Lucy Letby inquiry live: Hospital bosses ‘truly sorry’ for ‘significant delay’ in contacting police over nurse
Former bosses at the hospital where Lucy Letby murdered seven babies, and attempted to kill seven more, have apologised for the “significant delay” in alerting police, a public inquiry has heard.
In the fourth day of the Thirwall Inquiry at Liverpool Town Hall, an opening statement on behalf of the former senior managers at the Countess of Chester Hospital were read out.
It comes following days’ of evidence in which they have come under criticism for failing to properly deal with the attacks by the 34-year-old nurse.
On Wednesday, questions were asked on why hospital bosses didn’t contact police until May 2017 despite doctors’ concerns a year before.
On Friday morning, Kate Blackwell KC, solicitor representing senior managers including former medical director Ian Harvey, former chief executive Tony Chambers and former nursing director Alison Kelly, issued a statement on their behalf.
She said there was a “significant delay” in contacting police as bosses sought to investigate the matter, adding “for this, they [the managers] are truly sorry”.
Ms Blackwell has said the managers were also “truly sorry” over the communication with families of the victims, which the bosses accept could have been better.
Letby was sentenced to 15 whole-life orders following her convictions for the crimes in 2015 and 2016.
Key points
Managers ‘truly sorry’ for delay in contacting police
Senior managers ‘deeply affected’ by murders
Breathing tubes dislodged during Lucy Letby shifts prior to killings, probe told
Barrister brings up breathing tube incidents at a second hospital
‘Five basic failures’ at hospital where Lucy Letby worked, inquiry told
Hearing adjourned for Monday
11:36 , Alex Ross
That’s it for the opening statements, the inquiry has been adjourned for Monday.
NHS England ‘surprised’ at so few serious incidents reported during deaths
11:28 , Alex Ross
We’re now hearing from a solicitor speaking on behalf of NHS England.
He is not holding back in his criticism of the hospital trust in the recording of serious incidents, following the deaths of babies in the neo-natal unit, and the time taken to alert NHS England on the issue.
He also says it took too long for the hospital to involve Cheshire Police - although NHS England accepts it should have done more to scrutinise the hospital before police became involved, he says.
He says there were 13 deaths on the neo-natal unit between June 2015 and June 2016 - but just four were reported as “serious” incidents.
He says this was a “missed opportunity”.
On not informing NHS England on the high number of deaths on the ward earlier, he says was a “significant failure of governance”.
When senior managers became suspicious
11:10 , Alex Ross
Despite initially not suspected “foul play” in the matter over the number of deaths, the situation changed in June 2016 when concerns were raised for the first time by senior managers, the hospital bosses’ statement adds.
It continues: “The picture changed at the end of June when concerns were raised, for the first time, to senior managers by Dr Brearey, and Dr Ravi Jayaram, about Letby being connected directly to the deaths.”
But despite the concerns raised on the link between Letby’s shift pattern and the deaths, “nothing specific was ever articulated” by the doctors to show Letby had done anything wrong, the managers say in their statement.
It continues: “The neo-natal unit manager, Eirian Lloyd Powell, was firmly of the view that Letby was a good and competent nurse.”
Senior managers aware of deaths while Letby was in shift
11:05 , Alex Ross
Just going back to that statement from senior managers, we heard from it that bosses accepted they were aware that Lucy Letby had been on shift when a number of deaths had occurred on the neo-natal ward.
However, following a look the issue, they didn’t immediately suspect anything wrong as, they said, Letby “was a specialist practitioner and, therefore, because of her skills and training, more likely to be looking after the sickest infants”.
The statement continues: “Her willingness to work overtime when the acuity or unit was over capacity meant that she was on shift on a more frequent basis than other nursing practitioners.
“Senior managers were also told that there were no known performance management issues or complaints against her, and that she was considered by nursing colleagues to be a diligent nurse with excellent standards.
Care Quality Commission not aware of suspicion of criminal activity involving Letby until May 2017
10:58 , Alex Ross
We’re now hearing from a solicitors speaking on behalf of the Care Quality Commission, which carried out an inspection of Countess of Chester in 2016.
She says that the CQC first became aware of the trust’s concerns over Letby on the day its inspection report was published, on 29 June 2016.
Former nursing director Alison Kelly called up an inspector to inform them over the increased number of neo-natal deaths, and a link to Letby.
The body then first became aware of criminal suspicions involving Letby in May 2017, following the contact by the hospital with the police.
Hospital ‘had to be clear about the facts’ before contacting police - senior managers
10:48 , Alex Ross
As we’ve heard over the past few days, concerns over Letby and a high number of deaths on the neo-natal ward were raised by doctors, and the nurse was removed from her duties in July 2016.
Contacting the police was spoken about among senior managers, but Cheshire Police was not alerted formally until May 2016. Instead, reviews and investigations were carried out by the hospital.
In the statement from the senior managers issued this morning, they say: “The senior management team gave considerable thought to whether or not the police should be informed throughout the review and investigative processes, it was felt collectively that there was a responsibility to clinically investigate the concerns as far as possible before going to the police.
