UK - Lucy Letby - Post-Conviction Statutory Inquiry

[Tortoise]

14:45
Chambers didn't tell police about a suspicious incident observed by a consultant​

Judith Moritz
Special correspondent, reporting from the inquiry

The inquiry moves on to a meeting on 16 March 2017, when Chambers was told about a conversation HR director Sue Hodkinson had had with consultant Dr Ravi Jayaram the previous day.

In that conversation, Jayaram told Hodkinson about three suspicious occasions involving Letby and a premature baby girl known as Baby K. Letby has since been convicted of attempting to murder Baby K.

The baby was deteriorating in February 2016 and had a dislodged breathing tube. Jayaram walked into the room and found Letby standing by doing nothing.

Chambers says he spoke to Jayaram briefly after learning about this disclosure.

Asked if he asked for more information, Chambers says he does not recall asking the consultant directly about the revelation.

Nicholas de la Poer KC asks: "Wasn't that what you needed to do?"

"I suppose so, yes," Chambers replies, "but I didn’t want to put him in a position where he was being in anyway coerced. I wanted to give him a safe environment to express his concerns in an open way."

Chambers did not pass information on the disclosure to the police as possible eye witness evidence.

Hospital CEO told board of directors Letby wasn't responsible for spike in infant deaths
14:54​

Judith Moritz
Special correspondent, reporting from the inquiry

Tony Chambers is now asked about a meeting of the hospital board on 10 January 2017.

The minutes show that the former hospital CEO told the board that "there was an unsubstantiated explanation that there was a causal link to an individual. This is not the case."

Inquiry counsel Nicholas de la Poer KC asks him: “So you are telling the board that it isn’t the case that Letby is responsible for the increase in deaths?"

Chambers says he "can see that there can be a legal set of arguments here - but at the time, everything we were being told by experts, independent neonatology experts, was that there was no evidence of deliberate harm."

Inquiry counsel asks if Chambers misunderstood report findings about Letby
15:00​

Judith Moritz
Special correspondent, reporting from the inquiry

De la Poer points out to Chambers that none of the experts were asked to deal with the question of whether deliberate harm might have been caused.

Chambers denies this. "They said there was no evidence," he says.

"My understanding of what I was being told and reading was that there was nothing pointing to unnatural causes."

De la Poer asks if there is "a possibility that you were misunderstanding what the reports were saying?"

"I don’t think that’s fair," Chambers replies.

Chambers denies misleading hospital board of directors
15:01​

Judith Moritz
Special correspondent, reporting from the inquiry

Chambers is now told about comments from the former chairman of the hospital board, Sir Duncan Nichol.

Nichol has previously said the board was misled by executives at the hospital, after being told there was no criminal activity pointing to any one individual.

In response, Chambers tells the inquiry: "We would never mislead the board."

Ex-medical boss of Lucy Letby hospital says opportunities missed to spot harm three times

The former medical director of Lucy Letby's hospital, Ian Harvey, is appearing before the Thirlwall Inquiry, giving evidence about how the hospital handled the case.

www.bbc.co.uk

 

[marynnu]

They may not be swallowing it, but for me, it's hard to tell a lot of times, because jeez... they are so darn polite! Maybe it's just the unfailingly gracious way British English speakers come across to my shall we say, less refined American ear, and it might also sound different if I were actually hearing their voices, instead of reading it, but in their genteel way of putting everything, it can sound like they're letting them totally skate.

If you mean the lawyers, trust me they are all over it. The polite yet deadly approach is way more unnerving than raised voices or saying things directly!
Mr. de la Poer has a very nice line in British sarcasm I must say.

 

[Tortoise]

Consultant worried that doctors' relationship with management was 'breaking down'
15:11​

Judith Moritz
Special correspondent, reporting from the inquiry

The inquiry is now shown an email that consultant Dr Ravi Jayaram sent to Tony Chambers on 20 September 2016.

In it, Jayaram says: "I have a group of colleagues who do not feel that they are being listened to, or valued by the trust and consequently fear that our relationship with senior management is breaking down."

Inquiry counsel Nicholas de la Poer KC tries to move on to a new line of inquiry, but Chambers asks to speak about the email.

"One of the things that you find as a chief executive unfortunately is that you find yourself apologising for all sorts of things that other people had done, that you knew nothing about," he says.

He adds that the context of the email was to do with the consultants being angry over an issue with the hospital’s fundraising appeal for a new neonatal unit.

