Day two begins in a public inquiry into the circumstances around the crimes of Lucy Letby.
The child serial killer was sentenced to 15 whole-life orders after she was convicted of murdering seven babies and attempting to murder seven others at her Countess of Chester ward in 2015 and 2016.
The inquiry is not examining the convictions, but is exploring what happened at the time of the crimes, including how hospital staff dealt with the issue.
Yesterday, it heard how Letby was removed from nursing duties in July 2016 after senior consultant paediatricians raised concerns to their bosses about “patient safety” in the neonatal unit.
The inquiry heard in February 2017 she attended a “tea party” which a deputy unit manager explained to staff was to welcome her back. The 34-year-old was also able to make a number of supervised trips to Alder Hey to visit wards and outpatient clinics.
She was later told she would not return to nursing duties as police launched an investigation.
Counsel to the inquiry Rachel Langdale KC said a planned return to the neonatal unit at Countess of Chester was then only stopped by the “tenacious lobbying of the consultants”.
Key points
- The ‘tea party’ - why it was held and what happened?
- Letby visited Alder Hey just months after being dismissed from nurse duties
- Hospital executives side stepped repeated advice to call police over Letby
- ‘This allegation against Letby is massive’ said senior nurse
- ‘I will return in the coming weeks’, says chilling email from Letby
The ‘tea party’ - why it was held and what happened?
09:30
Alex Ross
The inquiry heard yesterday how Lucy Letby was switched to clerical work in July 2016 after senior consultant paediatricians raised concerns to their bosses about “patient safety” in the neonatal unit.
But it heard that in February 2017 she, along with another nurse referred to as Nurse Z, attended a “tea party” which Yvonne Griffiths, deputy unit manager, explained to staff was to welcome her back.
In a statement to the inquiry, nursery nurse Jean Peers said: “I was on (at) the weekend and so was Yvonne Griffiths, she said that Letby was coming with Nurse Z and that we would do a tea party to welcome her.
“We did cakes and tea, and she came in and we were all talking, and she did not say a word to us.
“Yvonne and I were talking a lot to make it nice and relaxed and when she went, we both said: ‘Oh my God, she is going to make it hard for us when she returns as she seems angry.’”
Counsel to the inquiry Rachel Langdale KC said Letby was told in April 2017 that her scheduled return to the unit was to be paused and it was recommended she stop any further visits.
Ms Langdale said: “This appears to be a reference to the fact that prior to this date Letby had been attending the neo-natal unit.
“Whether and how often this occurred and, if it did, who sanctioned it, are matters the inquiry will be investigating.”
Lucy Letby visited Alder Hey Children’s Hospital, inquiry told
08:53
Alex Ross
Child serial killer Lucy Letby made a number of visits to Alder Hey Children’s Hospital after she was removed from nursing duties at the Countess of Chester, a public inquiry has heard.
Letby, 34, was also said to have visited the Countess of Chester’s neonatal unit in the same period, including a “tea party” to welcome her expected return to the ward.
She was switched to clerical work in July 2016 after senior consultant paediatricians raised concerns to their bosses about “patient safety” in the neonatal unit.
The inquiry into the events surrounding the crimes of Letby heard she launched a grievance procedure in September 2017 over the removal which was resolved in her favour several months later.
Counsel to the inquiry Rachel Langdale KC said in late January 2017 Letby had been involved with discussions to attend Liverpool’s Alder Hey “to view theatre lists and have an observational contract”.
Ms Langdale said the inquiry would hear evidence that Letby went on to make a number of supervised visits including outpatient, clinics, ward rounds and team meetings – although a witness would say they believed she had no known unsupervised patient contact.
She said: “Letby attending Alder Hey Children’s hospital in any capacity during the period she was excluded from the neonatal unit is an area of particular concern for the inquiry.
Look back at yesterday’s opening day
08:41
Alex Ross
We heard how Lucy Letby would have been allowed to return to the neo-natal unit she murdered seven babies had it not been for “tenacious lobbying” from consultants at the hospital.
