Missed chances to probe patient safety during Letby attack spree, inquiry told

A number of opportunities were missed to ask more questions about patient safety during the 12-month attack spree of Lucy Letby, a NHS chief has told a public inquiry.

Former neonatal nurse Letby, 35, murdered seven babies and attempted to kill seven more between June 2015 and June 2016, but during that period the Countess of Chester Hospital only flagged up three “serious incidents” to NHS England.

Giving evidence on Friday, Professor Sir Stephen Powis, national medical director for NHS England, said the organisation was not aware of suspicion around a particular member of staff until March 2017.

Letby was moved out of the unit to non-clinical duties in June 2016 shortly after consultant paediatricians told bosses at the Countess of Chester that they feared she may be deliberately harming babies after the unexpected deaths on successive days of two triplet boys, Child O and P.

A series of independent reviews into the increased mortality were commissioned by executives as police were not called in to investigate matters until May 2017.

Sir Stephen told the Thirlwall Inquiry into events surrounding Letby’s crimes that a total of 16 incidents were reported in the 12-month period to its national and reporting learning system before she was removed from the neonatal unit.

He said: “Only three of them, one at the very start of that period and two right at the end, were reported through our serious incident process – in other words were declared as serious incidents.

“If more had been declared, then there would have undoubtedly been more scrutiny … it would have led to more questions, to more curiosity, during that period.

“Then, afterwards, if we had known that there was concerns around an individual we would have undoubtedly have required the police to be involved at an earlier point.”

Letby administered fatal injections of air to Child A, Child C and D within a fortnight in June 2015, but only the death of Child D was referred to NHS England, and then latterly the deaths of Child O and P in June 2016.

Sir Stephen told the inquiry he would have expected the three deaths in June 2015 to have been declared serious incidents.

He said: “The fact only one was reported meant that it did not trigger the concerns that a cluster of reports would have. And a year later when Baby O and P were reported in a very short timespan that immediately triggered concerns among the (NHS England) commissioners to scrutinise further and to seek further information.

“So if those in that initial cluster had been referred as a serious incident report, I am confident it would have triggered the same level of inquiry and curiosity from commissioners that occurred a year later.”

He added: “From the evidence I have seen, even with that first cluster of death, concerns around a particular member of staff were raised.”

Apologising “on behalf of the entire NHS” for the “abhorrent” events at the Countess of Chester, Sir Stephen said: “We recognise there were a number of missed opportunities where individuals within the trust but also individuals outside the trust including NHS England and its legacy bodies could have intervened, could have asked questions, could have been more curious.”

He said NHS England were kept informed of the independent review by the Royal College of Paediatrics and Child Health (RCPCH) launched in September 2016 into the increased mortality and said it “possibly could have asked more questions about the nature of the review”.

Sir Stephen said: “As it got towards the end of 2016, colleagues at NHS England and its legacy bodies were becoming more frustrated, more concerned, about the openness and the transparency of what was occurring at the Countess of Chester.

“We were not aware that there was suspicion around a particular member of staff until March 2017 and at that point it was our view the correct thing to do would be to involve the police.”

Counsel to the inquiry Rachel Langdale KC asked: “What do you think might have made that difficult to express those concerns about a member of staff – whether you are a doctor or manager?”

Sir Stephen said: “I think there are three things relevant here.

“One is the culture within an organisation, that culture of curiosity and openness.

“Clearly, from the evidence I have seen there were concerns around a particular member of staff at a very early stage, right at the beginning when the first cluster of deaths occurred, but that curiosity to an extent was not shared with all members of the leadership team within the Countess of Chester, and as I have already said NHS England became increasingly concerned about openness and transparency, and the culture of involving others.

“Secondly, you have processes and systems in place to allow escalation. Incident reporting was in place, safeguarding was in place. An early version of Freedom to Speak Up was in place.

“In our view, they were not used in a way they should have been used and that would have resulted in further escalation, further scrutiny and further curiosity.

“And, finally, you need to be aware of the possibility, however rare, however infrequently, that a healthcare professional could deliberately cause harm.

“Clearly, that possibility did arise in the minds of the paediatricians at a very early stage and became more of a concern as 2015 progressed into 2016.

“If it suspected that deliberate harm is occurring, then other agencies should be informed and, of course, foremost among those are the police.”

Letby, from Hereford, is serving 15 whole-life orders after she was convicted at Manchester Crown Court of murdering seven infants and attempting to murder seven others, with two attempts on one of her victims.

The inquiry will reconvene at Liverpool Town Hall on March 17 for closing submissions, and findings by chairwoman Lady Justice Thirlwall are expected this autumn.