Several senior managers and hospital leaders at the Countess of Chester Hospital were criticised in the Thirlwall Inquiry’s report into how Lucy Letby was able to continue killing babies.
The inquiry found that colleagues readily accepted Letby’s explanations while dismissing doctors’ concerns that she could be responsible for the rise in infant deaths.
Medical director Ian Harvey was found to have failed to consider whether measures were needed to protect other babies on the unit.
Giving evidence, he said he ‘sincerely regretted’ not contacting police sooner as concerns about Letby mounted. However, he claimed consultants had not shown him anything that ‘took it over the bar’ for detectives to be called in.
‘It was never raised, as something had been seen, something had been done,’ he said. ‘It was raised as there is an increase in the number of deaths, but we don’t understand why.’
The retired orthopaedic surgeon, who earned £175,000 a year, insisted that he took the concerns seriously when consultants who worked alongside Letby brought them to his attention.
Lady Justice Thirlwall wrote: ‘He had a duty to consider whether steps should be taken to safeguard other babies on the unit. He failed to do so.’
Ian Harvey, the former medical director at the Countess of Chester Hospital, arrives to give evidence at the inquiry. The former surgeon said he ‘sincerely regretted’ not calling police sooner
Alison Kelly, the hospital’s former director of nursing, arrives at the Thirlwall Inquiry at Liverpool Town Hall. She denied responding too slowly to concerns about Letby
His colleague Alison Kelly, the £130,000-a-year director of nursing, told the inquiry that she had ‘missed an opportunity’ to protect babies.
She rejected allegations that she had concealed the rise in mortality from Care Quality Commission inspectors or failed to act promptly on concerns about Letby.
However, Ms Kelly accepted that she should have been ‘more attentive’ and acknowledged that ‘it (the spike) could have been looked at in a more timely way’.
She said other staff should have ‘picked up the phone’ because her workload was ‘very large’ and she frequently missed emails. But she denied that she had been ‘too busy to do her job’.
Despite serving as the hospital’s safeguarding lead, she did not pass the consultants’ concerns to the local safeguarding board, the local safeguarding officer or NHS England.
Ms Kelly accepted that, had the concerns been reported, Cheshire Constabulary would have been alerted and Letby would probably have been suspended sooner.
The report rejected her denials to the inquiry that there was animosity between doctors and nurses.
Letby had an ally in Tony Chambers, the Countess of Chester Hospital’s £160,000 chief executive.
Himself a former nurse, he told the inquiry he sided with Letby after doctors raised concerns she was killing babies because she won her employment grievance against the Trust.
Karen Rees, former head of care nursing and Letby’s senior manager at the hospital, was also criticised over her judgement, previously praising the nurse as ‘the creme de la creme’
Mr Chambers denied stalling the police investigation for ten months to protect the reputation of himself and the hospital.
Several of the medics described Mr Chambers as being dictatorial and aggressive.
The report found he ‘never once scrutinised his own thought processes’, and ‘lost objectivity and made poor decisions’.
Letby also found loyalty in Eirian Powell, the head of the neonatal unit.
But as babies began dying, and the weight of evidence against Letby began to build, Ms Powell said there was no proof the nurse was to blame.
She insisted no one saw Letby do anything – and even as late as May 2016 was ‘vociferous’ in her support for her to remain on the ward.
She admitted that ‘with hindsight’ the police should have been called and she failed in her responsibilities to protect babies on the unit from harm.
The report found Ms Powell’s judgment was likely ‘affected by her view that Letby was a very good nurse (she was later to describe her as the “creme de la creme”) and that she was always available for extra shifts’.
The report found it was ‘ridiculous’ that Karen Rees, director of nursing care, baselessly believed a neonatal consultant and Letby had previously been in a relationship, prompting his request for her to be removed from the ward.
The report said: ‘That Ms Rees was comfortable making such an extreme allegation against a paediatrician without any basis demonstrates that she had lost all judgement in the face of what she had been told.’
The report accepted that Ms Rees, Ms Kelly and Ms Powell initially believed that Letby was not responsible for the spike in baby deaths.
But it added: ‘Loyalty seems to have prevented them from considering the doctors’ concerns with an open mind or thinking about safeguarding.’
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