Revealed: the staggering catalogue of failures that left Lucy Letby free to kill and harm babies

In the end, Lady Justice Thirlwall's report into what happened at the Countess of Chester Hospital between June 2015 and June 2016 made for grim reading.The hospital management was 'dysfunctional'.An 'us-versus-them' mentality pervaded between management and clinicians, and again between nurses and senior staff.Some of those who had suspicions about the uncharacteristically high number of deaths in the neonatal unit kept quiet.Others who raised the alarm were dismissed.Pointless reviews were carried out as opposed to calling in the police.It meant Lucy Letby was able to carry on with her quiet campaign of murdering babies, and seriously harming others, uninterrupted.'Errors were made by nurses, doctors and managers at the time of these events,' Lady Justice Thirlwall said today. Lady Justice Thirlwall highlighted a litany of failures that led to the murders of seven babies and serious harm to others at the Countess of Chester HospitalShe was presenting her findings having pored over more than a million pages of documents, taken evidence from in excess of 130 live witnesses, and read nearly 400 witness statements.'There was complete failure at all levels to invoke safeguarding procedures at any point,' she said.'Looking for clinical or other explanations for deaths and collapses was not wrong, but once there was suspicion that Letby may be causing harm deliberately safeguarding steps should have been taken.'She should have been removed from the ward as a neutral act and matters could have been investigated without risk to babies.'No one seems to have thought that safeguarding action is required when a member of staff is suspected of causing deliberate harm. Suspicion is enough.'LUCY LETBYWhile the inquiry was not charged with investigating Letby's criminal convictions or her guilt, it did at least offer a telling insight into the nurse at the centre of the probe.The inquiry heard evidence of her 'inappropriate' and 'callous' behaviour towards patients and colleagues.It emerged that feedback on Letby's performance was mixed while she was training.She was said to be lacking in enthusiasm for the job, and, chillingly, her communication skills with families and drug calculations were below par.Lucy Letby worked as a neonatal nurse at the Countess of Chester Hospital between January 2012 and July 2016And significant concerns were raised during her final placement in 2011.Her mentor noted that Letby was 'quiet, withdrawn and struggled to build relationships with children, families and colleagues'.The inquiry heard that despite Letby's efforts to address these issues, she failed a mid-year assessment.Her mentor concluded that Letby's progress remained insufficient and did not sign off on her final assessment.Letby qualified as a registered children's nurse in September 2011, but was found to be 'repeatedly untruthful' with friends and fellow nursing staff.She even shouted at her manager at one stage after being told she was being sent to work in a nursery away from intensive care.The senior nurse, Kathryn Percival-Calderbank, said: 'Lucy Letby then shouted at me for doing so because she felt she didn't want to be in [an] outside nursery she wanted to be in the intensive care setting because she felt that it was boring looking after the special care babies.'More significantly, one parent said she was aware her baby's medical records had been falsified by Letby 'to suit a different narrative'.The inquiry also heard she was particularly chummy with senior bosses, something which may have clouded their judgment.MISSED OPPORTUNITIESThe judge pulled no punches in pointing the finger of blame at senior managers Alison Kelly, Ian Harvey and Tony Chambers, who 'dismissed the idea that Letby was deliberately harming babies', as late as June 2016.She said it mattered little whether or not they believed allegations against Letby – they should have acted.Ultimately, there were delays in contacting police which could have prevented babies being killed or harmed.The judge said: 'It is striking that on 29 June 2016, Ms Kelly and Mr Harvey both believed that the doctors' concerns meant that the police should be called, but by the end of that day they had accepted Mr Chambers' view that other steps should be taken first, even though they both knew more about the detail of the concerns than he did.' The inquiry chairman was particularly critical of senior leaders and management at the hospitalMr Harvey, the medical director, told the inquiry he regretted that they did not go to the police in June 2016.Lady Justice Thirlwall said neither he nor chief executive Mr Chambers was in a position to decide whether the doctors' concerns about Letby had any credibility.She said: 'A criticism of the doctors from the managers was that they had not called the police – the point being, presumably, that if their concerns were genuine they would have done so.'The managers never considered whether the reason the doctors had not done so was because this was so serious that it needed to be dealt with at the most senior level of the hospital, exactly as Mr Harvey himself thought.'She said the managers acted with a lack of self-doubt.'The difference between them and the paediatricians was stark,' she said.She said safeguarding action should have been taken by moving Letby off the ward following the death of Baby I in October 2015.But there were even opportunities to stop her two months earlier after a consultant 'disregarded' evidence which suggested Letby poisoned a baby with insulin.Another doctor did not flag in February 2016 that he saw Letby's failure to act to help a baby girl, whose breathing tube she was later convicted of dislodging.Chief executive Mr Chambers was unaware of what was happening on the neonatal unit until after the deaths of two babies in June 2016.Yet the police were not called in for almost a year. The bombshell report found families were not told about investigations into LetbyTREATMENT OF PARENTSSome of the judge's most emotive language was reserved to describe the 'reprehensible' treatment of the babies' parents.She accused hospital bosses of using the potential risk of upsetting parents about the allegations against Letby as a 'convenient argument' to justify delaying contacting the police.Giving evidence to the inquiry, Mr Harvey said that some communication with families 'was both crass and inappropriate'.Families were not even told about the investigations into the deaths of their children.The mothers of four children were 'all misled', either in face-to-face meetings or in written communications, she said.Indeed the inquiry heard evidence from parents that they were not aware of any concerns that an individual had caused neonatal deaths and collapses at the Countess until Letby was arrested and the police contacted them in July 