UK - Lucy Letby - Post-Conviction Statutory Inquiry

[Tortoise]

Inquiry chair takes over with questions for Chambers​

11:27​

Judith Moritz
Special correspondent, reporting from the inquiry

Kate Blackwell KC has finished her questions for Tony Chambers.

The inquiry chair, Lady Justice Thirlwall says she has a few questions for Chambers.

She asks him about his career and what his degree was in.

He answers that his degree was in English, Media and Communications, and he worked as a registered nurse for three years in adult critical care.

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

oh, and there was me thinking he worked as a ringmaster.

 

[MollyHarps]

I have to say watching yesterdays evidence made my blood boil.

I used to work with the NHS many years ago now and it highlighted one of the issues I found when working there - People promoted way beyond their capabilities.

How was this man in charge if he couldn’t even handle a meeting with Lucy Letbys father? - in these meetings you’re allowed somebody with you for SUPPORT purposes - if he started to make threats on her behalf the meeting should have been suspended and Mr Letby escorted from the premises - what happened was the man in charge bowed down to him which likely gave Lucy Letby a feeling of invincibility.

 

[Tortoise]

'Chaotic' or 'busy' neonatal unit? Justice Thirlwall asks
11:32​

Judith Moritz
Special correspondent, reporting from the inquiry

Lady Justice Thirlwall asks Tony Chambers about his visit to the neonatal unit in December 2015. He previously described the unit as “busy”.

Earlier this morning, he described it as “chaotic”. Lady Justice Thirlwall asks him to clarify.

He says that one of the consultants, Dr ZA, emailed him to say it was chaotic, but when he went to visit it didn’t actually strike him as such - and says that the workload on there was sufficient to enable the doctor to have a cup of tea with him.

Chambers says fair to assume he held bias
11:32​

Judith Moritz
Special correspondent, reporting from the inquiry

The inquiry chair asks Chambers about his regular use of the phrase “what I was hearing” when he talks about meetings with consultants and others.

She asks him - given his degree in communications - whether he means that he was applying filters to what people were saying - and allowing for conscious or unconscious bias.

He says yes.

She asks: "Would it be fair to assume that that would have affected the way you heard what the consultants were saying?”

He answers that that would be fair to assume.

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 questioned on Letby's removal from duty​

11:42​

Judith Moritz
Special correspondent, reporting from the inquiry

Lady Justice Thirlwall asks Tony Chambers when he first heard about (lead neonatal consultant) Dr Steve Brearey’s “very clear” request to have Lucy Letby removed from duty.

He says that he’s not sure that he ever did hear about it, at the time. He suggests that the first time he may have been aware of it was at Letby’s criminal trial.

He says the Director of Nursing Alison Kelly (who the inquiry heard from on Monday) didn’t tell him about it, and he didn’t know about it when he spoke to consultants about their suspicions at the end of June 2016.

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

YAWN - oops pardon me

 

[Tortoise]

Chambers says his style was collaborative, not direct
11:46​

Judith Moritz
Special correspondent, reporting from the inquiry

Lady Justice Thirlwall says she wants to ask Tony Chambers about his demeanour.

"Your demeanour - you describe yourself as direct and you don’t say this - but plain speaking. Do you accept that some people see that as being somewhat intimidating?"

Chambers says he "described my approach to one meeting as being direct. My style is much more collaborative than that, much more open than that. From my own experience as a chief executive it’s better not to offer your own opinion, because that often closed down discussions."

"So generally you weren’t direct?" the chair asks.

Chambers replies: "No I was much more collaborative than that, much more of a collective leadership style, seeking to listen, seeking to try to understand and always recognising peoples’ contributions."

Justice Thirlwall asks: "Do you think there are ever circumstances when people find you intimidating?"

"There’s no doubt from what we’ve heard in evidence around the meeting of the 29 June that my probably uncharacteristic direct style was more impactful because it was very different to what people would have been used to," Chambers replies.

She asks: "Are you agreeing that that might be intimidating?

Chambers says: "Possibly, possibly. It can be intimidating inevitably because it’s the chief executive who’s having the conversation."

Chambers says he couldn't get everything done as chief executive
11:47​

Judith Moritz
Special correspondent, reporting from the inquiry

Lady Justice Thirlwall asks Chambers if he ever felt that he was so busy he couldn’t get everything done in his role as CEO.

He says: "There was a culture of very long hours, reading emails early in the morning and late at night and the operational reality of a hospital continues, and the Countess of Chester was a very busy district general so yes, everybody was stretched.”

Lastly, the chair asks Chambers about Letby’s grievance complaint - which was upheld in her favour.

He says this “just made a difficult situation even more difficult".

