acknowledge that these concerns were raised through the appropriate
channels in line with both the Trust Speak Out Safely policy and the guidance proffered by the
GMC. I do not find, however, that the Consultants' concerns when reiterated to the Executive Team
were clear, honest and objective." First of all, they have not been asked anything, have they,
about Speak Out Safely policy and how they have raised concerns with Executives, that is not part
of the grievance, is it, you are not really looking at that?
WEATHERLEY: I think there was a question that Lucy asked about it so that was in respect of one of
the questions.
LANGDALE: Shall we go back to the questions and tell me which one you think that was in a moment.
Give me a moment. So you thought that was relevant. Did you think that was something you needed to
look at?
WEATHERLEY: Sorry, can you just go back to the question that you are asking me, so which part of
that highlighted paragraph?
LANGDALE: The whole paragraph. Just what do you think that paragraph is saying?
WEATHERLEY: Well, that's confirming, isn't it, that nobody through the investigation was refuting
that the Consultants raised concerns about -- about Lucy having been commonality.
LANGDALE: What about that it had been done in line with the Trust Speak Out Safely policy?
WEATHERLEY: Yes, in that they had taken those concerns to their line management. But in this case
they took them to the Medical Director and the Executive Team.
LANGDALE: Mmm mm. But the next bit: "I don't find the Consultant concerns when reiterated to the
Executive Team, were clear, honest and objective." They were never asked in the interviews, were
they, about whether communicating with the Executives -- about that?
WEATHERLEY: Sorry, I am not -- I am not following your questions.
LANGDALE: What do you think that means, what does that mean: I do not find the Consultants'
concerns when reiterated to the Executive Team were clear, honest and objective.
What does that mean?
WEATHERLEY: In that they, they didn't give them the full picture of the reasons that they were
concerned. So through the evidence of statements that -- of other people that were interviewed as
part of the process including the Executives, beyond the commonality and gut feeling and having a
drawer of doom, there was nothing else that they shared and if they genuinely believed that there
was somebody murdering babies on their unit, they had a professional duty to call in the police.
They didn't do that and they were putting pressure on the Executive Team for Lucy to be removed
off the unit. That's not how you deal with somebody who's murdering children and therefore their
concerns when raised to the Executive Team didn't go through any of that. They didn't share with
them what their genuine concerns were.
LANGDALE: Dr Reynolds phoned the police --
WEATHERLEY: They had a commonality.
LANGDALE: Dr Reynolds phoned the police when she was concerned her patients had died and it was
an unusual pattern. Everybody that you interviewed knew about that pattern and you said to the
police you thought the police should have been called -- you said they should have been called in
at that time.
So where do you get to here when you say "only gut feeling and commonality, why aren't you saying
they are murdering babies?" How can you assert murder until there has been a proper investigation
of those suspicious circumstances? Who could possibly have said that at that time?
WEATHERLEY: But that's what they were saying. They were saying we -- we are concerned that Lucy is
deliberately harming babies.
LANGDALE: They hadn't said murder, though, had they? And you are criticising now in your answer,
you just said if they thought she was murdering babies, they should have said that. How could they
possibly say she is murdering babies at that time?
WEATHERLEY: Harming babies, they -- they were making reference to her as "the murderer".
LANGDALE: We will come on to that. We will come on to why you say that. But they had very
clearly, in the email you saw from Dr Ravi Jayaram, saying they suspected foul play, that was
clear to you, that is what they said: foul play. What does suspecting foul play mean?
WEATHERLEY: In Dr Jayaram's statement when he was asked about foul play in respect to Lucy Letby,
he said there was none and that that would be speculation.
LANGDALE: He said that was speculation but you saw emails that had gone between a number of
senior clinicians and Execs saying "suspected foul play". Did you put your common sense reality
hat on when he said that would be speculation and think: I have seen all of this, they clearly
think she is doing something wrong, but they are not saying it's murder. That is what was
happening wasn't it?
WEATHERLEY: They -- they weren't giving any other information. They didn't give it to the Trust
and the Trust were very clearly broadcasting that there could be some personal motive to this.
They didn't understand because there was no material evidence that was provided by any of the
Consultants, but particularly Dr Brearey and Dr Jayaram, that there was any link to Lucy causing
deliberate harm to the babies. So the Trust were suggesting well, what other motive could they
have? And is there something personal here and that was the broadcast that was coming across to me
in reading this.
LANGDALE: It was and you took it, you accepted it?
WEATHERLEY: And the Consultants -- and the Consultants in their own statements said that there was
a possibility that the outcome of the Royal College review could alleviate their concerns.
LANGDALE: The Execs said that too?
WEATHERLEY: So that was confused --
LANGDALE: The Execs said that; did you realise that?
WEATHERLEY: Sorry?
LANGDALE: Did you realise that the Executives thought that that review could alleviate concerns,
they commissioned it; did you realise that?
WEATHERLEY: They did, but I am just making reference, sorry, to what the Consultants said in their
statements.
LANGDALE: Yes, that is my point about this paragraph before we go back to the grievance. This has
suddenly been added to your grievance, communications between doctors and Consultants and whether
they were clear, honest and objective and whether they weren't saying she is a murderer loudly and
clearly to them and how she had done it. That appears there. If we go back to the grievance, INQ0002879, page 3, holding that paragraph in mind, can you help us with
which question that was answering on page 3? There is the grievance.
WEATHERLEY: I think it is in respect to I am now aware some Consultants have raised issues to the
Trust Executive Team.
LANGDALE: "I wish to know what these allegations are and how they are dealing with them."
Yes?
WEATHERLEY: Yes.
LANGDALE: So what have the Consultants said and what are the Trust doing and you find in the
report a suggestion that they have been treated properly with Speak Out Safely policy by the
Executives and they haven't been clear, honest and objective in communicating their concerns with
the Executives. What Letby's grievance asked for is what are the concerns, what are the issues,
doesn't she? So paragraph 1 of Dr Jayaram's interview would tell her although she knew already
what the issues were?
WEATHERLEY: Yes.
LANGDALE: So looking back at that added paragraph we have gone to, you didn't know it was added,
but did you focus on it -- probably not as much as we are now -- when that came to you as a
report, or did you just see that as a paragraph within the investigatory report?
WEATHERLEY: I agreed with that when I read that.
LANGDALE: You actively agreed with that?
WEATHERLEY: In reading all of those other interviews that the investigator led.
LANGDALE: Let's go to the hearing itself, please, INQ0003155, page 1. How long did it last while we are getting it on the
screen, roughly?
