Judith Moritz
Reporting from the inquiry

Rachel Langdale KC has finished the her opening statement by setting out a list of themes its chair, Lady Justice Thirlwall, is likely to consider when making her recommendations next year.

Among those the lead counsel to the inquiry highlights are:

• Implementing CCTV in neonatal units
• Senior managers and their responsibility to ensure that safeguarding is prioritised
• The role of external regulators and inspectors, and whether they should be strengthened
• If there is a problem with public inquiries in that the recommendations are not implemented and culture is not changed
• How to ensure the recommendations of the Thirlwall Inquiry are implemented
• If the culture of the NHS need to change, and how it can be changed

She says the "answers are important to all those who work in the NHS, and all of us that use its services".

Tomorrow the inquiry will hear opening statements for various core participants.

These including from lawyers on behalf of two family groups, and those representing the Countess of Chester Hospital.

Judith Moritz
Reporting from the inquiry

Before the start of the inquiry, Langdale says a questionnaire was sent to 120 NHS Trusts in England with neonatal units, to be completed by medical and non-clinical directors.

Most reported difficulties in meeting staffing requirements in relation to both the number and the qualifications of healthcare professionals, she says.

Of the total, 99 trusts reported that they had nursing vacancies and 68 said they did not meet staffing standards for nurses, Langdale adds.

Judith Moritz
Reporting from the inquiry

Counsel to the inquiry Rachel Langdale KC is speaking now to put the Thirlwall inquiry into context.

“This inquiry does not exist in isolation. It is preceded by over 30 inquiries that have arisen in healthcare settings over the last 30 plus years," she says.

Langdale references the Clothier inquiry and the Shipman inquiry, which she says had "arisen from cases where health professionals have deliberately harmed or murdered patients".

She says what most of the dozens of such inquiries have in common is that they have "addressed issues of patient safety, culture and governance".

They have "all found substantial failings", she says - and provided recommendations and areas for action.

But she adds some have not been implemented at all - or not effectively.

Two former heath secretaries - Baroness Virginia Bottomley and Jeremey Hunt - have provided statements to the inquiry on this subject, she says.

Judith Moritz
Reporting from the inquiry

The first three baby deaths (A, C and D) - which took place June 2015 - were all referred to the coroner, the inquiry hears.

Despite all three cases being unexpected and unexplained, there was no police investigation on behalf of the coroner.

Judith Moritz
Reporting from the inquiry

The inquiry also hears that four consultants referred Alison Kelly - the former director of nursing at Countess of Cheshire Hospital - to the Nursing and Midwifery Council in May 2020.

Following Letby's conviction, four members of the public also referred Kelly to the same regulator.

Investigations are still ongoing, barrister Nicholas de la Poer KC tells the inquiry.

Judith Moritz
Reporting from the inquiry

In response to the complaints, former medical director Ian Harvey told the General Medical Council (GMC) regulator on 14 September 2018 that allegations against him were "nothing new".

He retired and moved to France, requesting voluntary removal from the medical register in July 2019.

Harvey described one of his greatest regrets as being the “breakdown in the relationship between the executives and the consultant paediatricians," De La Poer says.

The GMC refused his application for voluntary erasure, as the default position is that it is not allowed when there are serious allegations or an ongoing police investigation.

The GMC then instructed an expert to examine Harvey’s conduct, but they decided to close the referral with no action.

After that, Harvey’s application for voluntary erasure from the medical register was granted.

Judith Moritz
Reporting from the inquiry

The inquiry is hearing about concerns which some consultant paediatricians had about the hospital medical director, Ian Harvey, in the way he was handling the situation.

In July 2018, a number of senior doctors referred Harvey to the General Medical Council (GMC), to assess whether he was able to his job properly.

The concerns included:

• Failure to act appropriately in response to concerns about the neonatal mortality rate
• Misusing the trust’s grievance procedures as evidence of wrongdoing by the consultants and innocence of the nurse in question
• Threatening paediatricians who would not enter into mediation with Letby
• Misleading the board of the trust and misleading the public in media statements

The inquiry is told that a case examiner at the GMC advised that further investigation was “inevitable"

If Harvey was “found to have failed to act appropriately when the staff were repeatedly raising serious (possibly criminal) concerns about patient safety, this would be a very serious matter,” the inquiry heard.

Judith Moritz
Reporting from the inquiry

Letby remained a registered nurse free to work without any restriction imposed upon her by the Nursing and Midwifery Council (NMC) for four years after concerns were first raised to the NMC in July 2016, the inquiry hears.

She was free to work free of restrictions from her regulator until November 2020, after she was charged by police.

