Letby link to baby deaths ‘subjective’, confidential report found

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The link between Lucy Letby and the deaths of babies at the Countess of Chester hospital was “quite subjective”, a confidential report found.
The Thirlwall Inquiry heard on Wednesday that the Royal College of Paediatrics and Child Health (RCPCH) wrote a report into the deaths at the hospital that was never published.
In the report, consultants had identified that Letby was on shift for all deaths and had become “convinced by the link”.
The authors of the report said this view was “quite subjective” and warned there was “no other evidence or reports of clinical concern beyond this simple correlation”.
Reviewers also interviewed Letby, who described herself as being “scapegoated” and “very vulnerable”, the inquiry heard.
A second version of the report which did not mention Letby was eventually published, which stated there was no obvious factor which linked the deaths. The team made a number of findings including that the unit was short-staffed.
Letby is serving 15 whole-life orders, making her the fourth woman in UK history to be told she will never be released from prison.
She was convicted of murdering seven newborn babies and attempting to murder seven others at the Countess of Chester Hospital between 2015 and 2016.
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Thank you for following our live coverage of the Thirlwall Inquiry. 
The inquiry is investigating what happened at the Countess of Chester hospital during the time Lucy Letby worked there.
It will reconvene at 10am tomorrow.
It will reconvene at 10am tomorrow morning when the inquiry will hear opening statements from representatives of the families of the babies, the Countess of Chester, the Nursing and Midwifery Council (NMC) and the Royal College of Paediatrics and Child Health (RCPCH).
Rachel Langdale KC has suggested that the inquiry may want to consider if CCTV be placed on all neonatal units to protect babies against “malicious and deliberate harm”.
She also suggested that Lady Justice Thirlwall might want to consider if the laboratory detection of artificial insulin should raise an immediate alarm.
A Cheshire coroner said he did not have the “slightest inkling or suspicion that anyone had deliberately harmed” babies at the Countess of Chester.
Nicholas Rheinberg has told the inquiry that he was not informed that anyone was being blamed for the deaths, and said he was “surprised” that he had not been told about the concerns of consultants.
In the case of Baby A, doctors involved in the care of the infant were asked to make statements but did not raise concerns about Letby or suggest deliberate harm.
An inquest was held by Mr Rheinberg in October 2016, after Letby had already been removed from the ward, yet the coroner said he was not told about suspicions.
The coroner recorded a narrative verdict stating that it could not be determined what caused Baby A’s death, nor whether it was natural or unnatural.
Mr Rheinberg told the inquiry that he would have probably spoken to police if he had known one nurse had been rostered on shift for all the deaths.
Countess of Chester medical director Ian Harvey retired and moved to France following the arrest of Lucy Letby, the inquiry heard.
Consultants referred Mr Harvey to the General Medical Council (GMC) in 2018 claiming he had “failed to act appropriately or timely in response to concerns raised by clinicians”.
An initial investigation found that Mr Harvey’s conduct may have fallen below the standard expected of a responsible and competent medical director.
The GMC closed the referral with no action and Mr Harvey voluntarily removed himself from the medical register.
The Nursing and Midwifery Council (NMC) refused to impose an interim suspension order against Letby even after her arrest, the inquiry has heard.
Nicholas de la Poer KC, counsel for the inquiry, said that the NMC mistakenly believed that her bail conditions prevented her from working as a nurse.
The inquiry heard how the NMC considered the lack of a criminal charge “a hurdle” to suspending the nurse.
The body has since changed its guidance so that nurses can be suspended as long as there is “some evidential basis that is cogent, and not fanciful, frivolous, obviously contradicted or entirely misconceived”.
Following her conviction, Letby was referred to the Fitness to Practise Committee of the NMC and was struck off on December 12.
Lucy Letby was described as an ‘angel of death’ at a meeting between police and executives at the Countess of Chester on April 27 in 2017.
