Why the Thirlwall Inquiry isn’t the last word on Lucy Letby

0:02Sky News, the full story first.

0:11The Lucy Letby inquiry says babies' lives could have been saved if the hospital had acted sooner. And this is why.

0:21The most excruciating period of politics that I can ever remember. I have to say as a government minister, never quite sure what the Cabinet Office did, but just hold meetings. It's gone down like a bucket of sick. I kind of thought that decades of experience meant that you weren't swallowing this vapid. Oh, blimey! Hello and welcome to Electoral Dysfunction with me, Beth Rigby. Me, Ruth Davidson. Me, Harriet Harman. And me, Jess Phillips. Electoral Dysfunction, wherever you get your podcasts.

1:01Hi everyone, Neil here, and look, just a warning right off the bat, this might not be an episode for younger listeners. Imagine if you can, working in a hospital and becoming concerned that a colleague might be hurting babies. Imagine raising those concerns and being told to apologise. Well, that's what happened at the Countess of Chester Hospital, where Lucy Letby worked. She's now serving whole life sentences for murdering seven babies and attempting to murder seven others. It is, by any measure, a horrific story, which today took another turn. Lady Justice Thurwell's inquiry said there was a complete failure to protect those children and that earlier action would have saved some of them.

1:41I spoke to Sky's Greg Milam, who's been at the inquiry today. Greg, damning is the words when it comes to this report, but let's start with what I imagine will be the most painful detail for a lot of people. The inquiry saying that some babies would have been saved if the hospital had acted earlier. What opportunities were missed? I think that's, for the families, certainly the most striking line out of this report. There were numerous missed opportunities. Lady Justice Thurwell said that there's no way of being certain, of course, that anything would have been different. But, for example, in August 2016, a baby died from insulin poisoning.

2:16that death was disregarded by the doctors as being of concern. So that was what two months after the first baby had died and the killing and attacks went on until June of the following year. So you can surmise from that the babies who were injured, the babies who died could well be alive if that opportunity alone had been taken. But even at the very beginning of this, June 2015, three babies died in the space of 14 days. It was something that usually would only happen over the course of a year. There were opportunities, there were concerns, people were noticing that there was one nurse on duty with all of those babies.

2:49There were repeated opportunities that could have made a difference and could have meant that 10 years on some of those babies were still with us. And it is not as if people were not noticing that these deaths had been taking place. Yeah, doctors primarily, senior doctors who were concerned by the proximity of Lucy Letby to some of these collapses that were taking place and went to the senior nursing teams to raise their concerns. What followed is what Lady Justice Thurwell called tribalism. The senior nurses didn't believe these senior doctors. That led to this prolonged delay in taking any sort of actions.

3:23In fact, the doctors were disbelieved to the extent that they were in fact investigated when Lucy Letby herself launched her own grievance procedure. Managers were dismissing parents' concerns. They were saying things like, Lucy Letby is a very good nurse. Creme de la creme was a phrase used to describe her as a nurse. She always took on extra shifts. And in fact, the senior nursing team was saying that these concerns were misconceived. And what Lady Justice Sirwell said about that tribalism is that it was never about doctors versus nurses. It was about keeping babies safe. And that fundamentally is where it all fell down in that division that was going on between the doctors and the nurses.

4:00Greg, I am really struggling to get to grips with how that situation could have unfolded like that. I mean, were we in a situation where people in that hospital were effectively waiting for proof of a crime before taking steps to protect babies. Well that's what the report says in essence and is damning of the executives who became aware of some of this. There was a head of safeguarding, Lady Justice Thurwell says, she knew she had to take action on this and she didn't do that. Whether it was because they were protecting the reputation of the hospital isn't clear. There were a number of reviews, internal and external reviews ordered by the hospital.

4:36But at the end of all of those reviews, there was still no explanation for several of the deaths. And this is what Lady Justice Thurwell has said about that. The failure to call the police at that point is impossible to defend. And I think that's the question a lot of people have. She described those managers as being high-handed, acting contrary to all safeguarding principles, being foolhardy. Those are the words she's using about those decisions taken because it was nearly a year after the last death in June of 2016 that the police were called in May of 2017. That delay, she says, impossible to defend.