The inquiry also hears that in July 2018, Cheshire police told the NMC that Letby’s bail conditions prevented her from working in any healthcare setting or having unsupervised contact with anyone under the age of 16.

It was not until May 2019 that it was appreciated that Letby’s bail conditions only prevented her working with babies or children in a health care setting, not working in a healthcare setting altogether.

Judith Moritz
Reporting from the inquiry

The inquiry is also told that the medical director at the hospital, Ian Harvey, informed NHS England that the police were minded not to hold an investigation, but the paediatricians had sent a document "which was a very prejudiced view, effectively pointing the finger at one nurse".

He said his “own feeling” was that there would not be an investigation unless there was something ‘"new" disclosed by the paediatricians.

Harvey anticipated that the police would assist "in a message that will allow us to close down the speculation here and deal with the issues of culture", the inquiry hears.

Judith Moritz
Reporting from the inquiry

The inquiry hears that, by late April 2017, NHS England was "becoming increasingly concerned by the situation at the hospital".

Barrister Nicholas de la Poer KC, speaking on behalf of the counsel to the inquiry, also mentions a meeting at the hospital that same month - when Letby was described as "the angel of death".

The meeting was attended by Hayley Frame, the Chair of the Pan-Cheshire Child Death Overview Panel and Det Ch Supt Nigel Wenham from Cheshire police.

The Countess of Cheshire Hospital's then-medical director Ian Harvey and a senior consultant were also there.

In Frame’s evidence to the inquiry, she says it was only at this meeting that she became concerned that deliberate harm had not been excluded.

The "angel of death" description was from the recollection of the meeting by Wenham.

The inquiry previously heard that by September 2016, junior doctors at the hospital were referring to Letby as "Nurse Death".

Judith Moritz
Reporting from the inquiry

The inquiry has begun to hear about when police first became aware of the increase in baby deaths at the hospital.

In March 2017 there was a meeting of the Child Death Overview Panel, which had Det Ch Supt Nigel Wenham from Cheshire Constabulary attending.

In his statement to the inquiry, the senior officer says this was the first time the force became aware of the increase in neonatal deaths at the trust.

He describes being very concerned and was "absolutely clear" in his own mind that further examination was required.

Judith Moritz
Reporting from the inquiry

The inquiry hears next that a second medic, Dr John Gibbs, also contacted the British Medical Association (BMA).

He did so on 7 February 2017, explaining the increase of neonatal deaths from June 2015 to June 2016.

Gibbs told them he felt the rise in child deaths had "not yet been adequately explained nor investigated sufficiently".

He sent the same message to the Medical Defence Union.

De la Poer says that on 28 February 2017, Dr Ravi Jayaram sought advice from the BMA for the second time on the request that he engage in mediation with Letby.

He was advised to attend the preliminary meeting, the inquiry also hears.

Judith Moritz
Reporting from the inquiry

De La Poer tells the inquiry that the review report produced by the Royal College of Paediatrics and Child Health actually had two versions.

One version was described as a "confidential report" which included references to the allegations made against Letby.

But there was then a "dissemination copy" in which the references to the allegations were removed.

The inquiry hears that neither versions of the report recommended that concerns about Letby be escalated externally, whether to the police, local authority or the Nursing and Midwifery Council regulator.

The reports don't mention any discussions during the review visit of potential police involvement.

“This appears to have been by design", De la Poer says.

He goes on to add that earlier versions do contain some references. For instance, in one draft there is the comment “delayed to call police – remember Stepping Hill”.

This appears to be a reference to the a case at Stepping Hill Hospital in Stockport, where a nurse was wrongly accused of murder in 2011.

Judith Moritz
Reporting from the inquiry

The inquiry is told that consultant Dr Ravi Jayaram contacted the British Medical Association on 24 October 2016. He was seeking support following a grievance raised by Letby.

De la Poer says Dr Jayaram disclosed that "all the consultants" at the hospital "had expressed concern" at the increase of baby deaths and near misses when Letby was involved.

He wanted advice about how to handle the situation and to know if he was "putting himself at risk if he raised the possibility of deliberate harm by Letby," the inquiry counsel says.

It appears to have been agreed that Dr Jayaram would not raise this idea at the grievance meeting, the inquiry hears.

De la Poer adds: "It is notable that disclosure to yet another external agency had not provoked any consideration of, or advice on, safeguarding.”

Judith Moritz
Reporting from the inquiry

The inquiry hears that Letby sent a Facebook message the evening after the RCPCH interview, which said interviewers told her "off the record" they thought an investigation into the deaths would be recommended - and she needed to prepare herself as she would play a big part.

