Parents of babies murdered and harmed by Lucy Letby last night condemned hospital bosses for stalling a police probe and targeting whistleblowing doctors before keeping children safe.
They criticised senior executives at the Countess of Chester Hospital, who mounted an ‘exercise in spin’ and ‘prized’ protecting the reputation of the hospital over investigating why infants died, a public inquiry found.
Lady Justice Thirlwall, the judge who oversaw the hearings, concluded that three babies murdered by the neonatal nurse might have been saved, and seven others protected from attack, had detectives been called in sooner.
She found chief executive Tony Chambers, 60, a former nurse who was paid £160,000 and had a degree in media and communications, ‘obstructed the police investigation’ and was ‘so determined’ to bring down the doctors who were raising concerns about Letby ‘that he lost objectivity’.
Similarly, nursing director Alison Kelly’s ‘misguided determination’ to protect Letby because she was a fellow nurse overrode her professional judgment, the judge said.
The executives kept the families in the dark about the medics concerns because they believed a police investigation ‘would lead nowhere’ – a move which Lady Justice Thirlwall said was ‘disgraceful and reprehensible.’
Last night the relatives criticised the former executives, saying the report was a ‘shocking account of multiple and repeated failings by organisations and individuals.’
In a statement their lawyer, Tamlin Bolton, said it included ‘direct and frank’ criticism of managers, who ‘failed to put patient safety first’.
Parents of babies murdered and harmed by Lucy Letby last night condemned hospital bosses for stalling a police probe and targeting whistleblowing doctors before keeping children safe
Lady Justice Thirlwall found chief executive Tony Chambers (pictured) a former nurse who was paid £160,000, ‘obstructed the police investigation’
Ian Harvey Former Medical Director of the Countess of Chester Hospital arrives for a second day giving evidence at the Thirlwall Inquiry
In her damning 822-report, Lady Justice Thirlwall said there had been a ‘complete failure’ to protect babies at the Countess. She said the ‘prevention of reputational damage’ was ‘prized more highly’ than investigating the spike in deaths on the neonatal unit.
Managers and senior nurses never accepted consultants’ suspicions about Letby could be true, the judge said, and instead of alerting the police they commissioned pointless external reviews which failed to discover why babies were dying.
Leadership was ‘dysfunctional’ and relationships between the consultants raising concerns and executives ‘disintegrated,’ the Appeal Court judge said.
Instead of being treated as whistleblowers, doctors were threatened with referrals to the General Medical Council by hospital chiefs and attempts were made to ‘manage’ them out of their jobs. Lady Justice Thirlwall made 17 recommendations, which included:
- Cot cams to be fitted in incubators on all NHS neo-natal units;
- Digital devices or CCTV fitted to fridges to monitor access to insulin – the substance Letby used to try to kill at least two babies in her care;
- The introduction of a disbarring system – banning executives found guilty of incompetence and misconduct from moving in a ‘revolving door’ of top roles in the NHS;
- A strengthening of the duty of candour to include executives, as well as doctors and nurses.
In a response to the findings of the public inquiry– which cost £18.5million, heard from more than 130 witnesses and examined more than a million pages of documents and emails – Health Secretary Yvette Cooper apologised for the ‘unthinkable loss’ and ‘failure by the NHS to keep babies safe’.
She said she had tasked officials with ‘urgently’ developing plans to introduce video baby monitors for neonatal units ‘to help parents feel better connected to their babies when they aren’t able to be with them in person’.
Letby, 36, is serving 15 whole-life sentences after being convicted of murdering seven infants and attempting to murder seven more, one of whom she attacked twice, between June 2015 and June 2016.
The most prolific child serial killer in British history, she could be ‘shockingly cold,’ the report said.
The judge said that conflict developed between doctors and senior nurses, including Ms Kelly and Karen Rees (pictured), the director of nursing for urgent care, who were ‘tribal’ in their ‘unthinking loyalty’ to Letby because she was ‘one of their profession’
Former Director of Nursing at the Countess of Chester Hospital Alison Kelly arrives at Liverpool Town Hall to give evidence at the Thirlwall Inquiry
But she has maintained her innocence and her case is currently being examined by the Criminal Cases Review Commission, the body that investigates potential miscarriages of justice.
Lady Justice Thirlwall stressed her report was not an investigation into the criminal convictions or guilt of Letby.
It found that up to three children – two triplet brothers known as Baby O and P, who were murdered by Letby on consecutive shifts, in June 2016, and a two-month-old baby girl known as Baby I – would have lived had hospital bosses implemented proper safeguarding measures and if doctors had spotted abnormal levels of insulin in a twin baby boy, known as Baby F, who Letby poisoned, in August 2015.
But that test was ‘disregarded’ by the consultant, who cannot be named for legal reasons, who reviewed it, which meant Letby was allowed to continue.
She was convicted of harming up to seven more children – Babies G, H, J, K, L, M and N, at least one of whom was left with life-changing brain damage – before being removed from the ward, in July 2016.
Lady Justice Thirlwall’s report was highly critical of the senior nurses and hospital managers, including Mr Chambers, Ms Kelly and medical director Ian Harvey, who were ‘foolhardy’ and failed to understand safeguarding.
The judge said that conflict developed between doctors and senior nurses, including Ms Kelly and Karen Rees, the director of nursing for urgent care, who were ‘tribal’ in their ‘unthinking loyalty’ to Letby because she was ‘one of their profession’.
It meant they refused to accept the consultants’ concerns which ‘distracted’ them from protecting babies from harm.
Significantly, despite being the hospital’s safeguarding lead, Ms Kelly never flagged the consultants’ concerns to the local safeguarding board or to NHS England.
If they had been, Cheshire Constabulary would have been notified and Letby likely suspended earlier.
Ms Kelly ‘could not believe’ one of her nurses was causing their deaths, the report found, while Mr Harvey, an orthopaedic surgeon, believed there must be a ‘clinical explanation’ – despite neither having any experience with treating premature babies.
Ms Rees was the executive who refused to remove Letby from the ward, even after the deaths of the triplet brothers, Baby O and Baby P, on consecutive shifts, in June 2016.
Medics described their deaths as ‘the tipping point’ and they prompted Dr Stephen Brearey, the clinical lead on the unit, to call Ms Rees, the executive on duty that evening, to demand that Letby be stopped from working the following day.
But the report found Ms Rees wrongly refused because she ‘did not accept that the doctors’ concerns were held in good faith’.
Lady Justice Thirlwall described Ms Rees, who has since spoken out in support of Letby, and said she believes she is innocent, as ‘hostile’ and rejected her claims that Dr Brearey ‘bullied’ her during the phone conversation, saying the likelihood of that ‘was nil’.
After the triplets’ deaths the ‘them and us’ division between the managers and doctors also only got worse.
Mr Harvey, who was paid £175,000 a year, commissioned external reviews without consulting the medics and misled the hospital board and the babies’ families on their findings.
Both he and Mr Chambers told the inquiry they took the doctors’ concerns seriously, but the judge said she did not accept this was true.
A Cheshire Police investigation into potential corporate manslaughter and gross negligence manslaughter at the hospital continues.
In a statement Mr Chambers, Mr Harvey and Ms Kelly said they would be ‘carefully reviewing’ the report but it would be ‘inappropriate’ for them to comment while the police and CCRC investigations remain ongoing.
Last night Lucy Letby’s barrister Mark McDonald said: ‘Everything in this inquiry is tainted by the fact that they’ve worked on the wrong premise.’
Mr McDonald called for ‘everyone to pause, stop’ and allow the CCRC to make its decision on the evidence, which he believes will be in ‘just months’.
