UK - Lucy Letby - Post-Conviction Statutory Inquiry

[Kemug]

I still find it bizarre that Mummy and Daddy came charging to the rescue of their mid-20s daughter. Perhaps all her life they have protected her from having to face the consequences of her actions.

 

[Baby baby Jane]

This is an interesting report

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

The dad threatening was exactly the moment this person should have said.
“There will be no threats made at CCH, I’m going to ask you to leave or I will call security. This meeting is concluded. “

Then send them a letter recorded mail documenting the meeting and that their threats and behavior are not acceptable.

CCH needed to be in charge, not her pathetic parents.

Next time they attend a meeting, an escort from security.

 

[iamshadow21]

Every single administrator in this thought they were working PR for a corporation or political campaign, rather than safeguarding the most vulnerable human beings on the planet.

They're incapable of answering a straight question with a straight answer or admitting that they had all the information in front of them to make an informed decision that could have protected children from harm. Instead, they're all slipperier than a bag of eels, trying to wriggle out of every single question put to them. To take their word for it, you'd have to believe they never heard nuffin and had about as much power as the guy who mopped the floors to intervene.

MOO

 

[Kemug]

Every single administrator in this thought they were working PR for a corporation or political campaign, rather than safeguarding the most vulnerable human beings on the planet.

They're incapable of answering a straight question with a straight answer or admitting that they had all the information in front of them to make an informed decision that could have protected children from harm. Instead, they're all slipperier than a bag of eels, trying to wriggle out of every single question put to them. To take their word for it, you'd have to believe they never heard nuffin and had about as much power as the guy who mopped the floors to intervene.

MOO

Don't you mean the famous plumber?

 

[Legal]

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

I wonder if there is any potential criminal liability for board members?

 

[iamshadow21]

Don't you mean the famous plumber?

At least the plumber was open and honest on the stand. I'd trust his morality over that of any of this cast of villains.

MOO

 

[Legal]

I've just had a look at the composition of the current Board of Directors for COCH and there are 17 board members in total, 9 female and 8 male. However, going by the names and pictures, they are all white and middle-aged. I know that despite that, some board members may be part of other ethnic groups and also I know Cheshire isn't as multi-cultural as larger cities. However, I feel that this is important when they state on the website:

"Countess of Chester NHS Foundation Trust is dedicated to becoming an inclusive employer of choice for candidate’s ethnic minority groups, and to improving the workplace experiences of ethnic minority colleagues."

The same document also states over 11 % of the current workforce is BME, so at least 2 members of the board should be BME. I wonder if Ravi would have had more credibility with the executives if he had been 'in the club' (JMO).

https://www.coch.nhs.uk/corporate-information/board-of-directors.aspx

 

[Tortoise]

I wonder if there is any potential criminal liability for board members?

Well, you might be forgiven for thinking that, from the way they are all behaving as if they knew nothing about the doctors' real suspicions, didn't open their emails, don't recall their meetings or conversations, were far too busy, it was never considered by anyone to be a safeguarding issue, and they deny knowing about altered minutes of meetings requested by police, etc etc etc, and they couldn't have done anything differently to have prevented the murders of O&P or other attempted murders after April 2016, but as far as I understand it it's the corporation that is under investigation for corporate manslaughter by gross negligence, and there is currently no mechanism for attaching personal criminal liability.

I don't see why they shouldn't be charged as individuals, personally.

JMO

 

[Tortoise]

The end of proceedings yesterday. I just love Lady Thirlwall.


LADY JUSTICE THIRLWALL: Thank you. Then, Ms Blackwell, you have got how long?

MS BLACKWELL: At least 20 minutes.

LADY JUSTICE THIRLWALL: So shall we say half an hour. So it seems to me we might be better doing this tomorrow morning. Everyone is nodding. I imagine that's --Sorry, if I can just speak to you, Mr Chambers. I had considered an early start tomorrow morning, but I think that would not be convenient for those who are coming some distance. So I hope that it will be convenient for you, you haven't really got much choice about it --

A. No, no, I am happy to support.

LADY JUSTICE THIRLWALL: -- to come at 10 o'clock tomorrow morning.

