A sober fact-finding exercise - or an adversarial battleground?published at 13:04 British Summer Time 13 September

13:04 BST 13 September

Judith Moritz
Reporting from the inquiry

This week has given us a snapshot impression of the months to come.

The opening statements at any public inquiry are where you first hear those involved set out their stalls - giving a taste of their headline positions on significant issues, before witnesses start coming to give their evidence.

It’s already clear to me that this is an inquiry which will see different key players banging heads against each other.

Lawyers for the babies’ families didn’t hold back in their criticism of the senior managers at the hospital, accusing them of dishonesty, and a coverup which they suggest appears to have been motivated by the need to protect reputations.

The senior managers have dismissed this suggestion outright as being illogical - saying they didn’t prioritise the reputation of the hospital trust at any time.

They’ve hinted that they’re likely to criticise the consultants on Lucy Letby’s unit - asking why they didn’t contact the police, the nursing regulator or other external bodies directly.

Everyone who’s spoken this week has said that they support the inquiry, and the need to learn lessons.

It will be interesting to see whether that shared aim means that the hearings are a sober fact-finding exercise, or whether they become an adversarial battleground.

• You can follow all the updates to the inquiry here, and a here is a reminder of Lucy Letby's court case.

As the inquiry finishes for the week let's recap the main development of the last few days.

Day 1

• The "tenacious lobbying" of senior consultants may have prevented Lucy Letby from attacking more babies, but "significant opportunities" were missed to investigate her, the inquiry heard

Day 2

• Junior doctors referred to Lucy Letby as "Nurse Death", and paediatricians thought Letby was "the common denominator" in increased baby deaths on the neonatal ward
• Nicholas de la Poer KC said Letby had attempted to murder one of the babies during a hospital inspection at Countess of Chester Hospital

Day 3

• Babies' breathing tubes were found to have been dislodged at an unusual rate during Letby's placements at Liverpool Women's Hospital - Richard Baker KC said this occurs in less than 1% of shifts, but there were recorded incidents of this on 40% of the shifts Letby worked
• Baker told the inquiry that people who doubted her guilt "should be ashamed of themselves"

Day 4

• NHS managers said they were "truly sorry" for delay in contacting police over Letby and NHS England said it "could have done more to scrutinise the hospital" during the time it first became aware of the rise in neonatal mortality figures and when the police became involved

If you're just joining us this lunchtime, here's what we've been hearing from the Thirlwall Inquiry in Liverpool:

• Kate Blackwell KC, who was representing four NHS senior managers at Countess of Chester Hospital, said they were "deeply affected" by statements from the babies' families
• Blackwell said the managers were sorry for the delay in contacting the police about Lucy Letby
• Representing the Care Quality Commission (CQC), Jenni Richards KC addressed the fact that the health and social care regulator inspected the hospital in February 2016 - during the time window of Letby's crimes
• The CQC accepted there will be more for it to learn as a result of the inquiry, Richards said
• Jason Beer KC, who was representing NHS England, said it was "generally acknowledged that there was under-reporting of incidents on the neonatal unit"
• He added that the NHS considers it "could have done more to scrutinise the hospital" during the nine months between when it first became aware of the rise in neonatal mortality figures and when the police became involved

Judith Moritz
Reporting from the inquiry

The opening statements have all been delivered and Lady Justice Thirlwall is thanking all core participants.

Rachel Langdale KC tells the hearing that next week, the inquiry will hear from the babies’ parents directly.

The inquiry building will be closed to the media and public for this next phase. Some of the evidence given by the babies’ parents will be available for the media to listen to, and transcripts will be provided later.

That concludes the inquiry for this week, thank you for staying with us.

Judith Moritz
Reporting from the inquiry

Jason Beer KC, who is representing NHS England, concludes: “There are some areas where the inquiry may choose to make recommendations to address missed opportunities".

He lists examples, such as further training, a framework for reporting concerns to the police, a memorandum of understanding between the NHS and the police, and policies on social media to "increase safeguards around sharing information”.