1 December 2016, we know it's 10 o'clock start, roughly do you think when did you finish it?
WEATHERLEY: It was late after -- well, sort of maybe 3ish, 4ish, it was later on in the afternoon.
LANGDALE: So Dr Green, you, Deputy HR Director. We should include her as a panel member from what
you said earlier, yes, or helping you on the panel?
WEATHERLEY: She was with me on the panel.
LANGDALE: She was the panel as well. So the Trade Union rep, Letby herself, Sementa, the HR
specialist, and then this notetaker. Mrs Appleton-Cairns explains the meeting: we are here to hear
the grievance raised regarding her redeployment. Annette Weatherley was there to hear the
grievance and that she would be supporting. So Mrs Appleton-Cairns is supporting her, so providing
you with information, but you are the arbiter, are you, the independent arbiter; would you agree
with that?
WEATHERLEY: Yes.
LANGDALE: Dr Green asks how would you like to go through this. You say the conclusions to your
report that Lucy Letby raised you ask him if he scrutinised the off-duty or looking to the word of
others. What were you thinking there?
WEATHERLEY: That was the off-duty in respect to whether
Lucy could be supervised on the unit, the supervision of her practice.
LANGDALE: To see how often she was on duty when deaths occurred or something else?
WEATHERLEY: No. The -- the decision by the Trust team was that she would stay on the unit but she
would be supervised and she would redo her clinical competencies.
LANGDALE: Right.
WEATHERLEY: The reason -- the reason that was suggested through the investigation that that didn't
happen was because there was not enough staff to support supervision. So my question there was:
well, did you scrutinise the off-duty to come to that conclusion or was that what other people
told you?
LANGDALE: Right and I think later on, you amend that and say because you hadn't seen the evidence
to see they didn't have people to supervise, you would have preferred to see that before you said
she was supervised?
WEATHERLEY: Sorry.
LANGDALE: You would like to have known as a fact whether it was the case they didn't have enough
staff to have done that?
WEATHERLEY: They -- well, the nursing rota some of those rotas were in the pack and when I had
looked at it, whilst I am not a neonatal nurse and so I am not overly familiar with the neonatal
nursing safe staffing numbers, it appeared to me that she could have been supervised on unit, it
appeared to me that there were sufficient staffing. But again I am not a specialist neonatal
nurse.
LANGDALE: Please can the questions, you say further down, just be for clarity at this stage.
Going into it at that point did you need further clarity, you had obviously read something but not
--
WEATHERLEY: So just in respect to this, this is not a full chronology transcript of the -- of the
event. I did say that in my original statement to the Inquiry. It doesn't flow. There was
representation from both Lucy and her representative in respect of the grievance and there was
also representation made by Dr Green in his investigation and then thereafter there were questions
and the questions do not flow, so I am concerned that this is not an accurate --
LANGDALE: It is not complete, is it?
WEATHERLEY: -- record. No, it is not.
LANGDALE: Often they are not. So when we go to a question you think it wasn't said, please say
so. Dr Green hasn't challenged anything that has been written in it, but, you know, there may have
been more
stuff that you want to tell us about as we go through it. The issue you are exploring is who she
was told at this point not to speak with. So Letby says that Eirian Powell, if we go halfway down,
"she was told not to speak to me". This is the question about whether she was told there was no
contact. What did you understand the evidence was around whether she could contact people on the
unit?
WEATHERLEY: It was within the statements. The evidence was within the statements so I understand
that I think it was Karen Rees who said that she had advised her of that, but that's not what she
actually meant in that from a professional perspective, she had said not to go to the unit, not to
speak to people, but she hadn't meant that socially.
LANGDALE: Because Letby herself had said she felt isolated and not supported, that was upheld,
wasn't it, in the grievance; that she was isolated and unsupported and Karen Rees' communication
had been miscommunicated effectively, that she could speak to other people. That is where that
ended up, wasn't it?
WEATHERLEY: I would have to go back to -- go back to the grievance. So which, which --
LANGDALE: We will go to the grievance and see you upheld that.
WEATHERLEY: Okay.
LANGDALE: That's something that you accepted, that it wasn't deliberate by Karen Rees?
WEATHERLEY: Yes.
LANGDALE: But that Letby was isolated and vulnerable and wasn't feeling --
WEATHERLEY: That is how she felt, yes, that that made her vulnerable.
LANGDALE: On page 5, Dr Green discusses the second question: "This was discussed with the exact
nursing team. The Trust made the decision to redeploy Letby. I agree that Letby had a right to
know about this and the Trust had not been open and honest with their communication." You agreed
with that and that was right, wasn't it, you told the police that when you first spoke to them
they should have told her what they were doing?
WEATHERLEY: Sorry, could I just take a second to read it?
LANGDALE: Of course, yes. Page 5, have a look there.
WEATHERLEY: So I need to go back to what the original question was in the conversation.
LANGDALE: Dr Green is telling you there, isn't he, that Lucy Letby --
WEATHERLEY: Her second question of the grievance.
LANGDALE: Okay.
WEATHERLEY: This is discussed with the Exec nursing team, can you just refresh me what the second
question was?
LANGDALE: The second question was: "The reason for me being instructed not to have contact with
my NNU colleagues for an extended period of time." So it's not strictly limited to that question.
But he's making the observation to you there that she wasn't told fairly about an allegation and
concerns --
WEATHERLEY: Yes.
LANGDALE: -- about harming babies?
WEATHERLEY: Yes.
LANGDALE: Yes, and you upheld that and that was the case when you listened to that evidence,
wasn't it, she hadn't been told that directly?
WEATHERLEY: No, she hadn't.
LANGDALE: The Inquiry knows of course Mrs Griffiths had told her, her Union member, but the point
is the Trust hadn't told her in letters?
WEATHERLEY: No, they hadn't.
LANGDALE: So although she knew it, the Trust hadn't communicated that. If we go to page 7,
please. We see at box 4 Dr Green on that point says about the email that went out to explain the
redeployment: "The Executive Team have worked hard to keep any secret in hospital and they were
careful to say anything deliberate or confidential, however it is hard to keep any secret within
the hospital." That was difficult, wasn't it? Mrs Griffiths told us that she had moved and of
course people in a hospital, in a small hospital, are very interested in why people are moved and
what's going on, aren't they? Would you agree with that?
WEATHERLEY: I guess so.
