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Wow ….. a Masonic inference here from Dr B.
Can this case get any more bizarre ?
Can this case get any more bizarre ?
UK - Lucy Letby - Post-Conviction Statutory Inquiry
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reading testimony from Sharon Dodd, head of Child Death Overview Panel:
Q. Well, just looking at that a moment. The
Child Death Overview Panel, because it was there to look at patterns, and because you have identified you as the conduit were the person who could identify that pattern you have identified it?
A. (Nods)
Q. Why were you not then referring that on in June 2016 or at some point before that once you started to become aware of a pattern as it built four then five deaths, and so on? Why were you not referring that, at that point, to the Child Death Overview Panel or to someone?
A. That's a very good question and I can't --
I can't say why we didn't do that at the time. I do
know that part of the issue was that they didn't all live in our local area and therefore maybe we didn't see quite as robust a pattern as we potentially could have done.
[very annoying that they classified and logged the children's death by where they LIVED instead of where they died, imo]
Q. Well, just looking at that a moment. The
Child Death Overview Panel, because it was there to look at patterns, and because you have identified you as the conduit were the person who could identify that pattern you have identified it?
A. (Nods)
Q. Why were you not then referring that on in June 2016 or at some point before that once you started to become aware of a pattern as it built four then five deaths, and so on? Why were you not referring that, at that point, to the Child Death Overview Panel or to someone?
A. That's a very good question and I can't --
I can't say why we didn't do that at the time. I do
know that part of the issue was that they didn't all live in our local area and therefore maybe we didn't see quite as robust a pattern as we potentially could have done.
[very annoying that they classified and logged the children's death by where they LIVED instead of where they died, imo]
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No transcripts up as yet Katy, just bullet points from JM on Twitter.
Documents, evidence and transcripts | The Thirlwall Inquiry
Transcripts, publications and evidence related to investigations and the running of the Thirlwall Inquiry.
thirlwall.public-inquiry.uk
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From Dr Breary, statement July 12/2024
159. Throughout 2015 and early 2016, my aim as neonatal lead was to understand the increased mortality rate better and to work to improve clinical practices when this was needed. This was a challenging task in an already busy clinical job and with minimal support. The majority of evidence for our concerns that we presented to the police and Trust Executives was for babies who had died. So much focus on mortality throughout 2015 and 2016 did mean that we had very little time to consider and review morbidity (babies who did not die). Much of this morbidity evidence, if time allowed us to review it thoroughly, might have led to earlier action being taken. Better support from the Trust, particularly the Risk and Patient Safety Department, and more time allocated to my risk role away from my clinic duties might have given me or my colleagues more time and space to consider important morbidity cases.
Child H
160. I can remember Dr Ravi Jayaram talking to me about Child H in late September 2015. This was regarding the unusual nature of her pneumothoraces and need for more than one chest drain. I don't recall anyone at the time raising any concerns regarding the conduct of LL during Child H's care.
Child I
168. I was aware of Child I before she died, as she had been transferred back from LWH on 18 August 2015 and I was responsible for her care on 6 September 2015, after she had deteriorated overnight. Child I was transferred back to LWH that day for suspected NEC. The impression of the team at the time was that her deterioration was typical of NEC.
169. I cannot remember the exact time I was informed of Child l's death but I am sure that I either spoke to Eirian Powell or emailed her on the day Child I died (Friday, 23 Ocbber 2015) and discussed the association with LL I was concerned regarding the repeated nature ofChild l's collapses and the apparent rapid improvement after short admissions to LWH and Arrowe Park NNUs.
170. I was emailed by Eirian Powell on 23 October 2015 (IN00005609). In this email she gave her views about Child l's care, her views about the association with LL, and attached a staffing analysis (INQ0003189) of the deaths in 2015 including Child 1.1was keen to talk about LL with Eirian Powell because I felt we both needed to acknowledge the association between LL's presence on the NNU when these deaths occurred. I did not feel completely reassured by her assertions that all the cases were different, that some had NEC, gastric bleeding or congenital abnormalities and that some were ill on arrival.