“NHS England finishes by reflecting on what all those involved in this inquiry owe the families of the babies - candour, a willingness to reflect and learn, and to take forward recommendations," he says.

Judith Moritz
Reporting from the inquiry

Beer moves on to say that after Letby was removed from the neonatal unit, NHS England was made aware of a rise of mortality on the unit. This was in July 2016.

Beer says that NHS England now feels that it gave “too much deference and too much reliance to the view that senior managers at the Trust were demonstrating the right behaviours and taking the right action”.

“It took too long for the hospital or any of the individuals who held serious concerns… to involve the police".

He adds the body now considers that it "could have done more to scrutinise the hospital" during the nine months between when it first became aware of the rise in neonatal mortality figures and when the police first became involved.

Judith Moritz
Reporting from the inquiry

Jason Beer KC continues, saying it "seems to be generally acknowledged that there was under reporting of incidents on the neonatal unit".

"All providers including this hospital were required to comply with the Serious Incident Framework," he says.

None of the incidents involving harm short of death were reported via this framework.

Beer says it was not until July 2016 that broader concerns about a rise in morbidity and neonatal mortality were reported.

Judith Moritz
Reporting from the inquiry

Thank you for sticking with us as we bring you the latest from the inquiry.

We're now hearing from Jason Beer KC representing NHS England.

He starts by offering an apology to the parents of the babies harmed or killed by Letby, on behalf of the entire NHS, saying the organisation "continues to learn" from the events at the Countess of Chester Hospital”.

He calls for “compassion and candour to be the touchstones for dealings with all parents”.

“Neonatal services and the NHS more widely are very different now compared to 2015 and 2016," he adds, citing the publication of the Morecambe Bay Report and The Better Births Report in those years as “pivotal moments” in changing the way things are done.

Judith Moritz
Reporting from the inquiry

Richards continues by addressing a report published in July 2024 by the Department of Health and Social Care on its 'Review into the operational effectiveness of the Care Quality Commission'.

"It finds significant failings in the internal workings of the CQC. The CQC has accepted in full the failings identified, and the recommendations," Richards says.

“The consequence is that a significant process of internal reflection is underway to address the problems that have been identified," she adds.

“We fully accept there will be more for the CQC to learn as an organisation as a result of this inquiry”

Judith Moritz
Reporting from the inquiry

Jenni Richards KC tells the inquiry that on 16-19 February, 26 February and 4 March 2016, the CQC carried out the routine inspection of the hospital. The services inspected included the neonatal unit.

She says that as part of the inspection, an out-of-hours unannounced visit was carried out on 26 February and a further unannounced visit was undertaken on 4 March - including, on this latter occasion, a visit of the neonatal services. There were no particular triggers for these visits, Richards adds.

Judith Moritz
Reporting from the inquiry

We're now hearing from Jenni Richards KC, who is speaking on behalf of the regulator for health and social care providers, the Care Quality Commission (CQC).

She is running through the details of the inspection which the CQC made at the hospital in 2016 - during the time window of Letby’s crimes.

As a reminder, Letby has been convicted of attempting to murder a baby girl, baby K, in the early hours of the morning of the second day of the CQC inspection.

Judith Moritz
Reporting from the inquiry

Concluding her introductory speech, Blackwell says the medical staff at Countess of Chester have been "deeply affected" by what happened at the hospital.

"While we do not suggest, in any way, parity with what the families of those killed and harmed by Letby have experienced, it has been the most significant event of any of our professional lives - not a day goes by when we don’t think about what happened."

"That a nurse could be responsible for these heinous crimes is profoundly disturbing."

She finishes by saying this was not something ever expected to occur on a neonatal ward, "it being so against the natural order of what was contemplated or foreseen”.

Judith Moritz
Reporting from the inquiry

Blackwell moves on to discuss the integrity of professionals working in the NHS.