LANGDALE: "In terms of confident [I think that must mean 'confidentiality'] other people [two
boxes down] heard the words 'baby killer' and were associating Letby with these comments." Yes,
that is your ... The Union rep says two down: "The Consultant made the comment 'baby killer',
however provided no name." So the Union rep says Letby's not been named as the murderer or the
baby killer but they have said a comment but provided no name for who it is. Do you see that?
WEATHERLEY: Yes.
LANGDALE: Further down, you say:
"[Your] investigation is clear: were the team aware she deliberately set out to harm babies when
the Executive and Management Team have no allegations towards this?" Dr Green says yes, but no
evidence to suggest this is the case. Both of you, Dr Green and yourself, at this point, are
saying the Consultants have no allegations towards this. They have in the interview, Dr Jayaram
and Dr Brearey, set out the commonality of her presence with sudden and unexpected deaths that
they cannot medically explain and the children don't respond to resuscitation in some cases as you
would expect. They had set out their allegation, hadn't they, their suspicion of foul play?
WEATHERLEY: They hadn't made an allegation, they were suggesting that there was a commonality and
they both say that in their interview transcript as part of the investigation.
LANGDALE: So you didn't see that as an allegation or suspicion?
WEATHERLEY: I think the -- the investigation that Dr Green did which is the information that I
had, he had asked the question were there any allegations, specific allegations, and the response
from both the Consultants
and equally from the Executive Team was there was no allegations.
LANGDALE: If we go over the page, at page 9, Dr Green in that first box at the top says: "A very
complex situation, the suggestion that something could happen with the babies and the Trust were
not open and honest. To remove Letby, stop the police would have meant an arrest which would have
been damaging to Letby." And the Union rep says: "Damage to Trust too, they were protecting
themselves as this would have been in the paper." So at this point, the discussions around
openness and honesty are about the Executives being or HR being honest and open with her about
redeployment, aren't they?
WEATHERLEY: Yes.
LANGDALE: That is what matters here, she's been redeployed and no one has told her in a letter
why.
WEATHERLEY: That that's correct.
LANGDALE: That is the issue. If we go to page 13, Dr Green at the top: "Unit downgraded from a 3
to a 2. Escalated to the RCN. Letby well thought of, quality of her care. In my chat with the Exec
Team they want to see her back. The
Consultants will have issues with that, however the Exec Team need to deal with that." Pausing
there. Did Dr Green or anyone ever tell you about this Silver Command and 36 of them being in a
boardroom and being given different tasks and things to look at, like commonality?
WEATHERLEY: No, he didn't.
LANGDALE: And that he himself had been asked to take some samples in relating to two of three
Triplets that we now know two were murdered, he had to take and store TPN bags in case they could
be used?
WEATHERLEY: No, I didn't.
LANGDALE: You didn't know any of that?
WEATHERLEY: No.
LANGDALE: So he says this to you, they want to see her back and the Consultants will have issues.
You then say further down: "The Trust are already making plans and Letby says the Trust are
waiting for the report before they will confirm." Now, that is not the RCPCH report, that is the
second report. We know it as Dr Hawdon's report, but the forensic review. Is that what you
understood or did you not know which reports were? You have referred to two but I don't know if
you know what they were?
WEATHERLEY: I don't know which report she was referencing there but I think that she was talking
about the Royal College report because that's what I think she understood the Trust were telling
her they were waiting for.
LANGDALE: And yet as you had picked up, that was never going to answer the question, was it?
WEATHERLEY: No.
LANGDALE: Whether she had murdered babies, if that was going to be the question. But in fact what
the doctors were saying: we have got concerns, we are suspicious, we can't explain it, it needs
proper investigation. Do you agree, did you get that sense that that's what was needed?
WEATHERLEY: I got the sense they were saying that on the one hand but then on the other hand they
were saying that there is a possibility that the Royal College report could alleviate their
concerns. So it was a confused message from the Consultants that I was getting within this report.
LANGDALE: It is a confused picture by the time of this hearing of the grievance, isn't it?
WEATHERLEY: It is all confused.
LANGDALE: You are then moving to different -- when we deal with that honesty and openness it is a
totally
different issue that lands in the report or in Dr Green's investigatory report, do you agree, it
is not the issue that you are discussing here?
WEATHERLEY: Yes.
LANGDALE: At page 15, Letby says halfway down: "I have gone through all of this on their word
..." This is the Trust's words supporting her to go back what she has been doing. It's Mrs
Appleton-Cairns who says "Mediation?"
WEATHERLEY: Yes.
LANGDALE: Was that the first time that was suggested by her?
WEATHERLEY: Yes.
LANGDALE: She says, "Mediation?" and you said: "Do you feel strong enough to discuss this with
them?" She says: "I want to go back to work, yes." Had she mentioned to you that she was going to
suggest mediation before?
WEATHERLEY: No.
LANGDALE: So it cropped up in the meeting, said to Letby. She says when you ask her: "Well, how
will you feel? The nature of the work
on the unit, there will be deaths. How will you feel when that happens?" She says: "I would want
assurance that this wouldn't happen again." What did you think that meant that she wouldn't be
redeployed if there were deaths or anything else happened again?
WEATHERLEY: Yes, that's what I took that to mean.
LANGDALE: So she wanted to be back on the unit. We know through her member was requesting without
restrictions and she didn't want -- she's telling you here -- anything like this, assurances that
if a baby died or she was there when there's deaths that this would happen again, that she would
be redeployed?
WEATHERLEY: Not necessarily that she would be redeployed but the chaos, the mess that this was and
how she had been handled wouldn't happen again.
LANGDALE: Over the next page at 17, reference from you: "Everyone should be culpable." And the
Union member says: "The Trust have been held to ransom by two Consultants." Then he is saying --
well, actually Mrs Appleton-Cairns says:
"I am hearing what you say but I am wanting to know from Letby what comes next." He says: "You
tell me, Dee, what will be done to the Consultants?" "We don't know." You say: "Policy gives the
process for bullying and harassment." He says: "I can't stress enough you need to deal with them."
Mrs Appleton-Cairns says: "It's also what LL wants." Letby says: "It's nice to be asked as no one
has." Lucy Sementa: "Shall I explain what will happen when there is a return to the unit?" Mrs
Appleton-Cairns: "We can agree some more wording, suggest that Ruth Millward does an email to say
it was positive and to thank her for her hard work in the department." Pausing there. You comment
to the police about your view about her being placed in the Risk and Safety Department. What did
you think about that, that that was where she had been redeployed to, given the circumstances?