“It was felt that the hospital had to be clear about the facts first, in the absence of which, it was difficult to see what the police would be asked to investigate.”
Senior managers ‘deeply affected’ by murders
10:32 , Alex Ross
Concluding the statement from the senior managers, Kate Blackwell KC, says the senior managers have been impacted by the deaths at the hospital.
She says: “We have all been deeply affected by what happened the hospital.
“Whilst we do not suggest, in any way, parity with what the families of those killed and harmed by Letby have experienced, it has been the most significant event of any of our professional lives.
“Not a day goes by when we don’t think about what happened.
“That a nurse could be responsible for these heinous crimes is profoundly disturbing. It is not something that any of us ever expected to be happening on the neonatal ward of the Hospital, it being so against the natural order of what was contemplated or foreseen.”
Managers accept communication caused ‘hurt’ and ‘anxiety’ for families
10:27 , Alex Ross
Kate Blackwell KC, representing the senior managers, now addresses the communication with families.
This has been an issue of the inquiry with Peter Skelton KC, who is representing seven families of Letby’s victims, claimed there was failure was not to inform the families that the deaths were being investigated.
He said they were “kept in the dark”
Today, Ms Blackwell says: “[The issue of communication] has caused hurt and anxiety - and for this the senior managers are deeply sorry.
“This was not done with the intention to deliberately attempt to cause anguish nor was it to involve a conspiracy of dishonesty, at the time they believed they were providing the right level of information, they wanted to make sure that what they were saying was accurate. In hindsight, they could and should communicated far better than they did.”
Managers ‘truly sorry’ for delay in contacting police
10:20 , Alex Ross
We’re hearing more on this opening statement being provided on behalf of the senior managers at Countess of Chester Hospital, who are former medical director Ian Harvey, former director Alison Kelly, former chief executive Tony Chambers and former director of human resources Sue Hodkinson.
Kate Blackwell KC, solicitor representing them, says they are “truly sorry” for the delay in contacting police.
As we’ve already heard in this inquiry, concerns have been raised as to why it took until May 2017 for Cheshire Police to be notified over the suspected link in baby deaths and Lucy Letby.
Ms Blackwell acknowledges there was a “significant delay” in contacting police as bosses sought to investigate the matter, adding “for this, they [the managers] are truly sorry”.
She adds: “But the reviews were commissioned in good faith, not to conceal the truth, but to uncover it.”
Opening message on behalf of managers
10:09 , Alex Ross
Kate Blackwell KC, solicitor representing the senior managers, starts by reading a statement on their behalf.
She says: “They have read and listened carefully to the oral openings made by those who represent the families. They recognise and pay tribute to the dignity, the courage.”
Former medical director Ian Harvey, former director Alison Kelly, former chief executive Tony Chambers and former director of human resources Sue Hodkinson have reflected on their time at the Countess of Chester Hospital and will continue to reflect on their actions and their decisions, she says.
She adds: They know they will be asked diffficult questions, and they will answer the questions openly and honestly.”
We’re underway
10:02 , Alex Ross
Hearing has started
Today’s hearing due to start in five minutes
09:55 , Alex Ross
The fourth day of Thirlwall Inquiry at Liverpool Town Hall starts at 10am. We’ll be covering it right here
Reminder of Letby’s crimes
09:48 , Alex Ross
Letby, 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 carried out the crimes between June 2015 and June 2016.
Trusts accepts there were ‘significant communication failings’
09:47 , Alex Ross
As we heard yesterday from legal representatives of families unhappy about the communication from the hospital, Andrew Kennedy KC, representing the Countess of Chester Hospital Trust, acknowledged the issue.
He said: “The trust accepts that from July 2016 there were significant communication failings such that it failed in its duty of candour towards the parents.”
He added: “The trust remains committed to assist in any way it can and it recognises that the inquiry will identify failings on its part and potentially on the part of others.
“That’s a vital exercise so that it and the wider NHS may learn from those failings.”
Parents ‘kept in the dark'
09:38 , Alex Ross
One major issue coming out of the evidence over the past few days is the apparent failure by the hospital to keep families informed over the deaths of the babies.
On Wednesday, solicitors for the counsel said this would be looked at during the coming weeks of the hearing.
Yesterday, Peter Skelton KC, who is representing seven families of Letby’s victims, claimed there was failure was not to inform the families that the deaths were being investigated.
Mr Skelton said: “You will hear from some of the parents over the next few weeks about how they were kept in the dark about the collapses of the babies and the concerns and investigations that were being undertaken into their babies’ deaths.”
He said the consultants who flagged concerns about Letby “deserved the gratitude” of the families and had acted with “tenacity” and “courage” in “genuine fear of adverse professional consequences”.
Damning indictment by solicitor representing families
09:07 , Alex Ross
At yesterday’s hearing, we heard from Peter Skelton KC, who is representing seven families of Letby’s victims.
He criticised the hospital for not being quick enough to investigate Letby despite concerns raised by doctors over the baby deaths.