Within days police had begun investigating the nurse, but Ian Harvey, the medical director at Countess of Chester, believed that their enquiries would “close down speculation” about Letby.
Mr Harvey said police had been sent a letter by consultants which was “very prejudiced”, “effectively pointing the finger at one nurse”.
He stated that his own feeling was that there would not be an investigation unless there was something new disclosed by the paediatricians and anticipated that the “police would assist in a message which will allow us to close down speculation”.
However after interviewing consultants, Cheshire Police decided there was sufficient grounds to suspect a criminal offence and launched a criminal investigation on March 24 2017.
The Royal College wrote a second “confidential” report on deaths at the Countess of Chester, which included reference to Lucy Letby, which has never been published, the inquiry has heard.
It reported that consultants had identified that Letby was on shift for all deaths and had become “convinced by the link”.
The authors said this view was “quite subjective” and warned there was “no other evidence or reports of clinical concern beyond this simple correlation”.
Reviewers also interviewed Letby, who described herself as being “scapegoated” and “very vulnerable”, the inquiry heard.
A second version of the report which did not mention Letby was eventually published, which stated there was no obvious factor which linked the deaths.
The team made a number of findings including that the unit was short-staffed.
Doctors referred to Letby as “Nurse Death”, according to notes from a review into baby deaths by the Royal College of Paediatrics and Child Health (RCPCH) in 2016. 
Notes from the review period show that junior doctors had begun referring to Letby as “Nurse Death” which was causing “ripples through the team”.
Alison Kelly, director of nursing and quality at the trust, told reviewers there was “no issues of competency” or training with Letby and said she was highly thought of by the unit. 
Eirian Powell, the neonatal unit ward manager, described the allegations against Letby as “unfounded and malicious”, describing the nurse as “clever, exceptional and very professional”.
She said the doctors had “tunnel vision” about Letby’s presence. 
But interview notes show Drs Stephen Breary and Ravi Jayaram, both expressed their concern about Letby, and were threatening to go to the police. 
Ian Harvey, the medical director, said staff needed to “pull together before we press the nuclear button”.
The afternoon session of the Thirlwall Inquiry has begun and is looking at a review into baby deaths by the Royal College of Paediatrics and Child Health (RCPCH) in 2016. 
Lucy Letby is the second serial child killer nurse to strike on a hospital boss’s watch, an inquiry heard.
The Thirlwall Inquiry heard how Sir Duncan Nichol, Chair of Countess of Chester Hospital Board, had also been NHS Chief Executive when nurse Beverley Allitt was convicted of murdering and harming babies at Grantham and Kesteven Hospital in Lincolnshire in 1993.
Following Allitt’s conviction, Sir Duncan was then responsible for distribution of the Clothier Report, which was aimed at preventing and spotting future hospital serial killers.
Sir Duncan wrote to all hospitals to draw it to their attention. The inquiry said it will be questioning Sir Duncan about why “the parallel between Allitt and Letby was not drawn earlier at the hospital”.
Letby is serving 15 whole-life orders, making her the fourth woman in UK history to be told she will never be released from prison. 
She was convicted of murdering seven newborn babies and attempting to murder seven others at the Countess of Chester Hospital between 2015 and 2016.
Proceedings will resume shortly, but before that, here is a recap of what the inquiry heard so far today: 
The inquiry has risen for lunch and will resume at 1.45pm.
Inspectors from the Care Quality Commission (CQC) were not told about a spike in deaths or warned that a nurse may be harming babies when they reviewed the Countess of Chester Hospital in February 2016, the inquiry heard. 
The CQC – which monitors health and social care in England – sent inspectors into the hospital during the period where Letby was active.
Dr Stephen Breary, a consultant paediatrician at the hospital, said that he had told an inspector that consultants had “serious patient safety concerns” but did not feel they were being listened to by management.
However, in statements to the inquiry, all three inspectors said that nobody raised concerns about unexplained neonatal deaths or pointed out any correlation between the deaths and a member of staff.
