The hospital where Lucy Letby worked overlooked vital information with "fatal consequences", a lawyer representing the families of Letby's victims says
The Thirlwall inquiry also heard that those questioning Letby’s guilt “should be ashamed of themselves”
A lawyer for the health department says NHS England has introduced changes to the investigatory reporting process "to improve patient safety"
Former nurse Letby, now 34, murdered seven babies and attempted to murder seven others - she's in prison for life
The inquiry is looking at how the Countess of Chester Hospital handled Letby's crimes. Warning: This page contains distressing content
Staying on that subject area, Nicholas de la Poer KC says the inquiry will look at why the Care Quality Commission "did not detect prior to or during the inspection the concerns on the neonatal unit".
He notes that Letby "attempted to murder Child K in the early hours of 17 February 2016" - the second day of the inspection.
Judith Moritz
Reporting from the inquiry
England's healthcare regulator, the Care Quality Commission, inspected the trust in February 2016, and during unannounced visits on 26 February and 4 March 2016.
One of the inspectors, Elizabeth Childs, didn't recall discussion of increased unexpected or unexplained neonatal deaths during the inspection.
Nicholas de la Poer KC tells the inquiry: “Dr Brearey states that neonatal mortality was not brought up by the Care Quality Commission inspectors.
"He describes that one of his colleagues, Doctor ZA, told an inspector that ‘we have some serious patient safety concerns and don’t feel like we are being listened to’, but this was ignored and the inspectors left before there was time to expand upon concerns'."
Judith Moritz
Reporting from the inquiry
Image source, The Thirlwall InquiryThe inquiry is hearing about whether the hospital followed national and local guidance over what to do after the unexpected death of a child.
Nicholas de la Poer KC goes over the local Cheshire and national protocols supposed to be carried out, including informing the coroner and police in many instances for investigation
He then tells the inquiry that, other than in the case of Child C - where there was an initial strategy meeting 18 days after the death - there is little evidence demonstrating these local guidelines were adhered to.
De la Poer describes this as "troubling."
"You may consider that a troubling feature revealed by the evidence is that all too often it appears that a high threshold was believed to exist for raising concerns of potential harm to babies," he says.
“It is troubling because it is contrary to the clear guidance which safeguarding provides. Child protection, or safeguarding as it is now referred to, sets a low threshold for raising concerns in respect of child safety," he adds.
This is a distressing story, and upsetting details will be discussed over the course of this inquiry.
If you have been affected by any of the issues raised by this case you can visit BBC Action Line for details of where support is available.
Jonny Humphries
Reporting from the inquiry
It has been another rainy morning in Liverpool city centre where we've been listening to the second day of live hearings in the Thirlwall Inquiry.
This morning, Nicholas de la Poer KC, on behalf of the counsel for the inquiry, has been outlining the Countess of Chester Hospital’s processes for dealing with risk, its governance structure, and how burgeoning concerns about Lucy Letby were dealt with.
Here are five key points from this morning:
Jonny Humphries
Reporting from the inquiry
Concerns about the increased number of baby deaths on the hospital's neonatal unit were logged on the trust’s urgent care risk register in July 2016, De la Poer told the inquiry a little earlier.
However, the risk was categorised as “potential damage to the reputation” of the unit and the hospital - rather than a risk to the safety of babies on that ward.
He said: “We note there is no record of the consultants’ concerns of deliberate harm to babies in the urgent risk register, the executive risk register nor the corporate director’s group meeting minutes."
He says the inquiry will be seeking to understand why this is - and why it took so long for concerns to be formally recorded in this way.
Judith Moritz
Reporting from the inquiry
The inquiry has begun to hear about the role and involvement of external bodies in the events at the Countess of Chester Hospital.
De La Poer says the Nursing and Midwifery Council was notified there were concerns about Letby on 6 July 2016, but did not seek a fitness to practise referral until two years later, on 3 July 2018 - after she had been arrested.
It did not impose an interim suspension order until more than two years after that, on 20 November 2020, the inquiry hears - after she had been charged.
The Nursing and Midwifery Council is the regulatory body for nursing and midwifery professionals in the United Kingdom.
Judith Moritz
Reporting from the inquiry
The rows here in Liverpool Town Hall are full of lawyers representing all the "core participants" at the inquiry, including:
There are also legal teams here on behalf of the parents of the babies involved in the Letby case – all of those who she was charged with attacking – not just those she was convicted of murdering and attempting to murder.
Some of the parents themselves are in the hearing room too, but they’re not visible to those of us in the main area, as – at their own request – they are sitting in a screened-off area.
I'm sitting on the media bench at the rear of the room.
Judith Moritz
Reporting from the inquiry
On 28 March 2017, the inquiry hears, Sir Duncan Nicholl - former chair of the board of directors at the Countess of Chester Hospital - was told that consultant paediatricians were insisting on a police investigation.
