Lucy Letby was nicknamed “nurse death” by junior doctors after she was removed from duties on the neo-natal ward at Countess of Chester Hospital, a public inquiry has heard today.
But despite the staff concerns and references to the convicted murder, hospital bosses still did not act to contact police on the matter.
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 on the ward in 2015 and 2016.
In September 2016 - two months after Letby was switched to clerical work - the Royal Collage of Paediatrics and Child Health was invited to carry out a review at the hospital, although not all members of the team were aware of the nurse before the visit.
However, notes of the team’s initial interview with former medical director Ian Harvey recorded him highlighting Letby.
The notes, read out at today’s inquiry, recorded Mr Harvey as saying: “Had to intervene with the neonatal lead as junior doctors had been referring to her as ‘nurse death’.
“Ripples through the team..... can’t see how to conclude without calling the police.”
The trust did not formally contact police until May 2017.
Key points
- Junior doctors nicknamed Letby ‘nurse death'
- ‘Troubling’ over lack of escalation of matter to external agencies - inquiry
- Families of victims never told by trust about Letby
Lucy Letby ‘hid in plain sight’ like GP killer Harold Shipman, inquiry hears
Wednesday 11 September 2024 19:00
Alexander Butler
Serial killer Lucy Letby has been compared to Harold Shipman at a public inquiry opened up into the circumstances around the nurse’s murders.
The Thirwall Inquiry, which began on Monday, is looking into the events surrounding the crimes of Lucy Letby, including the failures of the hospital staff and leadership to respond to concerns raised.
The inquiry’s opening came amid growing speculation over the evidence used to convict Letby over the killings at Chester Countess Hospital last year. Chairwoman Lady Justice Thirwall started the hearing by stating it had caused “an enormous amount of stress” for the families of victims.
‘Not the slightest inkling or suspicion that anyone had deliberately harmed the children’ - coroner
Wednesday 11 September 2024 17:05
Alex Ross
We’re coming to the end of today’s evidence.
Mr Nicholas de la Poer KC tells the inquiry about evidence from Nicholas Rheinberg who was, at the time, the Senior Coroner for Cheshire. He retired in March 2017.
He has expresssed his surprise that the concerns over the death of the children from the consultants were not shared with him.
He also says that at two meetings with medical director Ian Harvey in February 2017, he was not made aware of suspicions or concerns relating to the involvement of a nurse in relation to any deaths.
Hospital’s former medical director believed police investigation would ‘allow us to close down the speculation here'
Wednesday 11 September 2024 16:35
Alex Ross
We’ve already heard how there were apparent concerns from NHS England that the hospital’s former medical director, Ian Harvey, was avoiding contacting police.
When it was confirmed that police would investigate, Mr Harvey believed that their enquiries would “close down speculation” about Letby, Mr Nicholas de la Poer KC tells the inquiry.
He says Mr Harvey said police had been sent a letter by consultants which was “very prejudiced”, “effectively pointing the finger at one nurse”.
On 15 May 2017, Cheshire Plice decided there were sufficient grounds to suspect a criminal offence and to launch a criminal investigation.
Letby called ‘angel of death’ in police meeting
Wednesday 11 September 2024 16:10
Alex Ross
We’re now hearing details from a meeting of police and executives at the Countess of Chester on April 27 in 2017.
By this point it was agreed that the matter had to be passed to police and days later Detective Chief Superintendent Wenham told officers that a letter would soon be coming from the hospital.
In the same week, police met with former chief executive Tony Chambers, and NHS England was informed that a police investigation would be launched.
At the meeting on 27 April, he “angel of death” description was from the recollection of the meeting by Det Chf Supt Wenham.
Countess of Chester Hospital’s former director of nursing and quality still under investigation
Wednesday 11 September 2024 15:30
Alex Ross
Alison Kelly, Countess of Chester Hospital former director of nursing and quality, was referred to the General Medical Council Fitness to Practise Team by four consultant paediatricians, Mr Nicholas de la Poer KC tells the inquiry.
Concerns included allegations that Ms Kelly mismanaged the concerns of the consultant body, failed to communicate effectively, failed to take appropriate action, made errors of judgment and damaging decisions, and did not act with honesty and integrity at all times.
The investigation was delayed until after Letby’s criminal trial, and is still continuing.
