Have you read Dr J’s testimony about how little action he took that was actually part of his role (scroll around page 50), where he is asked at every stage why he didn’t do what he was supposed to do and just relied on Dr Breaery reporting it. He even attended an interview with the CQC-later the same day he had seen Lucy with child K and failed to mention any concerns or the thematic review they were doing. Is there actually any evidence he did anything other than have a coffee room chat and send a few emails to Dr Breaery? Remember he was employed as the clinical director of children’s services at this time.
(8) The route by which the paediatricians raised their concerns
255 CoCH submits that in the extraordinary circumstances of 2015/16, it was appropriate for the paediatricians to escalate their concerns direct to those at the highest levels of the Trust outside of the established governance systems.
256 The concerns they were raising from February 2016 onwards were of the upmost seriousness. Far from being
inappropriate, it was if anything entirely
appropriate that they were escalated directly to those at the top of the organisation. Doing so was the clearest and quickest way to highlight the concern.
https://thirlwall.public-inquiry.uk...ospital-NHS-Foundation-Trust-4-March-2025.pdf
another extract:
(12) CoCH’s engagement and transparency with the CQC
269 CoCH accepts that there was a failure to be fully open and transparent with the Care Quality Commission (CQC) prior to and after the inspection undertaken in February 2016.
270 First, it is clear that by the time of the inspection in February 2016 and their meetings with the CQC as part of it, both Alison Kelly and Ian Harvey were aware of the increase in mortality on the NNU since the previous June. Whilst Mr Harvey appears to accept this [INQ0107653 §121], Ms Kelly’s evidence to the contrary simply cannot stand [Kelly/week11/25Nov/74/4]. That remains the case regardless of whether Ms Kelly had actually read the thematic review when it was forwarded to her by Mr Harvey in the context of the CQC’s visit [Kelly/week11/25Nov/72/19 and 75/6].
271 Second, the Trust accepts that it should have provided the thematic review to the CQC prior to the commencement of the inspection. That proposition appears to have been tacitly accepted by Ian Harvey in his oral evidence [Harvey/week11/28Nov/105/8, 29Nov/221/1]. Whilst Dr Brigham’s review may have been provided to the CQC, there is no evidence before the Inquiry that the thematic review was indeed disclosed at this time. Given the limited inspection records available, CoCH does not comment on what information may have been forthcoming during interviews between its staff and the CQC inspection team nor whether the questions asked in those interviews should have resulted in the issue of increased neonatal mortality being discussed.
272 Third, there were further failures to update the CQC as to concerns in the spring of 2016. Obvious opportunities to do so include:
(i) the dissemination of the final version of the thematic review on 2 March 2016; and
(ii) following the meeting between Ian Harvey, Alison Kelly, Dr Brearey, EirianPowell and Anne Murphy on 11 May 2016 at which concerns about Letby were raised.
273 Fourth, when the CQC was ultimately informed of the increase in neonatal mortality in June 2016, key information was still omitted. Ann Ford does not appear to have been given any details of the nature of the paediatrician’s concerns or that it was those concerns which had precipitated the Trust’s extensive actions in June/July 2016. Alison Kelly’s otherwise detailed email to Ms Ford dated 30 June 2016 is remarkably silent on that point [INQ0017411]. Further, insofar as her email implied that the thematic review had been shared with the CQC as part of the inspection datapack when it had not, that email was misleading [Kelly/week11/25Nov/89/8]. Ms Kelly’s duty was to keep the CQC, one of the Trust’s principal regulators, properly informed.
274 Fifth, there was then an ongoing failure to update the CQC as to concerns about Letby, and the need for both Dr Hawdon and Dr McPartland’s investigations in light of the findings of the RCPCH review. The update provided by executives during the CQC engagement meeting of 17 February 2017 was, if the note of the meeting is accurate, woefully deficient INQ0014405_0001].
275 A separate issue arises as to the engagement between CoCH’s paediatric and nursing staff and the CQC’s inspection team. CoCH makes the following submissions in that regard:
(a) CoCH accepts it is likely that Dr ZA did not, in 2016, raise concerns with the CQC about patient safety issues given she was away from work at the time of the inspection [ZA/week5/7Oct/47/15];
(b) the evidence suggests that the issue of neonatal mortality did not arise in the course of interviews held with paediatricians and nurses by the CQC’s inspectors during the February 2016 inspection. On any analysis, the evidence is inconsistent as to whether questions which would have elicited their concerns would have been asked by the CQC’s inspection team [Cain/week9/14Nov/62/4-65/3, Odeka/week9/14Nov/101/4, Potter/week9/14Nov/130/13-130/24]. That position is perhaps unsurprising given that the purpose of the inspection appears to have been to assess the Trust’s processes for monitoring and investigating incidents, rather than to interrogate the details of those incidents [Cain/week9/14Nov/61/21,Odeka/week9/14Nov/100/20, 101/4, 103/16, 106/25]. Whether that approach is correct is something other Core Participants are better placed to comment on than CoCH;
(c) Dr Brearey explained in evidence that he was conflicted at the time of the meeting with the CQC, having only recently escalated his concerns to the Executive Team [Brearey/week10/19Nov/104/14]. That hesitancy is, in CoCH’s submission, understandable, and should be seen in the context of his understanding that a meeting to discuss how to proceed in light of the thematic review was soon to be arranged with Ian Harvey;
(d) further, CoCH submits that bearing in mind Mr Harvey’s request for a copy of the thematic review, Dr Brearey was entitled to rely on the Trust to share it (and any other relevant data or documents) with the CQC inspection team. Put simply, if CQC inspections are to be conducted in a practical and efficient manner, it cannot be that every individual doctor or nurse is required to separately satisfy themselves that their Trust has fulfilled its obligations to the CQC as part of the inspection. In CoCH’s view, staff are entitled to expect that their Trust will have provided the inspection team with all necessary documentation.