Senior managers at the Countess of Chester Hospital were criticised for failing to act on doctors’ concerns about Lucy Letby, with the Thirlwall Inquiry finding that loyalty to the nurse hindered efforts to safeguard babies.
The report said several senior figures dismissed fears that Letby was responsible for a rise in baby deaths, while failing to consider whether police or safeguarding authorities should be alerted.
Ian Harvey, the hospital’s former medical director, was found to have failed in his duty to consider whether steps should be taken to protect other babies on the unit.
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.”
Mr Harvey, a retired orthopaedic surgeon who was paid £175,000 a year, told the inquiry he “sincerely regretted” not calling the police sooner. He said consultants had not shown him anything that “took it over the bar” for detectives to be brought in.
He said the issue had been presented as an unexplained increase in deaths, rather than as evidence that something had been seen or done to the babies.
Mr Harvey insisted he had taken concerns seriously when they were raised by consultants working with Letby.
Concerns were not escalated
Alison Kelly, the hospital’s former director of nursing, admitted she had “missed an opportunity” to keep babies safe.
Ms Kelly, who was paid £130,000 a year, denied concealing the rise in mortality from inspectors at the Care Quality Commission or responding too slowly to concerns about Letby. But she accepted that she should have been “more attentive” and that the increase “could have been looked at in a more timely way”.
She said her workload was “very large” and that she often missed emails, arguing that other staff should have “picked up the phone”. She denied being too busy to do her job.
Despite being the hospital’s safeguarding lead, Ms Kelly did not refer the consultants’ concerns to the local safeguarding board, the local safeguarding officer or NHS England. She accepted that, had this happened, Cheshire Constabulary would have been informed and Letby was likely to have been suspended earlier.
The report rejected her denials that there had been animosity between doctors and nurses.
Tony Chambers, the hospital’s former chief executive, was also criticised. A former nurse, he told the inquiry that he sided with Letby after doctors raised concerns that she was killing babies because she had won an employment grievance against the trust.
Mr Chambers denied delaying the police investigation for ten months to protect his own reputation or that of the hospital. Several doctors described him as dictatorial and aggressive.
The inquiry found that he “never once scrutinised his own thought processes”, and that he “lost objectivity and made poor decisions”.
Loyalty to Lucy Letby
Eirian Powell, the former head of the neonatal unit, continued to support Letby as the number of baby deaths rose and the evidence against her grew.
Ms Powell said there was no proof that Letby was responsible, insisting that nobody had seen the nurse do anything wrong. As late as May 2016, she was described as “vociferous” in supporting Letby’s remaining on the ward.
She later accepted that the police should have been called and that she had failed in her responsibilities to protect babies from harm.
The inquiry said her judgment was probably affected by her belief that Letby was an exceptionally good nurse and by the fact that she was always available to work extra shifts. Ms Powell later described her as “the creme de la creme”.
Karen Rees, the former director of nursing care, was also criticised over her judgment. She had baselessly believed that a neonatal consultant and Letby had previously been in a relationship, after the doctor requested that the nurse be removed from the ward.
The report described the allegation as “ridiculous”, saying that Ms Rees’s willingness to make such an extreme claim against a paediatrician without any basis showed she had “lost all judgement in the face of what she had been told”.
The inquiry accepted that Ms Rees, Ms Kelly and Ms Powell initially believed Letby was not responsible for the rise in baby deaths.
But it concluded: “Loyalty seems to have prevented them from considering the doctors’ concerns with an open mind or thinking about safeguarding.”