Former medical director Ian Harvey ‘may have fallen seriously below the standard to be expected'
Wednesday 11 September 2024 15:26
Alex Ross
Countess of Chester Hospital former medical Ian Harvey was referred to the General Medical Council Fitness to Practise Team over concerns he failed to act appropriately or timely to response to concerns raised by clinicians over the neo-natal mortality rate from February 2016.
Concerns also included threatening paediatricians, misusing the hospital’s grievance procedures as evidence of Letby’s innocence, misleading the public and trust board.
In September 2018, Mr Harvey, who had by now retired and was leaving in France, said the allegations were “nothing new to him”, Mr Nicholas de la Poer KC tells the inquiry.
He asked for voluntary removal from the register, but said he was prepared to “defend himself vigorously”, Mr de la Poer says.
Mr de la Poer adds: “He described as one of his greatest regrets the “breakdown in the relationship between the Executives and the Consultant Paediatricians…”
The GMC found Mr Harvey’s standard of care may have fallen seriously below the standard to be expected of a reasonably competent medical director.
GMC case examiners decided to close the referral with no action - although Mr Harvey’s application for voluntary erasure from the register was granted.
Letby remained a registered nurse free to work untill November 2020
Wednesday 11 September 2024 14:58
Alex Ross
Despite the police investigation launched in 2017, we’re just hearing from Mr Nicholas de la Poer KC that no restriction was imposed on her by the Nursing and Midwifery Council until November 2020 when she was charged.
This is despite the council being informed of concerns in July 2016.
NHS England concerned hospital trust ‘avoiding the issue'
Wednesday 11 September 2024 14:46
Alex Ross
After NHS England was notified of concerns over Letby and deaths on the neo-natal ward at Countess of Chester Hospital, Mr Nicholas de la Poer KC tells the inquiry that the body was “becoming increasingly concerned by the situation at the hospital”.
Dr Michael Gregory, from NHS England, emailed hospital medical director Ian Harvey for an update, to with Mr Harvey replied that the hospital was “following the process that would be [the] case in the event of an unexplained death out of hospital and are consulting with the Child Death Overview Panel.”
Dr Gregory forward Mr Harvey’s email to colleagues at NHS England, stating: “Avoiding the issue that we wish to see (contacting the police)”
Tony Chambers, former chief executive of the hospital, was unhappy at Dr Gregory’s accusation of evasiveness, and he wanted to exhaust internal processes first as involving the police could cause distress to the families, says Mr de la Poer.
NHS England first contacted over concerns on March 2017
Wednesday 11 September 2024 14:40
Alex Ross
We’re hearing more now on contacts made with outside bodies from Countess of Chester Hospital.
Mr Nicholas de la Poer KC tells the inquiry that Julie Maddocks, from the Cheshire and Merseyside Neonatal Network, which included the neo-natal unit at the Countess of Chester Hospital.
Ms Maddocks contacted NHS England in March 2017, asking if a police investigation was required.
NHS England say this was first time they understood there was a concern held by the hospital’s clinicians that there was a connection between a particular individual and neonatal deaths, says Mr de la Poer.
‘Need to keep the shutters down’ - non-executive director
Wednesday 11 September 2024 14:32
Alex Ross
We’re now hearing about an interview held with Andrew Higgins, a non-executive director at Countess of Chester Hospital, by the Royal College of Paediatrics and Child Health in September 2016.
Mr Higgins said he was aware of the allegations and there had been “long debates how to deal with them”, including calling the police, Mr Nicholas de la Poer KC tells the inquiry.
Mr de la Poer says: “The notes appear to attribute to Mr Higgins the comment ‘need to keep the shutters down and contain the situation. Not sure where to go next’”
The inquiry will ask Mr Higgins if he said that, and if so, what he meant by it.
In his statement to the inquiry, Mr Higgins said he could not recall saying it.
“[He] thinks the comment related to ‘the need to contain the situation so that no further incidents could occur and the facts behind the recent deaths could be established’,” says Mr de la Poer
Senior nurses say doctors ‘wanted her off the unit'
Wednesday 11 September 2024 14:19
Alex Ross
More people were interviewed as part of the review by the Royal College of Paediatrics and Child Health at Countess of Chester Hospital in September 2016.
They include senior nurses, who described Letby as “clever, exceptional and very professional”, Mr Nicholas de la Poer KC tells the inquiry.
