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.