Lucy Letby inquiry live: More breathing tubes dislodged during serial killer nurse’s shifts, audit finds
A public inquiry into how Lucy Letby was able to murder babies at a neo-natal unit over a two-year period is taking place
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An audit carried out by Liverpool Women’s Hospital, found that breathing tubes had been dislodged in 40 per cent of shifts that Lucy Letby worked, an inquiry has heard.
A lawyer representing the devastated families of Letby’s victims has said conspiracy theorists who “recklessly” promote misconceptions about the case should be “ashamed”.
It comes as a parent whose child was left severely disabled by Lucy Letby has said “the devil found her”, in a heartbreaking witness statement.
Hospital staff should have had “heightened awareness” given the crimes of Beverley Allitt, a nurse who killed four infants in 1991, a lawyer at the serial killer nurse’s inquiry has said.
Peter Skelton KC argued that healthcare workers should have been prepared to “think the unthinkable” and should have acted sooner.
Letby was nicknamed “Nurse Death” by junior doctors after she was removed from duties on the neo-natal ward at Countess of Chester Hospital in 2016 but hospital bosses still did not contact police until eight months later.
This year, Letby was sentenced to 15 whole-life orders after she was convicted of murdering seven babies and attempting to murder seven others on the ward in 2015 and 2016.
Lucy Letby felt ‘scapegoated’ over baby tragedies as junior doctors nicknamed her ‘nurse death’, inquiry hears- Baby deaths rise concerns ‘not discussed at board level until after Letby spree’
Baby killer Lucy Letby stopped from resuming nursing duties thanks to ‘tenacious consultants’, inquiry hears
Lucy Letby: The key questions still being asked over serial killer nurse’s convictions
More babies had breathing tubes dislodged during Letby.s shifts audit finds
One shock revelation during today’s hearing revealed that audits show more babies had their breathing tubes dislodged during Letby’s shifts than would usually occur.
The inquiry also revealed investigations have looked into babies’ care at Liverpool Women’s Hospital where Letby did two placements between October to December 2012 and January to February 2015.
Richard Barker KC, barrister for the second group of families said: “Given the prevalence of dislodgement of endotracheal tubes, in this case, my lady may perceive it as a common event, but the evidence suggests that it isn’t at all common. It is very uncommon, you will hear evidence that it generally occurs in less than 1 per cent of shifts,” he said.
“As a side note, you will hear that an audit carried out by Liverpool Women’s Hospital, whilst Letby was working there, dislodgement of endotracheal tubes occurred in 40 per cent of shifts that she worked.”
The inquiry has ended for the day
The inquiry has ended for the day and will resume tomorrow with opening statements from NHS England.
NHS maternity scandals expose ‘professional tribalism’
The inquiry heard criticism of the NHS from the DHSC over past scandals and investigations.
It said: “Issues of poor leadership and workforce culture have been raised repeatedly in previous investigations, inquiries and reports of maternity and neonatal services and undermine the safety improvements which have been made.
“It is clear that solutions are required which all trusts can implement and consistently adopt.
“Various reviews and inquiries have over many decades identified persistent issues of culture, painting a broadly consistent picture of incurious boards unresponsive to key patient safety concerns, of defensive and on some occasions bullying behavior, which does not create a culture in which speaking up is easy or welcomed, and of professional tribalism with associated tolerance of poor behavior and poor care.”
DHSC first told of concern about neonatal services in 2016
The DHSC said in October 2016 it became aware the change in admission arrangements to the Countess of Chester hospital’s neo-natal unit to focus predominantly on lower risk babies and of the request for an independent review.
It was then notified by the NHS about the planned announcement of the police investigation into deaths at the Countess of Chester hospital.
The inquiry heard: “The department is not routinely involved in day to day events in trusts at the relevant time, this was the responsibility of the trusts and foundation trusts themselves Monitor and the NHS Trust Development Authority and sometimes NHS England...was expected that where significant issues were identified the Department would be informed.
“However, the Department acknowledges that it would have been better if there had been more robust arrangements to share information between the trust NHS England and the department at the time.”
The government makes its statement to the inquiry
The Department for Health and Social Care’s barrister has begun his opening statement by referencing past maternity scandal reviews.
He says: “The independent review of maternity services at the Shrewsbury and Telford Hospital and the independent investigation into maternity and neonatal services in East Kent Hospital demonstrate a failure to learn from past incidents.
“The new secretary of state has acknowledged that in the past, recommendations have been made but action has not been taken. That is not good enough, the system must change. The secretary of state has spoken candidly describing how the NHS is broken.”
The inquiry has paused
The inquiry has paused for a lunch break. We will return with updates when it resumes.
Royal College admits to mistakes in key report
Fiona Scolding KC, representing the Royal College of Paediatrics and Child Health, has begun her opening statement.
In written statements submitted to the inquiry the Royal College said: “The RCPCH accepts that its actions in undertaking the review commissioned by the Countess of Chester Hospital (COCH) did not directly assist in uncovering the causes of death and recognise that this contributed to the uncertainty and lack of clarity that bedevilled the response.
“It also apologises that it was not sufficiently supportive to paediatricians and other clinicians then working at the hospital and acknowledges the stress, anxiety and damage that has been caused to them by the actions of Letby.”
NMC admits it could have sanctioned Letby sooner
Last month The Independent revealed the Nuring and Midwifery Council has changed its guidance on when temporary sanctions, called interim orders, can be placed on a nurse facing serious allegations.
No interim order was placed on Lucy Letby following her arrest.
Addressing this issue Ms Jones said: “We have seriously reflected on the decision not to apply for an interim order until Lucy Letby was charged, and have determined that our guidance in place at the time was not sufficiently clear to allow us to act on an extraordinary case such as this one in which a serious police investigation was underway in relation to potentially multiple instances of murder.
“We accept that it was not right for the NMC to wait to apply for an interim order until Lucy Letby was charged, and we considered that in this case, the fact of the arrest could have been sufficient to justify an interim order application, given the serious nature of the concerns and the absolute importance of maintaining public safety and also public confidence in the profession.”
UK nursing regulator lacked ‘curiosity’
Lady Thirlwall quizzes the NMC barrister over regulator’s repsonse.
She asked the NMC barrister: “If a call is received with the information that a nurse may present a serious risk to public safety. Is there no sort of natural curiosity as to what you know well? Why are you saying that? Why are you phoning?
Ms Jones responded: “We do appreciate the inquiry’s concern that we did not initiate an investigation at this point [in November 2016].”
“I hope will address the concern you just raised me about, why was there not a professional curiosity that should have been displayed at that time is that we have now published guidance to address learnings...Our guidance is titled, our culture of curiosity is available on our website, and it promotes and emphasizes the culture of curiosity in our fitness to practice investigations.”
Hospital boss told UK nursing regulator there was ‘no evidence’ to refer Letby
Ms Jones KC says: “The NMC has reflected on the steps it could and should have taken at the time it became involved in 2016 and we have identified a number of areas of improvement.
“As we’ve outlined in our written opening, written statement and witness statements, the NMC has taken serious steps to review its processes, to learn lessons and to implement, or begin to implement, practical measures to ensure that it to ensure that it can play its part in the prevention of the deplorable acts committed by Lucy Letby.”
She reveals in July 2016 chief nurse Alison Kelly told the NMC “there was not sufficient evidence to initiate a referral” of Letby.
“Alison Kelly first told the NMC of the concerns regarding a rise in neonatal mortality rates and concerns that Lucy Letby the may present a serious risk to public safety, we were told that there was no evidence available at that time to support those concerns.”
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