A hospital boss has described claims that he stalled a police investigation into baby deaths, and sought to ruin the careers of two consultants, as “outrageous”, the public inquiry into the crimes of Lucy Letby has heard.
Former chief executive Tony Chambers did not ask Cheshire Constabulary to look into a mortality spike at the Countess of Chester Hospital’s neonatal unit until more than 10 months after he first became aware of concerns that Letby may be deliberating harming infants.
Instead the hospital opted to commission a series of reviews into the increased number of deaths on the unit in 2015 and 2016, while Letby was redeployed to an administrative role, in response to fears voiced by consultant paediatricians after the deaths of two triplet boys on successive days in June 2016.
In May 2017 police were finally brought in to investigate the concerns, although plans were in place weeks before to return Letby to the unit, after she launched a grievance against her redeployment, which was upheld.
On Thursday, the Thirlwall Inquiry heard Mr Chambers had a meeting with the hospital’s HR director on May 11 2017, shortly after he spoke to police chiefs.
A note of the meeting, concerning senior consultants Dr Ravi Jayaram and Dr Stephen Brearey, was outlined “plan re management” and listed the words “GMC”, “mitigation from whistleblowers” and “action plan to manage out”.
Mr Chambers said he thought at the time the police did not seem to feel a criminal investigation was “likely”.
He said: “I needed to have it clear in my mind what would happen if this stance was not accepted by the consultants and there was resistance to try to move forward and focus on the safety of the neonatal unit.”
Richard Baker KC, representing families of Letby’s victims, said: “You are making clear that if the consultants do not accept your decision to move on you are going to refer them to the GMC (General Medical Council) and potentially ruin their careers?”
Mr Chambers said: “No, that’s not what that note represents. That note represents a discussion that if the police inquiry does not go ahead then we may have a problem.
“We were almost just exploring how that might need to be resolved. It was never a plan.”
Mr Baker said: “I suggest to you this shows a very clear insight into your character.
“You were putting pressure on whistleblowers contrary to the hospital’s own patient safety policy and you were planning to have them disciplined and moved on if they didn’t accept it.”
Mr Chambers replied: “No, that is not the interpretation of this or my character.
“My character is such that we always had a focus on patient safety and the wellbeing of our staff.”
Mr Baker went on: “You sought at every stage to stall and obstruct the police being called or this being made public, and ultimately sought to ruin the careers of the consultants who brought this to your attention.
“That is utterly reprehensible behaviour and unfitting of a CEO in the NHS, isn’t it?”
Mr Chambers said: “Had that been what I had done then it would be, but I think it’s an outrageous statement and I do not believe that represents my actions.”
The hospital’s then medical director Ian Harvey told the hearing he regretted not going to the police in the summer of 2016 rather than pursuing a series of reviews.
He said: “I am not convinced based on the communications and the conversations we had with the police nearly a year later that they would have necessarily acted at that point.
“But I have to accept there would have been the potential for oversight or advice with regard to the processes and the reviews we undertook, and the possibility that they could have stepped in sooner should something have been found.”
Mr Harvey said he listened to the concerns of the consultants and accepted what they were saying, and their level of expertise and knowledge.
He went on: “But by the same token they were not able to describe anything that took it over a bar where I had that extra level of concern.
“This was first raised as there was an association of one member of staff. It was never raised as something had been seen, something had been done. It was raised as there is an increase in the number of deaths but we don’t understand why.”
He said he was aware of the views of nursing managers, who the inquiry has heard were supportive of Letby, and was also mindful of the 2011 arrest of a nurse over a series of poisoning deaths at Stockport’s Stepping Hill Hospital.
Rebecca Leighton was charged with criminal damage and remanded into custody before prosecutors dropped the case and later charged her nursing colleague Victorino Chua, who was eventually convicted of two murders.
Mr Harvey told the inquiry: “I was very mindful at this time of Stepping Hill, the alternative story of Stepping Hill. That it was the nurse who had been incarcerated inappropriately and incorrectly for six weeks, and the effect it had on her life and career.”
At the start of his evidence Mr Harvey issued an apology to families of Letby’s victims.
He said: ” I am sorry for the hurt that has been caused to the parents and the families of the babies. I extend that to the parents and the families that were subject of the reviews but didn’t feature in the trial and are not part of this inquiry.
“It was only ever my desire to have a safe hospital and to be able to tell the parents what had happened on the neonatal unit, and if I failed in those aims then I am truly sorry.”
Counsel to the inquiry Rachel Langdale KC said: “Reflecting now, do you think you did fail in those aims to secure patient safety?”
Mr Harvey said: “I think the simple fact that there was an increase in mortality is an indication we got things wrong.
“I failed in my communication to the families in the nature and the quality of the information they were given.”
Questioned by Peter Skelton KC, representing families of Letby’s victims, Mr Harvey conceded that none of the various reviews undertaken were designed to detect criminality and did not exclude the possibility the nurse harmed children.
As a result of those investigations Mr Harvey and Mr Chambers advised the hospital board to support the return of Letby to the neonatal unit as the evidence against her was unsubstantiated, the inquiry heard.
Mr Skelton said: “I put to you that it was irresponsible and dangerous to return Lucy Letby to the unit because you could not be confident as the medical director of the hospital responsible for patient safety that she would not harm children again.”
Mr Harvey: “I would have to accept that, with retrospect, yes it would have been a risk for her to have gone back on the unit.”
Mr Skelton said: “One which should never have been countenanced.”
Mr Harvey said: “No.”
The medical director pointed out to the inquiry that he was unaware at the time of the blood test results of two infants, Child F and Child L, which showed raised levels of insulin.
He described the incidents – in which Letby attempted to murder the baby boys by poisoning them – as “clear evidence of harm” and “missed opportunities”.
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, sitting at Liverpool Town Hall, is expected to sit until early 2025, with findings published by late autumn of that year.
