Notable extracts
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Dr Martyn Pitman
Noah Robinson died about a year before the start of the indictment period with a very similar clinical picture to the index babies. He was never investigated. Why not? Because the investigation had already decided on its perpetrator and its timeframe.
Dr Martyn Pitman
Evans dismissed the other specialties — obstetrics, maternal-foetal medicine — and I believe that was partly financial and partly sheer professional arrogance. He believed he had sufficient cross-speciality expertise to do the work of all of them. That is an extraordinary claim.
Dr Martyn Pitman
The Swiss cheese model tells you that disasters happen when multiple layers of defence all fail simultaneously. What happened at the Countess of Chester was not one nurse — it was a system failing at every level.