159. Throughout 2015 and early 2016, my aim as neonatal lead was to understand the increased mortality rate better and to work to improve clinical practices when this was needed. This was a challenging task in an already busy clinical job and with minimal support. The majority of evidence for our concerns that we presented to the police and Trust Executives was for babies who had died. So much focus on mortality throughout 2015 and 2016 did mean that we had very little time to consider and review morbidity (babies who did not die). Much of this morbidity evidence, if time allowed us to review it thoroughly, might have led to earlier action being taken. Better support from the Trust, particularly the Risk and Patient Safety Department, and more time allocated to my risk role away from my clinic duties might have given me or my colleagues more time and space to consider important morbidity cases.
Child H
160. I can remember Dr Ravi Jayaram talking to me about Child H in late September 2015. This was regarding the unusual nature of her pneumothoraces and need for more than one chest drain. I don't recall anyone at the time raising any concerns regarding the conduct of LL during Child H's care.
Child I
168. I was aware of Child I before she died, as she had been transferred back from LWH on 18 August 2015 and I was responsible for her care on 6 September 2015, after she had deteriorated overnight. Child I was transferred back to LWH that day for suspected NEC. The impression of the team at the time was that her deterioration was typical of NEC.
169. I cannot remember the exact time I was informed of Child l's death but I am sure that I either spoke to Eirian Powell or emailed her on the day Child I died (Friday, 23 Ocbber 2015) and discussed the association with LL I was concerned regarding the repeated nature ofChild l's collapses and the apparent rapid improvement after short admissions to LWH and Arrowe Park NNUs.
170. I was emailed by Eirian Powell on 23 October 2015 (IN00005609). In this email she gave her views about Child l's care, her views about the association with LL, and attached a staffing analysis (INQ0003189) of the deaths in 2015 including Child 1.1was keen to talk about LL with Eirian Powell because I felt we both needed to acknowledge the association between LL's presence on the NNU when these deaths occurred. I did not feel completely reassured by her assertions that all the cases were different, that some had NEC, gastric bleeding or congenital abnormalities and that some were ill on arrival.
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Part 2 ----Dr Breary Statement from July 12, 2024
The triplets—Child0,ChildP & ChildR
238. I was aware of the triplets' birth on IP❑iJune2016 and that they were all in a stable condition up to the afternoon of 23 June 2016. Dr V was the consultant of the week. I was on NNU for another reason and was asked by Dr U to assist with Child O's intubation. The intubation was uneventful, but we did note what appeared to be a purpuric rash on the right side of his chest but with otherwise normal perfusion. When I returned to assist Dr U and Dr V after Child 0 had further deteriorated, it was noticeable that the previous rash was no longer present, but Child O's condition was much worse. Dr John Gibbs was also present. My focus was on resuscitating Child 0 with my colleagues until he sadly passed away.
I can remember LL being involved with the resuscitation, but I did not notice any outwardly suspicious actions. On recording my actions in the medical notes at 1800, I thought it important to record the rash that came and went because this was unusual and I could vaguely remember colleagues describing rashes in other babies who died in 2015...
[snipped....]
I was worried that another baby had died inexplicably after being previously stable, whilst under the care of LL. I have recorded that a debrief took place but I cannot remember who attended and what was discussed. I do not think LL was present and she might have been with the family. The main purpose of the "hot" debrief was for staff support after a traumatic event, rather than a detailed examination of the events.
I was very worried at this stage. My intention was to discuss with Eirian Powell as soon as possible, with the intention to agree to escalate to the Executives and request action to make the NNU safe. Dr John Gibbs had already reviewed the two surviving triplets, who examined normally but were started on iv antibiotics anyway. I had no idea at this point that LLwas returning to work the following day.I could not conceive that senior nursing staff would allocate LL to care for the surviving triplets.
