Former senior managers at the hospital where Lucy Letby murdered seven babies and attempted to kill a further seven gave evidence at the Thirwall Inquiry, which investigated how they handled the case.
Among them were former chief executive Tony Chambers, former medical director Ian Harvey and former director of nursing Alison Kelly – who were all in post at the Countess of Chester Hospital when Letby committed her crimes.
At the beginning of the inquiry, held at Liverpool Town Hall, the trio issued an apology for not alerting Cheshire Police sooner to concerns over Letby. Reading parts of a statement on their behalf, Kate Blackwell KC said they felt they had needed to first investigate concerns to gain potential evidence of wrongdoing before contacting police.
Ms Blackwell said: “This was a cause of a significant delay in contacting the police and for this, they [the managers] are truly sorry.
“But the reviews were commissioned in good faith, not to conceal the truth but to uncover it… on the issue of when such matters should be properly brought to the police in a hospital setting, guidance is overdue and such recommendations as the inquiry sees fit will be well appreciated.”
Concerns were first voiced over Letby at the end of June 2016 – before almost a year later, in May 2017, police were formally called in to investigate.
Here we look at the roles of key management members at the hospital:
Tony Chambers
Tony Chambers was chief executive at the Coutness of Chester Hospital at the time Letby murdered seven babies in 2015 and 2016. He resigned in September 2018.
He began his evidence at the inquiry by apologising to the families of Letby’s victims. “Right at the outset I just want to offer my heartfelt condolences to the families whose babies are at the heart of this inquiry,” he said.
“I can’t imagine the impact this has had on your lives and I am truly sorry for the pain that may have been prolonged by any decisions or actions I took in good faith.”
He said he first knew of concerns from consultant paediatricians over Letby harming babies in late June 2016.
Letby was redeployed to an administrative role when she returned from annual leave in July.
However, she was due to go back to the unit weeks before the police were finally called in by the hospital in May 2017 after bosses had instead opted to commission a series of reviews to look at the increased mortality.
When detectives began investigating, Mr Chambers told them the executives “felt that the explanations for what had happened do not lie in a single place or cause and are certainly not criminal”, the inquiry heard.
Mr Chambers said: “I think it’s fair to say that we were very much taking the independent experts’ view that there were no unnatural causes of deaths identified, there were two cases that were unascertained.”
He told the inquiry his biggest personal failing was the communications with families which “could and should have been better”. He also accepted that the trust’s systems failed and “there were opportunities missed to take earlier steps to identify what was happening”.
Ian Harvey
Ian Harvey was the hospital’s medical director. He left his post to retire in August 2018.
He had held other managerial roles within the trust and was medical director for six years.
Concerns over Letby were raised with Mr Harvey by neonatal clinical lead Dr Stephen Brearey in May 2016, the inquiry heard, with Dr Brearey saying the number of deaths in 2015 and early 2016 was “exceptional”. He also highlighted the only common theme was the association with Letby being on duty
But giving evidence, Mr Harvey said that “did not accord with my recollection of that meeting” and he did not remember Dr Brearey being “that detailed or that assertive”.
He added: “At no stage during this meeting did I feel that it was being reported because there was worry that Letby was responsible for the deaths.”
Mr Harvey went on to commission the series of reviews into the increased mortality as Cheshire Constabulary was not called in to investigate the matter until almost a year later. Consultants pressed on with expressing their concerns amid dropped plans in early 2017 to return Letby to the neonatal unit, the inquiry has heard.
Mr Harvey said: “One of the greatest regrets of my career is the breakdown in communication between the executives and paediatricians, and with me in particular.
“I recognise how intense and difficult a situation that was.”
Alison Kelly
Alison Kelly was director of nursing at the hospital before resigning in 2021.
She went work as director of nursing at the Northern Care Alliance NHS Foundation Trust, which runs Salford Royal Hospital and Royal Oldham Hospital. The trust said Ms Kelly no longer worked for them when asked this week.
The inquiry heard how Letby was moved off the unit in July 2016 to an administrative role after consultant paediatricians told Ms Kelly and other senior managers at the end of June that they were concerned she may be deliberately harming infants.
Police were not formally called in to investigate until May 2017 after the hospital bosses opted to commission the series of reviews.
Ms Kelly, who as part of her role was the executive lead for safeguarding children, told the inquiry she never regarded the increase in deaths as a safeguarding matter which could have led to contact with the police earlier.
When asked if she failed to take appropriate steps and trigger the safeguarding process while presented with concerns, she said: “Yes, that is one of the things that I have spent a lot of time reflecting on but at the time it didn’t feel obvious.
“There were lots of things going on and now I know so much more information it seems obvious to me that that should have happened.”
When consultants told Ms Kelly and senior managers of a pattern of six out of nine deaths occurring at night, and that the pattern stopped when Letby was moved to days, she told the inquiry that “we needed to get more facts” to gain a fuller picture.
She said: “I think we needed to look at everything in the round in terms of clinical outcomes as well as looking at one individual. I didn’t take the hearsay of consultants as evidence at the time.”