WEATHERLEY: In these circumstances, that was a highly inappropriate place to position her, in my
view.
LANGDALE: You say that, don't you, to the police of all the placements. Lucy Sementa says: "They
were the only two that showed no empathy." This is the Consultants. You say: "I believe the
staffing issue was a red herring. There is no difference between July and August and the evidence
supports this." In this hearing, it's also the case, isn't it, that at one point Dr Green says: "I
believe the two Consultants lied. I believe they lied." Do you remember?
WEATHERLEY: He did yes, he does.
LANGDALE: He did say that, didn't he, and he said yesterday if he had seen those minutes he would
have -- or notes -- asked it to come off because it was an off-the-cuff remark. But the fact is
you were the hearing adjudicator and the investigator says: "I believe the Consultants lied."
WEATHERLEY: Yes.
LANGDALE: When the investigator said that to you, what weight did you place on that?
WEATHERLEY: I could see why he had come to that conclusion. If you -- in the statement that I
provided I'm not sure which section it is, but I highlight the sections from everybody who was
interviewed, the elements that are relevant to why I considered that that was perhaps a fair
comment. I'm not sure which section it is in the actual statement.
LADY JUSTICE THIRLWALL: We will take you to that and have a look.
MS LANGDALE: We can go to your statement for that. It starts at paragraph 55. You say at
paragraph 55, this is about the honest, open and objective: "It was clear to me that these
standards were not reflected in the way the Consultants were behaving. The gravity of the
allegations being made by the Consultants was not reflected in their interviews with Chris Green;
there was suggestion by managers of Consultants having redacted relevant medical staffing
information prior to share with the Executive Team; interview transcripts evidenced a lack of
respect and the way in which the Consultants responded to and behaved towards
Chris Green, the investigating officer, was neither transparent, honest or respectful." So in
terms of the staffing information, you knew that Eirian Powell had added doctors because she tells
you in that long list and that that list of doctors didn't appear in another iteration or version
that was sent, so you are referring to that, something she had told you about --
WEATHERLEY: Yes.
LANGDALE: -- in that written material? Did you ask Dr Brearey about that? We know you didn't
looking at the transcripts that wasn't put to him, where are all the versions, although he offered
to send you the mortality review, didn't he?
WEATHERLEY: Dr Brearey?
LANGDALE: Yes. Dr Brearey in his interview said you can -- to Dr Green: why don't you have -- do
you want the copy of the mortality review? So you could have followed up, couldn't you, the point
about where doctors appeared and where they didn't appear and the many versions of the table if
you were interested in that.
WEATHERLEY: I don't think that -- again, my role was not to do any investigating into those
circumstances. It was to hear the grievance.
LANGDALE: You relied on what Eirian Powell had told you
about that?
WEATHERLEY: That she had the doctors on there and they had been removed.
LANGDALE: And yes, and they had been removed and you say that wasn't transparent?
WEATHERLEY: It was Eirian said it and it was also Ian Harvey and Alison Kelly.
LANGDALE: So Ian Harvey, Alison Kelly. You also say at paragraph 56: "Upon reviewing the
grievance investigation pack there were several interviews who stated their belief that this was a
witch hunt against Letby ... there was no evidence to support the allegations being made by the
Consultants which were purely circumstantial. The findings from the internal and external reviews
commissioned by the Trust had made no reference to any matters of foul play surrounding the
increase to neonatal mortality at that time. Despite the Trust informing the Consultants of the
findings of these reviews the Consultants continued to openly refer to Letby as the 'angel of
death', 'murderess' and 'baby killer'."
WEATHERLEY: Yes.
LANGDALE: You thought those two Consultants had done that?
WEATHERLEY: Were calling her names?
LANGDALE: Yes.
WEATHERLEY: Did I think that?
LANGDALE: Yes.
WEATHERLEY: According to the statements within the investigation, yes.
LANGDALE: So your impression from the combination of nurses who had given you information and Mrs
Appleton-Cairns and the others, that the two Consultants had openly referred to Letby as the
"angel of death", "murderess" and "baby killer"?
WEATHERLEY: Yes. In certain environments and meetings I believe that that's what the people -- a
number of people who were interviewed have disclosed in their interviews to Chris.
LANGDALE: Well, the Inquiry has heard all evidence from everybody where those remarks relate, so
thank you, we have got the primary material for that. But "openly", what did you mean
"openly"?
WEATHERLEY: In meetings and on corridors, I believe, but I think that was more the junior doctors
that had been overheard in public areas.
LANGDALE: I think Eirian Powell had told you about Nurse T and she had said that he had made some
comment that had worried her about coming to work and linked to
baby death; do you remember that?
WEATHERLEY: Yes, it is in a statement somewhere.
LANGDALE: You of course didn't have the benefit of hearing from Nurse T and what she said she did
in fact hear or know because you just relied on what you were told by Eirian Powell for that?
WEATHERLEY: I was relying on what Dr Green had said in his investigation. It was more than Eirian
Powell's, it was in numerous statements, those comments.
LANGDALE: You continue in this statement to the Inquiry, paragraph 57: "On the face of it, these
actions did present by the Consultants as a witch hunt against Letby in that she appeared to have
been singled out by them because of 'commonality' and 'gut feeling'. Had they genuinely believed
these concerns, I would have expected them to raise it immediately with the police. Instead, they
called Letby names in public spaces and were reluctant to explain the rationale for her being
singled out during the interviews with Chris Green, even though other individuals appeared to
share commonality, including medical staff." Is that what you thought around the indictment
babies, was it your understanding that other people shared commonality across the babies that were
murdered?
WEATHERLEY: Sorry, I couldn't quite hear?
LANGDALE: Did you understand --
LADY JUSTICE THIRLWALL: Sorry, just wait. Are you all right? Let's ask again.
MS LANGDALE: Did you understand that to be the case that other medical staff had the same level
of commonality across the murdered and deteriorating, unexpectedly babies?
WEATHERLEY: Not the same level but there was a concerning level of commonality with other members
of staff as well from the investigation and Dr Green.
LANGDALE: Again, did you rely on Dr Green for that?
WEATHERLEY: That was my role, to rely on that investigation.
LADY JUSTICE THIRLWALL: A concerning level of commonality?
WEATHERLEY: Sorry?
LADY JUSTICE THIRLWALL: Did I hear you correctly, a concerning level of commonality?
WEATHERLEY: There were other people whose name, whose commonality flagged as being, yes, worthy of
--
LADY JUSTICE THIRLWALL: Being what? Of concern.
