UK - Lucy Letby - Post-Conviction Statutory Inquiry

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katydid23 said:

Inquiry to explore 'overlap in remit' between various hospital groupspublished at 11:03 British Summer Time​

11:03 BST​

Judith Moritz
Reporting from the inquiry
The hospital had a multi-layered governance structure, with a range of divisional boards and sub-committees, de la Poer outlines.
"There seems to have been significant overlap in remit between these various groups," he says, adding the inquiry will explore whether this "affected how the hospital identified and dealt with concerns raised about neonatal mortality".
He says that there were a "number of routes" for issues to be referred from groups near the bottom of the hospital’s governance hierarchy, "all the way to the board", but that's "not what happened".
De la Poer adds the inquiry will look at why the "increase in neonatal mortality and the concerns raised about Letby were rarely discussed".


Doctor referred to Letby as 'elephant in room'​

​

Judith Moritz
Reporting from the inquiry

The hospital board met sixteen times between June 2015 and May 2017, the inquiry hears.

Concerns in relation to Letby were only explicitly discussed at four "extraordinary meetings" held in private, de la Poer says.

On 14 July 2016, Tony Chambers, former chief executive of the Countess of Chester Hospital, informed the board that there had been an unexplained increase in neonatal mortality at the trust, the inquiry is told.

The board were told a peer review had been undertaken, which was "inconclusive" - and Ian Harvey, former medical director of the Countess of Chester Hospital, would undertake his own review of the data.




Following the meeting on 14 July 2016, the board "did not discuss neonatal mortality nor the concerns raised about Letby again until the new year," de la Poer says.

Letby’s last shift on the neonatal unit was on 30 June 2016, de la Poer had outlined.
Click to expand...
That's almost unbelievable. Not discussed for half a year.
 

Hospital board were asked to assist Letby’s return to the neonatal unitpublished at
​

Judith Moritz
Reporting from the inquiry
We're now hearing about a meeting on 30 December 2016, involving:
  • Tony Chambers, former chief executive of the Countess of Chester Hospital
  • Ian Harvey, former medical director of the Countess of Chester Hospital
  • And Sir Duncan Nicholl, former chair of the board of directors at the Countess of Chester Hospital

“It was at this meeting, it appears, that the roadmap forward was set out," de la Poer says, which included a plan to endorse the transition of Letby back onto the neonatal unit.

An extraordinary meeting of the board was held on 10 January 2017 - where a statement by Letby was read.

De la Poer tells the inquiry the board were asked to "accept the Royal College report" and "support the executive team in assisting Letby’s return to the neonatal unit".

“Sir Duncan Nichol has publicly said the board were misled by Mr Chambers and Mr Harvey at this meeting," De la Poer says.
 

Inquiry hears about first communication with babies' families
​

Judith Moritz
Reporting from the inquiry

On 28 March 2017, the inquiry hears, Sir Duncan Nicholl - former chair of the board of directors at the Countess of Chester Hospital - was told that consultant paediatricians were insisting on a police investigation.

"There was no discussion of this at the board meeting on 4 April 2017," de la Poer tells the inquiry.

There was a third extraordinary meeting of the board on 13 April 2017.

De la Poer says: “During the meeting, Sir Duncan referred to the Beverley Allitt case.

"You will recall my lady that Sir Duncan was chief of the NHS management executive at the time of Beverley Allitt’s crimes and was tasked with dissemination of the Clothier Inquiry report across the NHS.

"There was no reference to the Allitt case in the previous extraordinary meetings of the board of directors," he adds.

The inquiry hears about the first communication with the babies' families about the unfolding situation.

De la Poer goes on to say that at the same extraordinary board meeting, on 13 April 2017, Ian Harvey - former medical director of the Countess of Chester Hospital - told the board the hospital had endeavoured to keep the families up to date, although there were things to be learned.

Tony Chambers, former chief executive of the Countess of Chester Hospital, said the hospital had written to the families advising them - in an "open and transparent way" - of what the hospital knew, the inquiry hears.

De la Poer says: “The inquiry is concerned to understand the basis on which Mr Harvey and Mr Chambers made these assertions to the Board.

"We will hear that parents of babies who were attacked by Letby were not contacted by the hospital in advance of the Royal College review; that parents received letters from the hospital informing them of publication of the Royal College report hours before it was due to go live; that parents struggled to arrange meetings to talk with Mr Harvey; and that parents were never told by the trust that concerns had been raised about the potential involvement of a particular nurse.”
 