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.
It heard how Letby was removed from nursing duties after senior consultant paediatricians raised concerns to their bosses about “patient safety” in the neonatal unit in July 2016.
Full story on yesterday here:
Timetable for the inquiry
06:30
Alex Ross
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.
Why a group of experts wanted this week’s inquiry postponed?
04:30
Alex Ross
Last month, a group of 24 experts wrote to the health secretary Wes Streeting, calling for the inquiry this week to postponed.
The letter said the natural assumption that the nurse was a murderer could mean important lessons were missed.
“Possible negligent deaths that were presumed to be murders could result in an incomplete investigation of the management response to the crisis,” the letter said.
In particular, concerns were raised over statistics on the number of deaths at the hospital’s neonatal unit, with it claimed that there were six deaths on the unit in the same period when Letby was not present that were not revealed to the jury.
Warwick University’s Prof Jane Hutton told the BBC the way the figures were presented was not in a way it should be.
Not until a year after first murder were deaths reviewed
02:30
Alex Ross
The inquiry on Tuesday heard how it was not until February 2016 following the unexpected collapse of Child J and the deaths of two further babies – who were not on the criminal indictment – that any review of the neonatal care of the babies who died during 2015 took place.
A total of 10 babies were the subject of the thematic review, which also covered January 2016, led by a neonatologist from Liverpool Women’s Hospital NHS Foundation Trust.
Letby was identified as being either among the nursing staff allocated and/or on duty at the time of the deaths in respect of nine of those babies, said Ms Langdale, although the report did not refer to Letby by name or whether the deaths could have been caused by incompetence or deliberate harm.
‘Significant opportunity missed'
Wednesday 11 September 2024 00:30
Alex Ross
The inquiry is looking 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 Rachel 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.
Case of killer nurse Beverly Allitt was part of Lucy Letby’s training
Tuesday 10 September 2024 22:30
Alex Ross
The case of serial killer Beverley Allitt formed part of nurse Lucy Letby’s training, a public inquiry has heard.
The 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 with a statement which referenced nurse Allitt, who attacked children at the Grantham and Kesteven Hospital, Lincolnshire, in 1991, and killer GP Harold Shipman.
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.
Baby killer Lucy Letby stopped from resuming nursing duties thanks to ‘tenacious consultants’, inquiry hears
Tuesday 10 September 2024 21:37
Alexander Butler
Child serial killer Lucy Letby would have been allowed to return to the neo-natal unit she murdered seven babies had it not been for “tenacious lobbying” from consultants at the hospital.
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.
It heard how Letby was removed from nursing duties after senior consultant paediatricians raised concerns to their bosses about “patient safety” in the neonatal unit in July 2016.
Lucy Letby ‘hid in plain sight’ like GP killer Harold Shipman, inquiry hears
Tuesday 10 September 2024 20:30
Alex Ross
Earlier in the inquiry, Rachel Langdale KC, counsel to the inquiry, compared Lucy Letby to Harold Shipman as she appeard to stamp down the validity of the convictions in the wake of speculaton.
Read more here:
Letby visited Alder Hey just months after being dismissed from nurse duties
Tuesday 10 September 2024 20:02
Alexander Butler
Child serial killer Lucy Letby visited Alder Hey Children’s Hospital just after she was dismissed from her nursing duties over safety concerns at her own hospital, a public inquiry heard.
Letby was switched to clerical work in July 2016 after senior consultant paediatricians raised the alarm about patient safety in her Countess of Chester neonatal unit.
But only months later in 2017, the 34-year-old was able to make a number of supervised trips to Alder Hey - one of the UK’s most prestigious children’s hospitals - to visit wards and outpatient clinics, the inquiry heard.
This year, she was sentenced to 15 whole-life orders after she was convicted of murdering seven babies and attempting to murder seven others at her Chester ward in 2015 and 2016.
Appeal judgement on Letby convictions ‘marked a watershed'
Tuesday 10 September 2024 18:30
Alex Ross
Letby, 34, 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.
