The grieving families of Lucy Letby’s victims have demanded the government orders a full independent public inquiry into how the nurse was able to go on a prolonged killing spree at a neonatal unit.
The families join senior doctors and MPs who want the inquiry upgraded, amid fears it lacks the powers needed to unearth potential evidence of a cover-up at the Countess of Chester Hospital, and prevent a similar horror from ever unfolding in the NHS again.
Health secretary Steve Barclay announced an independent inquiry on Friday after Letby was found guilty of murdering seven babies and the attempted murder of six others in the hospital where she worked between June 2015 and June 2016.
But he stopped short of setting up an inquiry with statutory powers, meaning witnesses will not be required by law to attend, raising concerns that hospital managers could avoid being held accountable for putting reputation before child safety.
Lawyers representing the families of two of Letby’s victims fear this may mean they will never truly get justice and labelled the current plan “inadequate”, while one of the doctors instrumental in finally stopping Letby’s heinous campaign demanded NHS bosses be forced to “acknowledge that their actions potentially facilitated a mass-murderer”.
In a joint statement, Richard Scorer and Yvonne Agnew of Slater and Gordon, who are representing two of the victims’ families, said: “As a non-statutory inquiry, it does not have the power to compel witnesses to provide evidence or production of documents and must rely on the goodwill of those involved to share their testimony. This is not good enough. The failings here are very serious and an inquiry needs to have a statutory basis to have real teeth.
“An inquiry also needs to look at why the NHS’s ‘duty of candour’ seems to have failed in this case, with hospital managers seemingly prioritising the hospital’s reputation above child safety.
“We do not believe that ‘duty of candour’ is an adequate substitute for a proper mandatory reporting regime, and any inquiry needs to examine this issue properly as failings here could be replicated elsewhere in the NHS.”
MPs and doctors have raised concerns that the inquiry cannot compel hospital managers to give evidence— (Sourced)
Senior doctors working with Letby warned for months that she had been the only medic present during the sudden collapses and deaths of a number of premature babies at the hospital in North West England.
However, their concerns were ignored and one consultant said babies could have been saved had hospital management acted sooner. But senior doctor Ravi Jayaram claimed he was persuaded not to contact the police because it would harm the hospital’s reputation.
Dr Jayaram, one of the doctors whose evidence helped convict Letby, called for “fundamental change in the culture and governance of NHS institutions”, adding that “it should start right now”.
He urged managers involved in the case, who are “still earning six-figure sums of taxpayers’ money or retired with their gold-plated pensions”, to “stand up in public to explain why they did not want to listen and do the right thing, to acknowledge that their actions potentially facilitated a mass murderer and to apologise to the families involved in all of this”.
Letby, who worked at the Countess of Chester Hospital between June 2015 and June 2016, on the day of her arrest— (PA Media)
The Countess of Chester Hospital is facing mounting questions over why Letby was not removed from the neonatal unit sooner. Concerns about her were first raised in June 2015 after three babies died over a period of two weeks. It was at this point Letby’s name was first mentioned among a group of consultants, one of whom was Dr Jayaram.
Despite this, she continued to work at the unit for a further 12 months until she was moved to clerical duties in July 2016 – after she had murdered seven newborn babies and tried to kill six others. The court heard that, on one occasion, a doctor walked into the room while she was suspected of being in the process of trying to kill a premature baby in February 2016.
Letby was convicted of the murder of seven babies and attempted murder of six others— (AFP via Getty Images)
Dr Susan Gilby, the hospital’s former chief executive who took over after Letby was arrested and has since left the trust, told The Independent she backed calls for a full public inquiry.
Dr Gilby commissioned an independant review of the management response to concerns raised by the paediatricians about Letby and called for it to be made public.
“The review should be complete by now. Provided all legal formalities are complete, the review needs to be shared with a public inquiry and with the families involved,” she said.
“When I met with the doctors on first joining the trust, I found them to be traumatised by the treatment they had received. I was shown evidence that they had been told to draw a line under the issues raised, forced to apologise to Letby and even to enter into mediation with her. It seemed that their clinical specialist knowledge had been disregarded.”
