An inquiry into the actions of serial killer nurse Lucy Letby has revealed a "staggering catalogue of failures" by hospital management, clinicians, and senior staff, which allowed her to continue harming infants. The report, led by Lady Justice Thirlwall, highlighted a dysfunctional environment at the Countess of Chester Hospital between June 2015 and June 2016, characterized by an "us-versus-them" mentality and a failure to invoke safeguarding procedures.
Lady Justice Thirlwall presented her findings after reviewing over a million pages of documents and evidence from more than 130 witnesses. The inquiry found a complete failure at all levels to implement safeguarding procedures when suspicions arose about Letby. "Looking for clinical or other explanations for deaths and collapses was not wrong, but once there was suspicion that Letby may be causing harm deliberately safeguarding steps should have been taken," the report stated. It emphasized that Letby should have been removed from the ward as a neutral act to allow for an investigation without risk to other babies.
Despite the inquiry not being tasked with investigating Letby's criminal convictions, it offered insights into her behavior. Evidence presented suggested "inappropriate" and "callous" conduct towards patients and colleagues. Concerns about her performance were noted during her training, with feedback indicating a lack of enthusiasm, poor communication skills with families, and issues with drug calculations. A mentor in 2011 described Letby as "quiet, withdrawn and struggled to build relationships with children, families and colleagues," and she failed a mid-year assessment.
Letby qualified as a registered children's nurse in September 2011. The inquiry heard she was found to be "repeatedly untruthful" and once shouted at a manager after being reassigned away from intensive care. One parent informed the inquiry that their baby's medical records had been falsified by Letby "to suit a different narrative."
Missed Opportunities
The report identified multiple missed opportunities to prevent harm. Senior managers, including Alison Kelly, Ian Harvey, and Tony Chambers, are criticized for dismissing the idea 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 are cited as a significant factor that could have prevented further deaths and harm.
On June 29, 2016, both Ms. Kelly and Mr. Harvey reportedly believed the doctors' concerns warranted police involvement, but they ultimately deferred to Mr. Chambers' view that other steps should be taken first. Mr. Harvey, the medical director, later expressed regret for not going to the police sooner. Lady Justice Thirlwall noted that neither he nor Chief Executive Mr. Chambers were in a position to judge the credibility of the doctors' concerns. The report indicated that managers acted with a lack of self-doubt, and the difference in approach between them and the pediatricians was stark.
Safeguarding action, such as removing Letby from the ward, should have occurred after the death of "Baby I" in October 2015. Earlier opportunities to intervene were also missed, including a consultant disregarding evidence suggesting Letby poisoned a baby with insulin, and another doctor failing to flag Letby's inaction in assisting a baby girl whose breathing tube she later dislodged.
Treatment of Parents
The report also condemned the "reprehensible" treatment of the babies' parents. Hospital bosses were accused of using the potential risk of upsetting parents as a "convenient argument" to delay contacting the police. Some communication with families was described as "both crass and inappropriate," and parents were not informed about the investigations into their children's deaths. The mothers of four children were "all misled," and parents only became aware of concerns after Letby's arrest in July 2018. Lady Justice Thirlwall stated that the distress caused to families by these delays was significant.
Nurse Management Failures
The report highlighted a "serious failure" and an ingrained "us versus them" attitude between doctors raising concerns and nursing colleagues who were perceived as protecting Letby. This led to senior nurses and managers defending Letby despite doubts about her competence. The report found that nursing colleagues and senior managers had moved from "professional support to personal friendship" with Letby, failing to maintain appropriate professional distance. Senior nurses exhibited "unquestioning loyalty" that prevented them from considering the doctors' concerns with an open mind.
Eirian Powell, Letby's manager, is noted for not accepting the doctors' fears in good faith and for criticizing the mother of "Baby H" after a complaint was raised. Karen Rees, director of nursing care, held a baseless belief that a consultant and Letby had a past relationship, which influenced her reaction to requests for Letby's removal from the ward. The report found Rees's approach wrong, lacking knowledge of pediatrics and unsupported by evidence.
Executive Actions and Investigations
Head of safeguarding Ms. Kelly is criticized for not acting when there was a suspicion of harm and potential risk to others. Mr. Harvey's actions undermined his claim of taking doctors' concerns seriously, as his approach suggested he did not consider them credible. The report indicates that hospital management prioritized reputational damage over transparency, with executive presentations to the board described as an "exercise in spin."
Chief Executive Mr. Chambers' attitude towards doctors flagging fears about Letby was deemed "dictatorial," with him dismissing concerns without scrutinizing his own thought process. The report stated his determination to challenge the doctors led to objectivity loss and poor decisions.
Lady Justice Thirlwall was critical of internal and external reviews commissioned by hospital bosses as an alternative to contacting the police. These reviews, including one commissioned by Mr. Harvey from the Royal College of Paediatrics and Child Health, failed to address the core issue of whether deliberate harm was being caused. The report found that these reviews did not explain the deaths and that there was still no explanation for several deaths, despite the reviews. The failure to call the police in July 2016 was deemed "impossible to defend."