Investigation revealed: “Five fundamental errors” in the hospital where Lucy Letby worked

Peter Skelton KC, representing seven of the families, gave an opening address on the third day of the Thirlwall Inquiry, which is seeking to establish how the 34-year-old nurse was able to commit her crimes in 2015 and 2016 on the neonatal ward of the Countess of Chester Hospital.

He said there were “five fundamental errors that occurred right from the start and continued for the next two years.”

Speaking at Liverpool Town Hall on Thursday, Mr Skelton said: “The first failure was to investigate quickly, carefully and methodically why each death occurred and whether there were any links between the deaths.”

He added: “This was a huge and catastrophic mistake.”

Mr Skelton said this resulted in important information being overlooked, which had “fatal consequences” for other children.

He said the spate of deaths and collapses should have been reported immediately to hospital management so they could conduct investigations.

Mr Skelton said: “From the outset, and without prejudice or preconceptions, those conducting and supervising the investigations should have had in mind that the spate of unexpected and unexplained deaths could have been caused by the criminal actions of a member of hospital staff.”

The lawyer said a report on Beverley Allitt, a nurse who killed children at Grantham Hospital in Lincolnshire in 1991, should ensure medical staff are open to the possibility of criminal behaviour.

In addition to the Allitt case, Mr Skelton said that in May 2015, shortly before Letby’s crimes began, nurse Victorino Chua was convicted of murdering patients at Stepping Hill Hospital.

He said: “It is difficult to understand why the events at Stepping Hill did not alert the people at the Countess of Chester’s from the outset that the cluster of unexpected deaths was the result of potential criminality and that active steps were needed to rule out that possibility.”

Mr Skelton said the police and coroner should have been informed from the outset as this could have had a “profound impact” on the course of events.

He told the inquiry that the fifth failure was not informing families that the deaths were being investigated to determine their causes.

Mr Skelton said: “You will be hearing from some parents over the next few weeks about how they were kept in the dark about the babies’ collapses and the concerns and investigations that were launched into their babies’ deaths.”

He said these failures were “all the more inexcusable” given the rising number of newborn deaths.

Doctors missed a “great opportunity” to solve crimes in August 2015 when an abnormal blood test result showed an elevated insulin level in a child, he said.

When pediatricians suspected in late 2015 that Letby was the immediate cause of death and that her actions may have been intentional, Skelton said Letby should have been suspended from her caregiving duties and contacted the police.

At this point, safeguards and whistleblowing procedures should also have been in place, as well as contact with the parents concerned to fully inform them of what might have happened to their children, he added.

Instead, there was “denial, distraction and delays on the part of hospital management,” the investigation said.

Mr Skelton said the consultants who raised concerns about Letby “deserve the gratitude” of the families and had acted with “tenacity” and “courage” out of “genuine fear of adverse professional consequences”.

However, he said they should have set out their concerns clearly and formally in writing and ensured that they were brought to the attention of management and the board.

And if they were dissatisfied, she should have spoken to the police, he said.

Mr Skelton said there were “growing divisions between doctors and nurses and between doctors and managers”, leading to an “obvious lack of perspective” needed to protect babies from a “ruthless and determined serial killer”.

Mr Skelton said it appeared that the hospital’s then medical director, Ian Harvey, could not accept that he should have informed the police about Letby sooner, nor did he take personal responsibility for her being caught sooner.

He said: “It was not Mr Harvey’s role to assess the validity of the concerns.

“He treated the consultants as a problem that would not simply go away.

“Over time, a deadlock developed in which the consultant’s assumptions were never satisfactorily reflected.”

Richard Baker KC, representing other families, said the convictions and charges against Letby “do not tell the whole story”.

A jury found Letby guilty of attempted murder of little girl K by intentionally ripping out her breathing tube in February 2016. The baby was taken to another hospital a few days later, where she died.

Mr Baker said Child K’s parents were “rightly” convinced she was murdered by the nurse.

No verdict could be reached on an alleged attack in November 2015 on another little girl, Child J, who survived, but Mr Baker said her parents also had “no doubt” that Letby had caused the collapse.

He said they also thought their daughter had been the victim of such an attack the following month, although Letby was never charged in that incident.

Mr Baker told Judge Thirlwall that breakdowns in neonatal units, such as the dislodgement of endotracheal tubes, were “unusual”.

He said: “It generally occurs in less than 1% of the layers.

‘You will hear that an audit carried out by Liverpool Women’s Hospital found that during Lucy Letby’s time working there, endotracheal tubes were displaced on 40% of her shifts.

“One wonders why?”

The killer nurse completed two internships at Liverpool Women’s Hospital in 2012 and 2015.

Letby, from Hereford, is serving a life sentence after being found guilty at Manchester Crown Court of the murder of seven young children and the attempted murder of seven more children between June 2015 and June 2016. Two of the murder attempts were aimed at one of her victims.

The inquiry, chaired by Judge Thirlwall, is expected to last until early 2025 and the results will be published in late autumn of the same year.

A court order prohibits the disclosure of the identities of the surviving and dead children involved in the case.