He said: “The first failure was to conduct swift, careful and methodical investigations into why each of the deaths occurred and whether there were connections between the deaths.”
He said it meant vital information was overlooked and that the cluster of deaths and collapses should have been escalated to senior management within the hospital trust immediately, so they could have overseen investigations.
He added: “From the outset, and without prejudice and without pre-judgment, it should have been in the minds of those conducting and overseeing the investigations that the cluster of unexpected and unexplained deaths might have been caused by the criminal acts of a member of hospital staff.”
NMC admits it could have sanctioned Letby sooner
07:00 , Holly Evans
Last month The Independent revealed the Nuring and Midwifery Council has changed its guidance on when temporary sanctions, called interim orders, can be placed on a nurse facing serious allegations.
No interim order was placed on Lucy Letby following her arrest.
Addressing this issue Ms Jones said: “We have seriously reflected on the decision not to apply for an interim order until Lucy Letby was charged, and have determined that our guidance in place at the time was not sufficiently clear to allow us to act on an extraordinary case such as this one in which a serious police investigation was underway in relation to potentially multiple instances of murder.
“We accept that it was not right for the NMC to wait to apply for an interim order until Lucy Letby was charged, and we considered that in this case, the fact of the arrest could have been sufficient to justify an interim order application, given the serious nature of the concerns and the absolute importance of maintaining public safety and also public confidence in the profession.”
This is why I think Lucy Letby is guilty – and you should too
06:00 , Holly Evans
There’s a new circus in town and its butterfly-themed banners are emblazoned with the name of a nurse called Lucy Letby. Increasingly, vocal supporters would have us believe that the 34-year-old has been wrongly convicted of murdering seven babies and attempting to kill seven more for which she has received 15 whole-life prison sentences.
Pitching her as a loving nurse whose life of selfless dedication has been wilfully destroyed because of a problematic neonatal unit in need of a scapegoat for the babies that died on their watch, she emerges as a perfect heroine, you might think, for the next Netflix blockbuster.
Except that in the real world, the evidence tells us there has been no miscarriage of justice. Letby was convicted by not just one, but two, juries at two separate trials. Having spent nights and early mornings compiling a 17,000-word timeline of that lethal year at the Countess of Chester Hospital, like them, I have no doubt of the culpability of this nurse.
Read the full article here:
This is why I think Lucy Letby is guilty – and you should too
Breathing tubes dislodged during Lucy Letby shifts prior to killings, probe told
05:00 , Holly Evans
Breathing tubes became dislodged on 40% of shifts that Lucy Letby worked as a trainee nurse in Liverpool before she went on her killing spree at the Countess of Chester Hospital, a public inquiry has heard.
Letby, 34, is understood to have completed two work placements at Liverpool Women’s Hospital between October and December 2012, and January and February 2015.
The Thirlwall Inquiry is examining how the 34-year-old was able to murder seven babies and attempt to murder others from June 2015 to June 2016.
Read the full article here:
Breathing tubes dislodged during Lucy Letby shifts prior to killings, probe told
Former Tory minister says he was quoted £100,000 for Lucy Letby court transcript
03:00 , Holly Evans
A Tory former minister probing the case of killer nurse Lucy Letby has complained after he was quoted £100,000 to obtain a transcript of her trial.
Sir David Davis said he was given the figure after contacting Manchester Crown Court to get a copy of the transcript from the trial in 2022 and 2023.
He said it was eventually reduced to £9,000 but insisted such documents should be freely available to parliamentarians.
Read the full article here:
Former Tory minister says he was quoted £100,000 for Lucy Letby court transcript
Countess of Chester Hospital will not ‘seek to shirk’ its responsibilities
02:00 , Holly Evans
The inquiry heard the hospital accepted there were failings and would not “seek to shirk” its responsibilities.
Andrew Kennedy KC, representing the Countess of Chester Hospital Trust, said: “The trust accepts that from July 2016 there were significant communication failings such that it failed in its duty of candour towards the parents.”
He added: “The trust remains committed to assist in any way it can and it recognises that the inquiry will identify failings on its part and potentially on the part of others.
“That’s a vital exercise so that it and the wider NHS may learn from those failings.”
‘Five basic failures’ at hospital where Lucy Letby worked, inquiry told
01:00 , Holly Evans
Basic failures by the hospital where killer nurse Lucy Letby worked had “fatal consequences” for babies, an inquiry into her crimes has heard.
On the third day of the Thirlwall Inquiry, set up to examine how the 34-year-old nurse was able to carry out her crimes in the neonatal unit of the Countess of Chester Hospital in 2015 and 2016, an opening statement was given by Peter Skelton KC, representing seven of the families.
He said there were “five basic failures which occurred right from the start and which continued for the next two years”.
Read the full article here:
‘Five basic failures’ at hospital where Lucy Letby worked, inquiry told
Breathing tubes dislodged in 40 per cent of shifts killer worked at second hospital
Friday 13 September 2024 00:00 , Holly Evans
Representing a group of families, Richard Baker KC told Lady Justice Thirlwall that collapses in neonatal units such as dislodgement of endotracheal tubes was “uncommon”.