He adds: “The doctors were described as tunnel visioned about Letby’s presence and their concerns were described as ‘Wanted her off the unit. Just the presence – gut instinct’”
Letby claimed she was being scapegoated
Wednesday 11 September 2024 14:15
Alex Ross
During the review at Countess of Chester Hospital by the Royal College of Paediatrics and Child Health in September 2016, Letby was also interviewed to give her an opportunity to giver her perspective, Mr Nicholas de la Poer KC tells the inquiry.
Letby had been removed from duties on the neo-natal ward two months before.
Mr de la Poer says: “The note of the interview states that Letby described being scapegoated and very vulnerable. She contended there was no reason or evidence to redeploy her.”
Doctors raised their concerns with the review team
Wednesday 11 September 2024 14:10
Alex Ross
Dr Stephen Brearey and Dr Ravi Jayaram, who worked on the neonatal unit at the Countess of Chester Hospital, raised concerns about Letby in 2015.
Mr Nicholas de la Poer KC tells the inquiry that they were also interviewed by the visiting review team from Royal College of Paediatrics and Child Health in September 2016.
Both doctors expressed their concerns in respect of Letby, said Mr de la Poer.
“It’s how the babies collapsed. No indication. Didn’t respond physiologically how they should have done. Seven of them so not always the same one… Nurse on shift at all times,” they were recorded as telling the review team.”
Both said they excited senior executives to call police.
Junior doctors nicknamed Letby ‘nurse death'
Wednesday 11 September 2024 14:05
Alex Ross
We’re now hearing more about the review carried out by the Royal College of Paediatrics and Child Health, and interviews carried out with hospital bosses.
In his initial interview, former chief executive Ian Harvey was recorded in notes as saying junior doctors referred to Lucy Letby as “nurse death”.
Mr Harvey went on to say it “ripples through the team”, and “can’t see how to concluse without calling police”.
Further notes taken from interviewing Mr Harvey show he was asked “what is the tippping point?” or “what is the tipping point? Not police?”
Mr Harvey was recorded as replying: “Need to pull together before we press the nuclear button.”
Alison Kelly, who was director of nursing at the hospital, was recorded as telling the review team there were “no issues with comptency of the nurse... no issues with training... highly thought by the unit.”
‘Elephant in the room’ - former chief executive to Royal College of Paediatrics and Child Health
Wednesday 11 September 2024 13:52
Alex Ross
The guide on invited reviews provides that the Royal College of Paediatrics and Child Health would not take on reviews where “the expected scope includes behavioural, misconduct, bullying, harassment or possible mental health concerns,” said Mr Nicholas de la Poer KC.
However, the concerns dominated the first interview with former medical director Ian Harvey, who is recorded as saying: “Correlation of one nurse – paediatricians see as elephant in the room. Lucy Letby. Pattern of babies collapse doesn’t seem to follow normal pattern and respond to resuscitation in normal way. Multifactorial. Want to think the worst – but nothing else is pointing to it.”
Royal College of Paediatrics and Child Health review
Wednesday 11 September 2024 13:49
Alex Ross
Royal College of Paediatrics and Child Health was invited to carry out a review at Countess of Chester Hospital on 1 and 2 September 2016.
However, despite their invite, it appears not all of the review team were aware of suspicions in relation to Letby, Mr Nicholas de la Poer KC.
But Sue Eardley, from the review team, said she was aware of suggestions of concern about a nurse, the inquiry heard.
The team was also given a list “a list of seven or eight unexplained deaths together with the names of nursing staff on shift and he noticed that Letby was present for all but one or two,” said Mr de la Poer.
Hearing resumes
Wednesday 11 September 2024 13:44
Alex Ross
Following a break for lunch we are back underway
Hospital advised not to report police in July 2016
Wednesday 11 September 2024 12:52
Alex Ross
We’ve now hearing correspondence between a legal team, called DAC Beachcroft LLP, and Susan Hodkinson, director of human resources and organisational development, over whether concerns over Letby shoud be reported to the police in July 2016 - almost a year before the call was made in May 2017.
After Ms Hodkinson asked Ms Slingo, a partner at the law firm, the question, Ms Slingo replied: “There does not currently appear to be any reason to formally alert the police to these issues, as there is nothing upon which one might reasonably base a suspicion of a criminal offence having been committed.”
