Context
Tony Chambers was Chief Executive of the Countess of Chester Hospital NHS Foundation Trust from 2013 until 2018. His Thirlwall Inquiry evidence addresses the consultants’ repeated requests throughout 2016 and 2017 that police be contacted, his decision to commission a service-level RCPCH review instead, and the instruction given to consultants to sign an apology letter to Lucy Letby. On 30 June 2025 Chambers was arrested by Cheshire Police on suspicion of gross negligence manslaughter; no charging decision had been announced at the time of writing.
Key passages
Opening apology. Before questions began, Mr Chambers, the Trust’s Chief Executive from December 2012, asked to address the Families. He said: “So right at the outset I just want to offer my heartfelt condolences to all the Families whose babies are at the heart of this Inquiry.” He went on: “I took in good faith. I am very grateful to have this opportunity to take part, openly and honestly, in this Inquiry and I hope that answers can be arrived at and recommendations made.”
A personal failure. Pressed repeatedly to identify his own most significant failing, rather than describing a system failure, Mr Chambers pointed to his witness statement’s acknowledgment that “I wholeheartedly accept that the operation of the Trust’s systems failed and that there were opportunities missed to take earlier steps to identify what was happening”. Asked what that meant for him personally, he said “our ability to have communicated what was a very complex set of messages, with information that was unclear” meant “the communications with the Families could of and should have been better”. After counsel queried his use of the word “our” rather than “my”, he said: “No, no I take fully and accept that as the accountable officer for the Trust, I must take some responsibility for that, take responsibility for that.”
First awareness. Counsel put to Mr Chambers that on 24 June 2016, five days before he says he learned of the concerns, the Director of Nursing, Alison Kelly, had been told the two most senior Consultants believed a nurse may have murdered a baby. He responded: “If — if that is the facts of the matter, if that is what Alison has understood to have heard that was said to her clearly and very explicitly articulated in the way that you have just described, then, yes, I am sure I should have been made aware.” Of his own knowledge, he said: “I don’t believe I knew about these matters before 29 June…I think it’s a fair assessment that I perhaps should have been told.”
What was told to police. Taken through the account given to Cheshire Constabulary in May 2016, which recorded “a notable high statistical relationship between a member of nursing staff and babies deteriorating in the unit” and “There is no evidence other than coincidence”, Mr Chambers said “I absolutely believe what we said there was our best understanding of the matters as we — as we saw them”. He accepted that the account did not mention that the pattern of collapses had stopped after the nurse was moved off the unit, telling the Inquiry: “The Datixes weren’t always being completed. So — but I don’t — I don’t know the facts of this matter but you are right, it’s not been articulated here.”
The Risk Register. Asked about a July 2016 entry on the Executive Risk Register describing “Potential damage to reputation of neonatal service and wider Trust due to apparent increased mortality within the neonatal unit”, Mr Chambers said the wording was “not necessarily capturing the origin to that risk” and that it should have reflected the need to maintain confidence in the safety of the unit rather than the organisation’s image. He rejected the suggestion that the Trust had prioritised its reputation, telling the Inquiry: “I don’t think that what’s been described here, if the proposition is that we were somehow putting reputation over safety, that’s not right.”
What to read alongside this
See our profile of Tony Chambers, the evidence of Dr Brearey, and the September 2016 consultants’ letter.