Lucy Letby: comment on convictions ‘has caused enormous stress for parents’, inquiry hears – live | Lucy Letby

Rachel Langdale KC has said that the inquiry will seek to determine whether internal reviews after the deaths of two of the triplet in the summer of 2016 were reflected in a “balanced and accurate summary” when management were told “nothing of significance was identified” in what was described as a “thorough internal review”.

The Thirlwall inquiry has been told by Rachel Langdale KC that during 2016 it was the deaths of Child O and Child P that first led the senior management to discuss “unexplained instances of infant mortality” in the department.

By the end of June 2016, Langdale says, “senior paediatricians were in agreement, Letby should be removed from the ward on the grounds of patient safety.”

Rachel Langdale KC has read out an email from Dr Brearey in which he conveyed in strong terms that the senior paediatricians did not believe Lucy Letby should have continued access to patients. This was again not acted on upon by the hospital.

Langdale is also saying the inquiry will be investigating why the first mention of involving the police in the case was in July 2016, but no action was taken to do so until a year later.

After one of a set of triplets unexpectedly died in June 2016, the inquiry is told concerns were raised about Lucy Letby’s presence, but this was not escalated and she was not taken off duty. A second of the triplets subsequently suddenly died, and the parents of the triplets have told the inquiry they believe it was only their insistence that the third child was moved to a different hospital that saved its life.

Rachel Langdale KC explains that there is some dispute in the timelines given by staff at the hospital in their evidence of the precise timing of who raised issues when with Letby’s presence over that weekend. She says the inquiry will examine this in oral testimony.

The Thirlwall inquiry has now resumed after lunch. Counsel to the inquiry Rachel Langdale KC is continuing to give the opening statement. She is running chronologically through the events at the Countess of Chester hospital. This morning she suggested that the evidence given to the inquiry so far indicates there were missed opportunities to prevent Lucy Letby from murdering and harming babies, and that the inquiry will address this.

Key moments from the first morning of the Thirlwall inquiry

The Thirlwall inquiry has risen for a lunchtime break.

The Thirlwall inquiry is hearing about a chain of messages about staffing at the hospital discussing Lucy Letby being moved on to day shifts, after some staff at the hospital had noted her presence at all of the deaths and the near fatal collapses in question. Rachel Langdale KC says the inquiry will be examining whether people at that point were more concerned with pressing issues of filling the staffing rota rather than escalating why Letby had been moved.

The inquiry is told that consultant Stephen Breary raised specific concerns about Letby in October 2015. These appear to have been dismissed by the neonatal unit ward manager, who seemed to have taken a view that it was “unfortunate” that Letby had been present.

Langdale told the inquiry that this appears to be the tone of the hospital response, that regardless of them being raised by a senior figure, the concerns were not seen as “urgent”.

Rachel Langdale KC has pointed out that non-fatal unexpected collapses were not included when there were review meetings into neonatal deaths, and that had that happened, it may have become clearer that Lucy Letby was on duty on all these occasions.

She points out that the Clothier report into the deaths of children at the hands of Beverley Allitt in the 1990s had recommended they be recorded.

The Thirlwall inquiry has been told that the death of Child E was another “missed opportunity”, and that the death of Child F should have been flagged up because of a test result indicating the presence of synthetic insulin.

The death of Child E was the fourth unexpected death in the space of two months, and the inquiry was told that head of risk and patient safety at Countess of Chester hospital Ruth Millward accepts it should have been flagged as a serious incident, which would have triggered an investigation.

In a statement given to the inquiry, one of the doctors involved in the cases, who has been granted anonymity, said it was assumed the test on Child F’s blood was inaccurate because it would have been “absurd and ridiculous unlikely” that anybody would have administered it to the baby. “The test being wrong seemed the only possible explanation,” they said.

Consultant Dr John Gibbs has, the inquiry heard, described it as a “collective failure”.

Rachel Langdale KC has said to the inquiry that one of the questions the Thirlwall inquiry is seeking to answer is whether the structures and processes at the hospital contributed to the failure at the Countess of Chester to protect the babies in its care.

She says it is “striking” that when there was a July 2015 meeting held to discuss the deaths there was only one doctor present, and that they, Dr Brearey, “had not personally been involved” in any of the attempts to resuscitate the babies.

Langdale says the inquiry will look at the hospital’s processes around recording infant deaths, its holding of risk registers, and the governance structure.