Nursing regulator didn't suspend Letby until after she was charged, inquiry told​


Judith Moritz
Reporting from the inquiry

The inquiry has begun to hear about the role and involvement of external bodies in the events at the Countess of Chester Hospital.

De La Poer says the Nursing and Midwifery Council was notified there were concerns about Letby on 6 July 2016, but did not seek a fitness to practise referral until two years later, on 3 July 2018 - after she had been arrested.

It did not impose an interim suspension order until more than two years after that, on 20 November 2020, the inquiry hears - after she had been charged.

The Nursing and Midwifery Council is the regulatory body for nursing and midwifery professionals in the United Kingdom.


:oops: :(
 

Neonatal deaths logged as a 'reputational' riskJonny Humphries​

Reporting from the inquiry

Concerns about the increased number of baby deaths on the hospital's neonatal unit were logged on the trust’s urgent care risk register in July 2016, De la Poer told the inquiry a little earlier.

However, the risk was categorised as “potential damage to the reputation” of the unit and the hospital - rather than a risk to the safety of babies on that ward.

He said: “We note there is no record of the consultants’ concerns of deliberate harm to babies in the urgent risk register, the executive risk register nor the corporate director’s group meeting minutes."
He says the inquiry will be seeking to understand why this is - and why it took so long for concerns to be formally recorded in this way.
 
Here are five key points from this morning:

  • The hospital’s head of risk and patient safety was “dismissive” of concerns about Letby while she was still killing babies
  • Increased deaths on neonatal unit were logged as a risk to the “reputation” of the hospital
  • The chairman of the hospital’s board had been responsible for sharing the previous inquiry into killer Beverley Allitt with hospitals across the NHS
  • A key safety committee discussed the increase in neonatal mortality or Lucy Letby just once between June 2016 and June 2016 – and no committee escalated concerns about Letby to the board
  • The hospital’s medical director and chief executive told the board the parents of babies were being “kept up to date” – parents say otherwise
 
Really not good, as early as child c there was supposed to be communication with the coroner and I believe this would have prevented everything after. They did not follow the rules, dear oh dear oh dear someone's for it I believe and rightly so. Genuinely shocked.

"Nicholas de la Poer KC goes over the local Cheshire and national protocols supposed to be carried out, including INFORMING THE CORONER and POLICE in many instances for investigation

He then tells the inquiry that, other than in the case of Child C - where there was an initial strategy meeting 18 days after the death - there is little evidence demonstrating these local guidelines were adhered to.

www.bbc.co.uk

Lucy Letby hospital inquiry live: Hospital logged baby deaths on Letby's unit as 'reputational' risk, inquiry told

Concerns about increased deaths were logged in July 2016 - but were not described as a risk to the safety of babies on the ward.
www.bbc.co.uk
 
The coroner would likely have been able to provide this evidence of wrongdoing If the protocol had been followed.

“Namely, that some sort of proof of criminality was necessary before those with the responsibility to investigate concerns could be notified. This is troubling, your Lady may think, because it is contrary to the clear guidance that safeguarding advice provides.."

www.independent.co.uk

Lucy Letby inquiry live: Killer nicknamed ‘nurse death’ by doctors

A public inquiry into how Lucy Letby was able to murder babies at a neo-natal unit over a two-year period is taking place
www.independent.co.uk www.independent.co.uk
 
"Mr de la Poer says: “The rationale for this was that the current evidence of concern was the ‘potentially circumstantial’ fact of one nurse on shift on more occasions than others but that deaths/deteriorations occurred when the nurse was not on shift.”

There was confusion about that then. Sometimes present Sometimes not. I bet she did try and blend murders with natural deaths.

www.independent.co.uk

Lucy Letby inquiry live: Killer nicknamed ‘nurse death’ by doctors

A public inquiry into how Lucy Letby was able to murder babies at a neo-natal unit over a two-year period is taking place
www.independent.co.uk www.independent.co.uk
 
Becky53 said:

I take it Dr U is Doc Choc…
He may be accompanied by a legal advisor.
Click to expand...

Interesting! We know that he emailed LL a confidential email. However, I’m particularly interested in hearing whether he was aware (and made LL aware) of the consultants discussing air embolism in their meeting on 29th June 2016 and Jayaram emailing the consultants a link to the 1989 paper the next day on 30th June. As it was at 3pm on 30th June 2016 that LL filed a datix about an open port being an air embolism risk!
 