5:08These internal and external reviews, given that they were provided with the same information that everyone else was, why could they not arrive at the conclusion that babies were being intentionally, deliberately harmed? Lady Justice Thurwell says there's a really simple problem at the heart of lots of this, and that is that the safeguarding policy didn't include any mention of deliberate harm by a staff member. In fact, she goes further and says that even to this day, there's no NHS-wide protocol for deliberate harm carried out by a staff member, and that's something she says in her recommendations that needs to change.

5:43This disbelief, if you like, that anything could be being done by a member of staff was institutionally. It was mentioned a number of times during the hearings of this inquiry that if it was a member of the public who brought their child in and there was harm, visible to staff, there would have been safeguarding practices put in action. Safeguarding investigations would have taken place. The fact that that didn't exist for staff who were there is a really big gaping hole in the middle of those processes and one that Lady Justice Thirlwell says needs to change because that was the gap. This belief that people needed to be certain of guilt before they reported anyone was a serious problem rather than just reporting their concerns or their suspicions that a member of staff was causing deliberate harm.

6:21So in essence, managers at the hospital were taking reassurance from reviews that hadn't investigated the thing that they needed reassurance about. We find ourselves in a situation where the three consultants who raised significant concerns about Lucy Letby were told to go off and apologise. Yeah, part of that grievance procedure, backed by Lucy Letby's parents who were very vociferous in supporting her and making a lot of noise about what would happen if it wasn't taken seriously. That grievance procedure took place. Those doctors, it was made very clear to them that there will be further consequences if they continue to make noises about Lucy Letby.

6:54They were told to apologise to her and there were plans in place for her to come back to the ward and resume nursing. This was after she'd been removed from duty. It's incomprehensible now when we look at what we know about what was happening and the evidence that we've seen over the years since. But those questions about the need for that policy, that protocol on deliberate harm and the fact that people who are whistleblowing need to be protected and feel they can come forward with concerns. I think no one now can avoid that as being the upshot of all of this, but at the time it simply wasn't there, and the result is what we have today.

7:26And throughout all of this, before the criminal investigation kicks in properly, what were the parents being told? Almost nothing. Almost nothing. The inquiry report says they were kept in the dark for years about what was happening, the fact that their babies might have been deliberately harmed by a nurse they trusted. it. It says in the report they weren't told about reviews, they weren't told about investigations. For many of them it was only when the police knocked on their door many years later and told them what had happened. That was the first they knew about the investigations and the concerns that existed within the hospital, within those people that they were seeing.

8:00They felt, the families felt then and still feel now, that the hospital was more concerned about protecting its reputation than looking into what was going on. And Lady Justice Thurwell said that lack of consideration for the parents was reprehensible. We heard a lot during the inquiry evidence from those families whose identities were protected for the rest of their lives and she said the anger was palpable and it was. They're very angry about what happened then, what happened since and they're very determined and they wanted their voices heard because they want change to come as a result of this even if it won't benefit obviously the children they lost or the children who suffered permanent damage as a result of Lucy Lepri's actions.

8:35I'm just trying to put myself in the position of a parent who has lost a very, very young baby in those circumstances, who for years, as you've just said, does not realise that there could have been a nefarious reason for this, that there could have been someone behind it. What, if anything, have we been hearing from those families? We've had a statement from a lawyer representing some of them. We'll hear more during the course of the day. They said it's an emotional day, talking about it being dispiriting and shocking to hear what was going on, this damning picture, as they say, painted of what was happening.

9:07But I think crucially they say this can't be the end of this. This report will go to Parliament. Ministers will talk about it, but they say that the government must put these recommendations into action. The lessons learned must be meaningful and they must bring lasting change in honour of the babies, in honour of their children, because otherwise this has all been for nothing. And it's interesting that at the beginning of this inquiry, Lady Justice Thurwell talked about all the other inquiries that have gone on over the years into NHS scandals. And so part of what she'd be looking at is to see whether the recommendations they made were implemented as a result of those inquiries.