She protested to the court “I’m innocent” as she was led from the dock when she was sentenced in July 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.
Referring to that judgment, Lady Justice Thirlwall said: “That judgment marked a watershed.”
She went on to say the subsequent speculation had impacted the families
Lucy Letby case could be ‘biggest miscarriage of justice in UK history’, lawyer says
Tuesday 10 September 2024 17:30
Alex Ross
Earlier, the inquiry chairwoman Lady Justice Thirlwall said speculaton over Lucy Letby’s convictions were distressing for the families of victims.
Among those putting foward questions is Letby’s own newly-appointed lawyer, Mark McDonald, who is preparing to launch an appeal for his client.
Here is speaks to The Independent on his case
Thirlwall Inquiry concludes for the day
Tuesday 10 September 2024 16:07
Rebecca Thomas
The inquiry has concluded for the day and will resume on Wednesday at 10am.
‘I will return in the coming weeks’, says chilling email from Letby
Tuesday 10 September 2024 16:03
Rebecca Thomas
Lucy Letby emailed the neonatal unit staff claiming in 2017, following the outcome of a grievance, according to the Thirlwall Inquiry
She said: “I was redeployed to the unit following serious professional allegations by members of the medical team...I have been fully exonerated and I will return in the coming weeks.”
It was only due to the persistence of doctors who were blowing the whistle that she did not return to the unit.
Hospital bosses did not believe there was enough evidence to call police
Tuesday 10 September 2024 15:57
Alex Ross
On 3 April 2017, there was a discussion between hospital executives about calling the police, but it didn’t happen for another month.
Stephen Cross, director for corporate and legal services created a document at the time which included the line: “In our view, there is no evidence to justify a criminal investigation.”
KC Langdale said the inquiry will look “at the content of this document in greater detail during the hearing, in terms of what it may reveal about the thinking of the executive directors at this time.”
‘This allegation against Letby is massive’ says senior nurse
Tuesday 10 September 2024 15:48
Rebecca Thomas
The head of nursing at the Countess of Chester, Karen Rees reportedly made a plea to allow her to begin working in the neonatal unit again.
The inquiry heard the head of nursing, described it as “immoral” that Lucy Letby was not being allowed to work directly with patients during this period.
She reportedly appears to have suggested concerns about Letby were based on “gut feeling” from the senior paediatricians and not evidence.
Rees said, “This allegation against Letby is massive and if anyone is of this belief then why have the police not been called?”
Letby would’ve returned to neonatal unit if not for whistleblower doctors
Tuesday 10 September 2024 15:37
Rebecca Thomas
It was not until a year after Letby was removed from the unit that police were contacted by the trust’s chief.
Following a grievance raised by Letby, decisions were made by the executive to allow her to return, however, this was resisted by paediatricians.
KC Langdon told the inquiry: “Without the consultants’ [persistent] approach, it is likely Letby would have been permitted to return to the unit.”
On 2nd May 2017, chief executive Tony Chambers told Cheshire Police there was “no single factor” that had been identified about the babies’ deaths. However, he said in four cases no causal factor had been identified at all which was not usual.
He requested that Cheshire Police undertake a forensic investigation to exclude anything untoward.
Hospital executives side stepped repeated advice to call police over Letby
Tuesday 10 September 2024 15:25
Alex Ross
The inquiry is hearing that there are records suggesting that medical director Ian Harvey was advised to contact the police in June 2016.
Rachel Langdale KC said on 29 June that year, Mr Harvey held a meeting with Stephen Cross, the director of corporate and legal services at the Countess of Chester Hospital trust, about the situation on the neonatal ward.
A contemporaneous note of that meeting written by Mr Cross states: “ADVICE ‘Police’ need to be involved now.
“Death of triplets has raised concern. Nurse was on duty at deaths. Sufficient level of concern that illegal activity in neonatal.”