“The evidence gathered appears to show that the Care Quality Commission was oblivious to the rise in mortality and the connected concerns relation to the unexpected nature of the deaths and the suspicions relation to Letby,” said Nicholas de la Poer KC, counsel for the inquiry,
“It is notable that Letby attempted to murder Child K in the early hours of 17th, the second day of the inspection.”
The deaths of Child A, C, D, E and I were not reported as concerning in Clinical Effectiveness meetings at the Countess of Chester Hospital, the inquiry has heard.
At a meeting in November 2015, none of the first four deaths were described as “unexpected”.
Nicholas de la Poer KC, counsel for the inquiry, said: “There was no discussion of concerns or deliberate harm, or increased morality.”
The death of Child I was likewise classed as “no harm” in hospital records, the inquiry was told.
The Countess of Chester took little action about Letby because the hospital believed “proof of criminality” was needed before reporting concerns to the police, the inquiry heard.
Nicholas de la Poer KC, counsel for the inquiry, said it was a “troubling feature” of the case that the hospital thought it was its job to investigate the allegations.
Mr de la Poer said there was actually a “low threshold” when it came to child safeguarding and outside bodies should have been informed earlier about fears regarding Letby.
“There were concerns that Letby may be harming children long before the disclosures to police on April 27 2017,” said the barrister. 
“All too often it appears that a high threshold was believed to exist for raising concerns of potential harm to babies, namely that some sort of proof of criminality was necessary before those with the responsibility to investigate concerns could be notified. 
“This is troubling because it is contrary to the clear guidance which safeguarding provides. 
“Child safeguarding sets a low threshold for raising concerns in respect to child safety.”
The barrister said that nurses and doctors should have reported Letby to the Nursing and Midwifery Council (NMC)  and General Medical Council (GMC)  if they had concerns. 
Sir Duncan Nichol, Chair of Hospital Board where Letby worked, was also the NHS Chief Executive when nurse Beverley Allitt was convicted of murdering and harming babies.
Following Allitt’s conviction at Grantham and Kesteven Hospital in Lincolnshire in 1993, Sir Duncan was then responsible for distribution of the Clothier Report, which was aimed at preventing and spotting future hospital serial killers.
An increase in baby deaths at the Countess of Chester was not mentioned in papers from the hospital’s Safeguarding Strategy Board until November 2017 – six months after the police investigation had already begun. 
The Thirlwall Inquiry heard that although there were widespread concerns about the rise in mortality on the neonatal unit, it was barely discussed at management level in review, strategy and board meetings. 
Although the Executive Board met 16 times during June 2015 and May 2017, the issue of increased mortality was raised on just five occasions.
The Nursing and Midwifery Council (NMC) was warned about Lucy Letby in July 2016, but did nothing for two years, the inquiry has heard.
The NMC, which registers and regulates nurses, only sought a fitness to practise referral on July 3 2018, more than a year after the police had started investigations. 
It did not impose an interim order, prohibiting the nurse from working until November 2020, after she had been charged the inquiry heard.
A board meeting in January 2017 recorded that Lucy Letby had been “exonerated” and should be allowed to return to the neonatal unit, the inquiry has heard.
At the meeting, Ian Harvey, the medical director at the Countess of Chester, presented a case review of the deaths and said it “comes down to an issue of leadership, escalation and timely intervention”.
Mr Harvey said he was hoping that “a line could be drawn under the issue” as soon as the final causes of deaths were ascertained.
Mr Chambers said the grievance procedure had exonerated Letby and the hospital would do everything it could to manage her safe transition back to the neonatal unit. 
The inquiry heard that on the same day, Mr Chambers told Letby the board was clear in its support for her return to work.
Letby was described as “the elephant in the room” at every child death, at a meeting of hospital directors in July 2016, the inquiry has heard. 
