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In the end, Lady Justice Thirlwall's report into what happened at the Countess of Chester Hospital between June 2015 and June 2016 made for grim reading.
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what → see → reading
The inquiry found that the hospital management was 'dysfunctional' and that an 'us-versus-them' mentality pervaded between management and clinicians, as well as between nurses and senior staff.
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mentality → find → nurses
Some of those who had suspicions about the uncharacteristically high number of deaths in the neonatal unit kept quiet, while those who raised the alarm were dismissed.
The hospital carried out pointless reviews instead of calling in the police.
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hospital → have → police
All of which allowed Lucy Letby to carry on with her quiet campaign of murdering babies and seriously harming others, uninterrupted.
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Letby → allow → others
'Errors were made by nurses, doctors and managers at the time of these events,' Lady Justice Thirlwall said today.
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Thirlwall → make → events
Lady Justice Thirlwall highlighted a litany of failures that led to the murders of seven babies and serious harm to others at the Countess of Chester Hospital
The chair of the inquiry was presenting her findings having examined more than a million pages of documents, taken evidence from in excess of 130 witnesses and read nearly 400 witness statements.
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chair → highlight → statements
'There was complete failure at all levels to invoke safeguarding procedures at any point,' she said.
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she → be → point
'Looking for clinical or other explanations for deaths and collapses was not wrong, but once there was suspicion that Letby may be causing harm deliberately, safeguarding steps should have been taken.
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steps → look → harm
'She should have been removed from the ward as a neutral act and matters could have been investigated without risk to babies.
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matters → remove → babies
No one seems to have thought that safeguarding action is required when a member of staff is suspected of causing deliberate harm.
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member → seem → harm
While the inquiry was not charged with investigating Letby's criminal convictions or her guilt, it did at least offer a telling insight into the nurse at the centre of the probe.
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it → charge → probe
The inquiry heard evidence of her 'inappropriate' and 'callous' behaviour towards patients and colleagues.
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inquiry → hear → patients
It emerged that feedback on Letby's performance was mixed while she was training.
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she → emerge → performance
She was said to be lacking in enthusiasm for the job and, chillingly, her communication skills with families and drug calculations were below par.
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skills → say → par
Lucy Letby is serving 15 whole-life sentences for murdering seven babies and attempting to murder seven others at the Countess of Chester Hospital
And significant concerns were raised during her final placement in 2011.
Her mentor noted that Letby was 'quiet, withdrawn and struggled to build relationships with children, families and colleagues'.
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Letby → serve → children
The inquiry heard that despite Letby's efforts to address these issues, she failed a mid-year assessment.
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she → hear → assessment
Her mentor concluded that Letby's progress remained insufficient and did not sign off on her final assessment.
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progress → conclude → assessment
Letby qualified as a registered children's nurse in September 2011, but was found to be 'repeatedly untruthful' with friends and fellow nursing staff.
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Letby → qualify → friends
She even shouted at her manager at one stage after being told she was being sent to work in a nursery away from intensive care.
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she → shout → care
The senior nurse, Kathryn Percival-Calderbank, said: 'Lucy Letby then shouted at me for doing so, because she felt she didn't want to be in [an] outside nursery, she wanted to be in the intensive care setting because she felt that it was boring looking after the special care babies.'
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it → say → babies
More significantly, one parent said she was aware her baby's medical records had been falsified by Letby 'to suit a different narrative'.
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records → say → narrative
The inquiry also heard she was particularly chummy with senior bosses, something which may have clouded their judgment.
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which → hear → judgment
The judge pulled no punches in pointing the finger of blame at senior managers Alison Kelly, Ian Harvey and Tony Chambers, who 'dismissed the idea that Letby was deliberately harming babies', as late as June 2016.
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Letby → pull → June
She said it mattered little whether or not they believed allegations against Letby – they should have acted.
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they → say → Letby
Ultimately, there were delays in contacting police, which could have prevented babies being killed or harmed.
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babies → be → police
The judge said: 'It is striking that on 29 June 2016, Ms Kelly and Mr Harvey both believed that the doctors' concerns meant that the police should be called, but by the end of that day they had accepted Mr Chambers' view that other steps should be taken first, even though they both knew more about the detail of the concerns than he did.
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he → say → concerns
The inquiry chairwoman was particularly critical of senior leaders and management at the hospital
Mr Harvey, the medical director, told the inquiry he regretted not calling in the police in June 2016.
Lady Justice Thirlwall said neither he nor chief executive Mr Chambers were in a position to decide whether the doctors' concerns about Letby had any credibility.
She said: 'A criticism of the doctors from the managers was that they had not called the police – the point being, presumably, that if their concerns were genuine they would have done so.
'
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they → tell → police
The managers never considered whether the reason the doctors had not done so was because this was so serious that it needed to be dealt with at the most senior level of the hospital, exactly as Mr Harvey himself thought.
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Harvey → consider → hospital
She said the managers acted with a lack of self-doubt.
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managers → say → doubt
'The difference between them and the paediatricians was stark,' she said.
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she → say → them
She said safeguarding action should have been taken by moving Letby off the ward following the death of Baby I in October 2015.
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action → say → October
But there were even opportunities to stop her two months earlier, after a consultant 'disregarded' evidence which suggested Letby poisoned a baby with insulin.
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Letby → be → insulin
Another doctor did not flag in February 2016 that he saw Letby's failure to act to help a baby girl whose breathing tube she was later convicted of dislodging.
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she → flag → girl
Chief executive Mr Chambers was unaware of what was happening on the neonatal unit until after the deaths of two babies, in June 2016.
Yet the police were not called in for almost a year.
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police → happen → year
Parents told the inquiry that they were unaware of any concerns that an individual had caused neonatal deaths at the Countess, until Lucy Letby was arrested and the police contacted them in July 2018
TREATMENT OF PARENTS
Some of the judge's most emotive language was reserved to describe the 'reprehensible' treatment of the babies' parents.
She accused hospital bosses of using the potential risk of upsetting parents about the allegations against Letby as a 'convenient argument' to justify delaying contacting the police.
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She → tell → police
Giving evidence to the inquiry, Mr Harvey said that some communication with families 'was both crass and inappropriate'.
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communication → give → families
Families were not even told about the investigations into the deaths of their children.
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Families → tell → children
The mothers of four children were 'all misled', either in face-to-face meetings or in written communications, she said.
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she → mislead → communications
Indeed, the inquiry heard evidence from parents that they were not aware of any concerns that an individual had caused neonatal deaths and collapses at the Countess until Letby was arrested and the police contacted them in July 2018.
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police → hear → July
Lady Justice Thirlwall added: 'Risks to reputation and disruption are not of the same order.
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Risks → add → order
…and 51 more, not listed.
The Aporia