Ms Langdale says Mr Harvey has stated he was “unable to recall the meeting”, and in his statement to the inquiry he added that he “does not remember anyone giving him advice at that point that the police should be contacted”.
At about the same time, Mr Harvey was also copied into an email chain involving the senior consultants in which it was suggested that the police should be called in.
Ms Langdale stated: “The Cheshire Police were not, in fact, contacted by the Trust until nearly one year later in April 2017.”
In a separate meeting, Mr Chambers is reported to have told doctors to call the police themselves. However, one doctor said in response “our career would be on the line if we called the police as it would be whistle-blowing.”
In a further warning, Dr Stephen Brearey said to Mr Chambers “you need to think about the police.”
“You need to leave this with us,” Tony Chambers said in response, according to the inquiry.
Grievance raised by Letby ‘dominated’ directors thinking
Tuesday 10 September 2024 15:13
Rebecca Thomas
After she was removed from the neonatal unit Letby raised a grievance against the trust, the inquiry has heard.
According to the inquiry, the outcome grievance was seen by executives to have “exonerated” Letby.
Ms Langdale said there is “evidence which may suggest that the grievance came to dominate the thinking” of executive directors and that, once completed, the grievance process was viewed as having “exonerated” Letby when, in fact, it contained no investigation into her actions whatsoever.
“We will be examining this issue with care. The use of a grievance process as a means to avoid scrutiny is something that the system must be capable of recognising and preventing.”
Executives said trust must ‘draw a line’ under allegations against Letby
Tuesday 10 September 2024 15:07
Rebecca Thomas
During a meeting on 30 December 2017, led by the chair of the Countess of Chester Sir Duncan Nichol, the trust’s executives reportedly called for a line to be drawn under the concerns about Letby.
This follows a Royal College review which pointed to staffing within the unit and other quality problems as factors in the babies’ deaths.
The inquiry barrister said: “In the course of his presentation to the board, Mr Harvey said in one of the instances to “draw a line” and this was repeated by Mr Chambers.”
Mr Chambers allegedly said there was an “unsubstantiated explanation that there was a causal link to an individual” and the mortality.
Mr Chambers told the inquiry he cannot remember being this “emphatic” about the matter but does character his position.
He also allegedly said a report done following a grievance submitted by Letby had exonerated her.
The barrister reveals further instances where he is later reported asking doctors to “draw a line” under the issue.
Executive warns ‘this is potentially very serious’ in email over Letby
Tuesday 10 September 2024 14:58
Rebecca Thomas
A hospital meeting in May 2016 took place to “discuss high mortality and the commonality of the presence of a nurse”, it has been reported.
According to KC Langdale, it was the first time that a member of the executive directors group from Countess of Chester Hospital was informed in writing that a member of staff’s shift pattern had been changed over concern about a nurse.
The KC referred to the response by chief nurse Alison Kelly to the information.
The barrister said, “Ms Kelly has told the inquiry that when she received this email the reference to ‘pressure on staffing numbers’ was the reason for the need to hold the meeting as soon as possible and the impact of moving Letby upon the nursing rota, rather than any concerns about deaths being from unnatural causes.”
Ms Kelly then forwarded the email to other managers including her deputy, and Karen Rees - the nurse in charge of urgent care at the hospital.
The email said: “Can you please look into this… if there is a staff trend here and we have already changed her shift patterns because of this, then this is potentially very serious!! I will check the report they sent through – I did not notice there was a staff trend!!”
Several senior managers and top executives defended Letby over concerns
Tuesday 10 September 2024 14:47
Rebecca Thomas
The Thirlwall inquiry has revealed repeated examples in which top executives at the Countess of Chester can be seen to have defended Lucy Letby.
These examples have included claims of a ward manager who was “vociferously” defending Letby, a chief nurse who said there was “absolutely no issue” and the chief executive Tony Chambers who wrote a letter confirming Letby could be returned to the neonatal unit after doctors’ concerns led to her being moved.
The inquiry will look into delays by the hospital executive to inform the police.
