Hospital managers showed a “lack of transparency” by failing to tell a healthcare watchdog about a spike in baby deaths during an inspection that took place nine months after Lucy Letby’s first murder, an inquiry has been told.
A senior manager at the Care Quality Commission (CQC) said executives at the Countess of Chester hospital had a “professional obligation” to alert inspectors to concerns about the rise in neonatal mortality during its review in February 2016.
Ann Ford, a director of operations at the CQC, told the Thirlwall inquiry that inspectors were not told about the “unexplained and unexpected” deaths until hours after it published its report on the hospital on 29 June 2016.
The inspection took place nine months after Letby’s crimes began and at a time when some of her colleagues were voicing fears that she may be harming babies.
That week, the hospital’s medical director, Ian Harvey, and other senior doctors and nurses received a copy of a thematic review of 10 deaths on the neonatal unit. It found there was “no clear cause for the deterioration/death” and that six babies had arrests between midnight and 4am. However, it concluded no common theme had been found in all the cases examined, the inquiry has heard.
Letby, 34, has been convicted of murdering five babies and attempting to murder another three in the nine months to February 2016. She was also found guilty of murdering another two babies and trying to kill a further four between then and July 2016, when she was removed from the neonatal unit.
The inquiry was told on Friday that this thematic review – which added to the mystery surrounding the deaths – was completed on 2 March 2016, days after the CQC’s planned visit in February but before an unannounced inspection on 4 March.
Ford said: “This wasn’t just information. This was about an emerging serious concern. It was a really, really significant issue and I think they should have made us aware of it immediately. Any documentation, any audits, any reviews, any work they had undertaken, should have been shared transparently and openly.”
She added: “What I’m finding very difficult to accept is the lack of transparency in not alerting us to those concerns because I think we would have acted very differently. I really do think the trust had a professional obligation, and an obligation to patients, to be open and transparent with us and I would have liked to have known about those concerns much earlier. I know we would have responded.”
The inquiry heard that detailed notes about the inspectors’ meetings at the hospital had since been lost or destroyed.
Nicholas de la Poer KC, counsel to the inquiry, said there were no records available of any of the core interviews with senior managers, including the hospital’s then chief executive, Tony Chambers, and its chair, Sir Duncan Nichol.
De la Poer said there was an “incomplete record” of a confidential meeting with consultant paediatricians and that “a number of other records which might have been expected to exist … cannot be found”.
Ford apologised on behalf of the CQC for the missing material. “I think I would have to accept that the way we managed the disclosure was not good enough and I think there are profound lessons to be learned and improvements to be made,” she said.
She said the CQC’s policy in 2016 was to destroy paper records related to inspections six months after the publication of the report in question, meaning material connected to the Countess review would have been destroyed in early 2017.
However, she accepted there were “missed opportunities” to retain as much material as possible when it became clear police were investigating the suspicious deaths in May 2017.
It was not until September 2023 – days before the Thirlwall inquiry was announced – that the CQC instructed staff to keep hold of documents potentially relevant to Letby’s crimes.
Ford said the CQC would consider referring itself to the Information Commissioner’s Office over its failure to retain and disclose key material.