He said: “It generally occurs in less than 1% of shifts.
“You will hear that an audit carried out by Liverpool Women’s Hospital recorded that whilst Lucy Letby was working there dislodgement of endotracheal tubes occurred in 40% of shifts that she worked.
“One may wonder why?”
The killer nurse completed two work placements at Liverpool Women’s Hospital in 2012 and 2015.
This is why I think Lucy Letby is guilty – and you should too
Thursday 12 September 2024 23:00 , Holly Evans
There’s a new circus in town and its butterfly-themed banners are emblazoned with the name of a nurse called Lucy Letby. Increasingly, vocal supporters would have us believe that the 34-year-old has been wrongly convicted of murdering seven babies and attempting to kill seven more for which she has received 15 whole-life prison sentences.
Pitching her as a loving nurse whose life of selfless dedication has been wilfully destroyed because of a problematic neonatal unit in need of a scapegoat for the babies that died on their watch, she emerges as a perfect heroine, you might think, for the next Netflix blockbuster.
Except that in the real world, the evidence tells us there has been no miscarriage of justice. Letby was convicted by not just one, but two, juries at two separate trials. Having spent nights and early mornings compiling a 17,000-word timeline of that lethal year at the Countess of Chester Hospital, like them, I have no doubt of the culpability of this nurse.
Read the full article here:
This is why I think Lucy Letby is guilty – and you should too
Breathing tubes dislodged during Lucy Letby shifts prior to killings, probe told
Thursday 12 September 2024 22:00 , Holly Evans
Breathing tubes became dislodged on 40% of shifts that Lucy Letby worked as a trainee nurse in Liverpool before she went on her killing spree at the Countess of Chester Hospital, a public inquiry has heard.
Letby, 34, is understood to have completed two work placements at Liverpool Women’s Hospital between October and December 2012, and January and February 2015.
The Thirlwall Inquiry is examining how the 34-year-old was able to murder seven babies and attempt to murder others from June 2015 to June 2016.
Read the full article here:
Breathing tubes dislodged during Lucy Letby shifts prior to killings, probe told
Police should have been contacted sooner after suspicions of Letby began
Thursday 12 September 2024 21:00 , Holly Evans
As paediatricians began to suspect in late 2015 that Letby was the direct cause of deaths and her actions may have been deliberation, Mr Skelton said the suspension of Letby from nursing duties and contact with the police should have followed.
Safeguarding and whistleblowing procedures should have also have taken place at that point as well an approach to affected parents to fully appraise them of what may have happened to their children, he added.
Instead what happened was “denial, deflection and delay on the part of the hospital executives, the inquiry heard.
Mr Skelton said the consultants who flagged concerns about Letby “deserved the gratitude” of the families and had acted with “tenacity” and “courage” in “genuine fear of adverse professional consequences”.
But he said they should have outlined their concerns clearly and formally in writing and ensured they were brought to the attention of the management and the board.
Report into Beveley Allit should have prepared healthcare staff remain open-minded
Thursday 12 September 2024 20:00 , Holly Evans
Barrister Peter Skelton KC, who represents seven of the families, said a report into Beverley Allitt, a nurse who killed children at Grantham Hospital, Lincolnshire, in 1991, sought to ensure that healthcare staff were prepared to keep their minds open to the possibility of criminal conduct.
As well as the Allitt case, Mr Skelton said that in May 2015, just before Letby’s crimes began, nurse Victorino Chua was sentenced for murdering patients at Stepping Hill Hospital.
He said: “It is difficult to understand why events at Stepping Hill did not at the very least alert those at the Countess of Chester from the start that the cluster of unexpected deaths were the result of potential criminality and that active steps were required to rule out that possibility.”
Mr Skelton said the police and coroner should have been informed at the outset, which could have had a “profound effect” on the course of events.
Former Tory minister says he was quoted £100,000 for Lucy Letby court transcript
Thursday 12 September 2024 19:00 , Holly Evans
A Tory former minister probing the case of killer nurse Lucy Letby has complained after he was quoted £100,000 to obtain a transcript of her trial.
Sir David Davis said he was given the figure after contacting Manchester Crown Court to get a copy of the transcript from the trial in 2022 and 2023.
He said it was eventually reduced to £9,000 but insisted such documents should be freely available to parliamentarians.
Read the full article here:
Former Tory minister says he was quoted £100,000 for Lucy Letby court transcript
Baby deaths rise concerns ‘not discussed at board level until after Letby spree’
Thursday 12 September 2024 18:00 , Holly Evans
Concerns about a spike in baby deaths were not discussed at hospital board level until after the year-long attack spree of “elephant in the room” Lucy Letby had ended, a public inquiry heard on Tuesday.
The nurse was removed from non-clinical duties after the deaths of two triplet boys and the suspected collapse of another boy at the Countess of Chester Hospital’s neonatal unit on three successive days in June 2016.
Consultant paediatricians had urged executives to move Letby, 34, out of the unit on the grounds of “patient safety” after a number of them had previously raised fears about her.