Ex-medical boss of Lucy Letby hospital says opportunities missed to spot harm three times

The former medical director of Lucy Letby's hospital, Ian Harvey, is appearing before the Thirlwall Inquiry, giving evidence about how the hospital handled the case.

www.bbc.co.uk

 

[Tortoise]

Chambers attended 'tense' meeting between consultants and management
15:14​

Judith Moritz
Special correspondent, reporting from the inquiry

The inquiry moves on to examine the minutes of a meeting held on 26 January 2017, which was attended by consultants, executives and the hospital's medical and nursing directors.

In part the meeting was to tell the consultants about the Royal College of Paediatrics and Child Health (RCPCH) review - none of them had been shown the full version.

Nicholas de la Poer KC says different recollections have emerged from those in attendance about Chambers' behaviour.

"Some have said you behaved in an oppressive, overbearing, or bullying way. I want to give you the opportunity to say whether you would recognise that description of yourself," he says.

Chambers replies: "I remember this meeting I remember it being very tense, I didn’t really understand why."

Former hospital CEO says he behaved professionally in meeting with consultants
15:20​

Chambers says he felt the need "to be fairly clear and direct" to the consultants about Letby's grievance. In it, there were allegations that derogatory and inappropriate language had been used.

"I wanted to be clear that that didn’t meet the values of the organisation and that we needed to not see any further examples of that," he says.

Chambers continues: "I didn’t feel that I was raising my voice, I certainly wasn’t angry. I felt that I behaved professionally, as they did, as everybody in the meeting did, and that was my recollection of that meeting."

It was during this meeting that consultants were told Letby would be coming back to work on the neonatal unit.

Ex-medical boss of Lucy Letby hospital says opportunities missed to spot harm three times

The former medical director of Lucy Letby's hospital, Ian Harvey, is appearing before the Thirlwall Inquiry, giving evidence about how the hospital handled the case.

www.bbc.co.uk

 

[Tortoise]

Consultants wrote in letter than no deaths followed Letby's removal from unit
15:29​

Judith Moritz
Special correspondent, reporting from the inquiry

The consultants sent a letter to Chambers on 10 February 2017, after meeting with the former hospital executive in January. By now they had seen the full reports by the RCPCH.

In the letter they make several points, including that there had been no deaths or unexpected resuscitations on the unit since Letby was taken off duty in July 2016.

Chambers is asked if this letter was reasonable. He accepts that it was, saying the points the doctors make are "not quite as simple as described here, but these are fair points".

He adds: "There’s never been a doubt in my mind, ever, that these doctors had the safety and well-being of these babies at the forefront of their minds."

Ex-medical boss of Lucy Letby hospital says opportunities missed to spot harm three times

The former medical director of Lucy Letby's hospital, Ian Harvey, is appearing before the Thirlwall Inquiry, giving evidence about how the hospital handled the case.

www.bbc.co.uk

 

[Tortoise]

15:33
Hospital's medical director questioned what doctors 'were plotting'​

Judith Moritz
Special correspondent, reporting from the inquiry

The inquiry is shown handwritten notes of 14 February meeting between hospital bosses, after they’d received this letter from the consultants.

Chambers is recorded as saying the doctors "seemed to have gone backwards". Medical director Ian Harvey is noted to have "wondered what they were plotting".

De La Poer notes "plotting is generally what you do against your enemies".

Chambers says "they certainly weren’t enemies any more than we were the enemies."

"We were just ordinary people trying to deal with an extraordinary set of circumstances, with very little or confusing information to hand, and we were trying to make the best sense of that", he says.

"The only thing that there was absolute consensus on was that we didn’t really know what the absolute causes of unexplained death were."

Ex-medical boss of Lucy Letby hospital says opportunities missed to spot harm three times

The former medical director of Lucy Letby's hospital, Ian Harvey, is appearing before the Thirlwall Inquiry, giving evidence about how the hospital handled the case.

www.bbc.co.uk

 

[Tortoise]

Chambers asked if he was listening to consultants' concerns properly
15:58​

Judith Moritz
Special correspondent, reporting from the inquiry

Nicholas de la Poer KC says the hospital executives’ position in February 2017 was that Letby was going to be allowed back onto the unit. He asks Chambers: "Do you think you were not listening properly to what the consultants [who had concerns] were saying to you?"

"No I don’t think that’s true," he says. "We’d been given really strong messages from the Royal College of Paediatrics and Child Health that the unit was calmer, the unit felt safer/"

But De la Poer puts it to Chambers that none of the external expert reviews had dealt with the question: "Has Letby done this?"

Chambers says all of the advice the experts were giving them was that “there was nothing pointing towards unnatural causes".

