Thirlwall Inquiry Days 56 and 57, 14 and 15 January, 2025 - (Corporate witnesses for CQC, Northern Care Alliance for End of Life Care and Bereavement, and DHSC; Expert Statistician)
With no reporting yesterday and already a very interesting discussion about one of the documents posted from part B, this post combines the evidence presented to Thirlwall from yesterday and today into one post.
14 January Witnesses:
Chris Dzikiti – Care Quality Commission (CQC) Corporate Witness
Fiona Murphy MBE – Corporate Director of Nursing at the Norther Care Alliance for End-of-Life Care and Bereavement
15 January Witnesses:
Professor Sir David Spiegelhalter OBE – Expert Statistician
William Vineall – Department of Health and Social Care (DHSC) Corporate Witness
Articles:
Spike in baby deaths on Lucy Letby ward ‘surprising and unusual’, says statistician (The Guardian)
Rise in baby deaths at hospital ‘not an outlier’, Letby inquiry hears (PA News)
Letby unit baby death rise 'not extreme' - inquiry (BBC News)
Documents:
INQ0102018 – First Witness Statement of Claire Raggett, dated 13/06/2024. Discussion here
INQ0108773 – Pages 1, 6 and 14 of Guidance from the British Association of Perinatal Medicine titled Recognising Uncertainty: An integrated framework for palliative care in perinatal medicine, dated 11/07/2024
INQ0108720 – Pages 1 and 5 of Implementation and Accreditation Framework from NHS Liverpool University Hospital NHS Foundation Trust titled SWAN A model for care for End of Life and Bereavement
INQ0108675 – Pages 1, 5, 7, 18 – 19, 27 and 33 of Guidance from the National Bereavement Care Pathway for Pregnancy and Baby Loss titled Neonatal Death, dated July 2022
INQ0108674 -Witness statement of Ann Ford (Director of Operations Network North, Care Quality Commission), dated 11/12/2024
INQ0107971- Second Witness Statement of Emma Kate Taylor, dated 06/09/2024.
INQ0103668 – Pages 1, 7 and 9 of Report from the Care Quality Commission titled Maternity and Gynaecology, dated 22/12/2015
INQ0103620 – Pages 1 and 26 – 27 of Report from the Care Quality Commission titled Countess of Chester Hospital NHS Foundation Trust Intelligence Presentation, dated 16/02/2016
INQ0102071 – Exhibit GG02: Document from the Countess of Chester Hospital titled Policy for Media Enquiries and Handling, dated 19/06/2024.
INQ0102070 – Exhibit GG01: Document from the Countess of Chester Hospital titled Draft Policy for Use of Internal Communication Channels, dated 19/06/2024.
INQ0102069 – Witness Statement of Gill Galt, dated 19/06/2024
INQ0012363 – Pages 1 and 4 of Report from The Royal College of Pathologists titled National Medical Examiner’s Good Practice Series No. 6, Medical examiners and child deaths, dated March 2022
INQ0102017 – Exhibit Bundle consisting of: CR/01- Job Description for the Assistant Trust Secretary & Executive Office Manager; CR/02- Executive Team Notes, Minutes of the Executive Directors Group meetings; CR/03- Minutes of the Board of Directors formal meetings; and CR/04- Email from Stephen Cross to Simon Medland, regarding the Neonatal Unit review, update from the Child Death Overview Panel meeting and investigation into the unexplained baby deaths, dated 13/06/2024. Produced by Claire Raggett in the first witness statement at INQ0102018.
INQ0098320 – Witness Statement of Sarah Louise Davies, dated 15/05/2024
INQ0017411 – email correspondenxe between Alison Kelly and Ann Ford, regarding the neonatal unit’s request for an independent review into neonatal deaths, dated 30/06/2016
INQ0017303 – Email from Lorraine Bolam to Ellen Armistead, Jacqueline Hornby, and Deborah Lindley, regarding the Countess of Chester’s neonatal deaths and police investigation, dated 16/05/2017
INQ0017300 – Agenda for engagement meeting between Care Quality Commission and Countess of Chester Hospital, regarding the publication and actions arising from the neonatal services external Royal College of Paediatrics and Child Health review, dated 17/02/2017
INQ0017298 – Agenda for engagement meeting between Care Quality Commission and Countess of Chester Hospital, regarding risk related to maternity / neonatal services, dated 22/12/2016
INQ0013059- Email between Fiona Reynolds and colleagues regarding CDOP Countess of Chester Hospital- Neonatal Review, dated 08/03/2017.