Last edited:

"Hospital trust where Lucy Letby worked feared ‘reputational harm’, ​

inquiry hears.​


A hospital trust
first characterised concerns over a high mortality rate on a neonatal unit where Lucy Letby worked
as a risk to 'reputational harm'
rather than
a threat to the safety of the infants,
an inquiry has heard."

:(

www.theguardian.com

Lucy Letby referred to as ‘nurse death’ two years before her arrest, inquiry told

Inquiry into Chester hospital’s neonatal unit also told inspectors ignored ‘serious patient safety concerns’
www.theguardian.com www.theguardian.com

More...

"Mr de la Poer said it was 'striking'
that the spike in neonatal baby deaths,
which fell under the remit of Quality, Safety and Patient Experience Committee,
was only discussed once by that committee
between June 2015 and June 2016,
when Letby was killing babies in her care.

'The Quality, Safety and Patient Experience Committee
was in fact the only board committee where neonatal mortality was even discussed.
And…
during the period of Letby's attacks,
the Quality, Safety and Patient Experience Committee
discussed the increase in the mortality rate on the Neonatal Unit
just once'."

https://twitter.com/x/status/1833854415289127206
 
Last edited:
As much as I feel for the parents having to go through all this again, I hope they're taking some comfort in the fact that so much of what has taken over the media recently is being held up to the light and given a thorough seeing to in this enquiry.
 
Sweeper2000 said:
We have to take the murders within the context of natural deaths on the unit. I have a idea she tried to blend them in together, imagine the confusion? Some natural some not and many just leaving more questions than answers.

I would like to know the dates of every collapse and death on the unit . There may be a pattern there you wouldn't see through what was in the trial.
Click to expand...
It's awful to know that throughout her whole time doing this, she would have to have secretly rejoiced whenever a baby died of natural causes (as opposed to by her hand), knowing that this terrible unfortunate event would only help to obscure her crimes and confuse the pattern and statistics.
 
sunspun said:
It's awful to know that throughout her whole time doing this, she would have to have secretly rejoiced whenever a baby died of natural causes (as opposed to by her hand), knowing that this terrible unfortunate event would only help to obscure her crimes and confuse the pattern and statistics.
Click to expand...

Gosh I had never thought of that angle … how horrific and yes I agree with you, she would have loved that.
 

Inquiry's opening ends with themes expected in final report

16:30 BST 11 September​

Judith Moritz
Reporting from the inquiry

Rachel Langdale KC has finished the her opening statement by setting out a list of themes its chair, Lady Justice Thirlwall, is likely to consider when making her recommendations next year.
Among those the lead counsel to the inquiry highlights are:
  • Implementing CCTV in neonatal units
  • Senior managers and their responsibility to ensure that safeguarding is prioritised
  • The role of external regulators and inspectors, and whether they should be strengthened
  • If there is a problem with public inquiries in that the recommendations are not implemented and culture is not changed
  • How to ensure the recommendations of the Thirlwall Inquiry are implemented
  • If the culture of the NHS need to change, and how it can be changed
She says the "answers are important to all those who work in the NHS, and all of us that use its services".
Tomorrow the inquiry will hear opening statements for various core participants.
These including from lawyers on behalf of two family groups, and those representing the Countess of Chester Hospital.
 

Round-up: Day 2 of the Thirlwall Inquiry

17:22 BST 11 September​



The second day of the Thirlwall Inquiry has come to an end. We'll shortly be closing our live coverage.
It's been set up to examine what happened, external at the Countess of Chester Hospital and the conviction of former neonatal nurse Lucy Letby of murder and attempted murder of babies there.
Here is some of what Barrister Nicholas de la Poer KC told the inquiry today:
  • Letby "attempted to murder Child K in the early hours of 17 February 2016" - the second day of the Care Quality Commission inspection
  • In the period June 2015 to March 2017, no board committee escalated to the board issues relating to neonatal mortality or Letby
  • The hospital board met 16 times between June 2015 and May 2017. Concerns in relation to Letby were explicitly discussed at four extraordinary meetings held in private
  • Junior doctors at the hospital were referring to Letby as "Nurse Death’" by September 2016
  • She was also described as "the angel of death" during a meeting at the hospital in April 2017
  • On 5 July 2016, a HR representative at the hospital sought legal advice from an employment lawyer. She told them about the increased neonatal death rate and staff were pointing fingers, adding a consultant made a reference to serial killer Beverley Allitt

You can read more about what was said at the inquiry today here.
 
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