Ex-medical boss of Lucy Letby hospital says opportunities missed to spot harm three times

The former medical director of Lucy Letby's hospital, Ian Harvey, is appearing before the Thirlwall Inquiry, giving evidence about how the hospital handled the case.

www.bbc.co.uk

 

[Tortoise]

Consultants were warned they would be referred to regulator​

16:15​

Judith Moritz
Special correspondent, reporting from the inquiry

The inquiry hears that medical director Ian Harvey wrote to the consultants on 1 March 2017, warning them of a referral to the regulator, the General Medical Council (GMC).

Chambers says he was not aware of this at the time.

Ex-medical boss of Lucy Letby hospital says opportunities missed to spot harm three times

The former medical director of Lucy Letby's hospital, Ian Harvey, is appearing before the Thirlwall Inquiry, giving evidence about how the hospital handled the case.

www.bbc.co.uk

yeah, not aware of the biggest thing going on his hospital at the time. yeah yeah yeah. Are counsels for the families going to get time with him today?

 

[Tortoise]

Chambers challenged over calls to manage critical doctors out of their jobs​

16:28​

Liz Roberts
Reporting from the inquiry

Now the inquiry is discussing a one-to-one meeting Chambers had with HR director Sue Hodkinson on 12 May - the same day as the second meeting with Cheshire Police.

De la Poer says Hodkinson says she was surprised and disappointed by what Chambers was saying in that meeting.

There was a discussion - that was never implemented - about how to manage some of the doctors out of the trust, including talk of a referral to the General Medical Council (GMC). Hodkinson has previously said she challenged Chambers about this in the meeting.

Chambers says: "I don’t remember the meeting, I do remember the context around the meeting."

"What was clear at the outcome of that meeting was that the police were themselves not sure whether this met the threshold of a criminal investigation," he adds.

"I was very clear before any decision could be made that there wouldn’t be an investigation that they should meet with the doctors again, which they did within a few days. And that led to the commencement of Operation Hummingbird."

Ex-medical boss of Lucy Letby hospital says opportunities missed to spot harm three times

The former medical director of Lucy Letby's hospital, Ian Harvey, is appearing before the Thirlwall Inquiry, giving evidence about how the hospital handled the case.

www.bbc.co.uk

Who asked about the police? FGS rein him in.

 

[Tortoise]

Hospital boss denies talking about referring doctors to regulator​

16:38​

Liz Roberts
Reporting from the inquiry

Nicholas de la Poer KC now asks Chambers why they were talking about referring two of the doctors from the unit - Dr Stephen Brearey and Dr Ravi Jayaram - to the GMC.

Chambers says "that's not what we were talking about".

"It was saying what are the potential things that we might need to do if there isn’t a police investigation. One, GMC, two, this... so it was nothing more than that."

Ex-medical boss of Lucy Letby hospital says opportunities missed to spot harm three times

The former medical director of Lucy Letby's hospital, Ian Harvey, is appearing before the Thirlwall Inquiry, giving evidence about how the hospital handled the case.

www.bbc.co.uk

 

[Tortoise]

Chambers says he didn't step down as hospital boss to avoid scrutiny​

16:52​

Liz Roberts
Reporting from the inquiry

Chambers is now being questioned about a potential vote of no confidence in him as the chief executive of the hospital.

He would eventually step down from his role in light of the ongoing police investigation into deaths at the hospital's neonatal unit.

Chambers says he "had a contract" and "had done nothing that was in breach of that" so had contractual right to a minimum six months' notice period.

"All I was wanting from this … if we could have got more that would have been great but as an absolute minimum was the opportunity to work my notice being useful to the NHS in some other organisation," he says.

"I wanted to be able to work my notice in an organisation so that I then had an opportunity to reset and maybe rebuild."

"I wasn’t aware, genuinely wasn’t aware, that there was ever going to be a vote of no confidence. That was something that began to be talked about but I genuinely wasn’t specifically aware of it," he says.

Asked if he left to avoid scrutiny of his leadership he says: "No, I mean there was no suggestion that... there could have been a vote of no confidence."

Was Chambers aware of the possibility babies were deliberately killed?​

16:55​

Liz Roberts
Reporting from the inquiry

Chambers is now being questioned by Peter Skelton KC, who represents a group of families.

"You were aware of the possibility that the babies had been deliberately killed, yes?" Skelton asks.

"I was only aware only of the concerns that were raised", Chambers says, "and the circumstantial link with an individual member of staff".

