The NHS does not have sufficient procedures in place to spot “bad apples” such as Lucy Letby, the public inquiry has heard.
Lady Justice Thirlwall called more witnesses to give evidence at Liverpool Town Hall this week as she continues to explore the serial child killer’s crimes.
Letby, 34, 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 next year, with findings published by late autumn 2025.
Here are six things we learned from the inquiry this week:
No procedures for dealing with ‘bad apples’ in NHS
Formal steps should be in place to deal with suspected “bad apples” such as Lucy Letby.
An expert witness told the Thirlwall Inquiry the challenges of not identifying them were illustrated by the cases of mass murderer Dr Harold Shipman and another child killer nurse, Beverley Allitt.
Giving evidence on Thursday, Professor Mary Dixon-Woods, from the University of Cambridge, said a doctor who began to suspect Allitt was harming infants in Grantham, Lincolnshire, in 1991 was “initially treated as having fanciful ideas and was not treated seriously”.
She said: “Partly this was because there wasn’t a recognition that bad apple behaviour can sometimes be the source of problems because there wasn’t a very clear procedure for dealing with it.”
Meanwhile, Shipman was a “snake” who managed to wriggle through holes in patient safety systems to commit his terrible actions before he was finally detected, she said.
Examples of bad apples were those who persisted with grossly incompetent clinical practice or demonstrated unacceptable behaviours such as bullying and racism, she said.
Prof Dixon-Woods went on: “There are also those who demonstrate transgressive behaviours which reach the threshold for criminality and that might include murder, assault, rape or other violations.”
She said the danger of assuming that such bad apples do not exist was highlighted by the Clothier Inquiry into Allitt’s crimes which concluded “the main lesson the Grantham disaster should serve is to heighten awareness in all those caring for children of the possibility of a malevolent intervention as a cause of unexplained clinical events”.
Countess of Chester not honest ‘at any stage’
The “supposed” duty of candour in the NHS was “certainly not honoured” by the Countess of Chester Hospital, the parents of two triplet boys murdered by Lucy Letby said.
On Wednesday, Child O and P’s mother stated to the inquiry: “I was never told anything about Letby by the Countess of Chester Hospital. It was only during the trial that I found out she had been taken off the ward.
“I do not believe the Countess of Chester were honest with us at any stage. In my view they never should have taken on our care in the first place. We were not made aware of the higher mortality rate in the neonatal unit which we now know they were aware of at that stage. I think as parents we should have been informed of this.
“They knew something untoward was going on and they continued to take on my care even though we could have been sent to a neonatal unit elsewhere.”
The triplets’ father stated: “Following the deaths of our children we didn’t receive any support or counselling from anyone. Had we received some support we might have been in a better position to try and act on what our instincts were telling us which was that something had gone badly wrong.”
At the time of Lytby’s retiral in July, Dr Nigel Scawn, medical director at the Countess of Chester Hospital NHS Foundation Trust, said: “We want to acknowledge the impact this continues to have on everyone involved in this case and restate our commitment to do everything we can to help families get the answers they deserve.
“We remain grateful for the unwavering cooperation and professionalism of our staff, some of whom returned to court to repeat evidence and relive events. We will continue to ensure our staff receive the care and support they need and we remain committed to fully and openly supporting the ongoing legal processes.”
NHS managers ‘should face criminal action’
Hospital bosses who ignored concerns over Letby were “complicit in the harm that was caused” and should face criminal action, a mother has told the public inquiry.
Giving evidence on Tuesday, Child N’s mother stated: “I would hope that the managers of the trust are held accountable for failing to investigate the whistleblowing allegations.
“A lot of the harm that Lucy Letby did could have been avoided if a thorough and prompt investigation had taken place after concerns were raised.
“The managers should be listening to what is reported to them. Ignoring these allegations or not giving them proper weight makes these people complicit in the harm that was caused.
“They shouldn’t be able to continue in their roles and should face criminal action.”
‘Fewer babies would have died if they had listened’
The parents of twins Child L and M, who Letby attempted to murder in April 2016, also criticised the then management at the Countess of Chester.
Letby poisoned Child L with insulin and injected air into Child M’s bloodstream.
In a statement, they said: “They allowed a nurse who was causing harm to babies to continue working after concerns were raised by consultants about her potential involvement in babies dying or deteriorating.
“If they had listened sooner, fewer babies would have died or been harmed. Fewer families would have been bereaved and damaged. It’s not enough to just say sorry to the families now.”
‘Babies should have been monitored on CCTV’
Babies in cots and incubators should be monitored by CCTV, the parents of a baby girl allegedly attacked by Lucy Letby told the inquiry.
Jurors at Letby’s 10-month trial could not reach a verdict on an allegation she attempted to murder the infant, Child J, who collapsed while in the nurse’s care.
The Crown Prosecution Service opted not to seek a retrial over the incident at the Countess of Chester Hospital’s neonatal unit in the early hours of November 27 2015 during which Child J had a seizure and required resuscitation.
The Thirlwall Inquiry into events surrounding Letby’s year-long killing spree heard that weeks later the baby suffered another nightshift collapse when the nurse was again on duty, although she was not charged in relation to that.
In a statement to the inquiry, Child J’s parents said: “We will never know the truth. It’s for this reason we believe babies should be monitored using technology such as CCTV. It should be here for each cot space and incubator.”
‘Letby handed me memory box even though my child didn’t die’
The mother of Child H, a baby girl who was allegedly targeted twice by Letby in September 2015, said she “struggled” with a message that Letby passed to her at the Countess of Chester Hospital.
The infant required resuscitation after two profound oxygen deteriorations in the early hours of September 26 and 27.
Jurors at Letby’s trial found her not guilty of attempted murder over the first incident and could not reach a verdict on the second incident.
Child H’s mother told the inquiry that Letby handed her a red box as her daughter was placed in an ambulance for transfer to another hospital 27 on September.
She said: “It had a teddy bear on the top and inside the box was a cot card and her wristband from the Countess of Chester. There was also a plastic bag with a white sticky label on the front that said ‘For my Mummy and Daddy xxx’.”
Inside the bag was was a hat her daughter wore when she was receiving breathing support from a Cpap (continuous positive airway pressure) machine, she said.
Child H’s mother went on: “To me it almost seemed a bit like a memory box. I remember thinking that it was quite morbid. You know, because she was not dead.
“I did ask about that during the criminal trial and I was told it wasn’t a memory box as such, that was something that they did.
“But I remember not feeling entirely comfortable about that. And especially the fact that the writing on that label… says ‘For my Mummy and Daddy’ with a ‘xxx’ on it from Lucy Letby, and the fact that she handed that over to us, I do struggle with that.”
