UK - Lucy Letby - Post-Conviction Statutory Inquiry

[Marantz4250b]

The finding about the breathing tubes being dislodged at Liverpool is really disturbing. More really important evidence that just confirms even more that the jury got this one right

Agreed!

The further back that her life is investigated the more seems to be coming out about her.

I've just been skipping things today (well, it's tomorrow now so yesterday) but I think these breathing tube dislodgements go back to at least around 2012?

So, she didn't suddenly start this murdery stuff in 2015.

We are three days into this inquiry and they've already got back to pretty much the start of her nursing career after graduating. If she's been doing this stuff - and on a industrial scale it seems - this early on in her career then there must surely be some deeply dark things lurking in her earlier life? She didn't start thinking like this when she became a nurse.

I dread to think of what's coming over the coming months, quite honestly. Some people are going to endure a grim Christmas, I fear.

 

[Baby baby Jane]

There’s quite a bit of information missing from that statement of just the two figures- they only did the audit whilst LL was on a placement there, so they have pulled the 1% from their guesstimates, rather than making a direct comparison using data collected from other trainee nurses- they have compared her figures to the whole unit and all other qualified staff. At that point LL was a student on a training placement- they make no comparison to the percentages with other student nurses at the same point in their training. If you have a look online there is massive issues with the dislodgement of breathing tubes and them being incorrectly inserted in neonatal wards- to the point that in 2021(many years after LL was training) a working party of 23 experts across Europe was created, their figures on it potentially occurring during student placements was up to 80% error rate.

https://www.bjanaesthesia.org/article/S0007-0912(23)00498-1/fulltext#au22

Apples & oranges in situations and in use of %. Yes, compilation of EU student placements across Europe vs LL on one ward.

 

[Tortoise]

So is the inquiry necessarily going to be widened to include missed opportunities for flagging up extremely unusual events during her placements at Liverpool Women's? Presumably these babies suffered breathing difficulties/were crashing, triggering monitor alarms, roughly every other shift she worked.

 

[Parker Knoll]

iii) whether the trust’s culture, management and governance structures and processes contributed to the failure to protect babies from Lucy Letby

Possibly ?

 

[JosieJo]

General nursing training is one thing- she was not qualified until spring 2015 to work in NICU or SCBU- she was doing her training placements in 2012 and 2015 and was not at that point qualified to work in special care baby units. That is why during the enquiry they referred to those 2 placements as training placements as she was not fully trained and qualified at that point to work in those specific units.
It perhaps doesn’t matter in the grand scheme of things- but I find it infuriating for the families when the hospital now comes out with how perfect it was normally and then during an audit LL was flagged- but we still passed her placement. The truth is likely much murkier- they didn’t need to mention there normal 1% (which shines a light on the magnificence of how they function normally) as to an outsider it makes me question why they also did and said nothing- what they actually know as fact is there was a UE on 40% of LLs shifts- so was it normal enough that no one flagged it and made her redo the placement or fail her placement, or was the teaching hospital failing the parents as well by not teaching the nurses how to do procedures properly. I’m sure there will be much more to come out about that audit and what if any impact it had (because if nothing else surely the point of an audit is to reflect and improve)

She worked in neonatal from qualifying so had been nursing ET tubes for years when she did her neonatal course at Liverpool

 

[JosieJo]

If the statistics are correct regarding dislodged breathing tubes ..and obviously we do not know the full context..but if they are they are damning because...

Having worked as a qualified nurse for years in neonatal before doing her specialist course at Liverpool she would have a lot of experience with babies ET tubes.

There would have been training nurses across all shifts not just LL yet the comparison to other shifts is stark

She may not have been pulled up on it at Liverpool if they were not babies she was supposed to be looking after or she was clever enough to make sure she wasn't directly around when alarms went off

 

[CatsnChickens]

Lucy Letby hospital inquiry: NHS bosses 'truly sorry' for delay in contacting police over Letby, inquiry hears

The Thirlwall Inquiry, which is examining the NHS response to Lucy Letby's crimes, is hearing from counsel for senior managers at the NHS.

www.bbc.co.uk

Todays live feed link

 

[katydid23]

Managers hope inquiry will operate 'with an open mind'​

​

Judith Moritz
Reporting from the inquiry

Blackwell says the the senior managers at Countess of Chester know "they will be asked difficult questions".