During one meeting, according to Rachel Langdon KC’s statement, the chief executive Tony Chambers said, “We are within our rights to phone the police but we didn’t believe it to have been a criminal issue without further investigation.”
The inquiry will examine whether the trust executives inaccurately operated under the belief that concerns about Letby had to be proved before informing the police. It will also ask if the executive director’s personal opinions of Letby influenced how they commissioned reviews into the babies’ deaths.
Countess of Chester chief executive letter claims no concerns over Letby
Tuesday 10 September 2024 14:29
Rebecca Thomas
The trust’s chief executive, Tony Chambers, wrote a letter in which he confirmed there were no concerns over Letby, after a decision, in late 2016, was made to allow her to return to the Countess of Chester neo-natal unit by January 2017.
She had been removed from the unit following the escalation of concerns into a non-patient-facing role.
Mr Chambers is one of several trust executives whose actions will be scrutinised by the Thirlwall Inquiry.
Chief nurse tells nursing regulator no concerns about Letby
Tuesday 10 September 2024 14:21
Rebecca Thomas
Chief nurse Alison Kelly reportedly told the Nursing and Midwifery Council on 31 August “As previously mentioned we undertook a thorough internal review nothing untoward was noted.”
Rachel Langdon KC said the inquiry will return and examine whether this was an accurate interpretation by Ms Kelly to the NMC.
UK’s nursing regulator to be probed by Letby inquiry
Tuesday 10 September 2024 14:14
Rebecca Thomas
The Nursing and Midwifery Council is set to be probed by the Letby inquiry, the inquiry’s counsel has revealed.
Letby’s nursing registration was not subject to any restriction by the NMC until she was charged with murder, according to the inquiry.
The inquiry will scrutinise the Nursing and Midwifery Council’s response to referrals of Ms Letby.
Rachel Langdon KC, said although the trust had the power to stop Letby from working with patients in the Countess of Chester “it had no power to stop her from seeking patient-facing work elsewhere, only the NMC has that power.”
Her words come after The Independent revealed a secret internal review by the NMC earlier this year into its actions over Letby prompted it to change its guidance and make clear nurses can face sanctions before criminal charges.
According to KC Langdon, initially, there was no initial referral from the trust chief nurse of Letby to the NMC.
Medical director asks for doctors to stop the 'chit chat’
Tuesday 10 September 2024 14:08
Rebecca Thomas
An email thread between medical director Ian Harvey and paediatricians at the Countess of Chester was revealed by KC Langdon.
Doctors were continuing to raise concerns about Letby and suggested outside organisations be contacted to get involved.
However, the medical director discouraged the doctors from emailing further asking them to “stop the chit-chat.”
Deaths of two triplets ‘catapulted’ concerns to the top of the executive team.
Tuesday 10 September 2024 14:05
Rebecca Thomas
In June 2016 Countess of Chester chief Tony Chambers, director of corporate & legal affairs Stephen Cross and HR director Susan Hhdkinson “became increasingly involved in the response of the hospital to concerns about Letby.”
Rachel Langdon KC said, “the deaths of two triplets catapulted neo-natal mortality to the top of the executive team.”
The inquiry will further examine whether they should have become involved sooner.
Records suggest there had been no discussions by these executives about the unexpected deaths and infant mortality.
During a meeting on 26 June 2016, Dr Steven Breary discussed Letby with Ms Alison Kelly, Dr Ian Harvey, nurse Murphy and Dr Ravi Jayaram. According to the inquiry evidence, Alison Kelly was “adamant” there were no concerns about Letby.
An email outlining actions going forward reveals Mr Harvey was to instruct a Royal College to undertake a review of the unit and Letby was to remain on days.
The inquiry has resumed
Tuesday 10 September 2024 13:48
Rebecca Thomas
The inquiry has resumed with a continuation of the opening evidence from Rachel Langdon KC, counsel to the inquiry.
Inquiry pauses for a short period
Tuesday 10 September 2024 12:53
Rebecca Thomas
The inquiry has paused and will restart in an hour. We will continue with updates when evidence resumes.
