Coroner 'horrified' not to be told of Letby fears

Lucy Letby killed seven babies and tried to kill seven others between June 2015 and June 2016

A retired senior coroner said it was "horribly disappointing" that he had not been informed about suspicions Lucy Letby was involved in babies' deaths.

The neonatal nurse murdered seven infants at the Countess of Chester Hospital between June 2015 and June 2016, and each death was reported to Nicholas Rheinberg, then senior coroner for Cheshire.

A public inquiry into the circumstances around Letby's crimes was told her first three murder victims had been injected with air within a two-week period in June 2015.

While Mr Rheinberg said he had initially regarded the cluster of deaths as "worrying", he later thought they "seemed to be explicable" following further investigation.

Nicholas Rheinberg said he felt "absolute horror" to learn a doctor had failed to mention suspicions about Lucy Letby

The Thirlwall Inquiry has heard Letby was identified as a common theme for a number of unexplained deaths as early as July 2015.

Consultant paediatricians told hospital executives they feared Letby may be deliberately harming babies following the deaths of two triplet boys in June 2016.

Mr Rheinberg, who held the senior coroner's post in Cheshire from July 1999 until his retirement in March 2017, said he was unaware of those discussions.

"It's horribly disappointing," he told the hearing at Liverpool Town Hall.

"We should approach all these tragedies not just in our own ivory towers but we should share all information because we might individually have pieces of the picture to put together."

He added: "I was probably regarded as a bit of a pain as I would go to the police with any suggestion of criminality."

The inquiry heard that consultant Dr Ravi Jayaram did not mention his suspicions about Letby when he gave evidence at an inquest in October 2016 into the death of the neonatal nurse's first victim, Child A.

'Police involvement'

Asked by Peter Skelton KC, representing Child A's family, what his reaction was to that omission, Mr Rheinberg replied: "Absolute horror.

"Why not? Why wouldn't you? If that had come out at the inquest I think I would have adjourned.

"It wouldn't have gone on any further and I would [have] probably sought police involvement."

Cheshire Constabulary was not called in by hospital bosses until May 2017 to investigate an increase in baby deaths.

The inquiry has heard that Countess of Chester executives opted instead to commission a series of reviews.

In January 2017, Mr Rheinberg received a copy of one of those reviews, from the Royal College of Paediatrics and Child Health.

Parts of it were redacted, however.

One passage of the report that was removed before it was handed to the coroner mentioned hospital staff had identified a link between a specific nurse and the deaths, and that some doctors were "convinced" Letby was involved.

Mr Rheinberg told the inquiry: "Certainly, so far as I was concerned, there was not a whisper of any suspicion."

Letby, 34, from Hereford, is serving 15 whole-life orders after she was convicted at Manchester Crown Court of murdering seven infants and attempting to murder seven others, with two attempts on one of her victims.

The inquiry is expected to sit until early 2025, with findings published by late autumn of that year.

Additional reporting by the Press Association.