Judith Moritz
Reporting from the inquiry

Attention now turns to when consideration was given to reporting Letby to police. The first recorded mention of involvement of the police, that the inquiry has been able to identify so far, appears on 29 June 2016.

Langdale says "we will be looking closely at whether this possibility was raised earlier and why, even after it was raised in June 2016, it was not taken forward for nearly a year.”

The inquiry learns that on 4 July 2016, the director of nursing, Alison Kelly, notified the Nursing and Midwifery Council that a registered nurse - Lucy Letby - “may present a serious risk to public safety although no evidence is available at this time.”

Rachel Langdale KC says “what is clear from the evidence gathered to date is that during a number of meetings over the 27 -30 June 2016 contacting the police was discussed. However, the decision of the senior managers appears to have been not to approach the police at this stage, but rather to commission reviews in the neonatal unit and inquire into the circumstances of the deaths on the unit.”

The inquiry is told that, in July 2016, the hospital opened its own ‘incident room’ to look at the deaths, and established something called ‘Silver Command’ - meetings were held in the morning and evening to take stock of what was being done.

Judith Moritz
Reporting from the inquiry

The inquiry has just been hearing a statement from medical director Ian Harvey who spoke of the "difficult balance" surrounding Letby remaining on the unit.

He says "this was a difficult balance as it was difficult at this stage to understand what the issue or issues were and whether it might relate to her competency or performance, or was completely unrelated to her practice.

"As far as I can recall, Letby was on annual leave so we had some time to figure out what we were going to do before she would be patient-facing again.

"My general recollection of the days that followed is that the clinicians became more vociferous about her being removed, whilst the nurses wanted her to remain on her unit. My recollection is that ultimately Letby never returned to the unit.”

Jonny Humphries
Reporting from the inquiry

More now on the deaths of two babies from a set of triplets in June 2016 that eventually led to Letby being removed from the ward.

The death of the first of those babies, Child O, was described as “completely unexpected” by other nurses on the unit.

Ms Langdale says Dr Steve Brearey, the leading neonatal consultant, was aware that Letby was involved in the resuscitation of Child O.

He did not notice “any outwardly suspicious actions” but described being “very worried” at this stage.

However he says he did not escalate his concerns to senior executives immediately on the night of Child O’s death.

Ms Langdale says Dr Brearey said he “could not conceive that senior staff would allocate Letby to care for the surviving triplets”, but that he “deeply regrets” not escalating his concerns urgently that evening.

The following day, Child P, the sibling of Child O, died on the ward.

Ms Langdale says after Child P’s death Dr Brearey phoned Karen Rees - the nurse in charge of urgent care at the hospital - at her home requesting that Letby be taken off the ward.

“This was not done”, the inquiry hears.

Judith Moritz
Reporting from the inquiry

The focus now turns to the deaths of two out of three triplet brothers, Child O and Child P, who Letby has been convicted of murdering in 2016.

Rachel Langdale KC says: "Every week there was a meeting of the executive directors group, to which all executive directors were invited. The records of their meetings suggest there had been no discussions about unexplained instances of infant mortality or of concerns about a rise in the death rate on the neonatal unit prior to June 2016.

"That was to change. The deaths of two of the triplets, Child O and Child P, catapulted the issue of Letby and neonatal mortality to the top of the executive team agenda.”

The inquiry hears that at the end of June 2016, hospital executives were still recommending that Letby remain working on the neonatal unit. The consultants on the unit wanted her to be removed from having any contact with babies.

Langdale says: “The message was unambiguous. The senior paediatricians were in agreement, Letby should be removed from the ward on the grounds of patient safety.”

Judith Moritz
Reporting from the inquiry

We are hearing more now from Rachel Langdale KC as she continues making her opening statement to the inquiry - she begins by talking about the extent to which Letby used to send messages to a paediatric registrar - a junior doctor anonymised as Dr U.

Langdale says over 1,300 Facebook messages were exchanged between Letby and Dr U between mid-June and 28 September 2016.

"Some of these messages discussed the collapses of babies that Letby was involved in. Dr U himself was involved in the care of Child I, Child L, Child M, Child O and Child P.”

As the inquiry returns from lunch, let's look at the key moments from this morning.

Lady Justice Thirlwall opened the first day of the inquiry by stressing that the babies who died and were injured, and their parents, would be "at the heart" of proceedings.

• An email from a nursing boss, sent in May 2016, revealed concern at a possible "staff trend" over deaths - they said "this is potentially very serious"
• Thirlwall says "noise" surrounding the case has caused "enormous additional distress" to the parents of those babies

• A senior doctor said he and his colleagues "did not suspect deliberate patient harm" after a cluster of deaths in June 2015
• A serious incident panel meeting in July 2015 ended with a decision for "no further investigation warranted"
• Ward manager Eirian Powell says "concerns, despite being raised, were not seen as urgent"

Jonny Humphries
Reporting from the inquiry

Just before the break, the inquiry heard that on 16 May 2016 there was an urgent care meeting in which Dr Brearey “intimated that he thought a member of staff was causing the increase in mortality”.