WEATHERLEY: Concern at that time in the -- in the investigation. I think there were a number of
doctors
who were named in some of the statements.
LANGDALE: Those are the reasons you give in your statement for supporting the suggestion there
wasn't honesty and objectivity by the Consultants. Is there anything else, have I missed anything
else?
WEATHERLEY: Everything that I said in my statement was the reason that, yes, I came to that --
LANGDALE: We have gone through that then. You also say at paragraph 60 and 61 -- it may be
helpful to have it on the screen rather than me read it out -- of your statement INQ0102370 [not
found] 0026, you set out what you said to the police earlier, really, at 60 and 61. (Pause) You
also -- I am just interested in the CQC and the NMC there. What would you say at that time if you
had been presented as an Exec Team member, what are you saying you would communicate with the CQC
and NMC about?
WEATHERLEY: So that would be usual practice, if you were suspending somebody pending an
investigation. You would advise the NMC that their member, you know, a registrant was being
suspended and you would also advise well, I would also and always have advised the CQC that there
was an allegation of concern that had resulted in somebody being suspended pending the
investigation.
LANGDALE: You also that can go down now but just for your benefit, at page 27, Mrs Weatherley,
you also make clear in your statement: "As the independent chair of a grievance hearing I was in
no way involved personally in any investigation into either Letby or the deaths of babies on the
neonatal unit." That's right, isn't it?
WEATHERLEY: Yes.
MS LANGDALE: You weren't, you were coming in to deal with that and weren't putting that evidence together. Can we just finally go to -- we know you had the final report from what you are saying, can we go to the letter. My Lady, I see the time, I don't know if I need to stop now, I have probably about another 10 minutes but I am conscious we have been going for an hour and a half?
LADY JUSTICE THIRLWALL: What is more convenient, would you like a break of about 15 minutes or
would you not? You are not bothered one way or the other.
WEATHERLEY: I am okay if you want to continue.
LADY JUSTICE THIRLWALL: Do you want to continue or shall we take the break?
MS LANGDALE: No, very happy to continue.
So we then come to your response to the grievance and we see your first letter INQ0056139, page 1. So you do this letter afterwards, this is your first
draft of this. You set out question number 1. You say about the supervision of practice "I
conclude in reviewing the staffing rotas these do appear to support the supervision. I accept
there may have been a challenge with skill set. However, numbers available according to the rota
demonstrated that this was available, so you support this part of the grievance." Were you meaning
there -- well tell us what did you mean there?
WEATHERLEY: The number of staff working at that time on the unit that would therefore support Lucy
being supervised.
LANGDALE: So you thought she could have been supervised and stayed on the unit if staffing?
WEATHERLEY: I did.
LANGDALE: So you upheld that wasn't a good enough reason not having staff to supervise her, not
to have her on the ward if that was the decision?
WEATHERLEY: Yes.
LANGDALE: Number 2, you set out there as we have referred to earlier miscommunication and
misunderstanding. So Karen Rees hadn't intended to
exclude her but it had left her being isolated believing that she couldn't speak to people and you
being told by her that Eirian Powell was told she couldn't speak to her?
WEATHERLEY: Yes.
LANGDALE: Question 3. We see the question and see your answer. You say you believe that the
Executive Team could have been more open and honest and communicated with her in a more regular
and coordinated way; they acted within the best interests. Were you aware how regularly they were
meeting with her and her parents on some occasions and how many members of staff were actually
keeping in touch with her?
WEATHERLEY: Only from the emails that were contained within the pack.
LANGDALE: Right. You say at number 4 "I would like the Trust to outline to me how its values,
such as being open and honest, have been adhered to" and you say "I fully support the conclusion."
Open and honest about what were you supporting the conclusion in respect of each other, in
relation to the redeployment or what?
WEATHERLEY: So can we just go to what Chris had said in respect of point 4 in his investigation.
That is what
I agreed with, but rather than reiterating all of that I was just saying that I upheld that.
LANGDALE: So if we go back then to INQ0002879 0217. We will have it in a moment. Take your time to have a read
of that. (Pause)
WEATHERLEY: Was it on the next page?
LANGDALE: Yes, it is on there and the next page as well at the end of page 18. We see that last,
"I recognise the board have found themselves in a difficult position, but I conclude the Trust
have not been honest and open in relation to the circumstances surrounding her redeployment."
WEATHERLEY: Yes.
LANGDALE: That is what you were meaning by honest and open.
WEATHERLEY: Yes.
LANGDALE: It was about how that was communicated. That can go down now, thank you. Again, you
support number 5: "Wish to be informed of any evidence." What actually you conclude and support
his findings, what he has said, I can read that to you because it is shorter at INQ0002879, page 218, "Dr Green had said during the course of this
investigation I have not been made aware nor has there been any allusion to any evidence relating
to any alleged wrongdoing by Letby. There has been repeated reference to a commonality between the
dates and times that Letby was on duty and the collapse death of a significant number of the
babies, but there's nothing to support that there is additional information or data beyond this
and that has not been shared with LL." So you support that part of the grievance.
WEATHERLEY: Yes.
LANGDALE: You support number 6, assurances from the Executive Team that this has been dealt with
appropriately. This is Mr Harvey having said that he had spoken to the Consultants or spoken to Dr
Jayaram about the concerns and comments that had been made. If we have a look at 0219, the second
paragraph. Have a look at that. "Obvious concerns regarding the alleged comments made but IH, Ian
Harvey, stated this has been addressed and there is no suggestion of any similar remarks being
made following this. Critically these did not name Letby and were not directly heard by any of the
individuals interviewed as part of this process." So you say you had relied on interviews, but Dr
Green in terms had said she was not named and not heard directly by anyone interviewed. And in
this paragraph you say you support that conclusion.
WEATHERLEY: Yes.
LANGDALE: Indeed they are saying to you or Eirian Powell's document refers to people saying but
nobody interviewed had heard anything openly and said that they had by who?
WEATHERLEY: I think they had. I think there was a number of people that had been in a meeting
where one of the Consultants had said "You're harbouring a murderess" and there was another
meeting.
LANGDALE: That was Eirian Powell saying that?
WEATHERLEY: In a meeting. A few of the people interviewed were in that meeting and there was a
couple of other meetings where Stephen Brearey, I think, had referred to her as the angel of death
and that was heard and that was somebody saying that he had said that to her. That might have been
Eirian. I can't remember without having all those statements in front of me, but it in was a
number of statements that people did say they had heard her.
