A 'dictatorial' boss, blind loyalty to Letby and grieving mums misled... the failings in full

In the end, Lady Justice Thirlwall's report into what happened at the Countess of Chester Hospital between June 2015 and June 2016 painted a grim and chaotic picture.

The hospital management was 'dysfunctional', and an 'us-versus-them' mentality pervaded among staff.

Some of those who had suspicions about the uncharacteristically high number of deaths in the neonatal unit kept quiet. Others who raised the alarm were dismissed. Reviews were carried out as opposed to calling in the police.

It meant Lucy Letby was able to carry on murdering babies, and seriously harming others.

'Errors were made by nurses, doctors and managers at the time of these events,' Lady Justice Thirlwall said in her report yesterday. 'There was complete failure at all levels to invoke safeguarding procedures at any point.'

LUCY LETBY

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. It emerged that feedback on Letby's performance was mixed while she was training.

She was said to be lacking in enthusiasm for the job and, chillingly, her communication skills with families and drug calculations were below par.

Lucy Letby was initially found guilty of murdering seven infants and attempting to murder seven more following a ten-month trial at Manchester Crown Court 

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 Her mentor noted that Letby was 'quiet, withdrawn and struggled to build relationships with children, families and colleagues'.

The inquiry heard that, despite Letby's efforts to address these issues, she failed a mid-year 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.

Yet she was particularly chummy with top bosses, something which may have clouded their judgment.

MISSED OPPORTUNITIES

The judge pulled no punches in pointing the finger of blame at senior managers including Alison Kelly, Ian Harvey and Tony Chambers, who 'dismissed the idea that Letby was deliberately harming babies', as late as June 2016.

She said it mattered little whether or not they believed allegations against Letby – they should have acted. Ultimately, there were delays in contacting police which could have prevented babies being killed or harmed. 

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.'

Mr Harvey, the medical director, told the inquiry he regretted that they did not go to the police in June 2016. Lady Justice Thirlwall said neither he nor chief executive Mr Chambers was in a position to decide whether the doctors' concerns had any credibility.

Lady Justice Thirlwall arriving at Liverpool Town Hall where she delivered her public inquiry report on Tuesday

She said safeguarding action should have been taken by moving Letby off the ward following the death of Baby I in October 2015. 

There were even opportunities to stop her two months earlier after a consultant 'disregarded' evidence which suggested Letby poisoned a baby with 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.

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.

Families were not even told about the investigations into the deaths of their children.

The mothers of four children were 'all misled', either in face-to-face meetings or in written communications, she said.

Lady Justice Thirlwall added: 'Risks to reputation and disruption are not of the same order.' The inquiry heard several parents were given leaflets about bereavement, but no support. The judge said: 'This was not good enough.'

NURSE MANAGEMENT

The report highlighted the 'serious failure' of a seemingly ingrained 'us-versus-them' attitude between doctors raising concerns about Letby and her nursing colleagues determined to protect her. 

It meant senior nurses and managers leapt to Letby's defence. Senior nurses demonstrated 'unquestioning loyalty to Letby' allied with the 'certainty that there was nothing in the consultants' concerns'.

This, said the inquiry chairman, 'seems to have prevented them from considering the doctors' concerns with an open mind or thinking about safeguarding'.

The inquiry heard nursing director Ms Kelly and medical director Ian Harvey did not attend a meeting arranged with senior paediatricians in June 2016 to discuss neonatal mortality.

The inquiry report, more than 800 pages in length, was released on Tuesday 

But head of nursing Karen Rees was of the view that there was a 'them-and-us' approach between the doctors and nurses. The report added: 'It should never have been about nurses against doctors. It was about keeping babies safe.

'Had that governed the approach of the managers, they would and should have sought to work with the doctors, not against them.

'Characterising this as nurses versus doctors distracted from the real issue: that steps needed to be taken to protect the babies.' 

HOSPITAL BOSSES 

The report found head of safeguarding Ms Kelly 'knew she had to act when there was a suspicion that a baby had been harmed, and that others might be at risk'. But, the judge said, Ms Kelly did not do so. 

Mr Harvey said he took the doctors' concerns seriously but Lady Justice Thirlwall said: 'His approach demonstrates that he did not consider them (the concerns) credible.'

Hospital bosses were particularly concerned about 'negative comments' or newspaper coverage, and so the reputational damage to the hospital was 'prized more highly' than transparency.

Lady Justice Thirlwall said executive presentations to the board as allegations against Letby whirled were 'an exercise in spin'.

She said Mr Chambers' attitude towards senior doctors flagging fears about Letby was 'dictatorial', and that he 'never once scrutinised his own thought process' .

INVESTIGATIONS

Lady Justice Thirlwall was critical of several internal and external reviews, commissioned by hospital bosses as an alternative to contacting the police. 

The report said these failed to address the single most important issue – whether deliberate harm was being caused to babies or not.

Medical director Mr Harvey then commissioned the Royal College of Paediatrics and Child Health to carry out an external review into the neo-natal unit, without any consultation with the medics, rather than call in police.

Lady Justice Thirlwall said the failure to call the police in July 2016 was 'impossible to defend'.