Conservative MP Dr Caroline Johnson said it was “completely unacceptable” that the hospital’s management did not immediately act on concerns flagged by the consultants.
Speaking to BBC Radio 4’s Today programme on Saturday, the consultant paediatrician and Commons health committee member, said: “To my mind, as it has been reported, it is completely unacceptable.
“To ignore one consultant, if the other six disagree, perhaps you could think ‘that is wrong’, but you could understand it. But when you’ve got seven paediatricians, experts in their field, looking after babies in a neonatal unit, telling you in their expert opinion that these events are unusual and they should not be occurring and there are unexpected collapses that are unexplained in babies that are leading to death, to then say you are not going to take action seems completely remarkable to me."
Dr Johnson said the consultants who raised concerns would have been “powerless to do anything more” because they did not have any “jurisdiction over the nursing hierarchy”.
The Sleaford and North Hykeham MP said there needed to be “clear lines of accountability in the NHS” to establish “who is accountable for making what decisions”.
She added that she backed the government’s decision to announce an independent review but warned ministers would need to “look again at the type of inquiry” if those working at the hospital “don’t come forward”.
Samantha Dixon, Labour MP for Chester, also raised concerns about a non-statutory inquiry.
“I do have some concerns about the risks around a non-statutory inquiry in that people are not obliged to attend and to give evidence,” she told BBC Breakfast.
The families of Letby’s victims have said they have been left “heartbroken, devastated, angry and feel numb” by her actions. But it is expected they will not see her when she is sentenced on Monday after the serial killer refused to attend court and will not take part in the hearing via video link from prison.
Lawyers representing some of the families have vowed to continue their search for answers.
Dr Bill Kirkup, a leading patient safety investigator, said the Letby case highlighted the “tragic” consequences of hospital managers “protecting reputations” above listening to the concerns of staff. He said there were “common features” between the Letby case and reviews he has conducted into poor care in maternity units in other hospitals.
“The first reaction of people under these circumstances in management, controlling organisations, is to protect reputations – the organisation’s reputation, their own reputation,” he told BBC Breakfast. “And when that comes ahead of being open and honest about what’s going on, that’s tragic. We have to be able to stop this.”
There were 13 deaths on the neonatal unit where Letby worked over a one-year period, the BBC reported, which is five times the usual rate, and the nurse was on duty for all of them.
In October of that year, after seven babies had died, a link was made between all the fatal collapses and Letby, who prosecutors described as a “constant malevolent presence” in the care of the infants. Despite this, the link was believed to be coincidental.
Dr Gilby, who took over as the hospital’s medical director a month after Letby was arrested, told the BBC: “The paediatricians were discussing the terrible nights on call that they were having. One of them said, ‘Every time that this is happening to me, that I am being called in for these catastrophic events which were unexpected and unexplained, Lucy Letby is there, and then somebody else said, ‘Yes, I found that,’ and then someone else had the same response.”
Paediatrician Dr Stephen Brearey, who blew the whistle on Letby in 2015, told The Guardian the hospital had been “negligent” in its handling of the killings.
Tony Chambers, the hospital’s former chief executive who was in charge at the time of Letby’s murders, said he would cooperate “fully and openly” with the inquiry.
Dr Nigel Scawn, medical director at the hospital, said in a statement on Friday: “Since Lucy Letby worked at our hospital, we have made significant changes to our services and I want to provide reassurance to every patient that may access our services that they can have confidence in the care that they will receive.”
But he walked away without answering when a journalist asked: “Why did hospital managers try to stop Lucy Letby from being investigated?”
The Department for Health and Social Care had said the independent inquiry would look at the circumstances surrounding the deaths and incidents, including how concerns raised by clinicians were dealt with.
But it said that “after careful consideration, a non-statutory independent inquiry was found to be the most appropriate option” and it would instead “focus on lessons that can be learned quickly”.
Mr Barclay said the inquiry would “seek to ensure the parents and families impacted get the answers they need”.
