A dysfunctional hospital culture

The Countess of Chester Hospital was chaotic between June 2015 and June 2016. An 'us-versus-them' mentality pervaded among staff, with some keeping quiet about suspicions.

“There was complete failure at all levels to invoke safeguarding procedures at any point.”

Letby's troubling training record

During training, Letby lacked enthusiasm and had poor communication skills with families. Her drug calculations were below par, a chilling detail given her later crimes.

Failed assessments went ignored

In 2011, Letby's mentor noted she was 'quiet, withdrawn and struggled to build relationships'. She failed a mid-year assessment but still qualified as a registered children's nurse.

Cozy with the bosses

Letby was particularly friendly with top hospital managers. This closeness may have clouded their judgment when doctors later raised concerns about her.

Managers dismissed the alarm

Senior managers including Alison Kelly, Ian Harvey and Tony Chambers dismissed the idea that Letby was deliberately harming babies as late as June 2016.

Police should have been called

On 29 June 2016, Kelly and Harvey believed police should be called. By day's end, they accepted Chambers' view that other steps should be taken first.

Missed chance after insulin poisoning

A consultant disregarded evidence suggesting Letby poisoned a baby with insulin in October 2015. Safeguarding action should have moved her off the ward then.

Parents were misled and abandoned

Hospital bosses used the risk of upsetting parents as a 'convenient argument' to delay calling police. Families weren't told about investigations into their children's deaths.

“Risks to reputation and disruption are not of the same order.”

Given bereavement leaflets, no support

Several parents received leaflets about bereavement but no actual support. The judge said bluntly: 'This was not good enough.'

Nurses versus doctors

Senior nurses demonstrated 'unquestioning loyalty to Letby' and certainty there was nothing in consultants' concerns. This prevented them from considering warnings with an open mind.

“It should never have been about nurses against doctors. It was about keeping babies safe.”

Managers skipped crucial meeting

Nursing director Kelly and medical director Harvey didn't attend a June 2016 meeting arranged with senior paediatricians to discuss neonatal mortality.

Safeguarding chief failed to act

Head of safeguarding Alison Kelly knew she had to act when there was suspicion a baby had been harmed. But the judge said Kelly did not do so.

Reputation over transparency

Hospital bosses were particularly concerned about negative newspaper coverage. Reputational damage to the hospital was 'prized more highly' than transparency.

A dictatorial chief executive

Tony Chambers' attitude towards senior doctors flagging fears about Letby was 'dictatorial'. He 'never once scrutinised his own thought process'.

Board presentations were spin

Executive presentations to the board as allegations swirled were 'an exercise in spin', according to Lady Justice Thirlwall.

Reviews instead of police

Hospital bosses commissioned internal and external reviews as an alternative to contacting police. These failed to address whether deliberate harm was being caused.

External review without consultation

Medical director Harvey commissioned the Royal College of Paediatrics to review the neonatal unit without consulting the medics who raised concerns, rather than call police.

Indefensible delay

The failure to call police in July 2016 was 'impossible to defend', Lady Justice Thirlwall concluded in her 800-page report.