Mr de la Poer says: “The rationale for this was that the current evidence of concern was the ‘potentially circumstantial’ fact of one nurse on shift on more occasions than others but that deaths/deteriorations occurred when the nurse was not on shift.”
The counsel for the inquiry says no advice was apparently requested from the local authority’s designated officer or the Nursing and Midwifery Council.
Working Together to Safeguard Children statuory guidance states reports of possible criminal offending be reported to the local authority.
Mr de la Poer says: “Your Ladyship may consider that this safeguarding threshold for referral to external bodies appears to have been ignored.”
Serious incident report to NHS England - but unclear why it wasn’t raised sooner - inquiry hears
Wednesday 11 September 2024 12:42
Alex Ross
In July 2016, a decision was taken to downgrade the Countess of Chester’s neo-natal unit over an increase in deaths.
Mr Nicholas de la Poer KC said it did not, however, include suspicions of deliberate harm by Letby that had been raised with the Nursing and Midwifery Council and a legal team.
In a statement to the inquiry, Professor Sir Stephen Powis, on behalf of NHS England, said it was unclear why the increased mortality was not reported as a serious incident at any earlier point in 2016.
Staff were pointing fingers at each other - inquires heard.
Wednesday 11 September 2024 12:38
Alex Ross
We’re now hearing how Dee Appleton-Cairns, from the Human Resources at the Countess of Chester Hospital, spoke to Ian Pace, an associate in the employment and pensions group at the solicitors’ firm DAC Beachcroft LLP.
“Ms Appleton-Cairns disclosed to Mr Pace the increased neonatal death rate and the fact staff were pointing fingers at each other,” said Mr Nicholas de la Poer KC.
Ms Appleton-Cairns said she was satisfied there were “no malicious issues involved” but Mr Pace asked how she could be sure.
He advised her that the employment aspects of the matter pale into insignificance given the potential issues involved and the suspicions that the death rate could be attributable to one in particular individual.
‘Troubling’ over lack of escalation of matter to external agencies - inquiry
Wednesday 11 September 2024 11:58
Alex Ross
Having gone through evidence that will go before the inquiry on the referral of a high level of infant mortality at Chester Countess Hospital, Mr Nicholas de la Poer KC is summing up on the matter.
“All too often that a high threshold was needed to exist for raising concerns on potential harm to babies,” he says.
“Namely, that some sort of proof of criminality was necessary before those with the responsibility to investigate concerns could be notified. This is troubling, your Lady may think, because it is contrary to the clear guidance that safeguarding advice provides..
“It was not necessary for those concerned about the safety of babies at the hospital to embark on their own investigation or evidence-gathering exercise before making referrals
“Working together provided that any allegation that a person working with a child has behaved in way that has harmed a child, may have harmed a child or that they have possibly committed a criminal offence.... should be reported immediately to a senior management within the organisation and the local authority designated officer be informed within one working day.
“That was not complied with.”
Families of victims never told by trust about Letby
Wednesday 11 September 2024 11:34
Alex Ross
Now we’re hearing more about the communication between the hospital trust and families of the babies were were keen to get answers on the tragic deaths.
At the third board meeting discussing the issue of infant deaths in the neo-natal unit in April 2017, former medical director Ian Harvey said that the hospital had “endeavoured” to keep the families up to date, although he admitted there were lessons to be learnt, Mr Nicholas de la Poer KC told the inquiry.
“The inquiry is concerned to understand the basis of to which Mr Harvey made these assertions to the board,” said Mr de la Poer.
Parents of babies who were attacked by Letby were not contacted by the hospital in advance of a Royal College of Paediatrics and Child Health report, the inquiry will show, said Mr de la Poer.
He said it will also show parents struggled to arrange meetings to talk to Mr Harvey and parents were never told by the trust the concerns had been raised about the potential involvement of a particular nurse.
Why were police not called in earlier?
Wednesday 11 September 2024 11:25
Alex Ross
Part of the inquiry is looking at the decisions made by hospital board directors on the concerns raised over the increase in neo-natal deaths and Lucy Letby, and when and why police were not called in until May 2017.
At a third meeting of the board of directors where the issue was discussed, it was said that the hospital should contact the police.
However, a director said there was not yet evidence of a crime, Mr Nicholas de la Poer KC said.
The minutes recorded one person saying: “You need to accept, if something is still unanswered or there are still genuine concerns in well-minded people, you should go to the police.”