Less than a fortnight later an extraordinary meeting of the board of directors was held in which chief executive Tony Chambers informed them there had been an unexplained increase in neonatal mortality at the hospital trust.
‘Five basic failures’ at hospital where Lucy Letby worked, inquiry told
Thursday 12 September 2024 17:00 , Holly Evans
Basic failures by the hospital where killer nurse Lucy Letby worked had “fatal consequences” for babies, an inquiry into her crimes has heard.
On the third day of the Thirlwall Inquiry, set up to examine how the 34-year-old nurse was able to carry out her crimes in the neonatal unit of the Countess of Chester Hospital in 2015 and 2016, an opening statement was given by Peter Skelton KC, representing seven of the families.
He said there were “five basic failures which occurred right from the start and which continued for the next two years”.
Read the full article here:
‘Five basic failures’ at hospital where Lucy Letby worked, inquiry told
Government to look at whether NHS managers should be regulated
Thursday 12 September 2024 16:16 , Rebecca Thomas
Robert Cohen, representing the Department of Health and Social Care (DHSC), since Letby’s crimes came to light, there has been a renewed focus within the government to look at whether additional measures are needed to enhance the accountability of senior NHS managers.
He said: “In the light of votes at the Countess of Chester hospital, there has been a renewed focus on whether additional measures are required to enhance the accountability of senior NHS managers, and whether extending regulation to senior managers would be an effective means of ensuring patient safety.”
“The new government committed in its manifesto to introducing professional standards for and regulation of NHS managers ensuring those who commit serious misconduct can never do so again. Detailed work will be required to determine the most appropriate and effective means of regulating senior NHS managers.”
In September 2023, the Professional Standards Authourity announced that it would look at whether non-clinical NHS Managers should be regulated.
The Department of Health and Social Care has also looked at whether extending regulatory powers to senior managers would help ensure patient safety, he said.
More babies had breathing tubes dislodged during Letby's shifts audit finds
Thursday 12 September 2024 16:06 , Rebecca Thomas
One shock revelation during today’s hearing revealed that audits show more babies had their breathing tubes dislodged during Letby’s shifts than would usually occur.
The inquiry also revealed investigations have looked into babies’ care at Liverpool Women’s Hospital where Letby did two placements between October to December 2012 and January to February 2015.
Richard Barker KC, barrister for the second group of families said: “Given the prevalence of dislodgement of endotracheal tubes, in this case, my lady may perceive it as a common event, but the evidence suggests that it isn’t at all common. It is very uncommon, you will hear evidence that it generally occurs in less than 1 per cent of shifts,” he said.
“As a side note, you will hear that an audit carried out by Liverpool Women’s Hospital, whilst Letby was working there, dislodgement of endotracheal tubes occurred in 40 per cent of shifts that she worked.”
The inquiry has ended for the day
Thursday 12 September 2024 14:56 , Rebecca Thomas
The inquiry has ended for the day and will resume tomorrow with opening statements from NHS England.
NHS maternity scandals expose ‘professional tribalism’
Thursday 12 September 2024 14:55 , Rebecca Thomas
The inquiry heard criticism of the NHS from the DHSC over past scandals and investigations.
It said: “Issues of poor leadership and workforce culture have been raised repeatedly in previous investigations, inquiries and reports of maternity and neonatal services and undermine the safety improvements which have been made.
“It is clear that solutions are required which all trusts can implement and consistently adopt.
“Various reviews and inquiries have over many decades identified persistent issues of culture, painting a broadly consistent picture of incurious boards unresponsive to key patient safety concerns, of defensive and on some occasions bullying behavior, which does not create a culture in which speaking up is easy or welcomed, and of professional tribalism with associated tolerance of poor behavior and poor care.”
DHSC first told of concern about neonatal services in 2016
Thursday 12 September 2024 14:41 , Rebecca Thomas
The DHSC said in October 2016 it became aware the change in admission arrangements to the Countess of Chester hospital’s neo-natal unit to focus predominantly on lower risk babies and of the request for an independent review.
It was then notified by the NHS about the planned announcement of the police investigation into deaths at the Countess of Chester hospital.
The inquiry heard: “The department is not routinely involved in day to day events in trusts at the relevant time, this was the responsibility of the trusts and foundation trusts themselves Monitor and the NHS Trust Development Authority and sometimes NHS England...was expected that where significant issues were identified the Department would be informed.
“However, the Department acknowledges that it would have been better if there had been more robust arrangements to share information between the trust NHS England and the department at the time.”
The government makes its statement to the inquiry
Thursday 12 September 2024 14:26 , Rebecca Thomas
The Department for Health and Social Care’s barrister has begun his opening statement by referencing past maternity scandal reviews.
He says: “The independent review of maternity services at the Shrewsbury and Telford Hospital and the independent investigation into maternity and neonatal services in East Kent Hospital demonstrate a failure to learn from past incidents.
“The new secretary of state has acknowledged that in the past, recommendations have been made but action has not been taken. That is not good enough, the system must change. The secretary of state has spoken candidly describing how the NHS is broken.”