‘Absolutely no issues with nurse and circumstantial’
Tuesday 10 September 2024 12:51
Rebecca Thomas
An email by Dr Steve Breary following May 2016 to chief nurse Alison Kelly highlighted Letby’s connection to babies’ deaths.
Ms Kelly then reportedly emailed medical director Ian Harvey asking for a meeting noting “Hi Ian please see Steve’s comments below which alarm me.”
“I’m currently reassured there were no issues but I think this is worth a wider review”
She allegedly was assured by ward nurse Eirain Powell that the creation of a table linking Letby to the deaths was more to do with concern over her well-being.
Notes by Ms Kelly of a meeting where concerns about Letby were discussed between herself, Mr Harvey, Ms Powell and another manager Ms Murphy state, “absolutely no issues with nurse and circumstantial.”
According to evidence by Ms Kelly, she described ward manager Ms Power as being “vociferous” in Letby’s defence and Dr Breary described her as “defensive” over the nurse.
However, Mr Harvey said the tone of the meeting was calm adding “I don’t remember anyone being forthright about concerns about Letby.”
Chief nurse claims there were ‘no grave concerns’ over Letby
Tuesday 10 September 2024 12:32
Rebecca Thomas
In 2016 one of the doctors, Dr Ravi Jayaram, who had been raising concerns, sent an email to other senior managers saying “I think we need to still talk about Lucy.”
According to KC Langdale, no meeting took place but Dr Jayaram claimed several “corridor conversations” were had about his concerns in relation to Letby.
A later meeting was requested with the trust chief nurse Alison Kelly. In evidence to the inquiry, Ms Kelly said at the time there was nothing in an email from ward manager Ms Powell to suggest there were grave concerns about Letby, the tone and content of the email did not suggest there was a need for an immediate meeting.
Referencing a thematic review which had been carried out in February 2016, the inquiry said by by March 2016 both Alison Kelly and medical director Dr Ian Harvey had received the report directly. Dr Harvey had received it twice by this point.
Ms Kelly reportedly called for a meeting to take regarding the report after recieving it but this did not happen until 11 May 2016.
Between 17 March and 11 May 2016, Letby was moved from night shifts to day shifts where she attacked two further children, the inquiry heard.
‘We did not think there was a connection’, says senior nurse manager
Tuesday 10 September 2024 12:17
Rebecca Thomas
Following the death of Child I, Dr Stephen Breary emailed senior managers and directors following a more detailed review of the baby’s death.
Rachel Langdale KC said there was no linking factor in the first, three deaths, however, it appears to be the death of Child I that first led Dr Breary to raise his concerns about Letby.
He allegedly noted the repeated nature of Child I’s collapses and improvement when they were moved away from the Countess of Chester to Arrow Park Hospital in Liverpool
However, in an email response Eirian Powell, who was the neonatal unit ward manager, said “It is unfortunate Letby was on [shift].”
Ms Powell attached to the email a table which identified all of the babies that died and all of the nursing staff on duty.
KC Langdale said, “This document was compiled by Ms Powell who held Letby in high regard.”
“We will be considering what it [the table] does and does not signify.
In a later email, she informed Dr Breary that said “We did not think there was a connection” between Letby and the babies’ deaths.
However, months later a further analysis would identify her as present at each incident.
Hidden insulin results may have change medical director’s view, he claims
Tuesday 10 September 2024 12:00
Rebecca Thomas
Following the death of child E, blood results indicating the presence of insulin in babies were not escalated or communicated, according to the inquiry evidence.
Countess of Chester medical director, Ian Harvey, has told the inquiry in his evidence that had the presence of insulin in the babies’ blood results been flagged to him, this would have changed his perception of what was occurring at the Countess of Chester neonatal unit.
The inquiry will return to examine the role of the executive board at the Countess of Chester Hospital.