LANGDALE: When you say statements, the interviews we have read together, the transcripts?
WEATHERLEY: Yes sorry the statements provided to the investigation.
LANGDALE: So we have got all of the documents that you had at the time?
WEATHERLEY: Yes.
LANGDALE: But interestingly you see the point, he is saying that, that is his conclusion, but at
paragraph 6 you seem to be agreeing with that conclusion that I have just read to you.
WEATHERLEY: Mmm.
LANGDALE: That they didn't name Letby, were not directly heard by any of the individuals
interviewed as part of this process and he wasn't particularly when he gave evidence engaged on
that topic.
WEATHERLEY: Okay.
LANGDALE: In other words, it wasn't a big feature for him when he had seen what Mr Harvey said
and everybody else had said, but it seems that was a big thing for you, your impression of
that?
WEATHERLEY: I think the names that we used in reference to Lucy by doctors in environments such as
meetings with other members of staff, so they had private meetings, yes, and there were meetings
that were not private meetings where these names were referenced, when in fact they were aware
that she had no knowledge of any of this that was going on, so that was behind her back. They also
had not gone to the police in respect of their concerns. So how seriously did they take their
concerns when
they were also considering the Royal College report might alleviate their concerns, but yet they
were calling her names behind her back. So I considered that to be unprofessional behaviour and
that's why that particular aspect of the investigation was of concern to me to your point.
LANGDALE: It's just that you haven't expressed that at paragraph 6 the difference of opinion or
set out your evidence for that. In fact, you have just contradicted what you have said now because
you said you supported what he said?
WEATHERLEY: Sorry, paragraph 6.
LANGDALE: Yes. Your answer at 6, if we go back to your determination. INQ0056139, page 2, you support what he said. I have just told you what he
said. There is a difference between you. So that was an error, was it, the way that's been
communicated there? See how you say you fully support his conclusion and uphold the part of the
grievance, whereas he had said, "I conclude the Trust has not failed to protect her
confidentiality with regard to the circumstances regarding her redeployment." So you are at
complete odds there, you and the investigating officer.
WEATHERLEY: I think it was she's asking for assurance that it is being dealt with appropriately.
And Chris had spoken to Ian Harvey who had given him the assurance that he had spoken with the
doctors and it would not happen again. I think that's what I am referencing in terms of upholding
I agreed with what Chris has said there.
LANGDALE: Because Mr Harvey has spoken to Dr Jayaram about?
WEATHERLEY: Who said about all of the doctors, it wasn't just him specifically who had given him
assurance it wouldn't happen again and he agreed it was unprofessional.
LANGDALE: And you still were of the impression it was Dr Brearey you thought, not Dr Jayaram who
had said something?
WEATHERLEY: Sorry.
LANGDALE: You were still under the impression it was Dr Brearey not Dr Jayaram who had said
something?
WEATHERLEY: They both said things.
LANGDALE: You thought both, from the evidence we have seen?
WEATHERLEY: In the investigation.
LANGDALE: Okay. Number 7, "I would like to know what I have been accused of." Again, you agree
with Dr Green. And number 8, we have got the reports, we can see where the agreements are and what
they both say,
Ms Weatherley, so I don't need to take you through them all. "And how will the Trust support me"
and you set out here, this is what you have concluded and determined: "The CEO and the
non-executive team as a Trust board to apologise in the presence of her parents." Why did you
think she needed to be apologised to, firstly, and, secondly, in the presence of her parents?
WEATHERLEY: So the apology was in respect to how she had been treated. The Trust hadn't followed
their own policies in as I had said what I would have done at the beginning which would have been
back in 2015 to suspend and then obviously pending investigation. But they hadn't communicated
with her. She didn't know what was going on and it was as if they were managing her against the
disciplinary policy but they had not actually told her that. So the redeployment she wasn't clear
why she was being redeployed. The information that she would redo her competencies and be
supervised but nobody else was and she didn't understand why that was, so I think it the whole
situation was chaotic and they didn't manage her very well at all and that's why I felt that they
needed to apologise for that.
LANGDALE: Who's "they" who did you want to apologise to
her?
WEATHERLEY: So the Executive Team who her grievance was against.
LANGDALE: So those --
WEATHERLEY: That was the first -- so they needed to apologise. The apology in respect of the
Consultants was as I described in your previous question in respect of them calling her names
without material evidence, when they knew that she wasn't aware of what they were saying or what
was going on.
LANGDALE: So you wanted them to apologise for calling her names?
WEATHERLEY: That was the Consultants.
LANGDALE: Right. And yet you hadn't asked any for them or either of them directly if they had
called her names or a murderer?
WEATHERLEY: That was not --
LANGDALE: Just pausing there, but they had to apologise for that, whether they had done that or
not; is that what you thought?
WEATHERLEY: So the information contained within the investigation, with the statements of
interview said that and that's what I had to work with as the grievance manager.
LANGDALE: The allegation was Dr McCormack, an
obstetrician --
WEATHERLEY: That was one of them.
LANGDALE: -- had said in a meeting, not Dr Jayaram or Dr Brearey; there is no allegation in
there. By all means take your time.
WEATHERLEY: Of them calling her names?
LANGDALE: Yes, those two. I am asking about those two.
WEATHERLEY: Yes, I believe that Dr Harvey spoke with Dr Jayaram about a comment that a name that
he had called her. Dr Jayaram agreed he had called her the name and said it was inappropriate.
LANGDALE: That is what you understood Ian Harvey had said?
WEATHERLEY: Yes, in the statement.
LANGDALE: Okay let's see what Ian Harvey actually says about that. If we go to INQ0002879, page 9. Go to page 10 of it, so INQ0002879, page 10. If we go down to that box near the bottom: "I wasn't
aware of that. There has been a number of behaviours on the ward that do not reflect too well. I
had to go -- to go and speak to Dr Jayaram that some of the trainees had been making reference to
angel of death, but no specific person was named. There was behaviour in clinic being heard
talking about killing babies on the unit. I had to speak to Ravi about comments about killing
babies. This was not denied and RJ did accept that it was inappropriate." You took that to mean
that Ravi Jayaram had been talking about killing babies openly on unit, did you, and that Dr
Jayaram had been spoken to in those terms by Mr Harvey?
WEATHERLEY: There was that and it was also in somebody else's statement. I think I reference it in
the statement to the Inquiry. I'm just not sure which point it was in my statement.
MS LANGDALE: My Lady, it may be a good moment to take a break so the witness has time to find that.
LADY JUSTICE THIRLWALL: Certainly.
