That still leaves a 5 month gap prior to November 2015, where having heard a lot more evidence they don’t believe they were culpable. I’m glad that has been acknowledged, but I’m still unsure why they want to pause the inquiry.
It's not the hospital that wants to pause the Inquiry, it's the former executives, and now Mark McDonald.
The hospital's written submissions set out why after the death of baby I in October 2015 the paediatricians had raised sufficient concern to have Letby removed and the matter potentially reported to police.
(3) October 2015
39 Dr Brearey undertook a review into Child E’s death in October 2015 [INQ0003296]. That review concluded that Child E likely died of perforated bowel secondary to NEC and that it was unlikely that changes in his management would have altered the outcome. Again, CoCH accepts that that betrays the limitations of paper-based mortality reviews. CoCH also accepts that it would have been helpful for this review (and others) to have been informed by closer involvement of the children’s families. It however recognises Dr Brearey’s evidence that clinical pressures and time constraints mean that this would not be ordinary practice, either at CoCH or elsewhere [Brearey/week10/19Nov/56/16].
40 On 22 October 2015 a meeting of the WCCGB made reference to three unexpected deaths. The minutes were received by Alison Kelly as executive lead [INQ0003223].
41 Child I was murdered by Letby on 23 October 2015. She had been the subject of several transfers between Liverpool Women’s Hospital, the Countess of Chester Hospital and Arrowe Park Hospital. At CoCH she had deteriorated on numerous occasions, something which had given the clinicians treating her the impression she was of fragile health [INQ0102740 §78]. Letby was charged with attacking her and causing her collapse on four occasions. Her death was subject to a Datix report [INQ0000457], referral to the coroner [INQ0002043_0003], a postmortem [INQ0002043_0037], and the CDOP process [INQ0001945]. She was discussed at the neonatal morbidity and mortality meeting on 26 November 2015 [INQ0003288]. On 31 October, Dr Brearey conducted a review of her care [INQ0003286]. A debrief was held on 9 November 2015 [INQ0000429_1543].
42 Dr Brearey’s evidence is that he would have spoken to Eirian Powell on 23 October 2015 about the death of Child I and the association between Letby’s presence and the five deaths since June. That account is entirely consistent both with the evidence of others [Griffiths/week6/16Oct/135/14] and with Eirian Powell’s email to Dr Brearey at 17.25 hours on 23 October which appears to reference prior knowledge of events [INQ0003106]. Attached to that email was a document produced by Ms Powell identifying Letby’s presence at the deaths of Child A, Child C, Child D and Child E [INQ0003189]. There is, in that email, an apparent acceptance of the need for Eirian Powell to escalate the events surrounding Child I to senior nurses within the Trust. It appears there was a failure to do so.
43 On 26 October 2015, Alison Kelly, Ian Harvey, Sian Williams and Ruth Millward attended an SUI meeting. Items for consideration included an NNU case review in respect of Child S and a list of potential claims against the Trust which included reference to the death of Child D [INQ0003614, INQ0008194, INQ0008195]. By this time, the deaths of Child A, Child C, and Child E had been reported on SBAR forms which were forwarded to Alison Kelly and, in the case of Child E, Ian Harvey. Alison Kelly had attended the serious incident review panel of 2 July 2015. CoCH submits that by this date, the increasing mortality on the neonatal ward must have been well known to Alison Kelly and that this should have informed her response to later events.
44 On 27 October 2015, Eirian Powell emailed Dr Brearey [INQ0003107]. That email makes two discrete points. First, Ms Powell gives her and Debbie Peacock’s view that they did not feel there was a connection. In light of Dr Brearey’s evidence as to his conversation with Ms Powell on 23 October 2015, the email of 17.25 on 23 October, and the attachment detailing the nurses on duty for each of the deaths since June, references to a connection are likely to be to an association between Letby and the deaths. Second, it can be seen that Ms Powell’s view is to reject the possibility of any connection and to instead propose that a table including all the doctors that was (sic) involved with the deceased patients on the unit is produced to ensure all avenues have been addressed.
45 CoCH accepts that there is no evidence that Eirian Powell specifically raised Child I’s death, or Dr Brearey’s observed connection between Letby and the deaths of Child A, Child C, Child D, Child E or Child I, with Sian Williams or Alison Kelly as implied by her email of 23 October [INQ0003106]. Instead, by the following Monday, Ms Powell’s response appears to have been to downplay Dr Brearey’s concerns and to explore other explanations for the deaths [INQ0003107]. The significance of the association between Letby and the deaths identified by Dr Brearey appears to have been lost.
46 These submissions will consider the evolving knowledge of the paediatricians between June 2015 and February 2016 in greater detail below. Nevertheless, it is clear that the death of Child I represented a significant change in the level of concern of certain members of the paediatric team as to the cause of the increased mortality since June. Dr Brearey’s evidence was that Child I’s death represented a significant moment that raised my level of concern quite considerably as to the prospect of deliberate harm [Brearey/week10/19Nov/71/15], albeit that he also had a duty to consider other things [Brearey/week10/19Nov/74/18]. Dr Jayaram’s evidence was that on returning to work in November 2015 he became concerned for the first time that Letby could somehow be causing inadvertent or even deliberate harm, although those concerns were tempered by uncertainty as to whether such worries were genuine, difficulties with thinking the unthinkable, an awareness of the risk of confirmation bias and seeing things which weren’t there [Jayaram/week9/13Nov/34/22]. Dr Newby recalled speaking to Drs Gibbs and Brearey about Letby’s presence at the deaths following the death of Child I, but also a recognition amongst them that there was a small pool of nursing staff who were frequently on duty [Newby/week4/3Oct/33/4]. It is also the case that, in the mind of the neonatal lead, those incipient concerns had been drawn to the attention of executives by this time [INQ0103104 §173].
47 The Trust accepts that, at the end of October 2015 when concerns were first openly articulated as to the possibility of deliberate harm, it would have been appropriate for CoCH to exclude Letby pending its own investigations. We do not consider the decision of Dr Brearey (and indeed Eirian Powell) to investigate the deaths themselves at this time to be unreasonable. In the vast majority of cases, concerns around deaths will ultimately have a clinical explanation which can be established by local investigation by those qualified to undertake it.
48 Had those investigations not satisfied the concerns raised, i.e. by providing clinical explanations for the events, then the only body with the skill set and powers to exclude criminality was the Police. The Trust considers that it is an unanswerable hypothetical as to whether any investigations by the Trust at that time, set against an understanding that the deaths had plausible natural explanations and that Letby’s presence was potentially explained by a small number of nurses working frequent shifts, would have resulted in referral to the Police. Nevertheless, the concerns raised, even if underdeveloped and incipient, ought to have been treated with the upmost seriousness.