A. Sorry, say again?

LADY JUSTICE THIRLWALL: 10 o'clock tomorrow morning. May I make one thing crystal clear in case it hasn't previously been made clear, that there should be no communication between you and your lawyers or indeed anybody else about the evidence that you are giving to this Inquiry.

A. Thank you.

LADY JUSTICE THIRLWALL: We will start again tomorrow morning at 10 o'clock. Thank you all for the long day.

(5.49 pm)

Full Transcript for yesterday

27/11/2024 – Transcript of Week 11 Day 3 | The Thirlwall Inquiry

Transcript of Part B Evidence: - Tony Chambers, Chief Executive Officer

thirlwall.public-inquiry.uk

 

[callmehenry]

I've just had a look at the composition of the current Board of Directors for COCH and there are 17 board members in total, 9 female and 8 male. However, going by the names and pictures, they are all white and middle-aged. I know that despite that, some board members may be part of other ethnic groups and also I know Cheshire isn't as multi-cultural as larger cities. However, I feel that this is important when they state on the website:

"Countess of Chester NHS Foundation Trust is dedicated to becoming an inclusive employer of choice for candidate’s ethnic minority groups, and to improving the workplace experiences of ethnic minority colleagues."

The same document also states over 11 % of the current workforce is BME, so at least 2 members of the board should be BME. I wonder if Ravi would have had more credibility with the executives if he had been 'in the club' (JMO).

https://www.coch.nhs.uk/corporate-information/board-of-directors.aspx

I completely agree. I feel like his concerns possibly weren’t taken seriously because he wasn’t ’one of them’ and they all obviously thought they knew better than anyone else

 

[Sweeper2000]

The dad threatening was exactly the moment this person should have said.
“There will be no threats made at CCH, I’m going to ask you to leave or I will call security. This meeting is concluded. “

Then send them a letter recorded mail documenting the meeting and that their threats and behavior are not acceptable.

CCH needed to be in charge, not her pathetic parents.

Next time they attend a meeting, an escort from security.

I think he should have just said " I bet you can't even lift that cannon" and then added "not like the way NJ KC will at Lucy in due course".

 

[Tortoise]

He just appalls me.

This is after Alison Kelly's evidence which clearly showed their interventions to prevent the doctors' vote of no confidence going ahead.

from the transcript -

Tony Chambers:

A. ... It was never presented to me as a vote of no confidence. But clearly that's how it was likely to -- that's what was likely to be the outcome.

Q. It's important I give you the opportunity to deal with an interpretation of events so that you can have your say on the point. Did you leave in the circumstances you did in order to avoid scrutiny of your leadership --

A. No.

Q. -- during the period?

A. No. No, I mean, I -- there was no suggestion that -- well, I suppose maybe if I had not been supportive of these -- this plan, there could have been a vote of no confidence that would have probably meant that I had -- would be suspended. There would be -- but again that, that wasn't clear, that wasn't something that we were trying to avoid. I was just, together with Sir Duncan -- Sir Duncan and I had a very close professional and personal relationship. We -- he -- he was somebody who I looked to as a Chief Exec as a -- as somebody for guidance and we always had a very open and honest discussion about when it's time, if you like.

Q. The final document that I wish to ask you about is INQ0015683. This is the settlement agreement and we are going to go to page 30 which is one of the appendices to it. Forgive me, 31, it's an internal page, I beg your pardon. This is the schedule for narrative announcement. Now, was this something that was substantially drafted by your side of things?

A. That was something that Duncan and I collaborated upon.

Q. We can see in the third paragraph: "Tony's stepping down as CEO at the Countess is as a result of extraordinary circumstances. It is not a judgement on his ability as a CEO but more a reflection of his integrity as a leader." Do you consider that to be an accurate statement?

A. Absolutely.

Q. If it was the case that you stepped down to avoid a vote of no confidence and you have given evidence that that isn't why, that statement would require rather more detail, wouldn't it?