11:48
Chambers finishes his evidence​

Tony Chambers has finished giving evidence. The hearing is on a short break.

When we return, we'll be hearing from former medical director Ian Harvey.

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

Bye bye

 

[Sweeper2000]

I have to say watching yesterdays evidence made my blood boil.

I used to work with the NHS many years ago now and it highlighted one of the issues I found when working there - People promoted way beyond their capabilities.

How was this man in charge if he couldn’t even handle a meeting with Lucy Letbys father? - in these meetings you’re allowed somebody with you for SUPPORT purposes - if he started to make threats on her behalf the meeting should have been suspended and Mr Letby escorted from the premises - what happened was the man in charge bowed down to him which likely gave Lucy Letby a feeling of invincibility.

I would expect anyone in charge of this meeting to hold it under control and employ tact. Any acute reaction to the father may be seen as lacking empathy which actually will aggravate the situation. If that had of been me I would have explained the situation and that protocol dictates managerial action and we do not dictate protocol. I also would have said something along the lines of "anger although understandable is not an appropriate, helpful or acceptable part of what we are trying to achieve Mr letby and it will not be tolerated". Verbal warning then escalation. It doesn't sound like Mr Chambers can command that level though, more a tiptoe around the tulips approach. I honestly wouldn't have taken the gun threat seriously, its a dad going dad mode. He really didn't demonstrate leadership there though at all.

 

[Tortoise]

Former medical director takes oath​

11:59​

Judith Moritz
Special correspondent, reporting from the inquiry

Former hospital medical director Ian Harvey is taking his oath.

He’ll be questioned by counsel to the Inquiry Rachel Langdale KC.

12:00​

Who is Ian Harvey?​

We're now hearing from Ian Harvey, who was medical director of the Countess of Chester Hospital at the time of Lucy Letby's crimes.

We've never heard him speak publicly before - and he'll be questioned about how he handled things.

According to written statements,, external Harvey was one of the senior manager with whom the first concerns about Letby were raised back in 2016.

Harvey was also tasked with carrying out an overarching review to identify if there were any potential issues contributing to the rise in neonatal deaths, the written statement said.

Ian Harvey apologises 'for the hurt that has been caused'​

12:10​

Ian Harvey starts by saying: “I am sorry for the hurt that has been caused to the parents and the families of the babies.

"I extend that to the parents of the parents and families who were subject to the reviews but didn’t feature in the trial and aren’t part of this inquiry.

"It was only ever my desire to have a safe hospital and to be able to tell the parents what had happened on the neonatal unit and if I failed in those aims I am truly sorry.”

The lawyer says: "You say 'if I failed in those aims'. Reflecting now, do you think you did fail in those aims to secure patient safety and baby safety?"

Harvey says: "The simple fact that there was an increase in mortality is an indication that we got things wrong… I failed in my communications to the families, in the nature and quality of the information that they were given."

Langdale KC replies: "And did you fail to have Lucy Letby investigated by the police earlier and to be removed from the NNU?"

Harvey says: "I had expressed an opinion that we should approach the police and I sincerely regret that we did what we did at the time. I think looking at the process that we went through, I can understand why we did."

Harvey details his career​

12:11​

Ian Harvey is now asked about his career.

He is a consultant orthopaedic and trauma surgeon by training, and became medical director of the Countess of Chester Hospital in July 2012.

He applied for voluntary erasure from the medical register in June 2020, and is now retired.

Harvey has good relationship with hospital board, he says​

12:13​

Ian Harvey says that his relationship with the hospital board was good and collaborative, and he would meet with Sir Duncan Nichol - the board chairman - on a fairly regular basis.

He describes him as having “a high level of gravitas and huge experience which I found invaluable”.

He is asked if Nichol had a role in the NHS at the time of the Beverley Allitt case (a nurse who murdered four babies in Lincolnshire in 1991).

He says that he did not know this, and they never discussed Allitt - though he was aware of her case.

12:14​

Harvey's statement says hospital atmosphere changed from 2016​

In his written statement to the inquiry, Ian Harvey describes “a culture and atmosphere at the Trust which was generally positive. Senior medical posts in most specialities were sought after. It punches well above its weight".

In the same statement it says: “From 2016 there was a change in the atmosphere between the executives and the paediatric medical staff due to the issues on the neonatal unit."

12:24
Hospital risk management was not effective, Harvey says​

Ian Harvey is being asked about the “risk management” strategy within the hospital.

As medical director, he had responsibility for all medical staff.

Rachel Langdale KC asks Harvey: “How effective do you think the risk management system was at the hospital at the time for identifying the risk of babies being murdered?”