Ex-medical boss of Lucy Letby hospital says opportunities missed to spot harm three times

The former medical director of Lucy Letby's hospital, Ian Harvey, is appearing before the Thirlwall Inquiry, giving evidence about how the hospital handled the case.

www.bbc.co.uk

 

[Tortoise]

just light the coals and bring him back tomorrow

 

[Tortoise]

Board 'would have gone straight to police' if deliberate harm suspected - Chambers
17:06​

Liz Roberts
Reporting from the inquiry

Skelton presses Chambers: "Just to be clear, was it your evidence that you were not aware of the possibility that children may have been deliberately harmed at the end of June?"

"It was much less explicit than that," Chambers says, "if for one moment that’s what I believed, I had heard, and that was being said, the board would have gone straight to the police".

Skelton continues, asking Chambers: "When did you become aware of that possibility?"

Chambers replies by saying, "it was never concretely said in the way that you have said".

He then adds: "There’s so much hindsight inherent within your question. At the time that’s not the information I had or we had."

Ex-medical boss of Lucy Letby hospital says opportunities missed to spot harm three times

The former medical director of Lucy Letby's hospital, Ian Harvey, is appearing before the Thirlwall Inquiry, giving evidence about how the hospital handled the case.

www.bbc.co.uk

 

[Tortoise]

'Discussions' were had about whether babies had been harmed, hospital chief says​

17:11​

Liz Roberts
Reporting from the inquiry

Chambers continues, saying to Skelton: "when you use emotive language of murder...it becomes not something that I heard at that time."

He then adds: "if you are saying the possibility of harm, then there were discussions."

"There were a range of scenarios to explore."

Skelton asks when he was aware of that possibility.

"I think I felt those issues almost immediately."

Ex-medical boss of Lucy Letby hospital says opportunities missed to spot harm three times

The former medical director of Lucy Letby's hospital, Ian Harvey, is appearing before the Thirlwall Inquiry, giving evidence about how the hospital handled the case.

www.bbc.co.uk

That was his original question!

 

[Anxala]

They may not be swallowing it, but for me, it's hard to tell a lot of times, because jeez... they are so darn polite! Maybe it's just the unfailingly gracious way British English speakers come across to my shall we say, less refined American ear, and it might also sound different if I were actually hearing their voices, instead of reading it, but in their genteel way of putting everything, it can sound like they're letting them totally skate.

No. As @Tortoise says above, listen to and focus on the lawyers, those asking the questions, rather than those giving the answers. The lawyers, at every turn, are making sure to hold all the lies and discrepancies and contradictions up to the light. Focus on their words, their questions and their responses to the answers, and you'll see the razor-sharp intent behind them and their methodology. Getting everything, every last miserable, self-serving, lying excuse for how grimly these people failed those they were responsible for, on the record.

There's nothing genteel going on here, just professional civility.

 

[Phoenix Lazarus]

This is an interesting report

Letby's father 'threatened guns to my head', hospital boss claims

 

[Parker Knoll]

He’s back tomorrow and it won’t be pleasant for this utter COWARD.
Simply staggering again, these half a***d apologies are worthless from management as they are still unwilling to take responsibility not withstanding the fat pay cheque they get and got to oversea what was going on literally under their noses and deflect deflect deflect is a disgrace.
I imagine letby smirking in her miserable cell tonight while she watches the news.
My blood is boiling.

 

[Sweeper2000]

I'm almost certain now that had the case files been reviewed by someone who had been informed that deliberate harm was a possibility that they would have been looked at differently. No one reported correctly. That's shocking.

A sit down and private chat with the consultants as a group or individuallly would have been a professional and open approach. It's not conspiratorial and that information could have prompted proper communication in regards to the reviews and achieved a review with appropriately supporting information but in this case one that is open to all possible causes of death. This really could have changed the timeframe.

 

[Tortoise]

I'm almost certain now that had the case files been reviewed by someone who had been informed that deliberate harm was a possibility that they would have been looked at differently. No one reported correctly. That's shocking.

A sit down and private chat with the consultants as a group or individuallly would have been a professional and open approach. It's not conspiratorial and that information could have prompted proper communication in regards to the reviews and achieved a review with appropriately supporting information but in this case one that is open to all possible causes of death. This really could have changed the timeframe.

Yes. As Dr McPartland said, they should have asked for a forensic pathologist to run alongside a normal post mortem where they only look to explain it with natural causes. They don't have the same areas of expertise.

 

[Kemug]

This is an interesting report

Letby's father 'threatened guns to my head', hospital boss claims

Interesting, I somehow had the impression that it was Lucy's mother who was leading that battle. Well, well.