What the consultants asked for
The September 2016 letter from seven consultant paediatricians to the Trust’s executive team is a plain document. It asked the Trust to contact Cheshire Police about a pattern of unexplained deaths on the neonatal unit, and to treat the pattern as a patient-safety matter requiring external criminal investigation. The full letter is discussed at our consultants’ letter page.
What the consultants were asking for is an investigation of the deaths as individual events, by an organisation with investigatory powers, under rules that would treat the records as potential evidence.
What the Trust did instead
The executive response, over the following weeks, was to commission an “Invited Service Review” from the Royal College of Paediatrics and Child Health. An Invited Service Review is a specific, well-understood product within UK paediatrics: it reviews how a unit is staffed, how its pathways are configured, whether its referral criteria are appropriate, and whether its governance is fit for purpose. It does not investigate individual patient deaths. That is not what it is for.
The RCPCH conducted the review over autumn 2016 and reported in November 2016. The report’s conclusions addressed unit design, escalation protocols, and leadership culture. It made operational recommendations that would improve a struggling unit. It did not examine the individual patient records in the way a police investigation would.
What the RCPCH authors said at the Thirlwall Inquiry
At the Thirlwall Inquiry in autumn 2024, the authors of the 2016 Invited Service Review were asked in some detail how the review came to be scoped as it was. Their evidence (see our summary) can be reduced to four points:
- The terms of reference for the review were negotiated with the Trust’s executive team. The terms of reference are what controls what the review does. The executives therefore controlled the question.
- The review’s product — an Invited Service Review — was an operational-governance review, not an investigation. The review authors say they told the Trust this in writing.
- The review was not asked to investigate individual deaths. If the review had been asked to, the review authors say, the correct product would have been a different one: a Serious Untoward Incident review, or, if a criminal pattern were suspected, a police referral.
- The consultants’ concerns were, in the review authors’ words, “not the question we were asked to answer”. The review report did not, therefore, answer it.
How this ended up in the published narrative
Throughout late 2016 and early 2017 the RCPCH report was presented publicly and in internal Trust documents as having “looked at” the concerns. Executives told board meetings and regulators that the review had not identified deliberate harm. The review report’s own authors say they never looked for deliberate harm because that was not what they had been asked to do. But the report, once in circulation, was used as if it had.
This is the central documentary problem with the 2016 RCPCH review: the gap between what the review was commissioned to do, what it actually did, and how it was subsequently represented. The Thirlwall Inquiry’s evidence record makes the gap visible; the Trust’s contemporaneous framing did not.
Why this matters now
The Crown’s case at the original trial depended, in part, on framing the consultants as a single group of concerned clinicians whose concerns had been properly examined at the time by the RCPCH and not borne out until the Cheshire Police investigation opened in May 2017. The Thirlwall Inquiry evidence shows the Trust did not, in fact, get the RCPCH review to examine the concerns. The executives got the review to examine a different set of questions and represented the answers as having addressed the original set.
The CCRC application filed by Mark McDonald KC in October 2025 addresses this as part of the context under which the eventual police investigation was shaped. A case that starts from a mis-represented review cannot start from neutral ground.
Three ex-executives later arrested
In July 2025 Cheshire Police arrested three former Countess of Chester senior executives on suspicion of gross negligence manslaughter. At time of writing, no charges have been brought. The specific allegations on which the arrests were made are not in the public domain; but the gap between what the consultants asked for, what the RCPCH review did, and what the executives said the review had done, is the main documentary thread that a gross-negligence-manslaughter investigation would follow.