2018.Lady Justice Thirlwall added: 'Risks to reputation and disruption are not of the same order. The assertion that bringing in the police would have severe consequences for the unit, the hospital, staff, patients and other neonatal units in the region, as before, was wrong.'In light of later events, the references in the meetings to what would be upsetting for the families seem to be convenient arguments to justify the decision not to bring in the police.'The executives had no idea of how the families would feel. The distress caused to the families by delays has been significant.'Several parents spoke about being given leaflets about bereavement, but no other recognition of their situation, and no support.The judge said: 'This was not good enough.' Letby was initially found guilty of murdering seven infants but was also on duty or had recently clocked off shortly before another six diedNURSE MANAGEMENT The report highlighted the 'serious failure' of a seemingly ingrained 'us versus them' attitude between doctors raising concerns about Letby and her nursing colleagues determined to protect her.It meant senior nurses and managers leapt to Letby's defence despite doubts about her competence.Lady Justice Thirlwall said nursing colleagues and senior managers had 'good reasons' to support Letby as concerns about her mounted, but said that they 'stepped very quickly from professional support to personal friendship'.She added: 'They were all relatively senior people. They should have maintained an appropriate professional distance and not become involved.'Senior nurses demonstrated 'unquestioning loyalty to Letby' allied with the 'certainty that there was nothing in the consultants' concerns'.This, said the inquiry chairman, 'seems to have prevented them from considering the doctors' concerns with an open mind or thinking about safeguarding'.The report found Eirian Powell, Letby's manager in the neonatal unit, did not accept that doctors' fears were offered in good faith.Ms Powell also criticised the mother of Baby H, who survived an attack in September 2015, when the parent raised a complaint.The report found Ms Powell's loyalty was to her nurse, and led her to 'unjustified criticism of a mother who had proper cause for complaint'.The report found it was 'ridiculous' that Karen Rees, director of nursing care, baselessly believed neonatal consultant Dr Stephen Brearey and Letby had previously been in a relationship, prompting his request for her to be removed from the ward.It added: 'Everything about Ms Rees's reaction here was wrong. First, she was dealing with paediatricians of whom she had little knowledge or experience.'Second, there was nothing to support her theory.'A moment's thought would have led her to acknowledge that falsely accusing a nursing colleague of harming (or even killing) babies would be an extreme way of removing a nurse from a unit.'The inquiry chairman dismissed the idea that Dr Brearey 'bullied' her.The inquiry heard nursing director Ms Kelly and medical director Ian Harvey did not attend a meeting arranged by Dr Brearey with senior paediatricians in June 2016 to discuss neonatal mortality.But Ms Rees, who was also at the meeting, was of the view that there was a 'them and us' approach between the doctors and nurses.The report said: 'To take a them-and-us approach where what was required were cool heads and reason was a serious failure by senior managers.'The report added: 'It should never have been about nurses against doctors. It was about keeping babies safe.'Had that governed the approach of the managers, they would and should have sought to work with the doctors, not against them.'Characterising this as nurses versus doctors distracted from the real issue: that steps needed to be taken to protect the babies.'Ms Rees accepted in evidence that she had become too close to Letby.The report found it is likely that this made it impossible for her to be objective about the issues that had been raised by the doctors.Alison Kelly, the former director of nursing at the Chester hospital, arrives at the Thirlwall Inquiry at Liverpool Town Hall last yearCHIEF EXECUTIVESThe report found head of safeguarding Ms Kelly 'knew she had to act when there was a suspicion that a baby had been harmed, and that others might be at risk'.But, the judge said, Ms Kelly did not do so.Mr Harvey said he took the doctors' concerns seriously but the inquiry found this was undermined by his actions.'His approach demonstrates that he did not consider them (the concerns) credible.'Hospital bosses were particularly concerned about 'negative comments' or newspaper coverage, and so the reputational damage to the hospital was 'prized more highly' than transparency, the judge said.And she said executive presentations to the board as allegations against Letby whirled were 'an exercise in spin'.Mr Harvey also 'sought to control the narrative', and made sure that only evidence which supported his case was seen.She said Mr Chambers' attitude towards senior doctors flagging fears about Letby was 'dictatorial', and that he 'never once scrutinised his own thought process' and dismissed concerns.She said: 'If the doctors' concerns turned out to be well founded, the consequences for patients and their families were catastrophic.'Mr Chambers was so determined to bring down the doctors that he lost objectivity and made poor decisions.'INVESTIGATIONSLady Justice Thirlwall was critical of several internal and external reviews, commissioned by hospital bosses as an alternative to contacting the police.The report said these failed to address the single most important issue – whether deliberate harm was being caused to babies or not.Medical director Mr Harvey then commissioned the Royal College of Paediatrics and Child Health to carry out an external review into the neo-natal unit, without any consultation with the medics, rather than call in police.This is something that Mr Harvey noted, having told the inquiry: 'I regret that I didn't stick with my original view that we should have gone to the police.'The inquiry chairman said: 'When the dissemination report was eventually published in 2017, none of its findings explained any of the deaths - nor did the findings in the confidential report.'This important point was accepted by the RCPCH in its closing submissions.'She said there was still no explanation for several deaths, despite the reviews.'The worry should have increased exponentially. Instead, it subsequently came to be said that Letby had been exonerated,' the inquiry found.She said Mr Harvey had not been 'neutral' with the RCPCH about the doctors' concerns, which influenced their report.And she said had he been 'frank' with two consultant neonatologists then they would have 'taken a different approach' and 'likely that this would have led to the police being called'.She said the failure to call the police in July 2016 was 'impossible to defend'.