A hospital boss has apologised to the families of Lucy Letby’s victims “for the pain that may have been prolonged” by his decision-making.
Tony Chambers was chief executive of the Countess of Chester Hospital during the time the neonatal nurse murdered seven babies and attempted to murder seven others in 2015 and 2016.
Giving evidence at the Thirlwall Inquiry into the events surrounding Letby’s crimes, Mr Chambers said: “Right at the outset I just want to offer my heartfelt condolences to the families whose babies are at the heart of this inquiry.
“I can’t imagine the impact this has had on your lives and I am truly sorry for the pain that may have been prolonged by any decisions or actions I took in good faith.”
The former nurse told the hearing the first he knew of concerns from consultant paediatricians that Letby may be deliberately harming babies was when he met them in late June 2016.
Letby was redeployed to an administrative role when she returned from annual leave in July but was due to go back to the unit weeks before the police were finally called in by the hospital in May 2017 after bosses had instead opted to commission a series of reviews to look at the increased mortality.
Speaking of the June 2016 meeting, Mr Chambers said: “This was very shocking to hear. I have always felt the concerns they were raising were always based on their honest belief of their concerns as they understood them to be.
“I heard what they had to say. I needed to reflect on what else could be going on here.”
Counsel to the inquiry Nicholas de la Poer KC said: “Did you have difficulty accepting that they were speaking there as experts?”
Mr Chambers replied: “Absolutely not at all.”
Mr de la Poer asked: “Do you agree that there was a rational basis for them to be suspicious that serious crimes had taken place?”
Mr Chambers said: “Based on what was being presented there I had no reason to believe that there was no rational basis for what they were saying, but what I do know from my experience across the NHS is that we wouldn’t jump to criminality as a causal factor. We would want to explore a broader set of answers to those very difficult questions.”
Mr de la Poer said: “You know that they had looked at equipment, you know they had looked at clinical matters. They told you they had conducted a number of other investigations to exclude ordinary explanations within the NHS, didn’t they?”
Mr Chambers replied: “As you can see in the notes, post-mortems had been completed. There may have been a lack of agreement with the outcomes of those post-mortems but they had been completed, so it wasn’t clear.”
Mr de la Poer asked: “Neonatal clinical lead Dr Stephen Brearey has given evidence to this inquiry that he formed the impression that you thought the concerns they were were raising was to hide the doctors’ failings; was that your view?”
“Absolutely not,” said Mr Chambers.
When police were called in to investigate, Mr Chambers told them the executives “felt that the explanations for what had happened do not lie in a single place or cause and are certainly not criminal”, the inquiry heard.
Mr Chambers said: “I think it’s fair to say that we were very much taking the independent experts’ view that there were no unnatural causes of deaths identified, there were two cases that were unascertained.”
He said one of the reviews had noted clinical failures that “may well have changed the outcomes” and they had received legal advice which concluded there was not enough information to suspect a criminal offence had been committed.
Mr de la Poer said: “This wasn’t an investigation you were encouraging, it was an investigation you were discouraging.”
Documents displayed at hearings will be uploaded to #ThirlwallInquiry website after being reviewed for redactions and ciphers. Visit our evidence library:https://t.co/BiFG911e2f
— Thirlwall Inquiry (@Thirlwall_Inq) November 18, 2024
Mr Chambers replied: “Absolutely not.
“What we were saying is ‘We couldn’t find any evidence of criminality, you are the experts so please help us’.”
He said they were “ordinary people trying to deal with an extraordinary situation”, trying to make the best sense out of “confusing information”.
“The only thing there was an absolute consensus on was that we didn’t really know what the the causes of death were,” he added.
He said the information they had gathered from various reviews was “pointing away from deliberate harm”.
Mr Chambers said he had listened to both the concerns of the doctors and the support offered to Letby by fellow nurses.
He said: “It’s easy, really easy, when you look at these matters in the context of what we now know following a four-year police investigation, a 10-month trial and a retrial.
“But in 2016, and it’s probably the case even now, in the NHS the biggest cause of unnatural, unexplained deaths in maternity and neonatal units was not deliberate harm but failings in systems and care. There are many examples.”
Mr Chambers was reminded of an interview he gave to a local newspaper in February 2018 in which he said: “We have had various inquiries including the Royal College of Paediatrics review and there were just a few niggles that our clinicians said, ‘Look, we think we have got 90% of the answers but there are still bits that we need to, in a sense, be clear that we have not missed anything’.”
Mr de la Poer asked: “That is not an accurate characterisation of the consultants’ position before you went to the police, is it?”
Mr Chambers replied: “Yes, I agree with that. It certainly was clumsy.
“I wrote to the paediatricians once this article went out to apologise.”
The article also reported that Mr Chambers “candidly acknowledged communications with parents could have been better in the early days but overall feels the situation has been managed ‘really well’.”
Mr Chambers told the inquiry: “I know, listening to the families’ evidence at the start of this inquiry, we didn’t get it right in terms of the communications with families and I’m so terribly sorry about that.
“It was not me deliberately trying to be misleading or trying to trivialise or paint a picture that we were getting everything right.”
He told the inquiry his biggest personal failing was the communications with families which “could and should have been better”.
He also accepted that the trust’s systems failed and “there were opportunities missed to take earlier steps to identify what was happening”.
Mr Chambers said: “I think, as the accountable officer, it’s my responsibility for the safety and the delivery of safe care within the hospital, and clearly the processes we had in place weren’t being used properly and I must take some responsibility for that.
“But, as a chief executive of a large hospital with over 4,000 staff, you are very much reliant upon your people, the five different layers of governance that exist in the hospital, to do their job.”
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, sitting at Liverpool Town Hall, is expected to sit until early 2025, with findings published by late autumn of that year.
