Babies’ lives would have been saved if hospital bosses had acted sooner to remove Lucy Letby, a report leaked to the Mail’s The Trial podcast has revealed.
Inexperienced NHS managers missed 14 opportunities to suspend the nurse when the link between her and infants’ deaths on the Countess of Chester Hospital’s neo-natal unit was made, the investigation found.
They ‘completely ignored’ an internal staffing review highlighting Letby was on duty every time a child died and became ‘blinkered’ to the possibility she was responsible.
Instead of alerting the police, the bosses commissioned external investigations which failed to discover why babies were dying.
Executives also ‘ostracised’ and ‘bullied’ doctors when they continued to raise concerns and demand police be called in, the report – commissioned after Letby was first arrested – revealed.
The baby killer, 35, is serving 15 whole-life sentences after being convicted of murdering seven infants and attempting to murder seven more, one of whom she attacked twice, between June 2015 and June 2016.
Barristers for the managers yesterday applied to suspend the public inquiry investigating her crimes, led by Lady Justice Thirlwall, saying there was a ‘real possibility’ Letby’s convictions may be overturned. Kate Blackwell KC said ‘new’ evidence was being considered by the Criminal Cases Review Commission, which looks at miscarriages of justice, and any report made may become ‘redundant’.
But Richard Baker KC, for the families, said the application was another attempt by Letby to ‘cynically control’ the narrative. He insisted the evidence presented by a panel of experts and her defence team at a press conference last month was ‘nothing new’ and accused the bosses of trying to pause proceedings to avoid criticism.
Mr Baker said their failure to stop these crimes ‘allowed babies to die or be harmed’, adding: ‘The trust and leaders put reputation ahead of patient safety.
‘[They] lied to the families, misled external organisations, misled its own board of directors and ultimately tried to avoid a police investigation at all costs.’
The bombshell report found NHS managers missed 14 opportunities to suspend Lucy Letby (pictured). Listen to the full report on Mail podcast The Trial now. Only on The Crime Desk, from The Daily Mail. Subscribe here.
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Letby was initially found guilty of murdering seven infants but was also on duty or had recently clocked off shortly before another six died
The leaked report, by healthcare consultancy Facere Melius, does not reveal which babies might have lived but makes clear that, by February 2016, the hospital’s then-medical director, Ian Harvey, and ex-director of nursing, Alison Kelly, knew the link between Letby and the deaths.
She tried to kill four children, Babies K, L, M and N, and murdered two triplet brothers, Babies O and P, before being removed in July that year.
‘Earlier action potentially would have reduced the number of baby deaths,’ the independent report concluded. ‘Had different decisions been made the spike in baby deaths would have been picked up sooner internally and externally and, potentially, lives could have been saved.’
Entitled Hidden in Plain Sight, the investigation was ordered by Dr Susan Gilby, who took over from former hospital boss Tony Chambers when he was forced out in September 2018, three months after Letby’s arrest.
Dr Gilby told the public inquiry into the murders she wanted the document published soon after Letby was convicted, in August 2023, but her request was met with ‘a great deal of resistance’ from NHS bosses – and its contents have never been made public until now.
The 243-page report focuses on 13 baby deaths that occurred on the neo-natal unit between June 2015 and June 2016 and the hospital’s response to the rising mortality rate. Letby was found guilty of murdering seven infants but was on duty or had clocked off shortly before another six died.
Facere Melius analysed more than 25,000 pages of emails, meeting notes and minutes, notebooks and reports, and talked to 34 hospital staff members.
They found medics tried 15 times to raise concerns, but calls for a review of each death were ‘continually dismissed’ as bosses were ‘paralysed’ by the risk of ‘reputational damage’.
Alison Kelly, the former director of nursing at the Chester hospital, arrives at the Thirlwall Inquiry at Liverpool Town Hall last year
The Countess’s former medical director Ian Harvey arrives to give evidence at the inquiry
The report was ordered by Dr Susan Gilby, who succeeded Mr Harvey as the hospital’s medical director following Letby’s arrest
Bosses kept the hospital board in the dark about the spike in deaths, which was not flagged or scrutinised at the hospital’s patient safety committee.
They also flouted NHS whistleblowing protocols and safeguarding guidelines, which meant they ‘comprehensively failed’ to protect children from harm.
Facere Melius learned the first crucial mistake was made as early as June 2015 – soon after the first three infants died.
Ruth Millward, who was the hospital’s head of risk and patient safety, misinterpreted NHS guidance and failed to class the deaths as a ‘serious incident’.
No one from an outside agency was subsequently given the chance to track the rise in mortality from the start.
As the executive responsible for safeguarding, Ms Kelly should also have flagged the deaths to the hospital’s safeguarding board and the local safeguarding children board, the report said.
She told the public inquiry looking into Letby’s crimes it ‘never occurred’ to her that such baby deaths could be a safeguarding matter. But the report found she had a ‘lack of understanding’ and her failure to consult others was a ‘serious omission’. In February 2016, Ms Kelly and Mr Harvey, an orthopaedic surgeon, were sent a table highlighting that Letby was on duty for all but one of ten infant deaths over nine months.
Still nothing was flagged to the authorities. There were 16 meetings between July 2015 and June 2016 but the deaths and Letby’s presence were never discussed.
Only when the two triplets, Baby O and Baby P, were murdered on consecutive shifts in June 2016, was the board told.
Mr Harvey then asked the Royal College of Paediatrics and Child Health to conduct a review into the neo-natal unit. When they advised that a review of each death be conducted by a neonatologist and pathologist he ‘failed to comply’, the report said.
Mr Harvey instead presented ‘at times misleading’ information to the hospital board, which was enough for it to allow Letby to return to the neo-natal unit.
The report also found Mr Harvey and Mr Chambers ‘bullied’ medics when they refused to drop their concerns. The pair denied this when they gave evidence to the Thirlwall Inquiry in November.
Cheshire police is continuing its investigation into Letby, who has twice failed to have her convictions overturned on appeal.
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