"There was no discussion of this at the board meeting on 4 April 2017," de la Poer tells the inquiry.
There was a third extraordinary meeting of the board on 13 April 2017.
De la Poer says: “During the meeting, Sir Duncan referred to the Beverley Allitt case.
"You will recall my lady that Sir Duncan was chief of the NHS management executive at the time of Beverley Allitt’s crimes and was tasked with dissemination of the Clothier Inquiry report across the NHS.
"There was no reference to the Allitt case in the previous extraordinary meetings of the board of directors," he adds.
The inquiry hears about the first communication with the babies' families about the unfolding situation.
De la Poer goes on to say that at the same extraordinary board meeting, on 13 April 2017, Ian Harvey - former medical director of the Countess of Chester Hospital - told the board the hospital had endeavoured to keep the families up to date, although there were things to be learned.
Tony Chambers, former chief executive of the Countess of Chester Hospital, said the hospital had written to the families advising them - in an "open and transparent way" - of what the hospital knew, the inquiry hears.
De la Poer says: “The inquiry is concerned to understand the basis on which Mr Harvey and Mr Chambers made these assertions to the Board.
"We will hear that parents of babies who were attacked by Letby were not contacted by the hospital in advance of the Royal College review; that parents received letters from the hospital informing them of publication of the Royal College report hours before it was due to go live; that parents struggled to arrange meetings to talk with Mr Harvey; and that parents were never told by the trust that concerns had been raised about the potential involvement of a particular nurse.”
Judith Moritz
Reporting from the inquiry
We're now hearing about a meeting on 30 December 2016, involving:
“It was at this meeting, it appears, that the roadmap forward was set out," de la Poer says, which included a plan to endorse the transition of Letby back onto the neonatal unit.
An extraordinary meeting of the board was held on 10 January 2017 - where a statement by Letby was read.
De la Poer tells the inquiry the board were asked to "accept the Royal College report" and "support the executive team in assisting Letby’s return to the neonatal unit".
“Sir Duncan Nichol has publicly said the board were misled by Mr Chambers and Mr Harvey at this meeting," De la Poer says.
Judith Moritz
Reporting from the inquiry
The hospital board met sixteen times between June 2015 and May 2017, the inquiry hears.
Concerns in relation to Letby were only explicitly discussed at four "extraordinary meetings" held in private, de la Poer says.
On 14 July 2016, Tony Chambers, former chief executive of the Countess of Chester Hospital, informed the board that there had been an unexplained increase in neonatal mortality at the trust, the inquiry is told.
The board were told a peer review had been undertaken, which was "inconclusive" - and Ian Harvey, former medical director of the Countess of Chester Hospital, would undertake his own review of the data.
Quote Message"The official minutes recorded Dr Ravi Jayaram asking for one matter not to be minuted. In a set of handwritten notes for the meeting, Dr Jayaram was noted to set out Letby’s association with neonatal deaths, referring to Letby as the “elephant in [the] room.”
Nicholas de la Poer KC, at the inquiry
Following the meeting on 14 July 2016, the board "did not discuss neonatal mortality nor the concerns raised about Letby again until the new year," de la Poer says.
Letby’s last shift on the neonatal unit was on 30 June 2016, de la Poer had outlined.
Judith Moritz
Reporting from the inquiry
The hospital had a multi-layered governance structure, with a range of divisional boards and sub-committees, de la Poer outlines.
"There seems to have been significant overlap in remit between these various groups," he says, adding the inquiry will explore whether this "affected how the hospital identified and dealt with concerns raised about neonatal mortality".
He says that there were a "number of routes" for issues to be referred from groups near the bottom of the hospital’s governance hierarchy, "all the way to the board", but that's "not what happened".
De la Poer adds the inquiry will look at why the "increase in neonatal mortality and the concerns raised about Letby were rarely discussed".
Judith Moritz
Reporting from the inquiry
Image source, EPAI'm sitting in the hearing room at the inquiry in Liverpool Town Hall - it's an impressive setting.
The room, which is furnished in oak, mahogany and brass, is used to hosting council meetings and civic functions.
It’s arranged with the inquiry chair Lady Justice Thirlwall sitting on a dais, looking out across rows of semi-circular benches.
Judith Moritz
Reporting from the inquiry
Image source, The Thirlwall InquiryContinuing, de la Poer says the "increase in neonatal mortality at the hospital and the concerns about Letby" were matters that fell "squarely within the quality, safety and patient experience committee’s (QSPEC) remit.
They held monthly meetings between June 2015 and June 2016, he says, and the "increase in the mortality rate on the neonatal unit was discussed just once".
