The case of serial killer Beverley Allitt formed part of nurse Lucy Letby’s training, a public inquiry has heard.
The Thirlwall Inquiry, which will probe how Letby was able to attack babies on the Countess of Chester Hospital’s neo-natal unit in 2015 and 2016, opened on Tuesday with a statement which referenced nurse Allitt, who attacked children at the Grantham and Kesteven Hospital, Lincolnshire, in 1991, and killer GP Harold Shipman.
Chairwoman Lady Justice Thirlwall said the inquiry would not examine Letby’s convictions, saying an “outpouring of comment” on their validity had “caused enormous additional distress to the parents”.
The 34-year-old, from Hereford, is serving 15 whole-life orders after she was convicted at Manchester Crown Court of murdering seven infants and attempting to murder seven others, with two attempts on one of her victims.
In her opening statement at Liverpool Town Hall, counsel to the inquiry Rachel Langdale KC said the Clothier Inquiry had been carried out following the crimes of Allitt, who was convicted of four counts of murder, three of attempted murder, and a further six of grievous bodily harm on children.
She said: “Nevertheless, and distressingly, 25 years later another nurse working in another hospital killed and harmed babies in her care.”
Ms Langdale said the inquiry would hear from a senior lecturer in the child nursing programme at the University of Chester, where Letby qualified in 2011, who said the case of Allitt formed part of student training and learning.
She said the motive for Letby’s crimes would not be examined during the hearings, and referenced an inquiry into the crimes of Shipman, thought to have murdered hundreds of his patients, which “shed very little light” on why he carried out the killings.
She said: “For ordinary, decent, right-thinking people, the actions of Letby will remain unfathomable. We will not be inviting speculation from witnesses about her motive or mindset.”
The inquiry will look into the experiences of the parents of babies, the conduct of others working at the hospital and the culture and management in the wider NHS.
Ms Langdale said the death of Child D on June 22 2015 was the third neonatal death in under two weeks.
This exceeded the total number of deaths in 2013 (two deaths) and equalled the total deaths in 2014 (three deaths).
In addition to three deaths, there had also been the near fatal collapse of Child B, the twin of Child A, she said.
A meeting took place on July 2 between various department heads but a decision was reached that no further investigation was warranted, she said.
Ms Langdale told the inquiry: “With hindsight, this decision may represent a significant opportunity missed.”
She said it would take the sudden and unexpected deaths of another two babies, Child E and Child I – in August and October 2015 – before the issue of commonality of staffing was revisited and a further investigation was considered necessary.
Again no further investigation was deemed necessary following the death of Child E, the inquiry heard, and it was said to be a “further missed opportunity” to report the increase in neonatal deaths since June 2015 as a serious incident.
Ms Langdale said: “This would have triggered a comprehensive investigation into the increased mortality rate at an earlier stage.”
Letby was also convicted of attempting to murder Child E’s twin brother, Child F, in August 2015 by poisoning him with insulin.
The barrister said consultant paediatrician Dr John Gibbs had stated to the inquiry that blood tests on Child F were “not interpreted correctly at the time and so, highly regrettably, an indication that someone was deliberately harming patients was overlooked”.
Following a pattern of repeated collapses of Child I, who died in October 2015, it appeared that caused the “first explicit concerns to be raised about the correlation between Letby’s shifts and the unexpected collapse or death of babies”, said Ms Langdale.
In July, Letby protested: “I’m innocent”, as she was led from the dock when she was sentenced to her 15th whole-life order after a jury convicted her at retrial of the attempted murder of a baby girl.
In May, she lost her Court of Appeal bid to challenge her convictions from the first trial which took place between October 2022 and August 2023.
Lady Justice Thirlwall said that judgment gave “finality” to the parents, but it was “not to be”.
She said: “In the months since the Court of Appeal handed down its judgment, there has been a huge outpouring of comment from a variety of quarters on the validity of the convictions.
“As far as I am aware it has come entirely from people who were not at the trial. Parts of the evidence have been selected and criticised, as has the conduct of the defence at trial, about which those defence lawyers can say nothing.
“All of this noise has caused enormous additional distress to the parents who have already suffered far too much.
“It is not for me to set about reviewing the convictions. The Court of Appeal has done that with a very clear result.”
The first week of the inquiry will hear opening statements from the counsel to the inquiry, along with legal representatives from core participants including the families of Letby’s victims.
Lady Justice Thirlwall said it was planned that the hearings in Liverpool would finish in early 2025 and she expected her findings to be published by late autumn of that year.
A court order prohibits reporting of the identities of the surviving and dead children involved in the case.
