Lucy Letby was not referred to the nursing regulator after concerns about her were raised to hospital bosses because there was a “lack of evidence” she may be killing babies, a public inquiry has heard.
Consultant paediatricians on the neonatal unit at the Countess of Chester Hospital flagged up their increasing worries over Letby in late June 2016 following the deaths of two triplet boys.
Senior managers opted to commission a series of reviews into the increased mortality on the unit in 2015 and 2016 instead of calling the police.
The Thirlwall Inquiry into the events surrounding Letby’s crimes was told that director of nursing Alison Kelly phoned the Nursing and Midwifery Council’s (NMC) employer link representative Tony Newman on July 6 2016 to discuss Letby.
Ms Kelly told him about the rise in mortality of babies and said they had not detected any medical incompetence.
The inquiry heard she added one registrant had been present at nearly all the incidents and that some clinicians were concerned the registrant may present a serious risk to public safety, although no evidence was available.
Giving evidence on Thursday, Mr Newman told the inquiry he advised Ms Kelly that the health trust carry out its own “local” investigation and there was “no allegation and no evidence” to support a fitness to practise referral for Letby.
Mr Newman said: “There was no allegation made on the call. Alison never said to me ‘we suspect she could be deliberately harming babies’.
“Had she said that it would have set off all sorts of alarm bells and we probably would have said, even with a lack of evidence, we would have recommended a referral at the time so we could contact the police.
“The key aspect of the Nursing and Midwifery Council is to protect the public but in order to do that we need clear information and evidence to restrict someone’s practice.”
Letby was redeployed to non-clinical duties at the Countess of Chester in July 2016 but the inquiry has heard she made a number of “observational visits” to Liverpool’s Alder Hey Children’s Hospital in March and April 2017.
The child serial killer nurse was also said to have attended a tea party at the Countess’s neonatal unit in February 2017 ahead of her expected return to the unit.
But the move was put on hold as hospital bosses finally contacted Cheshire Constabulary in May 2017 to ask them to investigate the increased number of deaths.
She continued to work in the hospital’s Risk and Patient Safety department until her 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.
Following her convictions she was stripped of her nursing credentials and struck off the register at a NMC fitness to practise hearing in December 2023.
The Thirlwall Inquiry will resume at Liverpool Town Hall in January when it will hear its final two weeks of evidence, with findings expected to be published in autumn 2025.
