Context
Dr Stephen Brearey was the lead consultant on the Countess of Chester neonatal unit and the first clinician to raise concerns, from July 2015 onwards, about the cluster of unexpected deaths and collapses. He kept contemporaneous notes of meetings with management and of his escalation attempts throughout 2016 and 2017. His Thirlwall Inquiry witness evidence is one of the most important single records of how consultant concerns were handled by the Trust’s executive team.
Key passages
Dr Stephen Brearey
I first raised concerns in July 2015. I can be specific about that because I noted it at the time. The pattern I was seeing was not a pattern of natural deterioration that I recognised from my training or from my earlier career on this unit.
Dr Stephen Brearey
My recollection — and the notes I kept at the time support this — is that the response from senior management was one of irritation. I was repeatedly told that this was an HR issue, a team-dynamics issue, a dispute between nurses and doctors. It was none of those things. It was a patient-safety issue.
Dr Stephen Brearey
I believed then, and I believe now, that the police should have been contacted by September 2016 at the latest. It was not a difficult call. We had a serial pattern. Police were contacted in May 2017. I do not know how else to explain that delay except in terms of the executive team wanting to avoid reputational harm.
Dr Stephen Brearey
I was asked — I was, in truth, instructed — to sign a letter apologising to the nurse in question. I did sign it, to my continuing regret. I signed it because I was told in clear terms that if I did not, my own position on the unit was in jeopardy.
What to read alongside this
See our pages on Tony Chambers, Ian Harvey, and the September 2016 consultants’ letter. The timeline tracks the escalation month by month.