I would have expected senior nursing staff to have given LL lower acuity babies to care for after the stressful events of Child 0's death and I knew at least two senior nurses on the unit (Eirian Powell and Laura Eagles) were aware of the consultants' concerns. I could also not conceive that, if LL was responsible, she would choose to act again within 24 hours. I deeply regret not escalating my concerns urgently on the evening of 23July 2016.
240. Regarding the comment in my police statement, "on the morning that Child 0 died I was just passing through the unit and I walked past Nurse Letby. She was very upbeat, happy and more confident than normal. She said, "Hello Doctor Brearey" and looked me in the eye very confidently" (INQ0001390).
I made this comment after direct questioning from the police investigator asking if I had any interactions with LL that day. It was not intended to indicate anything significant. In retrospect, it was striking how normal LL's behaviour and mood was. Many other nurses, less involved than LL with the deaths, were extremely upset and anxious following these events.
The triplets—Child0,ChildP & ChildR
238. I was aware of the triplets' birth on IP❑iJune2016 and that they were all in a stable condition up to the afternoon of 23 June 2016. Dr V was the consultant of the week. I was on NNU for another reason and was asked by Dr U to assist with Child O's intubation. The intubation was uneventful, but we did note what appeared to be a purpuric rash on the right side of his chest but with otherwise normal perfusion. When I returned to assist Dr U and Dr V after Child 0 had further deteriorated, it was noticeable that the previous rash was no longer present, but Child O's condition was much worse. Dr John Gibbs was also present. My focus was on resuscitating Child 0 with my colleagues until he sadly passed away.
I can remember LL being involved with the resuscitation, but I did not notice any outwardly suspicious actions. On recording my actions in the medical notes at 1800, I thought it important to record the rash that came and went because this was unusual and I could vaguely remember colleagues describing rashes in other babies who died in 2015...
[snipped....]
I was worried that another baby had died inexplicably after being previously stable, whilst under the care of LL. I have recorded that a debrief took place but I cannot remember who attended and what was discussed. I do not think LL was present and she might have been with the family. The main purpose of the "hot" debrief was for staff support after a traumatic event, rather than a detailed examination of the events.
I was very worried at this stage. My intention was to discuss with Eirian Powell as soon as possible, with the intention to agree to escalate to the Executives and request action to make the NNU safe. Dr John Gibbs had already reviewed the two surviving triplets, who examined normally but were started on iv antibiotics anyway. I had no idea at this point that LLwas returning to work the following day.I could not conceive that senior nursing staff would allocate LL to care for the surviving triplets.
I would have expected senior nursing staff to have given LL lower acuity babies to care for after the stressful events of Child 0's death and I knew at least two senior nurses on the unit (Eirian Powell and Laura Eagles) were aware of the consultants' concerns. I could also not conceive that, if LL was responsible, she would choose to act again within 24 hours. I deeply regret not escalating my concerns urgently on the evening of 23July 2016.
240. Regarding the comment in my police statement, "on the morning that Child 0 died I was just passing through the unit and I walked past Nurse Letby. She was very upbeat, happy and more confident than normal. She said, "Hello Doctor Brearey" and looked me in the eye very confidently" (INQ0001390).
I made this comment after direct questioning from the police investigator asking if I had any interactions with LL that day. It was not intended to indicate anything significant. In retrospect, it was striking how normal LL's behaviour and mood was. Many other nurses, less involved than LL with the deaths, were extremely upset and anxious following these events.
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Dr Breary. Police Statement July 12, 2024
Child P:
I was in clinic, adjacent to the NNU, on the morning of 24 June 2016. 1can remember being asked to undertake an echocardiogram for Child P as soon as possible. The echocardiogram was requested to exclude a cardiac cause for Child P's collapse and it was essentially normal.