9:40I think we know hundreds of them weren't and she's made recommendations that that needs to change, that the National Auditors Office needs to take responsibility for implementing these recommendations. Otherwise families like those who lost their children at the hands of Lucy Letby will feel it has all been for nothing. And I do want to ask about those recommendations in just a second but how much of what we have learned from this report identifies failures at a particular hospital. And how much does the report say this could happen elsewhere in the NHS? I think that lack of a protocol for deliberate harm, for example, is something that extends to hospitals across the country.

10:15Obviously, much of it is specific about the Countess of Chester Hospital, and the Countess of Chester Hospital has changed a lot in the intervening years. I'm sure we'll hear from them during the course of today. But I think these are recommendations that do go much more broadly than just one hospital and one series of incidents. She's very concerned that the lessons are learned everywhere. Those recommendations are pointed. Many of the people involved in what happened in 2015, 2016 have moved on. The hospital staff is very different. The hospital is very different. There are lessons that need to be learned countrywide, systemwide, NHS-wide, really to ensure, as Lady Justice Sirwell said at the end of her remarks, that this kind of thing doesn't happen to other families in the future.

10:53Walk us through those recommendations, and they are pretty punchy, starting with live streaming cameras in those neonatal cots and incubators. Yeah, in all hospitals, in cot cameras and cameras in incubators that stream live videos so the parents who are away from their children can observe them at all times remotely. And also, she says, that would deter anyone who has the intent to cause deliberate harm. That's a recommendation. She's put timeframes on many of these recommendations. Another one is restrictions on access to insulin for medical staff and recording of uses of insulin because that was a feature in a number of the cases.

11:27Maybe surprising to those of us who don't work in a hospital that that doesn't exist already. And then on this question of the suspicion of deliberate harm, the development of a policy that would take effect across the country and would oblige staff to contractually abide by that policy to report suspicions of deliberate harm and a duty of candour on managers as well, bearing in mind some of what went on of people not being candid, certainly with families, about what was happening. and as I said there's a recommendation about the recommendations that the National Audit Office should take a responsibility to make sure they're put into effect.

12:00So these 17 recommendations, all the other recommendations, are meaningful and have a meaningful effect in the future.

12:12The most excruciating period of politics that I can ever remember. I have to say as a government minister, never quite sure what the cabinet office did but just hold meetings. It has gone down like a bucket of sick. I kind of thought that decades of experience meant that you weren't swallowing this vapid. Oh, blimey! Hello and welcome to Electoral Dysfunction with me, Beth Rigby. Me, Ruth Davidson. Me, Harriet Harman. And me, Jess Phillips. Electoral Dysfunction, wherever you get your podcasts.

12:52devastating findings and criticisms in this report. What happens now to the people that face those criticisms? I mean, are there any potential consequences? Well, Cheshire Police have said today that their investigation is continuing into whether there are any offences of corporate manslaughter or gross negligence manslaughter related to that hospital. They say there's no timeframe for that investigation. We know that a number of people have been arrested and released on bail over the last year as part of that investigation. So we wait to see if there's further action there. We wait to hear from the Secretary of State for Health about actions being taken more broadly on the recommendations.

13:26And of course, the questions about Lucy Letby persist. There was a noisy protest here today in support of her. We should say that this inquiry has never been about whether Lucy Letby is innocent. Its starting point was those criminal convictions that she had and how she was able to kill and go on killing, not whether this debate about her guilt or innocence should play out. So very focused on what it was about and what it wasn't about. And Lady Justice, though, we're making the point today that people who do have that debate, and there are lots of them, continue to keep in mind the families and their suffering in the middle of all of that debate that goes on.

