Context
Dr John Gibbs, consultant paediatrician, was one of the longest-serving senior clinicians on the Countess of Chester neonatal unit during the cluster period. He co-signed the September 2016 joint letter demanding police involvement and gave extensive Thirlwall Inquiry evidence on the sequence of internal reviews that ran from late 2015 through late 2016.
The internal-review sequence
Dr Gibbs described the earliest institutional response to the cluster as a “Serious Incident Review of the first three deaths”, held around 2 July 2015 and understood to involve Dr Brearey, the Director of Nursing and risk management — though he said he did not know if it had been “reported to the right channel”. That gave way to the thematic review of neonatal mortality, held on 8 February 2016 with a doctor from the Neonatal Network, which he said “did identify some sub optimal care issues, none of them thought to be very significant” while highlighting “that there had been several — it doesn’t mention how many — unexpected, unexplained deaths”.
The hospital’s own internal review followed in July 2016: Gibbs and nurse Anne Martyn examined babies transferred out of the unit as, in his words, “a proxy for a limited type of unexpected collapse”, with findings presented to the Medical Director on 13 July. The Royal College review followed that September, and on 26 January 2017 executives told the consultants that its findings, together with Dr Hawdon’s, showed “no evidence of any wrongdoing” and that Letby was exonerated. Gibbs said: “I was too stunned to ask anything at the end of that meeting. My head was swirling.”