"They have deliberately refrained from responding to criticisms made by them by number of individuals and organisations which have been reported in the media".

She adds she hopes the inquiry will "scrutinise" the complex facts of the case "unblinkered by hindsight bias, and with an open mind".

NHS managers say inquiry should help lessons to be learned
​

Judith Moritz
Reporting from the inquiry

Kate Blackwell KC says the NHS senior managers have furnished the inquiry with extensive witness statements - running into hundreds of pages, and have done so willingly.

She says they hope that this inquiry will fulfil its terms of reference fully and for the first time produce a comprehensive account of what happened at the Countess of Chester hospital so that lessons are learned.

 

[Sweeper2000]

I think the audit was made using figures local to the lhw unit. This is actually good as it shows the stats relevant to Lucy and the other staff present who presumably had training the same as hers. Its also good as the audit was likely inclusive of her known activities ie she did try to deflect negative attention by targeting others babies so they didn't measure just her own patients but by her presence. I'm wondering if that was why the unit didn't figure it out, 40x the collapses due to her but dispersed over the entire unit. It would be much more noticeable if it was concentrated in one nurses records.

Josie I think your right as they mention "shifts" but not allocated patients. To me to think that 40x the regular amount but only on her shifts and never when she is not around signifies a problem.

 

[katydid23]

Doctors did raise concerns, Blackwell says​

Judith Moritz
Reporting from the inquiry

Blackwell continues by describing the working reality of consultants and doctors in a busy hospital, saying they were doing their "best to react to an unfolding picture".

"They didn’t have the benefit of all the evidence to which the inquiry now has access."

"The circumstances of what happened as things developed were unique and challenging."

Addressing submissions that have been made to in the inquiry suggesting the hospital staff lacked "professional curiosity", she says there were "a number of investigations" made, and that concerns were "not ignored".

NHS managers sorry for delay in going to police
​

Judith Moritz
Reporting from the inquiry

Blackwell continues, saying the senior managers accept that they believed that they needed to investigate so as to obtain evidence of wrongdoing before taking this matter to the police.

There was nothing tangible being alleged beyond Letby’s presence for a long period of time that they might say to justify a criminal investigation, she says.

This was the cause of significant delay in contacting the police, Blackwell says, adding that for this they are truly sorry.

Blackwell says the managers also accept that communication with parents was "inadequate" and also apologise for that.

 

[katydid23]

[ oh oh, as Senior Management begins their excuse-making, I hope it doesn't become 'evidence' for the LucyIsInnocent crowd.]​

​

​

Letby regarded as a 'good and competent nurse
​

Judith Moritz
Reporting from the inquiry

Blackwell is now addressing the frequency of infant mortality while Letby was working.
Senior managers were aware that she had had been on shift when "a number of deaths occurred for some time", she says, adding that Letby had specialist training which meant she was more likely to be with the sickest patients on her own.
She "showed her willingness to work extra shifts," she adds.

“The neonatal unit manager Eirian Powell was firmly of the view that Letby was a good and competent nurse.”

“The Senior Managers believe that, given the information with which we were provided, and the need to maintain an open mind about possible causes of the mortality rates on the NNU, we acted appropriately at the time.”

Blackwell says the managers believe they made "reasonable decisions" and were held to account by the hospital board and CEO.

 

[katydid23]

It's expected lessons will be learnt from inquiry - Blackwell
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Judith Moritz
Reporting from the inquiry

The legal representative speaking on behalf of NHS senior managers continues, saying the senior management team collectively welcome this public inquiry.

"We have complete faith in the process," Kate Blackwell KC says. "This will be the first time that the story of what took place at the hospital will unfold on the basis of the evidence of what took place.”

“The circumstances of what happened as events developed in 2015, 2016 and 2017 were unique, challenging and complex," she says.

Blackwell adds that the senior management team understands that, having gathered the evidence and then heard testimony from those who are able to assist with what was actually happening at the time, "the final story will be written by this public inquiry in its report".

