Context
Dr Stephen Brearey was the lead consultant on the Countess of Chester neonatal unit and the first clinician to raise concerns, from July 2015 onwards, about the cluster of unexpected deaths and collapses. He kept contemporaneous notes of meetings with management and of his escalation attempts throughout 2016 and 2017. His Thirlwall Inquiry witness evidence is one of the most important single records of how consultant concerns were handled by the Trust’s executive team.
Key passages
Opening apology. Before any questions were put to him, Dr Brearey, the neonatal unit’s Lead Clinician from 2008 to 2020, asked to address the parents directly. He said “Sorry for my part in not being able to protect your babies”, and told them: “This apology is to the parents in the indictment but also parents who are involved in the ongoing police investigation. I hope that you all get the truth and justice that you deserve.”
The audit data. Taken through the Trust’s National Neonatal Audit Programme figures, which he had compiled from BadgerNet records for an annual report recommended by the RCPCH College review, Dr Brearey said “our National Neonatal Audit Programme results for the years 15, 16 before and after were all very positive, all above usually above the — the mean for the local neonatal units both regionally and nationally and there were never really any significant outliers in terms of our results NNAP although it didn’t include mortality”.
The CQC dilemma. Dr Brearey described weighing whether to raise mortality concerns with Care Quality Commission inspectors in February 2016, before he had discussed them with the Medical Director, Ian Harvey. He said there was “a bit of an internal dialogue going on with myself in terms of what — what to say to the inspectors because if he can, effectively I would be raising concerns to the CQC before I raised concerns to the Medical Director”. He decided that “if asked, I would talk about it but otherwise I would leave it to a discussion with the Medical Director”, telling the Inquiry: “Knowing what I know now, we should have discussed it.”
Delay after Child O. Describing the evening Child O died, Dr Brearey said he was “exceedingly worried” and had intended to raise it with Eirian Powell and escalate to the Executives, but it was “early evening time when most sort of senior people would have not been in the hospital”. He told the Inquiry: “I did think it needed escalating…it was something I wanted to address as soon as possible the following day and obviously I regret waiting until the following day to act. It would have been far more appropriate to trigger something on that Thursday evening rather than wait to the following morning.”
Trust culture. Asked about a June 2016 meeting at which concerns about closing the neonatal unit and making it a crime scene were raised, Dr Brearey agreed reputational harm to the Trust had been given as a reason not to act, but said: “having lived through all this, I am a little bit sceptical as to whether that was a true concern or whether it was more on an individual basis, the people making that decision looking after themselves and trying to protect themselves through this, particularly if they had not responded to our concerns as early as they should have done”. Asked about a comment attributed to him in The Guardian about an anti-doctor agenda among senior leaders, he said of the Consultant body that “their morale was low and they didn’t feel particularly listened to”.
What to read alongside this
See our pages on Tony Chambers, Ian Harvey, and the September 2016 consultants’ letter. The timeline tracks the escalation month by month.