He pauses for a very long time. Then says: “I think that the answer is probably not well.. the answer is not.”

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]

12:33
'Murderers aren’t always caught red handed are they Mr Harvey?'​

Counsel to the inquiry Rachel Langdale KC looks at the risk register documents used by the hospital, where risks were ranked on a matrix from minor up to the most severe - which were classed as “catastrophic”.

She says: “In terms of the risk of babies being murdered, that would rank presumably as catastrophic?”

Harvey agrees that it would.

He says that the increase in the number of baby deaths wasn’t logged on the risk matrix as catastrophic because they didn’t understand why the rise was happening.

The lawyer asks: "Murderers aren’t always caught red handed are they Mr Harvey?

"And when you say there was nothing concrete to substantiate concerns, we are looking at risk here aren’t we? You knew there was a risk, and are you saying that because it wasn’t concrete, anything that had been seen… that you didn’t classify it as a risk?"

Harvey says: "No I am saying that in the way it was phrased (on the risk register documentation), I don’t think any of us perceived it as the sort of risk that would be catastrophic."

Harvey asked about consultants' concerns
12:41​

Langdale asks Harvey if he ever doubted that the consultants had "genuine misgivings" about Letby.

After a very long pause, he says: "I never doubted that Dr Brearey in particular had concerns. Those concerns were at the outset not fully voiced, and were difficult to follow on occasion but at no point did I doubt that the concern was real - as he perceived it."

Langdale follows up, pointing out the inquiry has heard medics other than Dr Brearey were concerned.

"At the time did you speak to any other doctors apart from the paediatricians? Did you ever take a walk onto the neonatal unit, or talk to younger doctors to see what was going on?" she asks.

Harvey says: "I did do visits to the unit but I don’t recall specifically going to the unit to talk to the junior doctors."

He adds that he had an open door policy for staff who felt that they had genuine concerns, and tried to make himself approachable.

Harvey had case of wrongful arrest in his mind
12:46​

The laywer asks if Harvey was ever concerned "there were unfounded allegations being made about a nurse?"

Harvey says he was "very mindful at this time of Stepping Hill.

"But it was the alternative story from Stepping Hill - which was the nurse who had been incarcerated inappropriately for six weeks and the effect that had on her life and her career and that was on my mind."

For context: In 2015, nurse Victorino Chua was convicted of murdering two patients and poisoning 20 others at the Greater Manchester hospital Stepping Hill.

Before Chua was found guilty, another nurse had been wrongfully arrested and jailed before charges were dropped.

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]

Harvey regrets not speaking to police earlier
12:52​

Ian Harvey is now asked about the failure to log the consultants’ concerns under the hospital’s ‘Speak Out Safely’ whistleblowing policy (which would have offered them protection).

Langdale says clearly the consultants were raising concerns but the policy was not employed.

Harvey agrees. "When the increased mortality was first raised, I viewed it as a clinical issue. The nature of the conversations were more to explain that increased mortality," he says.

Langdale describes that as a "serious error of thinking".

"You weren’t seeing what was really being said, were you," she puts to him.

Harvey replies: "I felt at the time that we were following what was a logical progression of investigation, based on the situation that we had been presented with, based on the information we were being provided with.

“Having reflected at length, I regret that I didn’t speak with the police in June/July 2016."

Harvey says he 'tried to hear what everyone was saying'
12:53​

Harvey is asked if he is "quite a rigid thinker" and if once he makes a choice, he will "stand on it."

He says he doesn't think he is.

"I don’t think that is the sort of thing that would work, coming from a clinical background and I certainly tried to hear what everyone was saying," Harvey adds.

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]

Harvey concedes 'missed opportunity' to report deaths
13:09​

Questioning now turns to the failure to report the deaths of three babies in June 2015 to the NHS England Serious Incident Framework., external

Ian Harvey is asked if failing to report the three deaths which happened in one month (this would normally have been the maximum number for an entire year) was a “missed opportunity”.

He says “potentially it was a missed opportunity.”

He adds the fact three deaths happened in one month (June 2015) “wasn’t viewed as a cluster that would have set off an alert that there was something linking them together”.

Rachel Langdale KC points out that it did set off the lead neonatal consultant Dr Steve Brearey to look at a summary of the cases, and conduct a thematic review.

13:09
Inquiry pauses for lunch​

The inquiry has just paused for lunch, and will resume shortly at 14:10 GMT.

Stay with us throughout the afternoon as we bring you the key lines from Ian Harvey's evidence.

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

 

[ColourPurple]

​

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”.

I so shouldn’t have tried to catch up with the inquiry on my lunch break. So much to be angry about, but this part …. WTF? Sure, triplets are rare but since when shouldn’t they have looked after twins ?