INQ0012781- Email chain between Anne McKenzie, Sharon Dodd and Sue Eardley, regarding the Cheshire CDOP Annual Review, dated between 02/09/2016 and 18/10/2016.
INQ0012634 – Witness Statement of Ian Trenholm, Chief Executive of the Care Quality Commission, dated 12/02/2024.
INQ0015453 – Witness statement of Patricia Marquis, dated 21/03/2024.
INQ0102689 – Witness statement of Patricia Marquis, dated 03/07/2024.
INQ0014599 – Witness statement of Rob Behrens, dated 13/03/2024.
INQ0017976 – Witness statement of Alan Clamp, dated 05/04/2024.
INQ0008966 – Witness Statement of Professor Sir David Spiegelhalter, dated 08/01/2024
INQ0108786 – Witness statement of Professor Sir David Spiegelhalter, dated 15/01/2025
INQ0013197 – Exhibit SLJ10: Minutes from The Local Safeguarding Children’s Board meeting , dated 27/07/2018.
INQ0108744 – Page 7 of Witness statement of Dr Edile Mohammed Nur Murdoch, dated 22/12/2024
INQ0108740 – Pages 1, 6 – 8 and 23 – 24 of Report from the Department of Health & Social Care titled Investigating Healthcare Incidents Where Suspected Criminal Activity May Have Contributed To Death Or Serious Life-Changing Harm, dated 17/12/2024
INQ0107810 – Page 7 of Code of Conduct for NHS Managers, dated October 2002
INQ0107127 – Witness statement of Lawrence Andrew Dixon, dated 30/07/2024.
INQ0107030- Witness Statement of Julie McCabe, dated 28/07/2024.
INQ0107019 – Pages 1, 4, 8 -10, 15 and 24 of Guidance from the Department of Health titled Guidelines for the NHS in support of the Memorandum of Understanding, Investigating patient safety incidents involving unexpected death or serious untoward harm: a protocol for liaison and effective communications between the National Service, Association of Chief Police Officers and the Health & Safety Executive, dated November 2006
INQ0106962 – Page 12 of Witness statement of Dr Edile Mohammed Nur Murdoch, dated 10/07/2024
INQ0102369 – Witness Statement of David Hunter, dated 20/06/2024.
INQ0101363 – Witness Statement of Heather Marie Wilshaw-Jones, dated 30/05/2024
INQ0101314 – Second Witness Statement of Mike Leaf, dated 03/06/2024.
INQ0017824 – Witness Statement of Sian Jones, dated 16/04/2024.
INQ0017758 – Exhibit SLJ9: Minutes of the Cheshire West and Chester Local Safeguarding Board meeting, dated 04/07/2018.
INQ0014686 – Pages 1 – 2, 5, 7, 11 and 19 of Memorandum of Understanding titled Investigating patient safety incidents involving unexpected death or serious untoward harm: a protocol for liaison and effective communications between the National Health Service, Association of Chief Police Officers and Health & Safety Executive
INQ0013199 – Exhibit SLJ11: Minutes from The Local Safeguarding Children’s Board meeting, dated 11/02/2019.
INQ0015453 – Witness statement of Patricia Marquis, dated 21/03/2024.
INQ0013196 – Exhibit SLJ8: Minutes from The Local Safeguarding Children’s Board meeting, dated 22/01/2018.
INQ0013195 – Exhibit SLJ7: Minutes from The Local Safeguarding Children’s Board meeting, dated 05/06/2017.
INQ0013187 – Exhibit SLJ12: Minutes from Cheshire West and Chester Safeguarding Children Partnership Executive meeting, dated 17/07/2019.
INQ0013028 – SLJ6: Report by Alison Kelly (Director of Nursing & Quality, Countess of Chester Hospital NHS Foundation Trust) titled Neonatal Review & Police Investigation into the increase in Neonatal Mortality at the Countess of Chester Hospital NHS Foundation Trust, dated 05/06/2017.
INQ0006755 – Page 1 of Screenshot of MBRRACE-UK’s data viewer titled Deaths within your organisation
INQ0004657 – Page 1 of Urgent Risk Register
INQ0003116 – Email chain between Stephen Brearey, Ravi Jayaram and colleagues regarding concerns about the Neonatal Unit, dated 28/06/2016.
INQ0002383 – Pages 1 and 25 of Report titled Gross negligence manslaughter in healthcare, The report of a rapid policy review