The Thirlwall inquiry has been told that at a July 2015 meeting at the Countess of Chester hospital after the deaths of three babies in quick succession it was decided that “no further investigation was warranted”.

Addressing the inquiry, counsel Rachel Langdale KC said the inquiry would examine if this was an “opportunity missed”.

She said that as well as not recommending further investigation, the meeting did not examine which staff had been present on each occasion, nor did it include the sudden near fatal collapse of Child B in the cases it was examining, despite it falling into the same period and staff at the time having noted similarities between Child B, who survived the collapse, and Child B’s twin Child A, who died.

Langdale suggests that had consideration been given to the collapse of Child B, and to the staffing make-up during the incidents, then it could have been noticed in that July that Letby had been present “at each sudden and unexpected death.”

The inquiry was told that the issue of which staff were working was not looked at again until a further two children had died.

The inquiry has been hearing about the death of Child D. It was, Rachel Langdale KC says, “the third neonatal death in under two weeks.”

“This exceeded the total number of deaths in 2013, two deaths, and equalled the total deaths in 2014, three deaths,” she says, adding that there had also been the near fatal collapse of Child B during the same period of time. She noted that Lucy Letby had been present on each occasion.

On-call consultant Dr John Gibbs has said in a statement to the inquiry “it was recognised that Letby had been present on each occasion, and this was also noted at the serious incident meeting.”

He went on to say in his statement “Letby worked more shifts than other neonatal nurses and I felt, as did my consultant colleagues at the time, that she was merely unfortunate to have been involved in the cluster of deaths. I was not suspicious of deliberate patient harm.”

Langdale says Child D had an unusual rash, as had Child A. She says there appears to have been a desire to arrange a staff debrief after the death of Child D, but “there do not appear to be minutes.”

Langdale says that in later oral evidence the inquiry will seek to find out more information about what was raised at contemporary meetings.

Rachel Langdale KC said one of the key questions before the inquiry was whether a “bias” towards Lucy Letby influenced the hospital’s response.

She said the inquiry would examine why detailed medical analysis of the deaths and collapses of babies did not take place earlier, and noted that “It was not until April 2017, almost two years after the first murder, that the hospital made a referral to the police and detailed multi-disciplinary medical scrutiny and analysis was finally conducted.”

The third part of the Thirlwall inquiry will consider wider NHS culture, governance and management structures.

The Thirlwall inquiry has been told that doctors admitted that the process for reviewing child deaths at the Countess of Chester hospital was “disparate and inconsistent.”

Rachel Langdale KC, counsel for the inquiry, has told the chair Lady Justice Thirlwall that the death of Baby A was “not just unusual, but also unexpected” and had left doctors and nurses shocked. Nobody at the time, Langdale said “considered the death of Baby A to be anything malicious.”

Langdale explained that the death of Baby A and the collapse of Baby B happened within a 36 hour period. They were twins. She said that Child A’s death was not reported as a “sudden unexpected death in childhood” as it should have been.

Langdale says that of the seven babies murdered by Lucy Letby, only Baby C had a doctor attend a sudden unexplained death in childhood meeting. Baby C died six days after Baby A, and four days after the collapse of Baby B.

“The deaths of Baby A and Baby C were unexpected,” Langdale explains, adding that the clinical signs around the deaths were considered “unusual”.

But she tells the inquiry medical staff did not link all the cases, and says to the chair that she might want to consider that other deaths could have been prevented if a different course of action had been taken at this point.

Rachel Langdale KC has said that the purpose of the inquiry is “keeping babies safe in future from a healthcare professional who seeks to harm them.”

She tells the inquiry that it and the presiding chair, Lady Justice Thirlwall, expect “witnesses to tell the truth, no matter how difficult that might be.”

She goes on to say:

You will hear heartbreaking and thoughtful evidence about the experiences of parents whose babies were named in the indictments. You will hear how their lives have been impacted forever.

She says it is important that each of them should be able to tell the inquiry “what happened from their own unique perspectives” in either oral or written evidence.

There are court-ordered reporting restrictions in place to protect the anonymity of the babies murdered by Lucy Letby, or those she attempted to murder. This anonymity extends to their families. The restrictions apply to the inquiry itself, as well as media reporting.

Thirlwall inquiry ‘unwavering focus will not be on examining Letby conviction’ but on the hospital’s response at the time