Hospital Executive Altered Review Into Baby Deaths, Inquiry Finds

A public inquiry has found that a hospital executive altered a review into infant deaths, including two murdered by nurse Lucy Letby, to falsely attribute their deaths to natural causes. Ian Harvey, 68, the former medical director at the Countess of Chester Hospital, modified the report without the author's knowledge to mislead the hospital board and allow Letby to return to the ward.

Letby, who was convicted of murdering seven infants and attempting to murder seven others between 2015 and 2016, never returned to work after doctors pressured executives to involve the police. Lady Justice Thirlwall, who oversaw the £18.5 million inquiry, stated in her 822-page report that three infants could have been saved if managers had acted sooner to suspend Letby and involve law enforcement.

Instead of immediate action, the hospital ordered reviews by external bodies, including the Royal College of Paediatrics and Child Health and neonatologist Dr. Jane Hawdon. These reviews failed to explain the rising number of infant deaths.

Dr. Hawdon, commissioned by Harvey, reviewed the medical notes of 17 babies—13 deaths and four 'near misses'—that occurred between June 2015 and June 2016. The inquiry report stated that Harvey "failed to mention any concerns about deliberate harm to babies by a staff member, nor that the deaths were unexpected or unexplained." The judge added, "He should have done."

Dr. Hawdon initially concluded that the deaths of five infants, identified as Babies A, D, I, O, and P, were unexpected and unexplained, warranting a broader forensic review. However, after receiving Baby D's post-mortem report from Harvey, she agreed with the pathologist that pneumonia was the cause of death. Harvey then amended her report to state Baby D's death was due to natural causes without Dr. Hawdon's consent.

"When giving evidence, Dr. Hawdon informed the Inquiry she was not consulted by Mr. Harvey before he did this, and that she was not aware of any of Mr. Harvey’s amendments until she was informed by the Inquiry," the report noted. Dr. Hawdon later re-evaluated the cause of Baby D's death after learning the infant died 'with' pneumonia rather than 'of' it, deeming it no longer a plausible cause.

Dr. Hawdon also acknowledged that Baby E, a twin who died in August 2015, should have been included in her list of unexplained deaths. Although she was told he died of a gastric bleed, the cause of the bleed remained unknown. Letby was convicted of murdering Baby E by inflicting trauma and injecting air into his airway.

During her testimony, Dr. Hawdon observed an addition to her report next to Baby E's name: 'necrotising enterocolitis' (NEC). She stated she did not make this notation, and that NEC, a serious bowel condition primarily affecting premature newborns, did not align with the infant's health issues preceding his collapse.

Harvey admitted during oral evidence that he amended Dr. Hawdon's report. Furthermore, Dr. Hawdon had assumed Harvey would follow NHS procedures and share her findings with the babies' parents, a step she considered a certainty. However, the judge found this did not occur.

Partial excerpts of Dr. Hawdon's report were sent to some parents about six months after she completed it. These excerpts, written in medical jargon, were described by one mother as "not meaningful at all." Dr. Hawdon expressed shock upon seeing the communication sent to the families.

The mother of Baby C, another infant murdered by Letby, told the inquiry that the report shared lacked introduction, authorship, date, signature, and context. She felt the communication was "woefully inadequate" and gave the impression that "something significant" was being concealed. Other parents were unaware that any investigations into their babies' deaths were underway or that their children's medical records had been shared without their consent.

Letby is currently serving 15 life sentences for the murders and attempted murders of the infants at the Countess of Chester Hospital.