Nurse shared her concerns with Letby over first deaths
Tuesday 10 September 2024 11:53
Rebecca Thomas
Following the first three deaths, doctors and nurses noted Letby was present but considered she was “merely unfortunate.”
One nurse shared concerns with Letby over the loss of three babies in 12 days.
She said in a message: “There’s something odd about that night and the fact that we lost three that went so suddenly...” she messaged Letby. She did not share her thoughts with anyone but Letby, there were no formal meetings, conversations or debriefs, according to the inquiry.”
Senior meeting following first cluster of deaths failed to make Letby connection
Tuesday 10 September 2024 11:41
Rebecca Thomas
The inquiry has resumed...
Counsel to the inquiry focuses on a serious incident meeting with senior doctors and nurses on 2 July 2015.
It is said those at the meeting failed to document which staff were present at each death so far and commonalities such as rashes, which were also seen on Child B. However Child B’s collapse was not included at the meeting.
KG Langdale said had these factors been considered in July 2015 as a minimum Letby’s presence at each death and the unexpected collapse of Child B would’ve been considered, including the rashes, and could’ve been considered in greater detail.
She said: “It would take two more babies [to be harmed] that staffing would be revisited.”
The meeting also did not include any of the doctors or nurses who were actively present during the incidents.
This, KC Langdale said, calls into question the efficacy of serious incident panels.
‘History tells us that serial killers are deceptive’ says inquiry lawyer
Tuesday 10 September 2024 11:46
Rebecca Thomas
In her opening, Rachel Langdale KC talked of other NHS clinicians who have been accused of harm and murder
She said: “History tells us that serial killers are deceptive, manipulative and skilled at hiding in plain sight.”
She said an inquiry into Harold Shipman, a GP thought to have murdered hundreds of his patients, shed little light on why he carried out his crimes and found he was able to kill undetected over many years, enjoying a high reputation.
She added: “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.”
She said the inquiry would examine why detailed medical analysis of the deaths and collapses of babies did not take place earlier and whether bias in favour of Letby influenced the hospital’s response.
She said: “It was not until April 2017, almost two years after the first murder, that the hospital made a referral to the police and detailed multi-disciplinary medical scrutiny and analysis was finally conducted.”
Inquiry breaks for short period
Tuesday 10 September 2024 11:30
Rebecca Thomas
The inquiry has paused for a break and will resume shortly. We will be bringing you all the latest updates once it resumes.
It is due to finish at 16:30.
‘Not Lucy not nice Lucy’- inquiry to consider ‘bias’ by senior staff in the hospital
Tuesday 10 September 2024 11:23
Rebecca Thomas
The inquiry will examine what and if any biases towards Letby influenced senior staff member’s actions.
According to evidence from KC Rachel Langdale, following the deaths of three babies in 12 days an executive meeting was called.
During a review meeting with top executives, on 2nd July 2015, including the chief nurse Alison Kelly, doctors and ward managers noted Letby’s presence during all of the incidents.
However, nothing untoward was suspected by those in the meeting.
Dr Stephen Breary remembered saying “Not Lucy, not nice Lucy.”
KC Langdale said, “We will consider what biases played a part in what inquiries and conclusions took place next.”
Letby underwent training at university covering crimes of 90s nurse killer Beverley Allitt
Tuesday 10 September 2024 11:01
Rebecca Thomas
Rachel Langdale KC, counsel to the inquiry, began her opening statement by speaking about serial killer nurse Beverley Allitt, who was convicted of four counts of murder, three of attempted murder, and a further six of grievous bodily harm on children at the Grantham and Kesteven Hospital, Lincolnshire, in the 1990s.
Ms Langdale said a statement had been received by the inquiry from former secretary of state for health Baroness Bottomley, who ordered an inquiry be conducted to establish the facts after Allitt’s crimes.
Ms Langdale said: “Nevertheless, and distressingly, 25 years later another nurse working in another hospital killed and harmed babies in her care.”
She said the inquiry would hear the crimes of Allitt formed part of the training course Letby underwent at the University of Chester.
