Hospital executives ignored pleas from a nursing chief to call in the police after she was “spooked” by a baby’s pattern of deteriorations when Lucy Letby was on duty, a public inquiry has heard.
Former deputy director of nursing Sian Williams was tasked by senior management at the Countess of Chester Hospital to undertake a staff rota analysis following a series of unexpected deaths and collapses of infants on the neo-natal unit.
The Thirlwall Inquiry into the events surrounding killer nurse Letby’s crimes has heard consultants told bosses at the end of June 2016 that patient safety was at risk and that Letby could be inflicting deliberate harm.
Bosses responded by commissioning an external review and a number of internal reviews rather than bringing in Cheshire Police, the inquiry has heard.
Giving evidence on Tuesday, Ms Williams said her staffing review discovered that Letby was “80% more likely to be on duty either during or before a baby collapsed”.
She presented her findings to the executive team in mid-July but considered them so significant that she sought out medical director Ian Harvey the next day for a one-to-one meeting.
Ms Williams said she highlighted to Mr Harvey the repeated overnight collapses of one baby on three occasions when Letby was on duty but then went back to being stable during the day when she was not present.
She said: “That spooked me, I have to say that spooked me.”
Ms Williams told Shahram Sharghy, representing some of the families of Letby’s victims, that Mr Harvey replied that he would check the information.
Mr Sharghy said: “Did he or any other member of the executive team seem surprised or indeed worried by what you had told them about your findings?”
Ms Williams said: “I don’t recall them saying anything that would give me that impression.”
She also told the executives about a previous occasion “many years ago” when the police were called in about possible deliberate harm being caused on an adult ward at the hospital.
Ms Williams said: “I got a phone call from a previous chief executive saying could I come down? He said somebody had brought this concern that somebody may be switching off pumps which deliver fluids to patients, I think it was in the high dependency setting.
“We had a very brief conversation and said we both believed we should inform the police and they would make their decision as to what do. So he rang the police.
“The police came in straight away. They didn’t want you to do your own investigation or anything like that.”
She said she urged bosses to consider a similar course of action but was repeatedly told they had “taken advice” that they had do to their own investigation first.
Mr Sharghy said: “In terms of the number of times you raised the issue about calling the police and it not being accepted, do you feel there was something wrong with the structure or the system within the trust that effectively didn’t listen to concerns of senior individuals such as yourself?”
Ms Williams replied: “Yes, I got the impression they had taken advice – where from I couldn’t say – and they firmly believed they were following what they should have done.”
She stated to the inquiry that she believed the executive team were “clear in their minds” the deaths were due to poor care and that Letby was not deliberately harming babies.
Mr Sharghy said: “Who discouraged you from going to the police yourself?”
Ms Williams said: “I wasn’t privy to all the information … I should have gone. However, the consultants didn’t do it.”
Mr Sharghy said: “And did you know because of either from your experience on the previous occasion or from just general everyday life, that you could have contacted the police anonymously?”
Ms Williams said: “I never even thought about doing it anonymously.”
The inquiry saw notes from a meeting between executives, managers and clinicians on July 11 2016 which was exploring what to do with Letby following the concerns raised by consultants.
On Monday, #ThirlwallInquiry recommenced its Part B & C evidence hearings. Over the coming weeks, we will hear from managers, reviewers, inspectors and directors. Find out more via the witness timetable 👇https://t.co/cCyvMRiI3E
— Thirlwall Inquiry (@Thirlwall_Inq) November 5, 2024
The then chief executive Tony Chambers was noted to have said: “There is correlation with a nurse but we know change in acuity and activity.
“A week ago only option to ring the police but now more info.
“We can create harm to nurse – fragile toxic.
“Need to protect it.”
Consultant Ravi Jayaram was noted to have said: “Should not be blinkered to the unspeakable. Fine balance, my objectivity compromised.”
Another consultant John Gibbs said: “Main worry is nurse therefore must be totally supervised. Cast iron assurance.”
Later that month, Letby was moved to clerical duties in the hospital’s risk and patient safety department rather than continuing to work supervised on the neonatal unit.
Cheshire Police were finally called by in Mr Chambers in May 2017, but Letby continued to work at the hospital until her first arrest in July 2018.
Letby, 34, from Hereford, is serving 15 whole-life orders after she was convicted at Manchester Crown Court of murdering seven infants and attempting to murder seven others, with two attempts on one of her victims, between June 2015 and June 2016.
The inquiry is expected to sit until early 2025, with the findings published by late autumn of that year.
