A public inquiry report has detailed significant systemic failures at the Countess of Chester Hospital between June 2015 and June 2016, a period during which nurse Lucy Letby murdered seven infants and seriously harmed others. The report by Lady Justice Thirlwall painted a picture of a "dysfunctional" hospital management, an "us-versus-them" mentality among staff, and a failure to invoke safeguarding procedures.
The inquiry, while not focused on Letby's criminal guilt, provided insight into her tenure. Concerns were noted during her training, including a lack of enthusiasm, poor communication with families, and subpar drug calculations. Despite failing a mid-year assessment in 2011, she qualified as a registered children's nurse. The report indicated that Letby was "repeatedly untruthful" with colleagues but appeared to have cultivated relationships with senior management, which may have influenced their judgment.
Senior managers, including Alison Kelly, Ian Harvey, and Tony Chambers, were criticized for dismissing the possibility that Letby was deliberately harming babies as late as June 2016. Lady Justice Thirlwall stated that regardless of their belief in the allegations, they should have acted. Delays in contacting the police may have prevented further harm or deaths.
"Errors were made by nurses, doctors and managers at the time of these events," Lady Justice Thirlwall said in her report. "There was complete failure at all levels to invoke safeguarding procedures at any point."
The report highlighted missed opportunities to intervene. Safeguarding action should have been taken by removing Letby from the ward after the death of Baby I in October 2015. Further opportunities to stop her occurred two months earlier when a consultant reportedly "disregarded" evidence suggesting Letby poisoned a baby with insulin. Another doctor failed to flag in February 2016 that he observed Letby's inaction to help a baby girl whose breathing tube she was later convicted of dislodging.
The treatment of parents was described as "reprehensible." Hospital bosses were accused of using the potential risk of upsetting parents as a justification for delaying police contact. Families were not informed about investigations into their children's deaths. The mothers of four children were "all misled" through face-to-face meetings or written communications.
The inquiry also found a "serious failure" stemming from an "us-versus-them" attitude between doctors raising concerns and nursing colleagues who supported Letby. This dynamic, characterized by "unquestioning loyalty to Letby," prevented managers from considering the doctors' concerns with an open mind. The report stated that the focus should have been on "keeping babies safe" rather than on interdepartmental conflict.
Hospital bosses, including head of safeguarding Ms. Kelly and medical director Mr. Harvey, were found to have failed to act on suspicions of harm. Mr. Harvey acknowledged regret for not going to the police in June 2016. Lady Justice Thirlwall noted that Mr. Chambers' attitude towards senior doctors flagging fears about Letby was "dictatorial."
Internal and external reviews commissioned by hospital bosses, rather than involving the police, were criticized for failing to address the core issue of deliberate harm. The decision not to call the police in July 2016 was deemed "impossible to defend."