A leading patient safety investigator has highlighted the “tragic” consequences of hospital managers “protecting reputations” above listening to the concerns of staff after serial killer Lucy Letby was found guilty of murdering babies in her care.
Numerous staff raised concerns about the actions of baby-killer Letby as she conducted a year-long killing spree at the Countess of Chester Hospital.
The 33-year-old nurse was convicted of the murder of seven babies and the attempted murder of six more during her shifts on the neonatal unit between 2015 and 2016.
The Countess of Chester Hospital is under mounting pressure over why the nurse was not removed from the neonatal unit sooner.
Dr Bill Kirkup said there were “common features” between the Lucy Letby case and reviews he has conducted into poor care in maternity units in other hospitals.
And an MP and paediatrician said it was “remarkable” that concerns of staff were not acted on.
It comes as police said they are reviewing the care of 4,000 babies who were admitted to the Countess of Chester – and also Liverpool Women’s Hospital when Letby had two work placements – going as far back as 2012.
And the Government has ordered an independent inquiry into the circumstances behind the murders and attempted murders.
Dr Kirkup, who led the reviews into poor care in maternity units in Morecambe Bay and East Kent, told BBC Breakfast: “I think there are a number of common features that underpin a lot of these different investigations and ring bells with what I’ve been hearing about what happened in the Countess of Chester Hospital, particularly the difficulty in persuading people that there’s a real problem here that must be investigated and must be looked at properly and independently.
“And particularly the chasm that can open up between clinicians who are reporting problems and managers who don’t necessarily want to hear.”
He added: “I heard yesterday for the first time in this connection, the phrase ‘protecting reputation’ on the part of the Trust and that rings a massive bell for me because that’s been a feature of everything that I’ve been involved with for the last 12 years or so.
“The first reaction of people under these circumstances in management, controlling organisations, is to protect reputations – the organisation’s reputation, their own reputation.
“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.”
The families of her victims have said they have been left “heartbroken, devastated, angry and feel numb” by her actions.
But is expected they will not see Letby when she is sentenced on Monday after the serial killer has indicated she will not take part in the hearing at Manchester Crown Court.
Lawyers representing some of the families have vowed to continue their search for answers.
Meanwhile MP and paediatrician Dr Caroline Johnson said that it was “completely unacceptable” that Countess of Chester Hospital management did not immediately act on concerns flagged by consultants.
“To my mind, as it has been reported, it is completely unacceptable,” the Conservative MP told BBC Radio 4’s Today programme.
“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 Kirkup said that the independent inquiry will give families a “chance to be heard”.
“I think the families who have suffered this unimaginable harm, need a chance to be heard, I think that the people involved at the hospital need the chance to be heard,” he said.
“Secondly, it does allow you to find out, usually very rapidly, what exactly the underlying problems were.”
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.
She could have been stopped as early as June 2015 when executives held a meeting where it was agreed an external investigation into the deaths would be held but it never was, the broadcaster said.
In October that year, after seven babies had died, a link was made between all the fatal collapses and Letby, whom prosecutors described as a “constant malevolent presence” in the care of the infants.
Despite this the link was believed to be co-incidental.
Dr Susan 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.
Consultants wanted to go to the police but officers were not called and, in September 2016, the Royal College of Paediatrics and Child Health was called to carry out a review of the unit, the BBC said.
It urged the trust to probe each death individually but this did not happen, it has been reported.
The killer nurse launched a grievance procedure against the paediatricians which found she had been “discriminated against and victimised”, and they were forced to write her an apology letter.
She was later taken off the neonatal unit that month following the deaths of two triplet boys.
She was still working at the trust when she was arrested at her semi-detached home in Westbourne Road, Chester, at 6am on July 3 2018.
During searches of her address, a number of handwritten notes were discovered.
On one green Post-it note, she wrote “I don’t deserve to live. I killed them on purpose because I’m not good enough to care for them”, “I am a horrible evil person” and in capital letters “I am evil I did this”.
Speaking to the BBC, Dr Gilby said of that time: “The strong opinion was that there would be nothing found.
“There was a brief overlap of three or four days between myself and the outgoing medical director, and his parting words to me were ‘you need to refer the paediatricians to the General Medical Council’.”
Former Countess of Chester Hospital NHS Foundation Trust chief executive Tony Chambers, who was in charge at the time, said he would co-operate “fully and openly” with the inquiry.
Dr Nigel Scawn, medical director at the Countess of Chester 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 as a journalist asked: “Why did hospital managers try to stop Lucy Letby from being investigated?”