On  July 14 2016 there was an Extraordinary meeting of the Board of Directors at the Countess of Chester in which Tony Chambers, the Chief Executive, noted there had been a rise in neonatal mortality. 
At the meeting Dr Ravi Jayaram described the presence of Letby at the deaths as “the elephant in the room”.
It was agreed that the unit should be downgraded so it no longer took the sickest babies and that Letby be kept under supervision. 
Nicholas de la Poer KC, counsel for the inquiry, said: “The board did not discuss neonatal mortality and concerns raised about Letby again until the New Year.” 
A midwife in charge of risk at the Countess of Chester found that Letby was the “common factor” in most unusual deaths, after going through the “table of incidents” using a highlighter, the inquiry has heard.
Annemarie Lawrence took up the role of Risk Midwife in May 2016, and asked for a copy of the thematic review into the unexpected deaths of babies in the neonatal unit. 
In a statement to the inquiry, she described going through the table with a highlighter and noting that Letby was present at most of the deaths. 
However after taking her concerns to Ruth Millward, the Head of Risk and Safety, she found her superior “dismissive of her findings”.
Miss Millward told the inquiry that at no point was there any suggestion that “this was a deliberate act by the nurse”.
“She took the implication to be that there may be clinical competence issues which needed to be raised with the nursing leadership team or human resources,” said Nicholas de la Poer KC, counsel for the inquiry.
“Miss Millward states that she did not view this as a risk and patient safety team issue.
“One question you will be considering is whether the structures and processes for the management and governance of the hospital contributed to a failure to protect babies on the neonatal unit from the actions of Letby.”
It is day two of the Thirlwall Inquiry and lawyers are looking at whether structures in place at the Countess of Chester had failed to protect the babies.
The inquiry has heard how Sir Duncan Nichol, Chair of Hospital Board, had also been NHS Chief Executive when nurse Beverley Allitt was convicted of murdering and harming babies at Grantham and Kesteven Hospital in Lincolnshire in 1993.
Following Allitt’s conviction, Sir Duncan was responsible for distribution of the Clothier Report, which was aimed at preventing and spotting a future hospital serial killer.
Sir Duncan wrote to all hospitals to draw it to their attention.
The inquiry said it will be questioning Sir Duncan about why “the parallel between Allitt and Letby was not drawn earlier at the hospital”.
Here is a summary of what the inquiry heard yesterday:
The inquiry has begun. Lawyers for the inquiry will continue their opening statements today. 
Yet another public inquiry got under way today, the 16th either up and running or about to start, writes Philip Johnston.
Hardly a day goes by without a demand for an inquiry into a perceived failure of public policy, a scandal, disaster or foul-up. Since 1990, about £1 billion has been spent on scores of them, with the biggest of them all – into Covid – also taking evidence once again. 
It is looking at how the NHS coped with the pandemic, with the words “not very well” already inked into the conclusions.
Coincidentally, the inquiry which began today is also looking into a part of the NHS, the Countess of Chester Hospital where Lucy Letby was a nurse. 
Read the full story here.
The public inquiry into the events surrounding the crimes of child serial killer nurse Lucy Letby will continue today.
The Thirlwall Inquiry, chaired by Lady Justice Thirlwall, will examine how the neonatal nurse was able to harm babies in her care. The probe will also examine the broader conditions in the neonatal unit where Letby worked.
Yesterday, the inquiry heard many staff at the hospital did not believe the nurse was responsible for the deaths, and had been reluctant to remove her from the unit. 
The counsel to the inquiry also compared Letby to Britain’s most notorious serial killer Harold Shipman, claiming she was “hiding in plain sight”.
Letby is serving 15 whole-life orders, making her the fourth woman in UK history to be told she will never be released from prison. 
She was convicted of murdering seven newborn babies and attempting to murder seven others at the Countess of Chester Hospital between 2015 and 2016.
Evidence at the inquiry is scheduled to begin next week and will continue until at least December.