 

[iamshadow21]

I so shouldn’t have tried to catch up with the inquiry on my lunch break. So much to be angry about, but this part …. WTF? Sure, triplets are rare but since when shouldn’t they have looked after twins ?

I think the implications that multiples tend to have a lower birth weight and more complex needs because they are multiple. He was basically implying they should have been handled at a higher level unit.

 

[ColourPurple]

I think the implications that multiples tend to have a lower birth weight and more complex needs because they are multiple. He was basically implying they should have been handled at a higher level unit.

Yup he made it sound like all
twins should be delivered in a level 3 unit though and should never be in a level 2.

 

[Anxala]

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.

Appalling seems way too mild a word for what he has shown, beyond a shadow of a doubt, himself to be.

On the plus side - I'm always looking for the pluses - this is him, finally and damningly exposed, for all to see.

 

[Sweeper2000]

Did he speak to the right honorable Ben myers before the trial? Sounds like it. Words without evidence. "Massive hospital failings" or a bit "chaotic". I think we can actually say now exhaustively that the unit was good but mismanaged. At current the only member of clinical staff that has been found to be a danger to babies, knowingly or not is Lucy letby. Its not the hygiene, its not the practice, its not any other aspect that led to the harm we have heard of other than lucy letby and the managers.

It really is quite shocking that nobody employed any discretion in trying to take control of this situation. A simple private word with the the speartip of what has led to this enquiry which was the consultants would have prevented so much harm.

 

[magikarpmagikarp]

They try to throw TC a bone here: "maybe you misunderstood".... and I think he probably did, but won't admit to it

 

[MrsAddick]

'Chaotic' or 'busy' neonatal unit? Justice Thirlwall asks​

11:32​

Judith Moritz
Special correspondent, reporting from the inquiry

Lady Justice Thirlwall asks Tony Chambers about his visit to the neonatal unit in December 2015. He previously described the unit as “busy”.

Earlier this morning, he described it as “chaotic”. Lady Justice Thirlwall asks him to clarify.

He says that one of the consultants, Dr ZA, emailed him to say it was chaotic, but when he went to visit it didn’t actually strike him as such - and says that the workload on there was sufficient to enable the doctor to have a cup of tea with him.

Chambers says fair to assume he held bias​

11:32​

Judith Moritz
Special correspondent, reporting from the inquiry

The inquiry chair asks Chambers about his regular use of the phrase “what I was hearing” when he talks about meetings with consultants and others.

She asks him - given his degree in communications - whether he means that he was applying filters to what people were saying - and allowing for conscious or unconscious bias.

He says yes.

She asks: "Would it be fair to assume that that would have affected the way you heard what the consultants were saying?”

He answers that that would be fair to assume.

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

And here lies the crux of the matter. Finally we get to the heart of it….

…arrogant people “hear what they want to hear” and they lack any degree of introspection required for self-awaress nor humility.

It smacks of privilege. The intrinsic sense of entitlement (‘gut feel’ if you will) that allows one to rise effortlessly far beyond ones capability (all is good, if you can ignore the collateral damage of good folk along the way).

 

[May72031]

[snip]

Key dates to help you navigate the details of today's hearing​

12:16​

Judith Moritz
Special correspondent, reporting from the inquiry

• In January 2017, the consultants were ordered by Tony Chambers to apologise to Letby
• Letby was posed to return to work on the unit at the end of March 2017, though this did not happen
• In April 2017, the Trust instructed a criminal barrister to advise them on what to do
• On 2 May 2017, Tony Chambers wrote to the Chief Constable of Cheshire to invite a police investigation. On 5 May 2017, the police investigation began
• On 3 July 2017, Letby is arrested
• On 11 November 2020, Letby is charged

Just catching up. Obviously, her first arrest was 3 July, 2018, not 2017.

 

[MrsAddick]

And here lies the crux of the matter. Finally we get to the heart of it….

…arrogant people “hear what they want to hear” and they lack any degree of introspection required for self-awaress nor humility.

It smacks of privilege. The intrinsic sense of entitlement (‘gut feel’ if you will) that allows one to rise effortlessly far beyond ones capability (all is good, if you can ignore the collateral damage of good folk along the way).

And while I’m having a little Friday rant (here in Australia)….

All these execs, who are clearly motivated entirely by self-interest, would have been far better suited to careers as Investment Bankers or some other job far far away from running a large hospital where you are supposed to (at least bloody pretend to) care about patients.

 

[MrsAddick]

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

This jumped out at me too. Let’s hope one of our clever silks find a way to weave this back into conversation