MS LANGDALE: If we resume at midday.
LADY JUSTICE THIRLWALL: We will take 15 minutes and start again at 12 o'clock.
(11.43 am) (A short break)
(12 noon)
MS LANGDALE: Ms Weatherley, is there anything after the break you want to specifically refers us
to from your statement about Dr Jayaram calling Letby a baby killer in the ward?
WEATHERLEY: Sorry, I didn't quite hear the start of the question.
LANGDALE: About Dr Jayaram calling Letby a baby killer; is there anything you specifically want
to take us to in your statement having had the break dealing with that point?
WEATHERLEY: Sorry, it wasn't my statement I was referencing. It was the statements contained
within the investigation.
LANGDALE: Okay I can take you to those then. Let's go to what they say unless you can remember
one specifically?
WEATHERLEY: I -- I am -- yes you will have to bear with my memory. But I seem to remember somebody
had overheard him, it might have been a nurse, in outpatients department and had raised that I
think possibly with Eirian.
LANGDALE: That's right. So let's have a look what was said at INQ0002879, page 38. We see there, at page 38, Ravi Jayaram was heard by a nurse; is that the right page?
LADY JUSTICE THIRLWALL: This is 238.
MS LANGDALE: Yes. It's 0038, 38. INQ0002879 0038. Here we are. "Ravi Jayaram was heard by a nurse, Nurse T,
in outpatients when asked if anything had come from the review [presumably the RCPCH review] to
say somebody's causing these deaths on the unit. Nurse T is
now anxious to return to the unit after RJ's statement. EP escalated to KR." So Eirian Powell says
Nurse T heard Ravi Jayaram say, "Somebody's causing deaths on this unit." The Inquiry has heard
evidence from Nurse T on what she in fact heard, but let's just focus on what you read there. That
doesn't say he said Letby is a baby killer or a murderer does it; it says he has commented on a
review to say somebody is causing these deaths on this unit.
WEATHERLEY: Yes, that one does.
LANGDALE: Yes. So do you put that in the category of calling someone a baby killer and a murderer
and terrible names which is what you said?
WEATHERLEY: Yes.
LANGDALE: Before that?
WEATHERLEY: And again sorry that I don't have all of the statements in front of me, but having
read the investigation and statements that were in it, there were a number of statements from
different people who said they had been in the environment when Consultants were calling her names
and there was reference to Ravi Jayaram having called her a name.
LANGDALE: Well the only reference to a Consultant -- let's go to INQ0002879 0030. I am going take you now
having read all of the interviews to what's said on this topic, 0030. I will wait until it's up.
At the bottom the page, "Have you heard about any allegations about Lucy to Sian Williams. I am
aware that they feel she's to blame. I was told by someone else that one of the doctors had
referred to in the context of there is a murderer on the loose out there in one of the outpatient
clinics but not by name." So a murderer on the loose out there, but not by name. If we link that
comment from Sian Williams to what you are told in the pack by Eirian Powell in her written
document at INQ0002879 0064. At a meeting, Eirian Powell tells you about Urgent Care
meeting that had been convened in May 2016, and says here: "Jim McCormack directed his statement
in anger in a raised voice that I was harbouring a murderess on the neonatal unit. I responded
again there was no evidence this was not a matter for us to discuss in this meeting." Again I am
not going to ask you about whether that did or did not occur, but you clearly read that from
Eirian Powell?
WEATHERLEY: (Nods).
LANGDALE: About harbouring a murderess, you had heard Sian Williams say someone said there is a
murderer on the loose out there. And you had heard about Nurse T. My question, going back to your
letter of conclusion is: why you concluded from that evidence that it was Dr Jayaram and Dr
Brearey that had to apologise for calling her names like baby killer? If we go back to your
conclusion at INQ0056139, page 2.
WEATHERLEY: So I think I mentioned before the break about Dr Brearey and angel of death.
LANGDALE: Angel of Death?
WEATHERLEY: Angel of death, yes.
LANGDALE: Who do you say said he said angel of death?
WEATHERLEY: Again it was in one of the statements in the investigation. It may have been Eirian.
I'm not sure who had said that to but it was in the investigation.
LANGDALE: We have all the statements in the investigation I know you have had this conversation
with Mrs Appleton-Cairns before the meeting which we don't have notes of. So I am really
interested in who you spoke to because you are talking with her about a witch hunt and where you
might have got that kind of information from because I have read you what we have got here and you
go right into the police with baby killers and what the Consultants are saying. Is that just from
this evidence or is there
a conversation that you have had?
WEATHERLEY: No. Can I say again for the record and for my integrity what I say to the Inquiry I
say under oath and it was true.
LANGDALE: Sorry?
WEATHERLEY: What I said to the Inquiry and I say under oath is true; that the only conversation I
had with Dee Appleton-Cairns on the morning of the hearing was: I said it felt or it feels like a
witch hunt. She said "Yes, we feel that too, it's very sad." That was the only conversation we had
about the hearing. The rest of my conclusions are based on the investigation report. That is all I
can make conclusions on. There was no other outcome I feel I could have come to with the chaos and
the lack of engagement and clarity from the Consultants and how they behaved and also from the
Executive Team in respect to what they were telling me, through the investigation report, in that
clearly they did not believe that the concerns were credible and they were looking for alternative
suggestions as to why the Consultants could be targeting this nurse. That's what I had to deal
with. Anything outside of that was outwith the remit of the grievance hearing.
LANGDALE: If you look at page 3, the next page of your
concluding findings, you say that the movement was orchestrated by Consultants with no hard
evidence to support this action. Is that what you thought even having looked at that paragraph
again today with Dr Jayaram's evidence to the grievance panel? That there was no evidence to
support the action moving her from the unit?
WEATHERLEY: Yes, Dr Jayaram's own words in his own statement to the investigation was there was a
link, there was a commonality. Beyond that there was nothing to suggest any foul play or any harm
or any wrongdoing on behalf of Lucy. That's in his own statement.
LANGDALE: You then say: "Failure to achieve a harmonious working environment should result in
disciplinary action taken by the Trust." So if the doctors, who you require to apologise to Letby,
don't do that, don't get on with that, there should be disciplinary action taken by the Trust?
WEATHERLEY: No, it should be considered as a recommendation.
LANGDALE: So that your --
WEATHERLEY: It's not -- it's not in my remit to tell the Trust what they need to do.
LANGDALE: Well, you say should result --
WEATHERLEY: But my recommendation, on the basis of what I had heard in the hearing, on the basis
of the investigation was that.