Langdale says that “it was at this meeting there was allegedly reference to there being 'a murderess on the neonatal unit’.

“There is a dispute on the facts here as to what was said by who at that meeting and this will be explored in oral evidence.”

Judith Moritz
Reporting from the inquiry

A few moments ago, the inquiry also heard that there was a hospital meeting in May 2016 to “discuss high mortality and the commonality of the presence of a nurse" - that is to say Letby.

Before the meeting, Dr Brearey emailed the director of nursing Alison Kelly to say a nurse on the unit had been present for “quite a few of the deaths” and explained that Letby had been moved onto day shifts.

Langdale says it was the first time that a member of the executive directors group from Countess of Chester Hospital was informed in writing that a member of staff’s shift pattern had been changed over concern about a nurse.

The barrister says: “Ms Kelly has told the inquiry that when she received this email the reference to ‘pressure on staffing numbers’ was the reason for the need to hold the meeting as soon as possible and the impact of moving Letby upon the nursing rota, rather than any concerns about deaths being from unnatural causes.”

Within four minutes of receiving this email, Kelly had forwarded it to other managers including her deputy, and Karen Rees - the nurse in charge of urgent care at the hospital.

She wrote: "Aah!! Can you please look into this… if there is a staff trend here and we have already changed her shift patterns because of this, then this is potentially very serious!! I will check the report they sent through – I did not notice there was a staff trend!!"

Jonny Humphries
Reporting from the inquiry

Before the break, the inquiry heard that the decision to move Letby from night shifts to day shifts, on 7 April 2016 was a “significant event”.

Neonatal ward manager, Eirian Powell has said that was her decision, after concerns were raised by Dr Brearey who, she says, suggested “we need to have more eyes watching really”.

In a statement, she says it was to: “Make sure [Letby] was alright and also to make sure there was no wrong doing anywhere.”

Lead counsel to the inquiry Rachel Langdale KC says Dr Brearey has stated that he was not told of this decision at the time and only found out in May 2016.

"The decision to move Letby to day shifts raises serious questions which we will be investigating.

"If there was sufficient concern to take Letby off night shifts, then how could a decision that left Letby in sole charge of neonatal babies during the day be justified," Langdale adds.

The inquiry has just taken a break for lunch, it will return at 13:45.

In the meantime, we'll be bringing you some more key lines that we haven't yet managed to get to shortly.

Jonny Humphries
Reporting from the inquiry

Langdale says a meeting took place on 8 February 2016, involving Dr Brearey, Dr Jayaram, and other senior hospital figures, to discuss and review the deaths of babies where the diagnoses had been uncertain.

Ahead of that meeting, a staffing analysis had been carried out and shared via email showing the correlation between Letby’s shifts and the deaths of babies on the neonatal unit.

Dr Brearey said that the meeting reviewed the care of all the babies who died in 2015 and January 2016 and the previous reviews that had been undertaken and looked for any common themes.

Langdale says Brearey explained that after all the cases had been discussed, he then raised the issue of staffing analysis, the association with a nurse and the fact that six of the nine babies had collapsed between 00:00 and 04:00.

He said he had been concerned, because if the deaths were as a result of natural causes he would have expected them to have occurred at all times of the day or night.

The barrister tells the inquiry: “It is currently unclear whether the possibility that Letby might have something to do with the deaths of babies was explicitly discussed or whether anyone at the meeting raised the issue of an associated nurse being removed from the unit pending further investigation.”

Judith Moritz
Reporting from the inquiry

The Inquiry has also been hearing about the death of Child I - a baby girl, in October 2015. It was the fifth death in under five months.

Dr Steve Brearey - the lead neonatal consultant - emailed the ward manager Eirian Powell in October 2015 to register his concern that Letby had been present at each death.

Powell replied: “It is unfortunate that she [Letby] was on – however each cause of death was different, some were poorly prior to their arrival on the unit", adding others had bowel disorders, gastric bleeding and congenital abnormalities.

"This email bears reading because in many ways it sets the tone that was to follow in the subsequent months," Langdale tells this inquiry.

"Concerns, despite being raised by the consultant lead of the neonatal unit, were not seen as urgent, and assumptions surrounding the underlying medical evidence were made," she adds.

Jonny Humphries
Reporting from the inquiry

Langdale tells the inquiry unusual blood results in the case of Child F were a result of Letby spiking a feedbag with synthetic insulin, causing a near fatal collapse.

One doctor, anonymised as Dr ZA, established that no other baby on the unit had been prescribed insulin “making accidental administration unlikely”

That doctor has told the inquiry in a witness statement that: "I felt that the most likely explanation for the results was some sort of inaccuracy with the test and I would have liked to repeat them."

