Case of killer nurse Beverly Allitt was part of Lucy Letby’s training, inquiry told

The Thirlwall Inquiry, which will probe how Letby was able to attack babies on the Countess of Chester Hospital’s neo-natal unit in 2015 and 2016, opened on Tuesday with a statement which referenced nurse Allitt, who attacked children at the Grantham and Kesteven Hospital, Lincolnshire, in 1991, and killer GP Harold Shipman.

Chairwoman Lady Justice Thirlwall said the inquiry would not examine Letby’s convictions, saying an “outpouring of comment” on their validity had “caused enormous additional distress to the parents”.

The 34-year-old, 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.

In her opening statement at Liverpool Town Hall, counsel to the inquiry Rachel Langdale KC said the Clothier Inquiry had been carried out following the crimes of Allitt, who was convicted of four counts of murder, three of attempted murder, and a further six of grievous bodily harm on children.

She said: “Nevertheless, and distressingly, 25 years later another nurse working in another hospital killed and harmed babies in her care.”

Ms Langdale said the inquiry would hear from a senior lecturer in the child nursing programme at the University of Chester, where Letby qualified in 2011, who said the case of Allitt formed part of student training and learning.

She said the motive for Letby’s crimes would not be examined during the hearings, and referenced an inquiry into the crimes of Shipman, thought to have murdered hundreds of his patients, which “shed very little light” on why he carried out the killings.

She said: “For ordinary, decent, right-thinking people, the actions of Letby will remain unfathomable. We will not be inviting speculation from witnesses about her motive or mindset.”

The inquiry will look into the experiences of the parents of babies, the conduct of others working at the hospital and the culture and management in the wider NHS.

Ms Langdale said the death of Child D on June 22 2015 was the third neonatal death in under two weeks.

This exceeded the total number of deaths in 2013 (two deaths) and equalled the total deaths in 2014 (three deaths).

In addition to three deaths, there had also been the near fatal collapse of Child B, the twin of Child A, she said.

A meeting took place on July 2 between various department heads but a decision was reached that no further investigation was warranted, she said.

Ms Langdale told the inquiry: “With hindsight, this decision may represent a significant opportunity missed.”

She said it would take the sudden and unexpected deaths of another two babies, Child E and Child I – in August and October 2015 – before the issue of commonality of staffing was revisited and a further investigation was considered necessary.

Again no further investigation was deemed necessary following the death of Child E, the inquiry heard, and it was said to be a “further missed opportunity” to report the increase in neonatal deaths since June 2015 as a serious incident.

Ms Langdale said: “This would have triggered a comprehensive investigation into the increased mortality rate at an earlier stage.”

Letby was also convicted of attempting to murder Child E’s twin brother, Child F, in August 2015 by poisoning him with insulin.

The barrister said consultant paediatrician Dr John Gibbs had stated to the inquiry that blood tests on Child F were “not interpreted correctly at the time and so, highly regrettably, an indication that someone was deliberately harming patients was overlooked”.

Following a pattern of repeated collapses of Child I, who died in October 2015, it appeared that caused the “first explicit concerns to be raised about the correlation between Letby’s shifts and the unexpected collapse or death of babies”, said Ms Langdale.

On the day Child I died, neonatal clinical lead Dr Stephen Brearey raised in writing his concerns about Letby in an email to ward manager Eirian Powell which she responded to and copied in the unit’s risk and patient safety lead and the lead nurse of children’s services.

Of the latter email, Ms Langdale said: “This email bears reading because in many ways it sets the tone that was to follow in the subsequent months. Concerns, despite being raised by the consultant lead of the neonatal unit, were not seen as urgent, and assumptions surrounding the underlying medical evidence were made.”

It was not until February 2016 following the unexpected collapse of Child J and the deaths of two further babies – who were not on the criminal indictment – that any review of the neonatal care of the babies who died during 2015 took place.

A total of 10 babies were the subject of the thematic review, which also covered January 2016, led by a neonatologist  from Liverpool Women’s Hospital NHS Foundation Trust.

Letby was identified as being either among the nursing staff allocated and/or on duty at the time of the deaths in respect of nine of those babies, said Ms Langdale, although the report did not refer to Letby by name or whether the deaths could have been caused by incompetence or deliberate harm.

Concerns remained among consultants with “several corridor conversations”, the inquiry heard, as Mr Brearey had also identified from the review that most of the babies had died at night.

Letby was moved to day shifts on April 7 2016 by ward manager Ms Powell who told police: “It was my decision to bring Lucy off night shifts for two reasons really, as if what Steve and the others were intimating we needed to have more eyes watching as well, to make sure Lucy was alright and also to make sure there was no wrongdoing anywhere.”

Ms Langdale told the inquiry: “The decision to move Letby to day shifts raises serious questions which we will be investigating. If there was sufficient concern to take Letby off night shifts, then how could a decision that left Letby in sole charge of neonatal babies during the day be justified? Who was consulted about this decision?”

She added: “The falsity of the suggestion that ‘more eyes watching’ was an an adequate safeguard against harm being caused is demonstrated by the fact that Letby was found guilty of the attempted murder of twins, Child L and Child M, on the day shift of April 9 2016.”

Letby was discussed at the “most serious level” of the hospital in a meeting on May 11 with attendees including medical director Ian Harvey and nursing director Alison Kelly, and also Dr Brearey.

Ms Langdale said the inquiry would hear that Mr Harvey’s understanding at the end of that meeting was “we were dealing with a spike in deaths on the NNU which were unexplained despite thorough review … at no stage during this meeting did I feel that it was being reported because there was worry that Letby was responsible for the deaths”.

The inquiry heard there was an urgent care meeting on May 16 at which Dr Brearey intimated he thought a member of staff was causing the increase in mortality, and “it was at this meeting there was allegedly reference to there being ‘a murderess on the neonatal unit'”.

In July, Letby protested: “I’m innocent”, as she was led from the dock when she was sentenced to her 15th whole-life order after a jury convicted her at retrial of the attempted murder of a baby girl.

In May, she lost her Court of Appeal bid to challenge her convictions from the first trial which took place between October 2022 and August 2023.

Lady Justice Thirlwall said that judgment gave “finality” to the parents, but it was “not to be”.

She said: “In the months since the Court of Appeal handed down its judgment, there has been a huge outpouring of comment from a variety of quarters on the validity of the convictions.

“As far as I am aware it has come entirely from people who were not at the trial. Parts of the evidence have been selected and criticised, as has the conduct of the defence at trial, about which those defence lawyers can say nothing.

“All of this noise has caused enormous additional distress to the parents who have already suffered far too much.

“It is not for me to set about reviewing the convictions. The Court of Appeal has done that with a very clear result.”

The first week of the inquiry will hear opening statements from the counsel to the inquiry, along with legal representatives from core participants including the families of Letby’s victims.

Lady Justice Thirlwall said it was planned that the hearings in Liverpool would finish in early 2025 and she expected her findings to be published by late autumn of that year.

A court order prohibits reporting of the identities of the surviving and dead children involved in the case.