LANGDALE: So we have now got into a situation that you haven't heard from those two doctors
directly about whether they have said those things in the terms you say they have after hearing
this kind of evidence. They should apologise otherwise disciplinary action results. Do you see
that's quite absurd from their perspective?
WEATHERLEY: I believe that Dr Brearey had also in a conversation with, I think it was Eirian, who
had said the impact of this on Lucy given their own statement suggested that there was no link to
Lucy other than commonality and a gut feeling. She asked him about the impact and she suggested,
you know: What if Lucy was to kill herself in respect of this or what about the damage to her
parents? And he said: "I really couldn't care less. I don't care." And then she mentioned about
another nurse who was also shown in the commonality and I believe his reference was that that
nurse was nice.
LANGDALE: Right, and you thought that was all true?
WEATHERLEY: So there were --
LANGDALE: You thought that was all true?
WEATHERLEY: I take what is in front of me as the truth.
LANGDALE: Let's go, please, to INQ00056151 [INQ0056151], page 1. I have just taken you to the letter that
you penned your answers to in very brief form and then we have this letter that is sent to Letby.
This is still a draft. No, this may be the one that's actually been sent, but look at the answer
to number 5. It has been expanded upon since your questions and answers that I have just taken you
through. So it is INQ0056151, page 2. This is a draft so it's not the one that she's
ultimately sent because we see more additions, but look at this at paragraph 5 "During the course
of this investigation this has been expanded upon" is this sent back to you? You have clearly done
your first draft with the questions and answers I have gone through on 1 December. Then we have
this one. Do you see? Are you aware whether it is Mrs Appleton-Cairns or Sue Hodkinson or anyone
else who do you think is adding to this?
WEATHERLEY: As far as I was aware nobody was adding to this, this was just myself and Dee.
LANGDALE: So it is Dee, it looks as though Dr Green's written things in his report and they may
have been lifted into this letter, so as far as you are concerned
she's supporting you to add to your letter?
WEATHERLEY: When the grievance had concluded, we sat and wrote together what I wanted the outcome
to be and where I upheld parts of what Chris has said, rather than us sit and write that out word
for word, I just said: You'll just need to cut and paste that from his report into this.
LANGDALE: So we see that addition at number 5, we see number 7. Then there is another version if
we go to INQ0056171 000. This one seems to come from Alison Kelly. Anyway: "Please
check as discussed, thanks, Alison." We see next page, INQ0056173 000: "Hi Annette, sorry for the delay I have also added in about
LL's mentor." So she's coming back to you this time with your name spelt correctly at the bottom.
And we see here at number 7 look what's been here in this one been put in. We need to go to INQ0056174, page 2. There's all this stuff about no party refutes concerns
were raised. Speak Out Safely policy. Do not find Consultants' concerns when reiterated to the
Executive Team were clear honest objective. We went through all this earlier. All this appears
further down.
Over the page. Did you appreciate Alison Kelly at any point was going to see your drafts before
finalisation?
WEATHERLEY: No.
LANGDALE: Then it's finalised. It comes to you, INQ0056175 000. Just made a couple of track changes one addition plus added
my signature are you happy for this. This is you sending it back. If we go to INQ0056176, page 1, so you have had a look at the copy that's come back to
you from Dee, you have Dee Appleton-Cairns and this is you now just finalising with your own pen
there at page 1. If we go to page 2, we see you correct "I have not been made aware any allusion
to a wrongdoing" and say "I have not seen." Because you had been made aware hadn't you so you have
bothered to correct that and seen it, you say "seen." Do you see? What is the significance of your
change there; why have you changed that?
WEATHERLEY: Is this my change?
LANGDALE: Yes?
WEATHERLEY: So it doesn't have track changes on with any names. I assume you have that.
LADY JUSTICE THIRLWALL: Yes, it should be in blue.
WEATHERLEY: No, sorry it doesn't say who's made the track change. How do you know that was me.
LANGDALE: Let's have a look the document before says "Hi both, this is now the final document
from Dee." We know from the document before she says "I have accepted it and it's ow the final
document. You might note from the most substantive page at page 3" -- let's have a look at page 3
who added this?
WEATHERLEY: Yes, it must be me because I did put that bit there. I would add "however."
LANGDALE: Yes as you have explained earlier, that's why, no just the emails I assumed it is
yours. That is correct. This is your final investigation being sent after Alison Kelly had looked
at it and it all seems to have come from her email I will say at this stage, but when you get to
this point you are adding tweaks and you want to say here they could have supervised her to remain
on the NNU with supervision, actually, because you weren't satisfied they didn't have enough
people to do that. So if they are your changes can you go please and have a look at the one on the
page before at page 2 and explain the change there in paragraph 5.
WEATHERLEY: I think I just felt it was a better, a more grammatical sentence.
LANGDALE: Or that it would be misleading to say that you had not been made aware, any allusion to
any evidence relating to --
WEATHERLEY: Well, it would because I had been made aware.
LANGDALE: Yes. Yes, you had seen it.
WEATHERLEY: Yes.
LANGDALE: So in terms of your own position you correct that?
WEATHERLEY: Yes.
LANGDALE: That can come down now, thank you. We know subsequently that the Consultants were
required to attend mediation. Looking at the picture overall, do you think the circumstances of
this case, this grievance, this situation, that was ever going to be a practical or sensible
conclusion?
WEATHERLEY: I think in the outcome letter I was clear in saying that so long as there is no
reference made to Lucy in the forensic review that had not yet concluded, that those were the
recommendations. I think given that four reviews had taken place, with no concern of foul play,
and certainly no reference to Lucy and foul play, given that the Royal College review found no
concern with Lucy of foul play that if then a further review, a forensic deep dive of all of those
case notes, also found no evidence of foul play that I felt that that was a fair conclusion to
make in the outcome of the grievance.
LANGDALE: So in terms --
WEATHERLEY: That she should be, sorry, that she should be returned to the unit.
LANGDALE: No, no so from your perspective the status of that Royal College review was significant
in your mind, whatever it was doing was significant to this issue?
WEATHERLEY: It was significant because it was understanding a wider review of the unit in respect
to issues that could be resulting in a rise in neonatal deaths.
MS LANGDALE: Thank you. Those are my questions, Ms Weatherley. There is none from anyone else, my Lady.
LADY JUSTICE THIRLWALL: I have no questions. Thank you very much, Mrs Weatherley. You are free to
go.
WEATHERLEY: Thank you.