The review visit was followed by a letter from the team to the Countess of Chester Hospital on 5 September 2016, recommending an investigation into the allegations against Letby.

What it appears was being suggested was an internal investigation, De La Poer says.

The barrister also tells the inquiry that nowhere in the notes or letter did it suggest reporting the matter to the police or other authorities.

The review also did not consider doing it themselves, he adds.

Judith Moritz
Reporting from the inquiry

Barrister Nicholas De La Poer next tells the inquiry that the Royal College of Paediatrics and Child Health (RCPCH) review decided to interview Letby.

She had not been on the original list of interviewees but was added to it during the first day of the visit in September 2016.

De La Poer, who is speaking on behalf of the counsel to the inquiry today, says RCPCH chief executive Robert Okonnu has described interviewing her as "highly unusual" and says it should not have taken place.

In her interview, Letby said she felt she was being scapegoated and very vulnerable. She also said there was no reason or evidence to redeploy her, notes described to the inquiry indicate.

A nurse who was present at the interview, Hayley Griffiths, has given a statement to the inquiry

Griffiths says the interviewers asked - after Letby left the interview room distressed - "does she know what is going on here and what she is potentially being accused of?".

The inquiry has just heard that the hospital's director of nursing Alison Kelly told the Royal College of Paediatrics and Child Health (RCPCH) review team that paediatricians thought Letby was "the common denominator" in the baby deaths.

But she told the team there were no issues with Letby's competency and training and the nurse was highly thought by her neonatal unit, De la Poer says.

She also said that the clinicians had “threatened to go to the police".

De la Poer tells the inquiry that notes taken by the review team indicate former hospital medical director Ian Harvey was asked "what is the tipping point?".

To this, it is noted he responded they "need to pull together before we press the nuclear button".

The review team next met with consultants Dr Steve Brearey and Dr Ravi Jayaram, which included a detailed discussion of the neonatal deaths.

Both doctors expressed their concerns over Letby at this meeting, but the inquiry is told that the review team decided to continue on with the task despite suspected criminality.

Judith Moritz
Reporting from the inquiry

The inquiry is hearing about a review in 2016 of the ward conducted by the Royal College of Paediatrics and Child Health.

Nicholas de la Poer KC, the barrister speaking today on behalf of the counsel to the inquiry, says that junior doctors at the hospital were referring to Letby as "Nurse Death’" by September 2016.

The barrister says this revelation comes from an interview the review team conducted with former Countess of Chester Hospital medical director Ian Harvey

Harvey says during this initial interview that he had had to "intervene with the neonatal lead" over the nickname given to Letby, De la Poer tells the inquiry.

Jonny Humphries
Reporting from the inquiry

A significant spike in death rates on the neonatal unit was missed by a key steering group, the inquiry hears.

That data showed there were eight baby deaths in 12 months on Chester’s neonatal unit – including three deaths in the first and second quarters of the 2015/16 financial year and two deaths in the third quarter.

What the steering group did not appear to notice was the large rise in deaths compared to the 2014/15 period – where there were a total of three deaths overall.

The steering group of the Merseyside Neonatal Network met on 29 January 2016.

De la Poer says Dr Charles Yoxall, known as Bill, was the director of the neonatal unit at Liverpool Women’s Hospital and sat on the steering group.

In his statement to the inquiry, Yoxall says that the presentation of the data did not include historic or expected death rates.

If the significance of the data had been appreciated, he says: “It is likely it would have prompted a discussion, and an explanation from [the Countess of Chester Hospital] would have been requested”

The notes of the January 2016 meeting do not include any discussion of unexpected deaths or deliberate harm at the Countess of Chester Hospital.

As the inquiry has just been told, Lucy Letby attempted to murder Child K on the second day of an inspection by hospital regulators, the Care Quality Commission.

Letby was convicted of attempted murder of Child K following a retrial, as at the previous trial jurors could not reach a verdict.

The retrial jury found her guilty of trying to murder the "very premature" infant by dislodging her breathing tube in the early hours of 17 February 2016.

The court heard how Letby had targeted the child after she was moved from the delivery room to the neonatal unit shortly after her premature birth.

After dislodging the tube, the nurse stood and watched the baby's blood oxygen levels drop, without intervening.

Dr Jayaram, who intervened to resuscitate the child, told jurors he saw "no evidence" that Letby had done anything to help the deteriorating baby.

Baby K was transferred to a specialist hospital later on 17 February because of her extreme prematurity and died there three days later, with the cause of death certified as extreme prematurity and severe respiratory distress syndrome.