Context
Dr John Gibbs, consultant paediatrician, was one of the longest-serving senior clinicians on the Countess of Chester neonatal unit during the cluster period. He co-signed the September 2016 joint letter demanding police involvement and gave extensive Thirlwall Inquiry evidence on the sequence of internal reviews that ran from late 2015 through late 2016.
The internal-review sequence
Dr John Gibbs
We conducted, I think, four separate internal reviews across late 2015 and 2016. Each one was, in my view, trying to satisfy management that there was no problem. By the fourth, the pattern was unmistakable: the same nurse was present at every unexpected collapse, and the pattern had become a statistical anomaly no consultant could reconcile with coincidence.
Dr John Gibbs
We were told, repeatedly, that we did not have enough to contact police. My view was that that decision was not ours to make. The function of police is to investigate. The function of clinicians is to raise concerns. We had raised ours, clearly and in writing.