There were already a large number of doctors present including Dr Oliver Rackham, a consultant from Arrowe Park Hospital and transport consultant. I therefore left the unit after the echocardiogram.
When I returned Child P had died and Dr Oliver Rackham was leading a debrief in a side room on the NNU. I sat down to join the team, sitting next to LL.
Dr Oliver Rackham praisedLL for her exceptional efforts during the resuscitation.I said to LL that I hoped she was going to have a good rest over the weekend and she informed me that she was back on shift the following day.
242.
I cannot remember talking to Eirian Powell on 24 June 2016. 1don't think many of my consultant colleagues were still at work after Child P died, other than Dr V who was on call. Whilst still on NNU, I phoned the switchboard in the evening of 24 June 2016 and asked to speak to the duty Executive, who happened to be Karen Rees. The conversation was as I described in court
Karen Rees refused to stop LL from working on NNU the following day, was prepared to take full responsibility for this and told me, "there was no evidence".
LL returned to work the following day (Saturday 25 June 2016) during which Child Q deteriorated whilst under her care.
Child P:
I was in clinic, adjacent to the NNU, on the morning of 24 June 2016. 1can remember being asked to undertake an echocardiogram for Child P as soon as possible. The echocardiogram was requested to exclude a cardiac cause for Child P's collapse and it was essentially normal.
There were already a large number of doctors present including Dr Oliver Rackham, a consultant from Arrowe Park Hospital and transport consultant. I therefore left the unit after the echocardiogram.
When I returned Child P had died and Dr Oliver Rackham was leading a debrief in a side room on the NNU. I sat down to join the team, sitting next to LL.
Dr Oliver Rackham praisedLL for her exceptional efforts during the resuscitation.I said to LL that I hoped she was going to have a good rest over the weekend and she informed me that she was back on shift the following day.
242.
I cannot remember talking to Eirian Powell on 24 June 2016. 1don't think many of my consultant colleagues were still at work after Child P died, other than Dr V who was on call. Whilst still on NNU, I phoned the switchboard in the evening of 24 June 2016 and asked to speak to the duty Executive, who happened to be Karen Rees. The conversation was as I described in court
Karen Rees refused to stop LL from working on NNU the following day, was prepared to take full responsibility for this and told me, "there was no evidence".
LL returned to work the following day (Saturday 25 June 2016) during which Child Q deteriorated whilst under her care.
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Where is the masonic bit?
Eta "I am not in the Square" dodgy horisontal handshake
Eta "I am not in the Square" dodgy horisontal handshake
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Child Q:
LL returned to work the following day (Saturday 25 June 2016) and worked a full day shift. Child Q deteriorated whilst under her care during this shift. I am aware that LL worked further shifts the following week after Ian Harvey agreed to remove her from clinical duties on Monday 27 June 2016.
I was aware during the week commencing 27 June 2016 of Child Q's deterioration and transfer to Alder Hey paediatric intensive care unit (PICU) for suspected abdominal pathology. By the time I was informed I was already escalating our concerns to Ian Harveyand requested that LL be removed from clinical duties. I did not feel any additional escalation was needed in light of Child Q's deterioration.
A follow on email from Karen Rees (1NQ0003267) was sent to me on Monday 27 June 2016.
Karen Rees said in the email that she had requested the site coordinators to visit the unit hourly over the weekend and no concerns were escalated to them. It was surprising that she seemed to be unaware of events around Child Q. She also informed me that she had spoken to Eirian Powell and Alison Kelly. I did not reply to the email because I was already planning on escalating concerns to Ian Harvey after the senior paediatric and neonatal nurses and paediatricians' lunchtime meeting on 27June 2016.