But Mr de la Poer said: “The course of action the board appears to have resolved was to not yet contact the police.”
Some of the non-executive members said there was still “geunine concern” on behalf of the doctors who had raised the matter.
Non-executive director James Wilkie asked whether the board could “truely say there had not been delay on its part.”
Non-executive director Andrew Higgins said that there was “a need for something bomb-proof as quickly as possible”.
It was asked what the timeline was to speak to a doctor on the matter, and non-executive director Rachel Hopwood said she felt “it had got away from us”, Mr de la Poer said.
First time time concerns raised at board level
Wednesday 11 September 2024 10:57
Alex Ross
A meeting of the quality, safety and patients’ experience committee in December 2015 was the first time concerns over neo-natal deaths were discusssed at board committee levels.
Nicholas de la Poer KC said: “While the minutes refer to an increase in both still births and neo-natal deaths there was no mention or query of the fact the paper presented did not consider neo-natal aspects of care.
“The committee appeared to be assured, or perhaps reassured, by the paper.”
Following the meeting, the board’s action log was updated to record the issue of neo-natal still birth review as “completed”.
Issue of deaths was raised lower down governance levels
Wednesday 11 September 2024 10:53
Alex Ross
The death of child A was discussed at the woman and children’s care governance board on 18 June 2015 - the minutes noted an incident report in respect of Child A’s death.
“However, it does not appear that the increase in the neo-natal mortality or consultants’ concerns were escalated quickly through this forum either, says Nicholas de la Poer KC, counsel.
In October 2015, minutes from the same governance board said: “Moderate harm incidents....and three unexpected neo-natal natals deaths”.
However, no resulting actions are identified, Mr de la Poer says.
Lack of discussion at board meetings on increase in infant mortality emerges
Wednesday 11 September 2024 10:47
Alex Ross
We’re hearing now how the issue of infant mortality on the neo-natal ward dealt with by managers.
The board of directors met 16 times between June 2015 and May 2017 - and on five of the meetings, the concerns over the deaths were discussed, with four classed as extraordinary and held in private.
The one public meeting where it was discussed took place in February 2017.
Nicholas de la Poer KC, counsel for the inquiry, says a “similar picture” appears in other board committees.
From June 2016 to May 2017, the concerns of deaths on the neo-natal ward were discussed at only one board committee; the quality, safety and patient experience committee.
“The concerns were never discussed in the audit committee, the finance and intregrated governance committee nor the people and organisational development committee,” Mr de la Poer.
Hospital governance to be investigated
Wednesday 11 September 2024 10:30
Alex Ross
There are several board committees that deal with governance and scrutiny at the hospital.
It’s been asked this morning by Nicholas de la Poer KC why no board committee ever escalated issues of neo-natal mortality from June 2015 to March 2017.
In March 2019, a review was carried out into governance at the hospital that found that the boards were operationally focused, but left insufficient time for individual items to be considered.
Non-executive director Andrew Higgins said there was often a lack of time for a discussion on board committees.
The governance will be looked at over the inquiry.
Hospital bosses concerned over damage to reputation
Wednesday 11 September 2024 10:19
Alex Ross
We’re hearing now how concerns were raised at the hospital’s corporate directors’ group, which included the director of nursing and trust chief executive.
It was in July 2016 when they were flagged in an urgent care risk register to the monthly meeting.
It was characterised as “potential damage to reputation of the neo-natal service and wider trust due to apparant increased mortality”, Nicholas de la Poer KC tells the inquiry.
“In other words, the risk was characterised in terms of harm rather in terms of risk to the safety of babies,” Mr de la Poer says.
The minutes of the meeting contained no record of discusson on the matter.
The inquiry is also to explore why it took until July 2016 for the matter to reach the corporate directors’ group - a year after the first baby death linked to Lucy Letby.
The inquiry will be looking at if this impacted the speed and manner in which the hospital addressed the mortality rate on the neonatal unit and the concerns of the doctors about it.
The inquiry has started
Wednesday 11 September 2024 10:01
Alex Ross
We’re underway on day two of the inquiry
The ‘tea party’ - why it was held and what happened?
Wednesday 11 September 2024 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
Wednesday 11 September 2024 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
Wednesday 11 September 2024 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
Wednesday 11 September 2024 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?
Wednesday 11 September 2024 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
Wednesday 11 September 2024 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.