Nurses and doctors made connections between unusual ‘rashes’ on two children
Tuesday 10 September 2024 10:53
Rebecca Thomas
Nurses and doctors made connections between unusual “rashes” on Child A and Child B, however, there was no evidence of a “debrief”.
KC Langdale sets out how following Child A’s death nurses and doctors noted a similar “florid” rash on Child B which “came out of nowhere.”
An incident note from the time by a nurse noted the “sudden and unexpected” death of a patient on the unit, which needed a post-mortum.
Despite the doctors’ and nurses’ reflections KC Langdale said there was no evidence a “debrief” was undertaken following the death of Child A
“Both nurses and doctors made connections between the rashes on Child A and Child B...The inquiry will be considering the steps that should’ve and were taken...were established processes followed and if not why not.”
The inquiry KC noted a comment from evidence given by one doctor that “Child death review processes are disparate and inconsistent.”
Child death reviews are supposed to occur following the unexpected death of a child - they are called child death overview panels.
Although emails show a doctor calling for a “debrief” following the death of Child A, KC Langdale said “It is unclear whether that debrief was held...If a debrief was held no notes were taken.”
Appeal judgement a ‘watershed’ moment for parents
Tuesday 10 September 2024 10:37
Rebecca Thomas
Opening the inquiry, Lady Justice Thirlwall said that appeal judgment was a “watershed” as the parents of the nurse’s victim could now turn their minds to the inquiry.
“It is time to get on with this inquiry,” said Lady Thirlwall opening the inquiry.
She said the parents of those harmed had waited years for their questions to be answered and it was her responsibility to focus on the inquiry’s terms of reference.
“It is time to get on with this inquiry,” she said.
Prior to Letby deaths hospital’s unit had two to three deaths a year
Tuesday 10 September 2024 10:31
Alex Ross
“We will not be speculating on her motive...we will be investigating why attacks on babies were able to continue to happen for a year,” says Rachel Langdale KC.
KC Langdale says prior to the year of Letby’s killings the mortality rate at Countess of Chester’s neonatal unit was two to three deaths a year, however added deaths on the neonatal unit were to become more frequent.
Her statement covers the alleged “shock” and “surprise” by doctors and nurses on the unit following the death of Child A who was a twin and considered the more stable of the two babies.
“Child A’s death was not just unusual it was also unexpected.”
Final Letby inquiry report to be published next autumn
Tuesday 10 September 2024 10:22
Rebecca Thomas
Lady Thirwall aims to publish the final report next autumn with hearings to continue into 2025.
Counsel to the inquiry Rachel Langdale KC has begun her opening statement.
“We will consider whether Letby’s crimes could’ve been prevented and whether she should’ve been removed from the unit sooner,” she said.
KC Langdale added: “The inquiry’s unwavering focus will not be examining the conviction but what the response should’ve been by those [at the hospital] to what they should’ve or shouldn’t have known.
“We will be investigating whether individuals had at their forefront the need to keep babies safe.”
It is not for me to review Letby’s conviction, says Lady Thirlwall
Tuesday 10 September 2024 10:14
Rebecca Thomas
Lady Thirwall opens the inquiry, saying “At the heart of this inquiry is the babies who died who were injured and their parents.”
She said the inquiry has her surname so the parents do not see the name of the person who has been convicted of killing and harming their babies.
The inquiry chair warned Letby’s “verdict did not bring immediate closure on what happened to their babies”
She said since Letby’s conviction, “there has been a huge outpouring of comment on the validity of the conviction which I understand has come entirely from people who were not at the trial, parts of the evidence has been critiscised...all of this noise has caused enormous distress who have suffered too much.”
“It is not for me to set about reviewing the conviction the court of appeal has done that - the convictions stand,” Lady Thirlwall added.
Inquiry starts in just over 10 minutes
Tuesday 10 September 2024 09:48
Alex Ross
The Thirwall Inquiry begins at 10am - we will be watching it and reporting from it live here.
