Hospital bosses apologise for not contacting police sooner over Letby concerns
The Thirlwall Inquiry heard how managers waited for nearly two years before raising concerns with the authorities
Senior managers at the hospital where child serial killer nurse Lucy Letby struck say it was the "collective responsibility" of everyone "from the ward to the board" to keep babies safe, an inquiry has heard.
The Thirlwall Inquiry is investigating how Letby, 34, was able to murder seven babies and attempt to murder seven more at the Countess of Chester Hospital between June 2015 and June 2016.
On Friday, Kate Blackwell KC, representing medical director Ian Harvey and director of nursing and quality Alison Kelly, said the pair were first made aware by consultants at the end of June 2016 that Letby may be directly connected to the deaths.
Both had already been made aware of the spike in mortality rates which resulted in a number of reviews and investigations, the inquiry sitting at Liverpool Town Hall was told.
Ms Blackwell said: "Issues were flagged within these reviews concerning elements of care. However, during the course of these reviews and investigations there was no suggestion of any concerns that the increase in mortality rates was connected to any unnatural event or the result of foul play.
"Furthermore, there were no concerns raised in relation to the conduct of any member of staff, including Letby.
"Senior managers were aware Letby had been on shift when a number of the deaths had occurred. However, it was understood that she was a specialist practitioner and, therefore, because of her skills and training, more likely to be looking after the sickest infants on the neonatal unit, often on her own.
"In addition to this, her willingness to work overtime ... meant that she was on shift on a more frequent basis than other nursing practitioners."
Aside from the link to Letby's shift pattern and the deaths, Ms Blackwell said, there was "nothing specific" articulated by any consultant in numerous meetings that followed from July 2016 to identify any wrongdoing, and that Letby's nursing bosses were "firmly of the view" she was a good and competent member of staff.
Ms Blackwell, who is also representing ex-chief executive Antony Chambers and former director of people and organisational development Susan Hodkinson, added that management were never told about Child F's blood test result in August 2015 for which accidental administration of insulin had been excluded. Letby was later convicted of attempting to murder Child F by poisoning him.
She said: "Clinicians are in the unique position of being able to identify if there is something concerning about a clinical presentation or if the conduct of other clinicians or staff is a concern. Such concerns must be reported or escalated in order for governance processes to work effectively.
"It is crucial to understand that the responsibility to keep babies safe is shared by everyone. From those who work on the ward all the way to the board. It is a collective responsibility."
Ms Blackwell said it was "felt important" that an open mind be preserved as to the cause of deaths and to obtain evidence of wrongdoing before going to the police - who were eventually formally asked to investigate in May 2017.
She said: "That was the cause of the significant delay and for that they are sorry.
"At all times they acted with honesty and in good faith. At no time did senior managers prioritise the reputation of the trust. They had no motive to do so and this was not a driving factor.
"At no time did they try to suppress concerns and attempts to blow the whistle."
She went on: "They know they (the senior managers) will be asked difficult questions and they will answer them openly and honestly.
"This inquiry is the first real opportunity to tell their story and they are grateful for that. This is a complex case and the facts of which need to be carefully scrutinised by the inquiry.
"We hope that this inquiry will for the first time produce a comprehensive account of what happened at the Countess of Chester Hospital so that the right lessons are learned and real change is implemented where needed."
Ms Blackwell said: "Each wish to express, once again, their deepest condolences to the families of the babies harmed so cruelly by Lucy Letby.
"Ian Harvey, Alison Kelly, Antony Chambers and Susan Hodkinson have worked in health care settings for many, many years and have never come across criminal behaviour such as this.
"They have been been deeply affected by what happened at the hospital. While they do not suggest, in any way, parity with what the families of those killed and harmed by Letby have experienced, it has been the most significant event of their professional lives.
"They all chose to work in the NHS to help deliver exceptional care to patients and to save lives. That a nurse could be responsible for these heinous crimes is profoundly disturbing.
"It is not something that any of them ever expected to be happening in a neonatal ward, it being so against the natural order of what could be contemplated or foreseen."
Ms Blackwell said it was accepted "regrettably" that communication and support to parents was inadequate.
Jason Beer KC, representing NHS England, said: "On behalf of the entire NHS, NHS England wishes again unreservedly to apologise to all of the parents and the families affected for what they have been through and for the mistakes and system failures in the way these crimes were reported and investigated.
"This includes the lack of compassion and candour in the way information was shared by the hospital and for the lack of support provided to the families and all those affected by the unspeakable events."
He identified missed opportunities to report deaths and collapses as serious incidents.
He added: "There was an ongoing lack of candour by the hospital in terms of information it shared with external bodies."
The inquiry continues next week with evidence from parents of Letby's victims.
Letby, from Hereford, is serving 15 whole-life orders after she was convicted at Manchester Crown Court of murdering seven infants and attempting to murder seven others, with two attempts on one of her victims.
The inquiry is expected to sit until early 2025, with findings published by late autumn of that year.
A court order prohibits reporting of the identities of the surviving and dead children involved in the case.