Context
The Royal College of Paediatrics and Child Health published its Invited Service Review of the Countess of Chester neonatal unit in November 2016. The review was commissioned by Trust executives two months after the consultants’ September 2016 letter demanding police involvement. It is an Invited Service Review — a specific product in the UK paediatrics toolkit — and not an investigation of individual patient deaths.
What an Invited Service Review is
An Invited Service Review is an external peer review of how a clinical service is configured, staffed, governed and supported. Its output is operational recommendations to improve the service. Its scope is deliberately general: it is not a case-by-case medical review, it does not examine individual patient records with a forensic eye, and it does not investigate allegations of deliberate harm. The review is commissioned by the Trust under negotiated terms of reference, and the Trust receives the resulting report.
The correct product for investigating individual deaths is different: a Serious Untoward Incident review, or, where a criminal pattern is suspected, a police referral. Those are not Invited Service Reviews and do not run on the same terms of reference.
What the 2016 report addressed
- Unit staffing levels and skill-mix.
- Gestation profile of infants being admitted versus unit designation (Level 2).
- Escalation protocols for deteriorating infants.
- Governance structures, leadership culture, and multidisciplinary team working.
- Transfer pathways to tertiary units.
The review made operational recommendations consistent with its scope. It did not identify deliberate harm because — as its authors later told the Thirlwall Inquiry — looking for deliberate harm was not what it had been asked to do.
How the report was subsequently used
Throughout late 2016 and 2017 the RCPCH report was represented in internal Trust communications and external briefings as having “looked at” consultants’ concerns and not found deliberate harm. The review authors told the Thirlwall Inquiry in autumn 2024 that this representation was not accurate: the review had not been asked to look for deliberate harm and had not done so. The representation served to rebuff consultants’ repeated requests for police involvement through the winter of 2016 and the spring of 2017.
Read alongside
Our analysis of how the RCPCH review functioned as the Trust’s alternative to calling the police, RCPCH authors’ Thirlwall evidence, Consultants’ letter (Sep 2016).