Langdale says Child F had no further periods of hypoglycaemia (low blood sugar) and was transferred back to his local unit. Dr ZA noted that she did consider whether insulin could have been delivered deliberately.

However, she says: "This seemed absurd and ridiculously unlikely so the tests being wrong seemed the only possible explanation."

Dr ZA accepted in her police statement that “with hindsight I should have flagged up this unexpected result".

Langdale makes clear that Dr John Gibbs, a former consultant paediatrician who worked at the Countess of Chester Hospital, agreed.

"The results were not interpreted correctly at the time and so, highly regrettably, an indication that someone was deliberately harming patients was overlooked" he says in a separate statement to the inquiry.

Judith Moritz
Reporting from the inquiry

Rachel Langdale KC says that Ruth Millward, head of risk and patient safety at Countess of Chester Hospital, has accepted that there was a "further missed opportunity" to report the the death of Child E - the fourth unexpected death in under two months - as a serious incident.

Millward also says this "would have triggered a comprehensive investigation into the increased mortality rate at an earlier stage", the inquiry hears.

The inquiry also hears that doctors on the unit accept they should have flagged up a blood test result which showed that Baby F had been given synthetic insulin.

Dr John Gibbs, a consultant, describes the "collective failure" on the part of the neonatal unit's paediatric team, not to have recognised the significance of the results.

Judith Moritz
Reporting from the inquiry

In further comments on the July 2015 meeting, Langdale says “one of the most striking features” was that no one who attended “had actually been present at the deaths or collapses or involved in the resuscitation attempts”.

“Dr Brearey was the only doctor at the meeting, and he had not personally been involved in any of the resuscitations of the babies being considered,” Langdale adds.

She says the inquiry will be looking at all aspects of how deaths were reported and investigated, “including the examination of committees within the hospital, of risk registers and the governance structure”.

“As set out in the terms of reference the Inquiry will address the question: Did the structures and processes for the management and governance of the hospital contribute to a failure to protect the babies on the neonatal unit from the actions of Letby?," she reminds the room.

Jonny Humphries
Reporting from the inquiry

The inquiry hears that a Serious Incident Panel meeting at the Countess of Chester on 2 July 2015 ended with a decision that “no further investigation was warranted at this stage as there were no concerns highlighted in the obstetric or neonatal reviews".

Rachel Langdale KC says the inquiry will be looking at why that decision was reached.

"With hindsight, this decision may represent a significant opportunity missed," she says.

The inquiry hears that had the cluster of deaths been flagged as a serious incident in July 2015, a “comprehensive review” would have followed.

Langdale says it “seems likely” that had it happened "Letby’s presence at each sudden and unexpected death and her presence at the collapse of Child B would have been highlighted".

She says: “In addition, the surprise and shock that doctors and nurses felt at the deaths and the prevalence of unusual clinical features, including the rashes, would have been considered in greater detail."

Judith Moritz
Reporting from the inquiry

Langdale tells the inquiry that Child D was observed by medics to have an unusual rash.

One of the doctors wanted to arrange a staff debrief after the death of Child D, the inquiry hears, and wanted Letby to attend, along with other staff.

"Once again, there do not appear to be minutes. If concerns were raised at this meeting about the unusual rash or the unexplained nature of the collapse, these were not recorded.

"Nor do they appear to have been raised at the quarterly Neonatal and Morbidity meeting held on 29 July 2015 attended by Dr Newby and Dr Brearey with a follow up meeting on 10 September 2015," the lead counsel to the inquiry adds.

Langdale says the inquiry will explore this in oral evidence with witnesses.

Jonny Humphries
Reporting from the inquiry

The inquiry has begun to hear about the death of a fourth child on 22 June 2015.

Rachel Langdale KC says: “The death of Child D was the third neonatal death in under two weeks. This exceeded the total number of deaths in 2013, two deaths, and equalled the total deaths in 2014, three deaths.

"In addition to three deaths there had also been the near fatal collapse of Child B."

She says the inquiry will examine whether there was “any suspicion of wrongdoing at this stage”.

Letby had been present on each occasion.

Jonny Humphries
Reporting from the inquiry

The inquiry has heard a statement by on-call consultant Dr John Gibbs, who was present during the collapse of Child C.

In it, the senior doctor says:

“From informal discussion between us consultants around July 2015, several of whom had each been involved with a death on the neonatal unit, it was recognised that Letby had been present on each occasion, and this was also noted at the serious incident meeting on 2 July 2015.

“Letby worked more shifts than other neonatal nurses and I felt, as did my consultant colleagues at the time, that she was merely unfortunate to have been involved in the cluster of deaths.

"I was not suspicious of deliberate patient harm to either Child C or the other babies who died in June 2015."

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.