Listing the names of senior team members relevant to the inquiry, she says "Ian Harvey, Alison Kelly, Anthony Chambers and Susan Hodkinson have collectively worked in the healthcare setting for many, many years and have never come across such criminal behaviour before.

She adds "the vast majority of professionals" with whom they have worked are "motivated with the highest of aims".

"They come to work every day, often in difficult circumstances, to help save lives. They do so by working long hours in the most challenging of environments.

"There is a tremendous amount of trust within the NHS between professionals which we know will be acknowledged by the Inquiry.”

Judith Moritz
Reporting from the inquiry

The legal representative speaking on behalf of NHS senior managers continues, saying the senior management team collectively welcome this public inquiry.

"We have complete faith in the process," Kate Blackwell KC says. "This will be the first time that the story of what took place at the hospital will unfold on the basis of the evidence of what took place.”

“The circumstances of what happened as events developed in 2015, 2016 and 2017 were unique, challenging and complex," she says.

Blackwell adds that the senior management team understands that, having gathered the evidence and then heard testimony from those who are able to assist with what was actually happening at the time, "the final story will be written by this public inquiry in its report".

“At the heart of this process is the expectation that lessons will be learned which is, we are certain, a goal shared by all Core Participants.

"This is to ensure that, as far as it is possible to do, that there can never be a repeat of what happened here.”

Judith Moritz
Reporting from the inquiry

Blackwell is now addressing the frequency of infant mortality while Letby was working.

Senior managers were aware that she had had been on shift when "a number of deaths occurred for some time", she says, adding that Letby had specialist training which meant she was more likely to be with the sickest patients on her own.

She "showed her willingness to work extra shifts," she adds.

“The neonatal unit manager Eirian Powell was firmly of the view that Letby was a good and competent nurse.”

“The Senior Managers believe that, given the information with which we were provided, and the need to maintain an open mind about possible causes of the mortality rates on the NNU, we acted appropriately at the time.”

Blackwell says the managers believe they made "reasonable decisions" and were held to account by the hospital board and CEO.

Judith Moritz
Reporting from the inquiry

Blackwell continues, saying the senior managers accept that they believed that they needed to investigate so as to obtain evidence of wrongdoing before taking this matter to the police.

There was nothing tangible being alleged beyond Letby’s presence for a long period of time that they might say to justify a criminal investigation, she says.

This was the cause of significant delay in contacting the police, Blackwell says, adding that for this they are truly sorry.

Blackwell says the managers also accept that communication with parents was "inadequate" and also apologise for that.

Judith Moritz
Reporting from the inquiry

Blackwell continues by describing the working reality of consultants and doctors in a busy hospital, saying they were doing their "best to react to an unfolding picture".

"They didn’t have the benefit of all the evidence to which the inquiry now has access."

"The circumstances of what happened as things developed were unique and challenging."

Addressing submissions that have been made to in the inquiry suggesting the hospital staff lacked "professional curiosity", she says there were "a number of investigations" made, and that concerns were "not ignored".

Judith Moritz
Reporting from the inquiry

Kate Blackwell KC says the NHS senior managers have furnished the inquiry with extensive witness statements - running into hundreds of pages, and have done so willingly.

She says they hope that this inquiry will fulfil its terms of reference fully and for the first time produce a comprehensive account of what happened at the Countess of Chester hospital so that lessons are learned.

Judith Moritz
Reporting from the inquiry

Blackwell says the the senior managers at Countess of Chester know "they will be asked difficult questions".

"They have deliberately refrained from responding to criticisms made by them by number of individuals and organisations which have been reported in the media".

She adds she hopes the inquiry will "scrutinise" the complex facts of the case "unblinkered by hindsight bias, and with an open mind".

Judith Moritz
Reporting from the inquiry

Kate Blackwell KC is the first legal representative to speak on behalf of four NHS senior managers.

She says each of the managers wishes to "express their deepest sympathy to the babies families".

"They have read the statements by the families and are deeply affected by them They recognise and pay tribute to their dignity", she says.