Lucy Letby’s doctor ‘boyfriend’ got her work placements at one of the UK’s biggest children’s hospitals while she was under suspicion of murdering babies, the inquiry into her crimes detailed today.
Lady Justice Thirlwall’s report found three of the babies murdered by Letby could have been saved if hospital bosses stepped in sooner.
There was a ‘complete failure to protect babies on the neonatal unit’ at the Countess of Chester Hospital where Letby murdered seven babies in 2015 and 2016, she found.
Parents were ‘kept in the dark for years about what was happening’ by hospital executives who were more worried about protecting the hospital’s reputation, she found.
In her report published today, the senior judge said families of the babies were not aware of concerns until the nurse was arrested and they were contacted by police in July 2018.
Sign up for all of the latest stories
Start your day informed with Metro’s News Updates newsletter or get Breaking News alerts the moment it happens.
Letby, 36, was moved from the neonatal unit to administrative duties in July 2016 after consultants expressed concerns about her to the hospital’s executive team.
The Thirlwall Inquiry was set up to examine how Letby was able to carry out her crimes.
It did not examine Letby’s convictions or motives but instead focused on the conduct of those working at the Countess of Chester, including the board, managers, doctors and nurses from when Letby started her employment in 2012.
Another area examined by the report were observations arranged for Letby at Alder Hey Children’s Hospital by Dr Mark Deakin, who was described by prosecutors as her ‘boyfriend’ during the criminal trial.
The consultant paediatrician, who died earlier this year, exchanged more than 1,300 Facebook messages with Letby while they were colleagues at the Countess between June and September 2016.
Lady Justice Thirlwall found he blurred boundaries and put his desire to help her above his duties to his patients.
Her report said the doctor, who is identified as Dr U in the report because of reporting restrictions which were lifted earlier this month, had contacted Letby after a mortality review for babies O and P in July 2016.
He told her she needed to ‘keep it to herself’ but said: ‘If you have any doubt about how good you are at your job stop now, documentation was perfect.’
Dr Deakin also forwarded an email to her from one of the whistleblowing consultants, Dr Stephen Brearey, in which he was told there was likely to be an inquest.
When asked at the inquiry why he did that, he said he was trying to reassure and ‘give her some insight’ but accepted, in hindsight, it was an error.
Lady Justice Thirlwall said: ‘I agree with him. It is another example of the blurring of boundaries.
‘Here, between his duties to his patients, and his desire to help and support a young nurse who had, as he did not realise, many people supporting her. He put her first.’
‘This cannot be allowed to happen again’
A total of 14 recommendations have been made in the report including the fitting of baby monitors in all cots and incubators in neonatal units and CCTV cameras focused on insulin storage fridges.
Lady Justice Thirlwall said baby monitors would ensure parents could observe their babies ‘remotely at any time’ – adding that NHS England should ‘set out a roadmap’ for how it could be implemented by March 31 next year.
She also said digital devices should be used to ‘restrict access of insulin to authorised people’, as well as recording access to insulin units.
Another recommendation was that all managers be subject to an ‘individual duty of candour to all patients and colleagues’, and that a code of conduct for senior managers should ‘set out, at the beginning, the uncontroversial duty of every manager to put patients first’.
Richard Scorer, head of abuse law and public Inquiries at Slater and Gordon, who acts for three families said: ‘The families I represent were looking for a clear analysis of what went wrong and strong recommendations to prevent this happening again.
‘The report delivers both. Lady Thirlwall is clear that the police should have been informed in August 2015, not 18 months later, and that hospital managers misled the families and the trust failed in its duty of candour.
‘My clients welcome the recommendations around CCTV, access to insulin, strengthening of the duty of candour to include hospital managers and barring of managers guilty of incompetence and misconduct.
‘The challenge now is to ensure that recommendations are implemented without delay. Far too often public inquiry recommendations are left to gather dust.
‘This cannot be allowed to happen again.’