Senior Paediatricians' Meeting Monday 27 June 2016
353. Before we had access to the reports, Dr Sean Tighe, who had read the RCPCH report, spoke to Dr Ravi Jayaram to tell him there was no record of us raising concerns to the reviewers in the report. This was very surprising. Dr Ravi Jayaram therefore emailed Sue Eardley on 30 January 2016 to request transcripts of our interviews and suggested to colleagues that we do
INQ0103184 : the same (see Exhibit SB53). I also requested transcripts in an email on 31January 2017 (INQ0003396).
Release of RCPCHReview to Consultants on 3 February 2017
354. Stephen Cross phoned me to inform me I could pick up a copy of the RCPCH report from his office on 3 February 2017. I believe all paediatric consultants were contacted on this day with the same instructions. My first response after reading the report was recorded on WhatsApp message to my paediatric consultant colleagues on 4 February 2017 (see Exhibit
INQ0103168 SB42): "Really doesn't reassure me. Let's wait for the case note review." There followed a discussion regarding how the consultants would feel if LL returned to work.
On reading the report it was obvious to me that parts of the report had been edited or removed. There were double full stops in places (page4 and page24); inappropriate large gaps between paragraphs (page7); reference to "in response to this allegation" (page8) without any previous mention of it; no appendix 4 referenced in page7; a large gap mid- sentence (page 11); and no recommendation j) on page25. I was most concerned about the absence of an accurate record of the discussions we had with reviewers.
[...snipped...]
There were other misleading comments as follows:
"The review team agreed that there were no obvious factors which linked the deaths". I find this comment hard to believe.
The thematic review revealed "no definite causal correlation" identified. The report did not clarify there was a definite correlation with a staff member. Investigation into causation is what we had been asking for.
"Further in-depth analysis by the neonatal lead in July 2016" —this was actually undertaken by Ian Harvey.
I cannot recall "the investigation reports from the infant deaths showed a pattern of insufficient senior cover and reluctance to seek advice". I disagree with the comment but because the report was produced predominantly from discussions with staff members, I don't know how the reviewers obtained this information or how they cross-checked it for accuracy.
LL returned to work the following day (Saturday 25 June 2016) and worked a full day shift. Child Q deteriorated whilst under her care during this shift. I am aware that LL worked further shifts the following week after Ian Harvey agreed to remove her from clinical duties on Monday 27 June 2016.
I was aware during the week commencing 27 June 2016 of Child Q's deterioration and transfer to Alder Hey paediatric intensive care unit (PICU) for suspected abdominal pathology. By the time I was informed I was already escalating our concerns to Ian Harveyand requested that LL be removed from clinical duties. I did not feel any additional escalation was needed in light of Child Q's deterioration.
A follow on email from Karen Rees (1NQ0003267) was sent to me on Monday 27 June 2016.
Karen Rees said in the email that she had requested the site coordinators to visit the unit hourly over the weekend and no concerns were escalated to them. It was surprising that she seemed to be unaware of events around Child Q. She also informed me that she had spoken to Eirian Powell and Alison Kelly. I did not reply to the email because I was already planning on escalating concerns to Ian Harvey after the senior paediatric and neonatal nurses and paediatricians' lunchtime meeting on 27June 2016.
Senior Paediatricians' Meeting Monday 27 June 2016
353. Before we had access to the reports, Dr Sean Tighe, who had read the RCPCH report, spoke to Dr Ravi Jayaram to tell him there was no record of us raising concerns to the reviewers in the report. This was very surprising. Dr Ravi Jayaram therefore emailed Sue Eardley on 30 January 2016 to request transcripts of our interviews and suggested to colleagues that we do
INQ0103184 : the same (see Exhibit SB53). I also requested transcripts in an email on 31January 2017 (INQ0003396).
Release of RCPCHReview to Consultants on 3 February 2017
354. Stephen Cross phoned me to inform me I could pick up a copy of the RCPCH report from his office on 3 February 2017. I believe all paediatric consultants were contacted on this day with the same instructions. My first response after reading the report was recorded on WhatsApp message to my paediatric consultant colleagues on 4 February 2017 (see Exhibit
INQ0103168 SB42): "Really doesn't reassure me. Let's wait for the case note review." There followed a discussion regarding how the consultants would feel if LL returned to work.
