Context
Dr Nim Subhedar is a consultant neonatologist at Liverpool Women’s Hospital — the regional tertiary referral centre that would normally have received babies too sick for the Countess of Chester’s Level 2 unit. He was among the senior external clinicians involved in reviewing the Countess of Chester cluster. His Thirlwall Inquiry evidence is weight-bearing because, as a practising tertiary-centre neonatologist, he was the kind of external reviewer best placed to see what the unit was actually doing wrong.
Key ground
Dr Subhedar, clinical lead for the Cheshire and Merseyside Neonatal Network, said the network’s Clinical Effectiveness Group discussed Countess of Chester neonatal deaths through 2015 and into January 2016 for “learning from reviews that had been completed” rather than to monitor death rates. He recalled Dr Brearey telling him informally, after the January meeting, that a staff member appeared associated with the deaths, and said he pushed for a fuller staffing review. He agreed the situation reached the safeguarding threshold once other explanations were excluded, and that the network’s oversight of mortality in 2015/16 “could have been improved.”