A. It -- it probably would. But that was not the position and it's fair to say that in all interviews subsequent to me leaving the Countess, I was never gifted a job. I always had to apply for a job, I was interviewed and I was always very straight and open and transparent about my time at the Countess. Which -- which is really easy when we are just focusing on 1% of the business, which is the matters of the neonatal unit that we have spent our day talking about, but the Countess was -- was -- was much bigger than a neonatal unit. It -- and my time at the Countess was demonstrably successful, as outlined in this, this note here.

 

[Tortoise]

Lawyers for babies' families to question Chambers
10:02​

Judith Moritz
Special correspondent, reporting from the inquiry

I’m back in the hearing room at Liverpool Town Hall, for another big moment at the Inquiry.

The public gallery is already filling up, and rows of lawyers are limbering up for a long day ahead.

Yesterday’s evidence with Tony Chambers was expected to complete in one day, but it overran - so he’ll be back in the witness box again this morning, and will face questions on behalf of the babies’ families, and also questions by his own barrister Kate Blackwell KC.

Once Mr Chambers has finished, he’ll be replaced in the witness box by his former colleague Ian Harvey - who was the Medical Director of the Countess of Chester Hospital at the time of Lucy Letby’s crimes.

It will be the first time that Mr Harvey has spoken publicly about how he handled things - and the first time for him to face heavy criticism which has been laid at his door.

'What we had were gut feelings,' former CEO says
10:21​

Judith Moritz
Special correspondent, reporting from the inquiry

Richard Baker KC begins by referring Tony Chambers to his evidence from yesterday.

He says: “You accepted on multiple occasions that the paediatricians were the experts in the room?”

Tony Chambers replies: “They were our experts, they were our doctors and they were the ones that were closest to these issues."

He then goes on to say that the consultants may have been presenting things as clear cut, but “it was not a simple, single thing. We understood from history that it was multifactorial”.

Richard Baker KC picks up Tony Chambers’ point about past cases, from recent history. He cites Harold Shipman and Beverley Allitt.

Chambers says with the Allitt case there was evidence of deliberate harm, to which Baker replies "there was evidence here!".

Chambers replies "what we had were gut feelings and nothing was presented in a very explicit way that would make you feel this was the only explanation for the matters that we were facing".

By way of context, Harold Shipman was a GP exposed as a serial killer, responsible for the deaths of more than 200 patients. He killed himself in 2004.

Beverley Allitt was working at Grantham hospital in Lincolnshire when she killed four children and tried to murder another nine in 1991.

Inquiry shown action plan note
10:22​

Judith Moritz
Special correspondent, reporting from the inquiry

Image source,Thirlwall Inquiry

Richard Baker KC moves on, to show the inquiry a handwritten note, from 12 May 2017, which details a conversation that Tony Chambers had with the director of HR Sue Hodkinson, about an action plan for the consultants.

It contains reference to them being referred to the GMC, and includes the line “action plan to manage out”.

It also mentions “mitigation from whistleblowing”.

For background, the inquiry has previously heard that the consultants didn’t have the protection of the ‘Speak Out Safely’ hospital whistleblowing policy.

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

 

[Parker Knoll]

I cannot see any reason why misconduct in public office cannot apply here with management.

Misconduct in Public Office | The Crown Prosecution Service

www.cps.gov.uk

 

[Tortoise]

Chambers says notes are not his
10:27​

Judith Moritz
Special correspondent, reporting from the inquiry

Tony Chambers says, of the notes above, “These are not my notes, they’re from Sue Hodkinson. I've never seen these notes.

"I don’t remember any discussion around mitigating Speak Out Safely or whistleblowing policies."

Chambers accused of misleading police
10:33​

Judith Moritz
Special correspondent, reporting from the inquiry

Image source,Thirwall Inquiry
Richard Baker KC takes the inquiry to notes of a meeting which Tony Chambers attended at Cheshire Police HQ on 12 May 2017.