“At the heart of this process is the expectation that lessons will be learned which is, we are certain, a goal shared by all Core Participants.

"This is to ensure that, as far as it is possible to do, that there can never be a repeat of what happened here.”

'Tremendous trust between staff in the NHS'​

Judith Moritz
Reporting from the inquiry

Blackwell moves on to discuss the integrity of professionals working in the NHS.

Listing the names of senior team members relevant to the inquiry, she says "Ian Harvey, Alison Kelly, Anthony Chambers and Susan Hodkinson have collectively worked in the healthcare setting for many, many years and have never come across such criminal behaviour before.

She adds "the vast majority of professionals" with whom they have worked are "motivated with the highest of aims".

"They come to work every day, often in difficult circumstances, to help save lives. They do so by working long hours in the most challenging of environments.

"There is a tremendous amount of trust within the NHS between professionals which we know will be acknowledged by the Inquiry.”

 

[katydid23]

Letby's crimes are 'profoundly disturbing', Blackwell says
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Judith Moritz
Reporting from the inquiry

Concluding her introductory speech, Blackwell says the medical staff at Countess of Chester have been "deeply affected" by what happened at the hospital.

"While we 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 any of our professional lives - not a day goes by when we don’t think about what happened."

"That a nurse could be responsible for these heinous crimes is profoundly disturbing."

She finishes by saying this was not something ever expected to occur on a neonatal ward, "it being so against the natural order of what was contemplated or foreseen”.

 

[katydid23]

Inquiry now moves on to CQC and baby K​

Judith Moritz
Reporting from the inquiry

We're now hearing from Jenni Richards KC, who is speaking on behalf of the regulator for health and social care providers, the Care Quality Commission (CQC).

She is running through the details of the inspection which the CQC made at the hospital in 2016 - during the time window of Letby’s crimes.

As a reminder, Letby has been convicted of attempting to murder a baby girl, baby K, in the early hours of the morning of the second day of the CQC inspection.

CQC inspection in 2016 included neonatal unit, Richards says
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Judith Moritz
Reporting from the inquiry

Jenni Richards KC tells the inquiry that on 16-19 February, 26 February and 4 March 2016, the CQC carried out the routine inspection of the hospital. The services inspected included the neonatal unit.

She says that as part of the inspection, an out-of-hours unannounced visit was carried out on 26 February and a further unannounced visit was undertaken on 4 March - including, on this latter occasion, a visit of the neonatal services. There were no particular triggers for these visits, Richards adds.

 

[katydid23]

CQC accepts failings identified in government report, says Richards​

​

Judith Moritz
Reporting from the inquiry

Richards continues by addressing a report published in July 2024 by the Department of Health and Social Care on its 'Review into the operational effectiveness of the Care Quality Commission'.

"It finds significant failings in the internal workings of the CQC. The CQC has accepted in full the failings identified, and the recommendations," Richards says.

“The consequence is that a significant process of internal reflection is underway to address the problems that have been identified," she adds.

“We fully accept there will be more for the CQC to learn as an organisation as a result of this inquiry”

​

 

[katydid23]

'NHS very different now compared to 2016'​

Judith Moritz
Reporting from the inquiry


We're now hearing from Jason Beer KC representing NHS England.

He starts by offering an apology to the parents of the babies harmed or killed by Letby, on behalf of the entire NHS, saying the organisation "continues to learn" from the events at the Countess of Chester Hospital”.

He calls for “compassion and candour to be the touchstones for dealings with all parents”.

“Neonatal services and the NHS more widely are very different now compared to 2015 and 2016," he adds, citing the publication of the Morecambe Bay Report and The Better Births Report in those years as “pivotal moments” in changing the way things are done.

'There was under reporting of incidents on neonatal unit' - Beer
​

Judith Moritz
Reporting from the inquiry

Jason Beer KC continues, saying it "seems to be generally acknowledged that there was under reporting of incidents on the neonatal unit".

"All providers including this hospital were required to comply with the Serious Incident Framework," he says.

None of the incidents involving harm short of death were reported via this framework.

