A senior doctor has told a public inquiry that he is “ashamed” that he failed to protect babies from harm by serial killer nurse Lucy Letby.
Consultant paediatrician Dr John Gibbs apologised to parents of Letby’s 14 victims shortly after he was sworn in to give evidence on Tuesday at the Thirlwall Inquiry into the events at the Countess of Chester Hospital’s neonatal unit.
The now retired medic said: “I deeply regret and I am ashamed that I failed to protect the babies from harm by Letby, but I do understand that the parents concerned would probably prefer explanations rather than apologies.”
He said he and his fellow consultants should have contacted the police in early 2016 before Letby went on to attack other infants including the murders of two triplet boys in June that year.
The inquiry heard that following a third baby death in June 2015, he emailed his consultant colleagues to relay concerns from registrars that the infants involved “showed a strange purpuric looking rash” and that nurses on the unit were also “very worried”.
Dr Gibbs said Letby’s name came up as a “common factor” in July 2015 because she was involved in the resuscitation attempts of all three babies and another infant who was successfully revived.
But he told counsel to the inquiry Nicholas de la Poer KC that he had no suspicions that deliberate harm was being caused at that time.
He said: “It had been felt she had been unlucky to have been involved in a number of incidents.
“It can happen to any of us and it happened to me during my career, that you have a bad run. But then that stops happening if it’s just an unfortunate coincidence.”
Immediate concerns about possible deliberate harm should have been raised, though, in August 2015, he said, with a blood test result which indicated Child F had been administered synthetic insulin.
Dr Gibbs said he did not see the result and his colleagues appeared to not appreciate its significance, but he classed it as a “collective failure” by the paediatric team.
He said: “We all had the chance to look at those results.”
He acknowledged a similar “collective failure” in April 2016 when another infant, Child L, was poisoned with insulin by Letby, but medics again missed the significance of another blood test.
The consultant said he was “unsettled” by the sudden and unexpected death of Child I in October 2015 and that towards the end of that year and into 2016 he became “more concerned”.
Dr Gibbs said: “We were trying to make sense of the number of collapses and deaths that were happening, and realising Letby was around for many of them, not all of them.”
The consultant said the “full enormity of it all hit me” when he saw an external thematic review in February 2016 which looked at deaths on the unit throughout 2015.
He said: “It identified some suboptimal care issues but none of them thought to be significant enough to have caused any of the deaths.”
He said around that time he was perhaps “influenced” but “not convinced” by a “very firm pushback” from senior nurses that suspicions about Letby were “totally wrong”.
Dr Gibbs said: “There was a very strong argument put forward by the senior nurse on the unit that the suspicion was totally wrong and that we were maligning nurse Letby, and she was a very competent, safe nurse.
“I know from Dr Stephen Brearey (the neonatal clinical lead) that there was a very firm pushback from the senior nursing level that this was utterly wrong and we were being very unfair on nurse Letby.
“I was aware what happened at Stepping Hill Hospital where the wrong nurse had been accused because she happened to be on duty every time and someone else had done it and managed to conceal their activities.”
Mr de la Poer said: “If your suspicions were right, then Letby might pose a very serious danger?”
“Yes,” replied Dr Gibbs.
Mr de la Poer said: “If that was your reasoning at the time, does that risk not require immediate action? ”
Dr Gibbs said: “Yes, it should have done but perhaps it was more maybe our views were influenced by the conviction that we were wrong from the nursing side, and I regret that we, or I, didn’t go to the police at this time after the thematic review.”
Letby, 34, 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, between June 2015 and June 2016.
The inquiry is expected to sit at Liverpool Town Hall until early next year, with findings published by late autumn 2025.
