Context
Dr Rachel Lambie, consultant paediatrician, gave Thirlwall Inquiry evidence on the clinical picture of the cluster as it unfolded, the unit’s staffing and capacity problems, and the executive response to the consultants’ escalation.
On the unit’s capacity
Dr Rachel Lambie
We were routinely caring for babies whose acuity should have had them in a tertiary centre. Staffing was stretched. The margin for error was narrow and sometimes, in my view, not present. This was the context in which the cluster of deaths occurred, and it cannot be separated from any assessment of cause.