The inquiry has paused
Thursday 12 September 2024 13:20 , Rebecca Thomas
The inquiry has paused for a lunch break. We will return with updates when it resumes.
Royal College admits to mistakes in key report
Thursday 12 September 2024 12:52 , Rebecca Thomas
Fiona Scolding KC, representing the Royal College of Paediatrics and Child Health, has begun her opening statement.
In written statements submitted to the inquiry the Royal College said: “The RCPCH accepts that its actions in undertaking the review commissioned by the Countess of Chester Hospital (COCH) did not directly assist in uncovering the causes of death and recognise that this contributed to the uncertainty and lack of clarity that bedevilled the response.
“It also apologises that it was not sufficiently supportive to paediatricians and other clinicians then working at the hospital and acknowledges the stress, anxiety and damage that has been caused to them by the actions of Letby.”
NMC admits it could have sanctioned Letby sooner
Thursday 12 September 2024 12:32 , Rebecca Thomas
Last month The Independent revealed the Nuring and Midwifery Council has changed its guidance on when temporary sanctions, called interim orders, can be placed on a nurse facing serious allegations.
No interim order was placed on Lucy Letby following her arrest.
Addressing this issue Ms Jones said: “We have seriously reflected on the decision not to apply for an interim order until Lucy Letby was charged, and have determined that our guidance in place at the time was not sufficiently clear to allow us to act on an extraordinary case such as this one in which a serious police investigation was underway in relation to potentially multiple instances of murder.
“We accept that it was not right for the NMC to wait to apply for an interim order until Lucy Letby was charged, and we considered that in this case, the fact of the arrest could have been sufficient to justify an interim order application, given the serious nature of the concerns and the absolute importance of maintaining public safety and also public confidence in the profession.”
UK nursing regulator lacked ‘curiosity’
Thursday 12 September 2024 12:29 , Rebecca Thomas
Lady Thirlwall quizzes the NMC barrister over regulator’s repsonse.
She asked the NMC barrister: “If a call is received with the information that a nurse may present a serious risk to public safety. Is there no sort of natural curiosity as to what you know well? Why are you saying that? Why are you phoning?
Ms Jones responded: “We do appreciate the inquiry’s concern that we did not initiate an investigation at this point [in November 2016].”
“I hope will address the concern you just raised me about, why was there not a professional curiosity that should have been displayed at that time is that we have now published guidance to address learnings...Our guidance is titled, our culture of curiosity is available on our website, and it promotes and emphasizes the culture of curiosity in our fitness to practice investigations.”
Hospital boss told UK nursing regulator there was ‘no evidence’ to refer Letby
Thursday 12 September 2024 12:21 , Rebecca Thomas
Ms Jones KC says: “The NMC has reflected on the steps it could and should have taken at the time it became involved in 2016 and we have identified a number of areas of improvement.
“As we’ve outlined in our written opening, written statement and witness statements, the NMC has taken serious steps to review its processes, to learn lessons and to implement, or begin to implement, practical measures to ensure that it to ensure that it can play its part in the prevention of the deplorable acts committed by Lucy Letby.”
She reveals in July 2016 chief nurse Alison Kelly told the NMC “there was not sufficient evidence to initiate a referral” of Letby.
“Alison Kelly first told the NMC of the concerns regarding a rise in neonatal mortality rates and concerns that Lucy Letby the may present a serious risk to public safety, we were told that there was no evidence available at that time to support those concerns.”
Nursing and Midwifery regulator makes opening statement
Thursday 12 September 2024 12:12 , Rebecca Thomas
The NMC barrister Samantha Jones, begins her opening statement on behalf of the Nursing and Midwifery Council, the UK’s nursing regulator.
She says: “May I first take this opportunity to express on behalf of everyone at the NMC our sincere and heartfelt condolences to the families and loved ones of the babies who were harmed or killed by Lucy Letby.
“Having a baby is one of, if not the, most, important moment in any parent’s life. Every child’s life is sacred, and protecting babies and children from harm is fundamental. To have the baby’s life intentionally harmed or taken away is devastating. It grossly undermines basic human morals and should never, ever be allowed to happen.”
Countess of Chester apologises to families
Thursday 12 September 2024 12:06 , Rebecca Thomas
Andrew Kennedy KC, who represents the Countess of Chester Hospital Foundation Trust says the parents’ statements “bring home the horror of these events” and the trust has “the utmost sympathy for the suffering of the parents of the babies”.
“Losing a child is the greatest sorrow any parent can experience,” he says.
“Those who have not experienced that loss will never truly understand the magnitude....”
Kennedy says the trust “apologises without reservation” for its “inexcusable” failures in communication with parents.
Hospital bosses had an ‘opportunity to act’ trust admits
Thursday 12 September 2024 11:50 , Rebecca Thomas
The Countess of Chester Hospital had admitted there were missed opportunities to act.
The inquiry heard: “By the 21st of March 2016 the information available to those in senior clinical, managerial and executive posts was such that we recognise that there were legitimate questions concerning the trust’s response to concerns about mortality. More importantly, there was a clear opportunity to act.”
