Context
Dr Jane Hawdon is a consultant neonatologist and experienced external reviewer. She gave Thirlwall Inquiry evidence on the reviews commissioned around the cluster and the structural constraints under which those reviews operated — particularly the terms of reference set by the commissioning Trust.
Key ground
Dr Hawdon described being instructed by Mr Harvey to carry out Casenote Reviews of 13 neonatal deaths and four near misses at the Countess of Chester, working from records she found “loosely filed” and incomplete. She said she was not told a nursing staff member was suspected, and that, had she known, “I would have made urgent personal contact with Mr Harvey urging him to follow appropriate Trust safeguarding and governance processes.”
Cross-examined, she agreed that a Casenote Review “by its nature is a fairly superficial exercise”, based only on the papers supplied, and agreed such a review would not be capable of revealing deliberate harm.