Letby inquiry: Hospital bosses reprimanded for failing to report spike in baby deaths to watchdog
Hospital managers have shown a “lack of transparency” by failing to inform a healthcare watchdog of a spike in infant deaths during an inspection that took place nine months after the first murder of Lucy Letby.
A senior manager at the Care Quality Commission (CQC) said executives at the Countess of Chester hospital had a “professional obligation” to alert inspectors to concerns about the rise in neonatal deaths during the February 2016 review.
Ann Ford, director of operations at the CQC, told the Thirlwall inquiry that inspectors were only made aware of the ‘unexplained and unexpected’ deaths just hours after the report on the hospital was published on June 29, 2016.
The inspection took place nine months after Letby’s crimes began and at a time when some of her colleagues expressed fears she was harming babies.
That week, the hospital’s medical director, Ian Harvey, and other senior doctors and nurses received a copy of a thematic review of ten deaths in the neonatal unit. It found that “there was no apparent cause for the deterioration/death” and that six babies were arrested between midnight and 4am. However, the study concluded that no common theme was found across all cases examined.
Letby, 34, was convicted of murdering five babies and attempting to murder a further three in the nine months to February 2016. She was also found guilty of murdering a further two babies and attempting to murder a further four killing babies between then and July 2016, when she was removed from the neonatal unit.
The inquiry was told on Friday that this thematic investigation – which added to the mystery surrounding the deaths – was completed on March 2, 2016, days after the CQC’s scheduled visit in February, but before an unannounced inspection on March 4.
Ford said: “This wasn’t just information. This was about an emerging serious problem. It was a very important issue and I think they should have informed us immediately.
“All the documentation, all the audits, all the reviews, all the work they had undertaken should have been shared transparently and openly.”
She added: “What I find very difficult to accept is the lack of transparency in not pointing out these concerns because I think we would have acted very differently.
“I really think the trust had a professional obligation, and an obligation to patients, to be open and transparent with us, and I would have liked to have known about these concerns much earlier. I know we would have responded.”
The investigation found that detailed notes about the inspectors’ meetings at the hospital had since been lost or destroyed.
Nicholas de la Poer KC, counsel to the inquiry, said no records were available from key interviews with senior managers, including then hospital chief executive Tony Chambers and its chairman Sir Duncan Nichol.
De la Poer said there was an “incomplete record” of a confidential meeting with paediatricians and that “a number of other documents that might have been expected to exist… cannot be found”.
Ford apologized on behalf of the CQC for the missing material. “I think I would have to accept that the way we managed the disclosure was not good enough and I think there are profound lessons to be learned and improvements to be made,” she said.
She said the CQC’s policy in 2016 was to destroy paper documents relating to inspections six months after the publication of the relevant report, meaning material relating to the Gravin review would have been destroyed by early 2017.
However, she accepted there were ‘missed opportunities’ to withhold as much material as possible when it became clear police were investigating the suspicious deaths in May 2017.
It was only in September 2023 – days before the Thirlwall investigation was announced – that the CQC instructed staff to preserve documents potentially relevant to Letby’s crimes.
She said the CQC would consider turning to the Information Commissioner’s Office over its failure to preserve and make public important material.