14:03You said previously, we are still waiting to hear from the hospital. But do we know at all what may have changed in the 10 years since these deaths began at the Countess of Chester? If you're a parent living in the area, you probably want some degree of reassurance before taking yourself into the maternity wing there. A lot has changed. Physically, the building has changed. The building back in 2015, 2016, Lady Justice Thirlwall's report says was cramped. It was out of date. At the time, actually, they were trying to fundraise to build a new building. Lucy Letby's picture was in some of that fundraising literature.

14:35They did build a new facility there. There's a new mother and child wing. It is a much more updated, a much more modern facility from the one back then when parents were kept on a different floor to babies in the neonatal unit. So that has changed. The people have changed. And the processes undoubtedly have changed as well. It lives with the stain of what happened in 2015 and 2016. Not just, as we now know, just the actions of Lucy Letby as a nurse, but those around her, those in positions of power, who did sometimes worse than nothing in covering for what was happening and not passing on those concerns so that proper action could have been taken at the time and preventing some of those deaths from taking place.

15:12I think it's worth reiterating your point Greg that this inquiry certainly wasn't you know an appeal against Lucy Letby's convictions but there is a process ongoing where does that process currently stand? It's currently with the Criminal Cases Review Commission which has said that it's continuing to review what has been presented to it by Lucy Letby's legal team. You have to remember she was convicted at two criminal trials, two attempts at appeal were rejected so what the Criminal Cases Review Commission could do is send it back to the Court of Appeal if they believe there is a case for that to happen.

15:44Her legal team had tried to have this inquiry shelved at its very outset because they believed it was working on the basis she was guilty. If it turned out to be that she wasn't guilty then it would have undermined the recommendations and the outcome of this inquiry. Lady Justice Thurwell dismissed that attempt to have this process stopped but that criminal appeals process could well resume. We know Lucy Letby won't face any more criminal charges. Cheshire Police did pass files to the Crown Prosecution Service. They decided that they didn't meet the evidential threshold to prosecute her further.

16:15That was for the collapses of other babies at hospitals she'd worked at, but it's very much the focus of her appeal. And that noisy, very vocal support is still very much in existence. A lot of people who believe there are questions about the safety of her conviction, a legal team and a panel of experts who've presented evidence, they say that that backs that up. That will be the next milestone in this case if the Criminal cases review commission decide to send this back to the court of appeal we will see what happens with that but look greg like you i was listening to lady justice thirlwell as she brought the inquiry to conclusion reading out her conclusions and thanking the people of liverpool the support staff that is the end of her involvement but to me and i don't know if this is the same for you it certainly doesn't feel like the end of the story and i'm not talking about any potential appeal process for lucy let be just that the detail in the inquiry's findings is so frustrating so upsetting.

17:06If I were one of the parents bereaved or one of the parents of those who have been affected by this I would be angry. I would be angry beyond measure. I think they are angry and I think what we've heard today from those who represent them is that this anger lives on and their questioning of what needs to happen next lives on. This doesn't end now and until they see those recommendations enacted by the government they won't rest. I don't think much of what we heard from Lady Justice Thirlwell today will have been a surprise to many people who sat through the hearings. They heard what the families had to say, they heard their frustrations, they heard their experiences.

17:41But seeing it written down and announced in a very austere setting and knowing that's now being passed to the government, I think it's very different. And I think for the families, that's some vindication, I guess, but there's a lot more that needs to happen before they will be satisfied at the outcome of this process. Greg, thanks very much. and that's your lot do let us know your thoughts I suspect the case of Lucy Letby will prompt many of them why at sky.uk we're back tomorrow

18:17the most excruciating period of politics that I can ever remember I have to say as a government minister never quite sure what the cabinet office did but just hold meetings It has gone down like a bucket of sick. I kind of thought that decades of experience meant that you weren't swallowing this vapid. Oh, blimey! Hello and welcome to Electoral Dysfunction with me, Beth Rigby. Me, Ruth Davidson. Me, Harriet Harman. And me, Jess Phillips. Electoral Dysfunction, wherever you get your podcasts.