The notes show that Tony Chambers told the police (who were in the early days of their ‘Operation Hummingbird’ investigation) that “it was felt that the explanations of what has happened do not lie in a single place or cause, and certainly not criminal”.

Baker says: "You are making the point that you do not believe there’s any evidence to warrant a police investigation, and you are misleading the Cheshire Constabulary suggesting to them this matter has been fully investigated."

Chambers replies: "I think I am representing what our thoughts were at the time."

Chambers denies pressuring whistleblowers
10:42​

Judith Moritz
Special correspondent, reporting from the inquiry

Image source,Thirlwall Inquiry

These notes also show that Tony Chambers told the police that “it will become a wider GMC [General Medical Council] issue” and referred to the consultants “blocking the ability to move forward which creates a more difficult and dangerous environment for sick babies”.

Baker says: "You are making clear that if the consultants do not accept your decision to move on you are going to refer them to the GMC and potentially ruin their careers?"

Chambers replies: "No. That is not what the note represents."

Baker then follows up: "I suggest this shows a clear insight into your character that you were putting pressure on whistleblowers contrary to the hospital's own patient safety and you were planning to have them disciplined, and moved on if they didn’t accept it."

Chambers denies it: "That’s not the interpretation of this or my character. My character is such that we always had a focus on patients’ safety and the well being of our 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

 

[Parker Knoll]

Close personal and professional relationship with Sir Duncan eh ?
Interesting turn of phrase here Tony !

 

[Tortoise]

'We should have done better,' Chambers says​

10:45​

Judith Moritz
Special correspondent, reporting from the inquiry

Richard Baker KC moves on to the failure to tell the babies’ families about concerns that a nurse had caused deliberate harm.

Baker says: "The lack of candour in this case is staggering for one reason - that it kept the families in the dark. You took every step possible to keep the consultants’ concerns from becoming public.

Chambers replies: "It’s a difficult balance between a duty of candour and a duty of care. This was a balance that we were - or I was - trying to get right and it was not something that I got right. I am absolutely clear in my own mind that we could have and should have done better in terms of the communications with the families."

Baker then says: "The Countess of Chester Hospital accepted in their opening statement to this inquiry that there was a total failure by the trust to fulfil the duty of candour. Do you take responsibility for that failing?"

Chambers replies: "This is something in my reflections yesterday that I absolutely acknowledged that we hadn’t got right. We could have done better, we should have done better."

Chambers denies stalling police investigation​

10:53​

Judith Moritz
Special correspondent, reporting from the inquiry

Richard Baker KC is now summing up, accusing Chambers of seeking "at every stage to stall and obstruct the police being called or this being made public".

Bakers tells Chambers he "ultimately sought to ruin the careers of the consultants who brought this to your attention", describing it as "utterly reprehensible behaviour and unfitting of a CEO in the NHS".

Chambers says "had that been what I had done it would be".

"But I think it’s an outrageous statement and I do not believe that it represents my actions," he says.

As a reminder, Chambers said in yesterday's evidence that he decided to contact police on 27 March 2017, but didn't write to the police until 2 May, after consulting a criminal barrister. The first meeting with police was 5 May.

Neontal unit 'felt chaotic', Chambers says​

11:02​

Judith Moritz
Special correspondent, reporting from the inquiry

Tony Chambers is now being questioned by his own barrister, Kate Blackwell KC.

She begins by talking to Chambers about the atmosphere in the meeting on 29 June 2016, when he first sat down with consultants to hear their concerns.

He says it was “very open and very friendly and people were very candid. Despite it being a difficult meeting it felt that this was a team of people coming together, trying to resolve some very difficult issues".

Tony Chambers is quoted, in that meeting, as having said “if twins and triplets, why did the trust take them on?”.

He is asked about this. He answers: “I was just surprised that we had this level of complexity and acuity being cared for on our neonatal unit.”

He says that multiple births should have been looked after at a more specialist unit.

He adds "at times the unit felt chaotic”.