On reading the report it was obvious to me that parts of the report had been edited or removed. There were double full stops in places (page4 and page24); inappropriate large gaps between paragraphs (page7); reference to "in response to this allegation" (page8) without any previous mention of it; no appendix 4 referenced in page7; a large gap mid- sentence (page 11); and no recommendation j) on page25. I was most concerned about the absence of an accurate record of the discussions we had with reviewers.
[...snipped...]
There were other misleading comments as follows:
"The review team agreed that there were no obvious factors which linked the deaths". I find this comment hard to believe.
The thematic review revealed "no definite causal correlation" identified. The report did not clarify there was a definite correlation with a staff member. Investigation into causation is what we had been asking for.
"Further in-depth analysis by the neonatal lead in July 2016" —this was actually undertaken by Ian Harvey.
I cannot recall "the investigation reports from the infant deaths showed a pattern of insufficient senior cover and reluctance to seek advice". I disagree with the comment but because the report was produced predominantly from discussions with staff members, I don't know how the reviewers obtained this information or how they cross-checked it for accuracy.
I remember this being referenced before, and it is incredibly sinister. It is a like a scene from any standard thriller film.
Highlandspring
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Yes definitely. Indeed, many/most of LL's words are sinister in retrospect, but I agree this is a stand out one. Beyond sickening.
As for Baby P collapsing let alone dying, when there was so much supposed surveillance of LL, cognisant staff and pure 'redhandedness' fgs, you can't help but hold several seniors responsible for that. Can't imagine how the triplets' parents feel. Well I can, recalling their impact statement at sentencing and thinking about what they now know. Heartbreaking.
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What was it that made Dr b think a conspiracy was afoot? Tc and ih kind of bringing down the shutters so to speak? Drawing a line under it and if crossed there will be consequences?
Thanks @Tortoise and @katydid23 for all the updates. Much appreciated.
And a massive bravo to those helming this Inquiry.
And a massive bravo to those helming this Inquiry.
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Highlandspring
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It was during questioning of SB by Richard Baker for the families and he referenced Brearey's Facere M interview. So must be at the end of the transcript.
Worth reading the grilling they gave Lyn Simpson yesterday. She was the woman tasked with finding Tony Chambers a lovely shiny new role to move to. Every word she wrote in her notes has a different meaning to its usual meaning apparently.
thirlwall.public-inquiry.uk
Q. Then coming to the period that we are going to be focused upon, between May 2016 and April 2019, were you the Executive Regional Managing Director for the north for NHS Improvement?
A. I was.
[...]
Q. We can then go on to 3. You and Sir Duncan Nichol agree that the suggested way forward was to prevent the vote of no confidence and that Sir Duncan Nichol -- so this is you agreeing that the chair should try and talk the paediatricians out of their vote of no confidence; is that right?
A. I'm not sure that's what was fully meant by that.
Q. What does --
A. I am suggesting that to -- he understands the rationale for the vote of no confidence, what alternatives there might be and whether that needed to take place. He needed to be sure, he was the leader of that organisation of the chair and he needed to be sure that if that was going to occur, that there was no other route than a vote of no confidence.
Q. What does the word "prevent" mean?
A. It literally means to stop something.
Q. That's what you wrote?
A. It is. But, again, these were my notes, that's not what I was meaning to stop a vote of no confidence.
Q. So you wrote "prevent", but you meant investigate the reasons behind?
A. Yes, some of this was shorthand notes for me.
[...]
Q. Then we see we the return to this subject of vote of no confidence: "Paediatricians are keen to go down the route of a vote of no confidence and [Sir Duncan Nichol] was trying to prevent this." So we see the word "prevent" again?