The statement added: “Important to keep in mind the realities of medical practice in a busy acute hospital, whilst periods of elevated morbidity and mortality will occur from time to time.
“Instances of deliberate harm by healthcare staff are exceedingly rare when a period of elevated mortality is preserved, the cause is therefore likely to be a product of random variations in outcome due to medical factors, particularly where numbers are small, insofar as the cause is related to a member of staff, it is far more likely to be a competency issue than to be due to criminality.”
Countess of Chester Hospital makes opening statement
Thursday 12 September 2024 11:44 , Rebecca Thomas
Barrister for the Countess of Chester makes opening statements to the inquiry.
The inquiry hears defence over why suspicions were not shared with families earlier.
He says: “As we observed in our written opening, this is a complex issue. It involves balancing of competing interests.
“In our written opening, we identified the following issues that the inquiry may wish to consider, first, the need to be open and transparent to further patient choice and autonomy and promote patient Safety.
“Second, the risk of inaccuracy in communication, or unhelpful vagueness if disclosure is made at an early an early stage. Third, a loss of confidence in service provision, if concerns turn out to be misplaced and fourth, the impact that such communication may have on the potentially innocent individual concerned, both from a well being and employment perspective.”
Hospital medical director accused of lying to families
Thursday 12 September 2024 11:22 , Rebecca Thomas
The inquiry hears how parents were mislead by the Countess of Chester medical director Ian Harvey.
In one incident he told parents nothing could have been changed about their son’s care or prevented his death. However at the time he was aware of a report which had criticised the quality of care given to their baby. This report concluded the death may have been preventable and the standard of care been better.
“Ian Harvey was aware at the time of this meeting that serious concerns have been expressed by consultants in the unit that Lucy Letby had been deliberately involved in harming patients on the unit in he was aware mother and father C had been provided with an incompetent version of a royal college report.”
Mr Harvey later wrote a letter to mother and father C and to other families on 3 March 2017 stating that the Royal College report had indicated “a small number of areas of investigation.”
However, days earlier on 1 May chief executive Tony Chambers recieved a letter from consultants on the unit expressing their concerns that unexpected collapses had not yet been adequately investigated.
Mr Baker said “It is implausible that Mr. Harvey was unaware of the strength of feeling amongst the consultants in the unit at this stage, or that he did not recognise the limits to the investigation undertaken his letter to the parents was therefore, at best, a serious distortion of the truth, but worse, an outright lie.”
Barrister brings up incidents connected to Letby at a second hospital
Thursday 12 September 2024 10:53 , Rebecca Thomas
Mr Baker sets out how unexpected collapses of children would usually be a rare occasion, but these incidents increased during Letby’s shifts.
Letby had training placements at Liverpool Women’s Hospital between October to December 2012 and January to February 2015.
“Given the prevalence of dislodgement of endotracheal tubes, in this case, my lady may perceive it as a common event, but the evidence suggests that it isn’t at all common. It is very uncommon, you will hear evidence that it generally occurs in less than 1 per cent of shifts,” he said.
“As a side note, you will hear that an audit carried out by Liverpool Women’s Hospital, whilst Letby was working there, dislodgement of endotracheal tubes occurred in 40 per cent of shifts that she worked.”
Hospitals should be aware of staff with ‘homocidal ideations'
Thursday 12 September 2024 10:43 , Holly Evans
On Tuesday the Thirlwall Inquiry counsel Rachel Langdale KC reflected that serial killers must “hide in plain sight”.
Reflecting on Ms Langdale’s opening Richard Barker says: “So many patients expressed towards Harold Shipman who they regarded as a diligent and caring doctor until that is the truth was known.
“We can add to that list many other superficially charming or apparently normal individuals who were later revealed to be monsters. It should be no surprise to this inquiry that insofar as other respectable and responsible professional professions may attract sexual predators, so healthcare professions may equally allow those harbouring malign or homicidal ideations to live out their fantasies unchecked.
“It is, as Mr Skelton points out, thankfully rare, but it is a risk that hospitals and trusts should be alive to in examining this issue.”
Turning to the emotional toll this has taken on the families, he said: “To them, their babies were miracles, they were often conceived against the odds.
“The father of [Child] G says this has damaged his faith. He says every day he would pray to God to save her. He did. He saved her.
“But the devil found her,” Baker adds.
Families do not want to be attractions in a ‘ghoulish sideshow’
Thursday 12 September 2024 10:40 , Rebecca Thomas
Richard Baker KC, barrister for the second group of families, said: “Everybody who recklessly promotes conspiracy theories or who parrots without questioning the same tired misconceptions about this case should be ashamed of themselves.”
He added: “The position of the families in this inquiry is unique. They are anonymised by ciphers, as are their children. Some are concerned that this has the effect of dehumanising them in the eyes of the public and media, and has cultivated an environment where people feel able to express vile opinions through social media, an environment where the serial killer who murdered or attacked their children is, by contrast, humanised or even venerated.