Beer says it was not until July 2016 that broader concerns about a rise in morbidity and neonatal mortality were reported.

Hospital took 'too long' to involve the police - Beer
​

Judith Moritz
Reporting from the inquiry

Beer moves on to say that after Letby was removed from the neonatal unit, NHS England was made aware of a rise of mortality on the unit. This was in July 2016.
Beer says that NHS England now feels that it gave “too much deference and too much reliance to the view that senior managers at the Trust were demonstrating the right behaviours and taking the right action”.

“It took too long for the hospital or any of the individuals who held serious concerns… to involve the police".

He adds the body now considers that it "could have done more to scrutinise the hospital" during the nine months between when it first became aware of the rise in neonatal mortality figures and when the police first became involved.

 

[Parker Knoll]

Opening statement from the management in full here

https://thirlwall.public-inquiry.uk/wp-content/uploads/thirlwall-documents/Written%20Opening%20Statement%20of%20the%20Senior%20Management%20Team.pdf

 

[katydid23]

NHS England owes families 'a willingness to learn' - Beer​

​

Judith Moritz
Reporting from the inquiry

Jason Beer KC, who is representing NHS England, concludes: “There are some areas where the inquiry may choose to make recommendations to address missed opportunities".
He lists examples, such as further training, a framework for reporting concerns to the police, a memorandum of understanding between the NHS and the police, and policies on social media to "increase safeguards around sharing information”.
“NHS England finishes by reflecting on what all those involved in this inquiry owe the families of the babies - candour, a willingness to reflect and learn, and to take forward recommendations," he says.

Lady Justice Thirwell thanks core participants​

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Judith Moritz
Reporting from the inquiry

The opening statements have all been delivered and Lady Justice Thirlwall is thanking all core participants.

Rachel Langdale KC tells the hearing that next week, the inquiry will hear from the babies’ parents directly.

The inquiry building will be closed to the media and public for this next phase. Some of the evidence given by the babies’ parents will be available for the media to listen to, and transcripts will be provided later.

That concludes the inquiry for this week, thank you for staying with us.

Lucy Letby hospital inquiry: NHS bosses 'truly sorry' for delay in contacting police over Letby, inquiry hears

The Thirlwall Inquiry, which is examining the NHS response to Lucy Letby's crimes, is hearing from counsel for senior managers at the NHS.

www.bbc.com

 

[Sweeper2000]

CQC accepts failings identified in government report, says Richards​

​

Judith Moritz
Reporting from the inquiry

Richards continues by addressing a report published in July 2024 by the Department of Health and Social Care on its 'Review into the operational effectiveness of the Care Quality Commission'.

"It finds significant failings in the internal workings of the CQC. The CQC has accepted in full the failings identified, and the recommendations," Richards says.

“The consequence is that a significant process of internal reflection is underway to address the problems that have been identified," she adds.

“We fully accept there will be more for the CQC to learn as an organisation as a result of this inquiry”

​

Interesting. I can easily agree with this. How often is it that we get a baby killer working on units like this? Virtually never so it's only with exceptional rarity that institutions get the chance to learn, adapt and tailor guidelines to it. Same principle applies to staff on the unit concerned, you just wouldn't assume its someone until the results are undeniable.

 

[katydid23]

Six key moments from the inquiry today
​

If you're just joining us this lunchtime, here's what we've been hearing from the Thirlwall Inquiry in Liverpool:

• Kate Blackwell KC, who was representing four NHS senior managers at Countess of Chester Hospital, said they were "deeply affected" by statements from the babies' families
• Blackwell said the managers were sorry for the delay in contacting the police about Lucy Letby
• Representing the Care Quality Commission (CQC), Jenni Richards KC addressed the fact that the health and social care regulator inspected the hospital in February 2016 - during the time window of Letby's crimes
• The CQC accepted there will be more for it to learn as a result of the inquiry, Richards said
• Jason Beer KC, who was representing NHS England, said it was "generally acknowledged that there was under-reporting of incidentson the neonatal unit"
• He added that the NHS considers it "could have done more to scrutinise the hospital" during the nine months between when it first became aware of the rise in neonatal mortality figures and when the police became involved