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The Letby inquiry: a complete failure to protect babies
An 822-page inquiry found NHS bosses chose the hospital's reputation over dead babies, and three of them might still be alive.
In brief
An 822-page inquiry found NHS bosses chose the hospital's reputation over dead babies, and three of them might still be alive. Suspicion was enough to act. Nobody at the Countess of Chester understood that, and babies died while managers waited to be sure. Originally reported by Dailymail.
Cot cams for every unit
Health Secretary Yvette Cooper has told officials to urgently draw up plans for video baby monitors in NHS neonatal cots and incubators, after the inquiry recommended them.
“I have asked my officials to urgently develop plans for cot cams”
A deterrent and a comfort
The monitors would let parents watch their baby on a livestream from anywhere, and act as a deterrent to the rare person who wants to harm babies.
Three babies who should have lived
Lady Justice Thirlwall found that two triplet brothers, Baby O and Baby P, and a baby girl, Baby I, would have survived if bosses had put proper safeguarding in place.
Complete failure at every level
The judge's verdict on the Countess of Chester neonatal unit was blunt. Managers and senior nurses never accepted that the consultants' suspicions about Letby could be true.
“There was a complete failure to protect babies on the neonatal unit”
Reputation came first
Rather than call police, executives commissioned external reviews that explained nothing. Parents were kept in the dark for years, which the judge called reprehensible.
“The lack of consideration shown to the parents at that time was reprehensible”
Whistleblowers were punished
Doctors who kept demanding police involvement were threatened with GMC referrals and hospital chiefs tried to manage them out of their jobs.
Suspicion was enough
No one grasped that you do not need proof to raise a safeguarding concern. Letby could have been moved off the ward as a neutral act while it was investigated.
“Suspicion is enough.”
The insulin blood test
In August 2015 a test showed Baby F, a twin boy, had been poisoned with insulin. The judge called it a bright line. The consultant who reviewed it disregarded it.
Seven more babies harmed
After that missed signal, a jury found Letby harmed seven more children before she was finally removed from the ward in July 2016. One was left with brain damage.
Walking in on her
In February 2016 Dr Ravi Jayaram found Letby doing nothing to help a baby girl whose breathing tube she was later convicted of dislodging. He did not report it.
“should have had more courage”
The protocol nobody used
Even the first death, Baby A in June 2015, was unexpected enough to trigger sudden death protocols and bring in police. Staff assumed those rules did not apply inside a hospital.
Tribal loyalty to a nurse
Director of nursing Alison Kelly and urgent care nursing director Karen Rees defended Letby because she was one of their profession. Kelly said it never occurred to her this was a safeguarding matter.
The board never knew
No reports on any of the baby deaths reached the hospital board, which the judge called a serious failure of governance.
The inspectors asked nothing
Care Quality Commission inspectors visited in February 2016 but were never handed the data on the spike in deaths, so they did not know what to ask.
The review that was ignored
Eirian Powell and Dr Stephen Brearey documented the unexplained deaths and Letby's presence at nearly all of them. Kelly ignored a request to meet and said it raised no significant concerns.
Shouted down in May
At a meeting on 11 May 2016, the consultants' fears were shouted down by nurses and ignored by executives. Brearey's confidence in his own judgement buckled.
“He did not have to be sure.”
The tipping point refused
After the triplets died on consecutive shifts, Brearey rang Karen Rees to demand Letby be pulled from the next shift. She refused, saying she did not think the doctors were acting in good faith.
A pass at her
Rees told the inquiry she believed Brearey and Letby were in a relationship and asked the nurse if he had made a pass at her. The judge called the theory ridiculous, with no evidence behind it.
“There was no evidence in support of this theory, but she believed it.”
The decision that was reversed
On 29 June 2016 Ian Harvey and Alison Kelly agreed police must be called. After chief executive Tony Chambers was told about the deaths, the decision was undone.
Exonerated by nothing
Harvey drip-fed information to the reviewers he hired, then misled families about what they found. With every innocent explanation ruled out, the judge said failing to call police was impossible to defend.
“The worry should have increased exponentially.”
The main idea
Suspicion was enough to act. Nobody at the Countess of Chester understood that, and babies died while managers waited to be sure.