A. I do. Inappropriate use of language in my --my log. I accept that.
Q. But you have twice used the word that means to stop when you meant something different; that is one explanation?
A. Yes.
Q. The alternative is that that is what is happening and that is what you are recording?
A. No, I don't think that was what was happening. I do think on reflection it was an inappropriate word used because that was not what I was implying at the time.
Q. Why did you use it twice?
A. I'm sorry, I don't recollect why I used it twice. These were my notes, my log. It was simply an aide memoire for me.
[...]
Q. Let's look at 4: "LS advised Duncan Nichol has a meeting with the clinicians and that he would be looking to get them to pull back from the vote of no confidence." So just reflect upon how sustainable your suggestion is that Sir Duncan Nichol was not trying to prevent. You have used a different phrase here: get them to pull back?
A. I have.
Q. That is what's going on here, isn't it?
A. There was never -- there was never a request from me to stop a vote of no confidence. I was asking -- maybe some loose language in my log, but my recollection was that I was asking Duncan Nichol to pursue -- be clear that he was confident that he pursued all avenues, to support the clinicians and that a vote of no confidence was still what they wished to pursue.
Q. I just want to invite you to reflect upon the loose language. You have twice used the word "prevent" and then you have used the phrase "get them to pull back". They all mean the same thing. You have used them across two meetings in three different parts of -- across your notes; isn't that the reality here?
A. No, because I think if I had truly meant to stop, I would have used the word to stop a vote of no confidence. I didn't use the word "stop".
Q. You used the word "prevent"?
A. I did. Because when I was using the word "prevent" I was asking him to look at a range of options.
Q. "Prevent" means exactly the same as "stop", doesn't it?
A. It depends in the context I think in which it's used.
Q. Well, I'm sorry I am going to have to challenge you on that. You give me an example of where it means something different?
A. I would need to think about that.
Q. All right. Well, I don't want to put you on the spot, further about it?
A. Thank you.
Q. If you need time, so be it.
[...]
Q. You have been calling them clinicians so far, but you knew it was the paediatricians, didn't you?
A. I did.
Q. So again, just reflect on that. The neonatal unit is the subject of a police investigation. The paediatricians are pushing for a vote of no confidence. You made no connection whatsoever in your mind at the time that there may be a relationship between the two?
A. No, I didn't. And when I have said there about paediatricians, I didn't say neonatologists, which are linked much more to a neonatal unit. Paediatricians can be community paediatricians, hospital-based paediatricians, it doesn't always link to them being involved with the neonatal unit.
Q. Given all of your experience in the NHS and bearing in mind this is a district hospital which didn't in fact have any neonatologists, in fact all of the paediatricians will work on the neonatal unit which is we know what happened. So is that really a line of reasoning that is sustainable in terms of you thinking about whether the two are connected?
A. I believe it to be so.
21/11/2024 – Transcript of Week 10 Day 4 | The Thirlwall Inquiry
Transcript of Part B Evidence: - Lyn Simpson, Former Executive Regional Managing Director for the North (NHS Improvement) - Ian Pace, Former legal adviser (Solicitor) to the Countess of Chester Hospital - Corinne Slingo, Former legal adviser (Solicitor) to the Countess of Chester Hospital -...
thirlwall.public-inquiry.uk
Q. Then coming to the period that we are going to be focused upon, between May 2016 and April 2019, were you the Executive Regional Managing Director for the north for NHS Improvement?
A. I was.
[...]
Q. We can then go on to 3. You and Sir Duncan Nichol agree that the suggested way forward was to prevent the vote of no confidence and that Sir Duncan Nichol -- so this is you agreeing that the chair should try and talk the paediatricians out of their vote of no confidence; is that right?
A. I'm not sure that's what was fully meant by that.
Q. What does --
A. I am suggesting that to -- he understands the rationale for the vote of no confidence, what alternatives there might be and whether that needed to take place. He needed to be sure, he was the leader of that organisation of the chair and he needed to be sure that if that was going to occur, that there was no other route than a vote of no confidence.