Chambers questioned about Letby apology order​

11:03​

Judith Moritz
Special correspondent, reporting from the inquiry

Kate Blackwell KC asks Tony Chambers about his order to the consultants, that they had to apologise to Letby.

She asks: "Was this something that the executive pushed in circumstances where there was an option NOT to ask the consultants to apologise? Or was this something that came out of (Letby’s) grievance process?"

Chambers replies: "It was something that was clearly as a result of the outcome of the grievance process."

'I needed to be clear and direct,' Chambers says​

11:08​

Judith Moritz
Special correspondent, reporting from the inquiry

Kate Blackwell KC asks Tony Chambers about his meeting with the consultants in January 2017.

She refers to suggestions the tone of the meeting was set by him as "intimidating and bullying".

Chambers says he needed to be "clear and direct".

"I was very professional. I didn’t raise my voice I wasn’t angry but it was an odd meeting because the consultants didn’t seem to be able to engage fully in the meeting," he says.

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 disagrees that executives were shutting down concerns
11:17​

Judith Moritz
Special correspondent, reporting from the inquiry

Kate Blackwell KC asks Tony Chambers about evidence which the inquiry has previously heard from former detective chief supt Nigel Wenham who said that in his opinion the executives were trying to shut down concerns, and they were trying to shut the doors on the police investigation.

Tony Chambers says “I am unclear as to how he arrived at that view".

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

you couldn't make this up!!!

 

[Lord Peter Flimsy]

He just appalls me.

This is after Alison Kelly's evidence which clearly showed their interventions to prevent the doctors' vote of no confidence going ahead.

from the transcript -

Tony Chambers:

A. ... It was never presented to me as a vote of no confidence. But clearly that's how it was likely to -- that's what was likely to be the outcome.

Q. It's important I give you the opportunity to deal with an interpretation of events so that you can have your say on the point. Did you leave in the circumstances you did in order to avoid scrutiny of your leadership --

A. No.

Q. -- during the period?

A. No. No, I mean, I -- there was no suggestion that -- well, I suppose maybe if I had not been supportive of these -- this plan, there could have been a vote of no confidence that would have probably meant that I had -- would be suspended. There would be -- but again that, that wasn't clear, that wasn't something that we were trying to avoid. I was just, together with Sir Duncan -- Sir Duncan and I had a very close professional and personal relationship. We -- he -- he was somebody who I looked to as a Chief Exec as a -- as somebody for guidance and we always had a very open and honest discussion about when it's time, if you like.

Q. The final document that I wish to ask you about is INQ0015683. This is the settlement agreement and we are going to go to page 30 which is one of the appendices to it. Forgive me, 31, it's an internal page, I beg your pardon. This is the schedule for narrative announcement. Now, was this something that was substantially drafted by your side of things?

A. That was something that Duncan and I collaborated upon.

Q. We can see in the third paragraph: "Tony's stepping down as CEO at the Countess is as a result of extraordinary circumstances. It is not a judgement on his ability as a CEO but more a reflection of his integrity as a leader." Do you consider that to be an accurate statement?

A. Absolutely.

Q. If it was the case that you stepped down to avoid a vote of no confidence and you have given evidence that that isn't why, that statement would require rather more detail, wouldn't it?

A. It -- it probably would. But that was not the position and it's fair to say that in all interviews subsequent to me leaving the Countess, I was never gifted a job. I always had to apply for a job, I was interviewed and I was always very straight and open and transparent about my time at the Countess. Which -- which is really easy when we are just focusing on 1% of the business, which is the matters of the neonatal unit that we have spent our day talking about, but the Countess was -- was -- was much bigger than a neonatal unit. It -- and my time at the Countess was demonstrably successful, as outlined in this, this note here.

The arrogance and total lack of awareness is something that we almost come to expect by Senior Managers in Public bodies. I would say this apparent 1% was more of a true reflection of this guys abilities/attitude than the other 99%. It’s almost as those infants lost were part of his 1% so we shouldn’t use that to judge him.

 

[Tortoise]

I'm furious.

Goodness knows how the families are feeling witnessing this.