He says it appeared to have been raised on 14 December 2015 and not followed up after that.
De la Poer says the inquiry will be seeking to understand why this was the case, "given that attendees of that committee were, from February 2016 at the latest, sighted on the fact that concerns existed in the neonatal unit".
Judith Moritz
Reporting from the inquiry
Nicholas de la Poer KC is talking about the hospital board and their role in risk management and how ultimately, the board was "responsible for the performance of the hospital".
De la Poer describes the board committees as having a "delegated responsibility for scrutiny and assurance" within each of their respective remits.
"In the period June 2015 to March 2017, no board committee ever escalated to the board issues relating to neonatal mortality or Letby,” he tells the room.
Just before this, de la Poer was explaining the system of various risk registers in the hospital trust.
“We note there is no record of the consultants’ concerns of deliberate harm to babies in the urgent risk register, the executive risk register nor the corporate director’s group meeting minutes," he says.
He adds: "The Inquiry will be seeking to understand why this is, and also why it appears that it took until July 2016, one year and one month after the first indictment baby death, and five months after the thematic review, for the concerns to be formally recorded in these forums."
Judith Moritz
Reporting from the inquiry
Image source, The Thirlwall InquiryThe inquiry is today looking at the role of governance, the board, and the "effectiveness" of the risk management in the hospital, Nicholas de la Poer KC says.
De la Poer tells the inquiry that in May 2016, while Letby was still on the unit, a woman called Annemarie Lawrence took up the role of “risk midwife” - and she became aware of the internal “thematic review” into baby deaths and requested a copy.
“Having read this document, she describes going through the table and noting, using a highlighter, that Letby was a common factor in the case of most of the deaths," De la Poer says.
He adds that Lawrence took these concerns to her boss Ruth Millward, the head of risk and safety, about what she had read.
Lawrence said in her witness statement that her boss was "dismissive of her findings".
Rowan Bridge
North of England correspondent
Today, lawyers for the inquiry will continue their opening statements, where I expect we will hear more about the broader scope of the Thirlwall Inquiry.
For example, it plans to look at previous inquiries that have taken place into NHS scandals and what change they did or didn’t bring.
The inquiry hearings are due to last until the start of next year, with the final report in autumn 2025.
This is a distressing story, and upsetting details will be discussed over the course of this inquiry.
If you have been affected by any of the issues raised by this case you can visit BBC Action Line for details of where support is available.
Rowan Bridge
North of England reporter
The inquiry will resume here at Liverpool Town Hall at 10:00 BST with barristers representing the inquiry continuing opening statements, outlining what the Thirlwall Inquiry will examine.
Former nurse Lucy Letby was convicted of murdering seven babies and attempting to murder seven others, while working as a nurse at the Countess of Chester hospital between June 2015 and June 2016.
But it’s clear there are many more details about the Letby case still to come out.
Yesterday, lead counsel to the inquiry Rachel Langdale KC revealed that the case of Beverley Allitt, a nurse convicted of murdering children at a hospital in Lincolnshire in 1991, formed part of Letby’s training.
There were also more details of what happened in 2017, when Letby was put on clerical duties because of concerns from medical staff about the threat she posed to patient safety.
The inquiry heard how Letby made a number of visits to Liverpool’s Alder Hey Children’s Hospital and observed clinics and ward rounds, and later returned to the neo-natal unit in Chester - where staff held a tea-party to welcome her.
Langdale also explained how there were potentially chances to stop Letby missed, like in June 2015 when concerns were raised over three deaths on the ward in two weeks.
It was discussed at a high level, but no further action was taken, which the barrister told the inquiry may have represented “a significant opportunity missed”.
Image source, PA MediaWe're re-starting our live coverage of the Thirlwall Inquiry.
It's been set up to examine what happened, external at the Countess of Chester Hospital and the conviction of former neonatal nurse Lucy Letby of murder and attempted murder of babies there.
The three areas include, according to the terms of reference, external:
1. The experiences of the hospital and other relevant NHS services, and all the parents of the babies named in the indictment.
2. The conduct of those working at the hospital including the board, managers, doctors, nurses and midwives with regard to the actions of Lucy Letby.
This includes whether suspicions should have been raised earlier, whether Lucy Letby should have been suspended earlier and whether the police and other external bodies should have been informed sooner of suspicions about her.
It also includes the responses to concerns raised about Lucy Letby from those with management responsibilities within the trust and whether culture, management and governance structures and processes contributed to the failure to protect babies.
3. The effectiveness of NHS management and governance structures and processes, external scrutiny and professional regulation in keeping babies in hospital safe and well looked after.
This also includes whether changes are necessary and, if so, what they should be, including how accountability of senior managers should be strengthened. This section will include a consideration of NHS culture.
The inquiry is expected to last until at least the end of the year.