Q. What does the word "prevent" mean?
A. It literally means to stop something.
Q. That's what you wrote?
A. It is. But, again, these were my notes, that's not what I was meaning to stop a vote of no confidence.
Q. So you wrote "prevent", but you meant investigate the reasons behind?
A. Yes, some of this was shorthand notes for me.
[...]
Q. Then we see we the return to this subject of vote of no confidence: "Paediatricians are keen to go down the route of a vote of no confidence and [Sir Duncan Nichol] was trying to prevent this." So we see the word "prevent" again?
A. I do. Inappropriate use of language in my --my log. I accept that.
Q. But you have twice used the word that means to stop when you meant something different; that is one explanation?
A. Yes.
Q. The alternative is that that is what is happening and that is what you are recording?
A. No, I don't think that was what was happening. I do think on reflection it was an inappropriate word used because that was not what I was implying at the time.
Q. Why did you use it twice?
A. I'm sorry, I don't recollect why I used it twice. These were my notes, my log. It was simply an aide memoire for me.
[...]
Q. Let's look at 4: "LS advised Duncan Nichol has a meeting with the clinicians and that he would be looking to get them to pull back from the vote of no confidence." So just reflect upon how sustainable your suggestion is that Sir Duncan Nichol was not trying to prevent. You have used a different phrase here: get them to pull back?
A. I have.
Q. That is what's going on here, isn't it?
A. There was never -- there was never a request from me to stop a vote of no confidence. I was asking -- maybe some loose language in my log, but my recollection was that I was asking Duncan Nichol to pursue -- be clear that he was confident that he pursued all avenues, to support the clinicians and that a vote of no confidence was still what they wished to pursue.
Q. I just want to invite you to reflect upon the loose language. You have twice used the word "prevent" and then you have used the phrase "get them to pull back". They all mean the same thing. You have used them across two meetings in three different parts of -- across your notes; isn't that the reality here?
A. No, because I think if I had truly meant to stop, I would have used the word to stop a vote of no confidence. I didn't use the word "stop".
Q. You used the word "prevent"?
A. I did. Because when I was using the word "prevent" I was asking him to look at a range of options.
Q. "Prevent" means exactly the same as "stop", doesn't it?
A. It depends in the context I think in which it's used.
Q. Well, I'm sorry I am going to have to challenge you on that. You give me an example of where it means something different?
A. I would need to think about that.
Q. All right. Well, I don't want to put you on the spot, further about it?
A. Thank you.
Q. If you need time, so be it.
[...]
Q. You have been calling them clinicians so far, but you knew it was the paediatricians, didn't you?
A. I did.
Q. So again, just reflect on that. The neonatal unit is the subject of a police investigation. The paediatricians are pushing for a vote of no confidence. You made no connection whatsoever in your mind at the time that there may be a relationship between the two?
A. No, I didn't. And when I have said there about paediatricians, I didn't say neonatologists, which are linked much more to a neonatal unit. Paediatricians can be community paediatricians, hospital-based paediatricians, it doesn't always link to them being involved with the neonatal unit.
Q. Given all of your experience in the NHS and bearing in mind this is a district hospital which didn't in fact have any neonatologists, in fact all of the paediatricians will work on the neonatal unit which is we know what happened. So is that really a line of reasoning that is sustainable in terms of you thinking about whether the two are connected?
A. I believe it to be so.
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Such a blatant liar! And on the stand!
INQ0102309 – Pages 2 – 7 of Notes of a meeting between Nigel Wenham and senior clinicians, dated 15 May 2017 | The Thirlwall Inquiry
Examining the events at the Countess of Chester Hospital and their implications following the trial, and subsequent convictions, of former neonatal nurse Lucy Letby of murder and attempted murder of babies at the hospital.
thirlwall.public-inquiry.uk
Interesting meeting between the consultants and the police.
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