The report also details how Dr Deakin organized for Letby to attend observations at Alder Hey Children’s Hospital while he worked there between December 2016 and April 2017.
It states he did not inform Alder Hey that Letby had been taken off the neonatal unit.
In his evidence to the inquiry, the doctor said he assumed that if Letby’s visits were inappropriate, HR or the nursing management team would have said ‘no’.
But he conceded he did not seek confirmation from the Countess, saying ‘in hindsight’ it was ‘remiss not to complete the loop and check that that was correct’.
His observation notes state: ‘Lucy demonstrated a keen interest in acquiring new skills and knowledge and I hope she felt this road show was beneficial.’
At the bottom, he wrote, ‘I have worked with Lucy between September 2015 and September 2016 on the CoCH [the Countess] Neonatal Unit’, despite the period ending in early July.
He then wrote: ‘We have worked together on babies with acute admissions, labor ward transfers and a range of gestations from 26‑40 weeks.’
But the inquiry report states: ‘Dr U was writing this in late August 2017. By then, he knew that Letby had not looked after babies on the neonatal unit for over a year.
‘He knew the police were investigating and that there were concerns about Letby. He did not mention that on his form. The form did not require it.
‘Nor did he mention that she had been moved from the neonatal unit to a non-clinical role. Again, there was no requirement upon him to do so.’
During his evidence to the inquiry, he said he had provided support by being ‘misled and maybe manipulated’.
He said: ‘I have a lot of regrets about how that period of time took place.’
During her trial, Letby broke down in tears and tried to leave the dock when the married father-of-two entered the witness box and answered questions from behind a screen.
The Thirlwall Inquiry was launched in 2023 in the wake of the former nurse’s multiple convictions for murder and attempted murder of infants at the Countess.
Hospital bosses carried out several reviews into the rising number of deaths in 2015 and 2016 but did not call in Cheshire Constabulary to investigate until May 2017.
Letby remained on site until her arrest more than a year later.
The Thirlwall report found that senior nurses never accepted that the consultants’ concerns were, or might be, justified, and that there was a prolonged delay by senior managers in calling the police.
It ruled that successive internal and external reviews commissioned by hospital leadership after concerns were raised about Letby did not address whether deliberate harm was being caused or not.
Publishing her final report, Lady Justice Thirlwall said ‘no-one seems to have understood that safeguarding action is required when a member of staff is suspected of causing deliberate harm and does not require colleagues to be sure of guilt’.
She went on: ‘How many lives could have been saved had the hospital acted differently? This is something we will never know for sure.
‘It is clear that some babies would have been saved and some attacks would have been prevented if action was taken earlier.’
The mum of one of Letby’s victims told the inquiry senior staff were ‘concentrating on saving their own skins and jobs and reputations’.
She added: ‘Babies died because someone in an office being paid hundreds of thousands of pounds didn’t want the hospital to look bad if they shut.’
Lady Justice Thirlwall, one of the country’s most senior judges, said today: ‘No one could disagree with any of these observations.’
The Thirlwall Inquiry found the lack of consideration shown to parents at that time was ‘reprehensible’.
Letby, from Hereford, is serving a whole life sentence after being convicted of murdering seven babies and attempting to murder seven others.
She maintains her innocence and a high-profile campaign is underway to try and persuade the Criminal Cases Review Commission (CCRC) to quash her convictions.
The CCRC, which investigates potential miscarriages of justice, is considering evidence presented on her behalf by an international panel of medics who claim poor medical care and natural causes were the reasons for the babies collapsing.
A court order prohibits reporting of the identities of the surviving and dead children involved in the case.
Investigations by Cheshire Constabulary into potential offenses of corporate manslaughter and gross negligence manslaughter remain ongoing.
Inquests into the deaths of babies who Letby was convicted of murdering are to take place in May 2027.
Get in touch with our news team by emailing us at webnews@usnewsrank.com.
For more stories like this, check our news page.