“You will understand that they have a simple and reasonable aim to live normal lives as disconnected from a monster who harmed them as possible. They have no interest in becoming permanent attractions as a ghoulish sideshow.”
Letby supporters must not demonstrate ‘closed mindedness’
Thursday 12 September 2024 10:36 , Rebecca Thomas
Amid speculation Lucy Letby was the “victim of a miscarriage of justice” Mr Skelton urges people not to fall into “closed-mindedness”.
He said: “There are strongly held and articulated questions in some quarters that she may be the unlucky victim of a miscarriage of justice... those raising those questions would not have been present at Lucy let me trial trials and so, unlike the juries that convicted her, they are not in a position to weigh up the evidence and reach an informed view.
“They are not, for example, aware that Lucy Letby was not convicted on the basis of questionable statistics but the factual and expert medical evidence demonstrated beyond reasonable doubt that she had harmed the children at the hospital.
“She was assisted at the time by a first-rate defence team, and it is important for the public to understand the decision-making that occurred within that trial about the use of expert evidence, for example, before coming into the view about what may now amount to a miscarriage.
“It is also important that people monitoring the Letby case, don’t demonstrate precisely the type of mindset and fallibilities that I have described in this opening statement, fallibilities that demonstrated closed-mindedness when it comes to facts that don’t support your own opinions.”
Most serious failings on Letby were by hospital bosses
Thursday 12 September 2024 10:31 , Rebecca Thomas
The inquiry hears how even eight years after Letby’s murders the trust’s board and senior managers “show little insight” into thier roles and responsibilities.
Peter Skelton KC says: “The most serious failings, must fall squarely on the managers of the neonatal unit, the hospital’s executive management and its board, in particular, Karen Powell, Alison Kelly and Ian Harvey, they failed to heed the rest the lessons of Grantham in Stepping Hill, and failed to act with professional curiosity and open minds when mortality increased in the neonatal unit and suspicions began to grow that Lepley was the cause.
“It is most striking that even now, eight or nine years later, they showed so little insight into their own roles, into what went wrong.
“So for example, in his long and detailed statement of the inquiry, Ian Harvey simply doesn’t accept personal responsibility for the fact that Letby wasn’t caught sooner.
“He does not address the obvious applicability of safeguarding obligations or the whistleblowing policies, despite being one of the hospital speak up champions, he does not recognise that Letby’s criminality was never adequately excluded as a possibility, because he did not ensure that it was directly investigated, both internally in the hospital and externally by the Royal College.”
Consultants deserve praise but should’ve acted sooner
Thursday 12 September 2024 10:23 , Sian Elvin
Consultants deserve the gratitude from the families but should have acted sooner, said KC Skelton.
He said: “The pediatric consultants, my lady, the consultants, deserve the gratitude of families for being the first to identify, let me as the connecting factor between the unexpected deaths and then the person who deliberately harmed the babies. They acted with tenacity and courage in the face of difficult and defensive managers...
“However, it must also be recognised that the consultants were in a position to initiate robust and comprehensive but did not do so. They were also in the position to trigger whistleblowing and safeguarding policies themselves, but did not do so.
“Most critically, as soon as they suspected that be at harm babies deliberately, they should have articulated their suspicions clearly and formally in writing and made sure that they were brought to attention of the senior managers and the board, and when those managers refused to take immediate and appropriate action, the consultants should have gone to the coroner or spoken to the police.”
One example of this failures, Peter Skelton said, was the failure to alert the coroner to at an October inquest about the concerning cluster of deaths at the hospital and that this was being investigated with concern to a member of staff.
Lessons from Beverley Allitt should have ‘heightened’ awareness
Thursday 12 September 2024 10:17 , Rebecca Thomas
Peter Skelton KC said: “Beverley Allitt’s actions should serve to heightened awareness in all those caring for children of the possibility of malevolent intervention as a cause of unexplained clinical events. My lady, this was a deliberately low bar.
“The Allitt inquiry was not advising that the suspicion of crime should be uppermost in the minds of healthcare staff responding to any unexplained events involving children - that would be an unnecessary and unrealistic expectation in the context of a national health system of healthcare and would create a culture of misplaced blame, fear and criminal investigation.
“But rather, the report was seeking to ensure that healthcare staff were prepared to think the unthinkable.”
Staff should have been prepared to ‘think the unthinkable’
Thursday 12 September 2024 10:11 , Rebecca Thomas
Peter Skelton KC for the first family group opens by referencing an inquiry following the murders of Beverley Allitt. Following this, he argues healthcare staff should be prepared to “think the unthinkable”.
He outlines five basic failures:
Failures to conduct swift methodical investigations into the deaths and why they occurred was a “catastrophic failing”
The cluster of deaths and collapses should’ve been escalated to the board immediately
It should have been in the minds overseeing the investigations that the clusters of deaths might have been linked to the criminal acts of staff
Police should have been contacted immediately
Inquiry opens for a third day
Thursday 12 September 2024 10:00 , Rebecca Thomas
The inquiry begins with barrister to the families. We will be following and provide the latest updates.
