Lucy Letby inquiry finds babies could have been saved - The Latest

0:00This is The Guardian.

0:30Great shopping to ship up to 15 times more with up to 90 % savings. Go to ShipStation.com and use code AUDIO to try ShipStation free for 60 days.

0:44The concerns that were raised by senior doctors weren't taken seriously by senior managers. There was also complete failure at all levels to invoke safeguarding procedures at any point. It's difficult to imagine the trauma that some of these families have gone through. You've got to remember this is 10 or 11 years since their children either died or were seriously harmed. Some of those children are still living with lifelong effects, so it's a really difficult experience for them. From The Guardians today in Focus, this is the latest with me, Nashi Nekbal. In a case that shocked us all, Lucy Letby was convicted for the murder of seven babies and the attempted murder of seven more in her care.

1:27she was sentenced to spend the rest of her life in prison. There was a public inquiry into the hospital where she worked, and that report has been published today. Josh Halliday, you're our North of England editor, and you've covered this distressing case from the very beginning. Before we come on to the findings of the report, can you remind us why this case captured so much attention? Yeah, of course. I mean, yeah, I've covered this from the moment Lucy Letpe was arrested. I vividly remember getting the email from Cheshire Police press office announcing that a member of hospital staff had been arrested on suspicion of murdering babies.

2:04And it's still one of the most shocking police emails I've ever received. It's just not something that you expect to ever have to cover. And then when it emerged that Lucy Letby was the nurse involved, you know, a young nurse who was almost fresh out of university working on the neonatal unit of this hospital, you know, the place where the most vulnerable babies are. It just became even more shocking. I think, you know, it's almost unthinkable that this kind of thing could happen in a hospital in Britain. And when she was convicted, it meant that she was Britain's worst child serial killer, such with a sort of scale of the offences that she was said to have committed.

2:52So it's one of the most shocking criminal cases in recent British times. Josh, Lady Justice Thirlwall published the findings of her inquiry to date. What did her report reveal and what stood out to you? It's been a long anticipated report from Lady Justice Thirlwall. We expected it about a year ago. It was quite a long inquiry. It took evidence from nearly 400 witnesses over the course of 60 days at Liverpool Town Hall. I covered many of them. And the conclusions that she would draw became quite clear during the course of the inquiry. So there were multiple failures that were identified by senior members of hospital staff in terms of how they responded to concerns that were raised about Lucy Letby from within days of three babies dying in unexplained circumstances in June 2015.

3:51And to put that into context, that's a whole year's worth of deaths on the neonatal unit in less than two weeks. So this inquiry was looking at how those concerns were managed by Lucy Letby's colleagues and in particular senior managers and hospital executives. It's always been clear that there were failures in the process that is meant to investigate suspicious incidents and unusual incidents in cases like this. But that was really made explicit in today's report. there's just over 822 pages of inquiry findings. It's quite clear that the concerns that were raised by senior doctors when these first three babies died and in the subsequent months weren't taken seriously by senior managers and they weren't properly acted on when they were received by executives.

4:55And so it's quite damning in its condemnation of institutional failures or failures of management, people working at that hospital. So what were Lady Thurwell's recommendations? So she made 17 recommendations and they're quite sweeping calls for urgent reform in the NHS. And there's a couple of particularly striking ones. One is that there should be baby monitors installed on every single incubator and cot on neonatal units in hospitals. Right. So parents will be able to watch essentially a live feed of their baby in hospital. It just seems so practical and straightforward and obvious when you think about it.

5:39Yeah, I mean, one of the things that a lot of people called for when they gave evidence to the inquiry, particularly the parents of the babies, was increased use of cameras in neonatal units, more CCTV. but it's been quite strongly pushed back on by certain doctors and by hospital leaders who are worried about the invasion of privacy as well as the practical implications of doing this. So to see Lady Justice Stillwell adopt this as her first recommendation, it's not buried in the report. This is the main thing I think that she wants to come from the report, was really quite striking. There are other things that you might think would be common sense, which are restricting access to insulin and recording its use on neonatal units, because there were concerns that nurses may have had access to insulin when they didn't need it for clinical reasons.

6:41And that's important because it was used in murder of babies. Yeah, the prosecution's case was that Lucy Letby deliberately poisoned two babies with insulin and she was convicted of those offences. But there was no record of who would take it, no proper record or digital record or nothing that you could trace to say who had taken out the insulin and how had they used it. There are further calls for reform into how hospital managers have to provide a duty of candour when they're dealing with people like coroners and that there should be a barring system for unfit managers in the NHS. Because there was a concern that you can essentially fail upwards in the NHS in one hospital, but then get moved somewhere else, perhaps to a different part of the country where you can start again with a clean slate.

7:39But one thing I thought was quite surprising in the report was that Lady Justice Thirlwall said she had little confidence or said she was not reassured that the government would implement these recommendations because it has a terrible track record of implementing the recommendations of inquiries into health scandals going back 30 years. Well, that's quite the challenge, isn't it, now that she's presented. And Josh, I mean, this was such a difficult case for so many reasons. And the story of it didn't end with the convictions, because after that, experts and journalists began to cast doubt on whether this was a safe conviction, you know, looking or raising concerns about the evidence presented in court and in the trial itself.

8:21Can you explain the journey that this case has been on, this quite peculiar journey, and, you know, since you first began reporting on it? Yes, so very soon after the trial ended at Manchester Crown Court, there were concerns about how some of the prosecution evidence was presented to jurors, in particular statistics that showed that she was the only member of staff on duty for each of the suspicious deaths and collapses. that was disputed by quite highly regarded statisticians. And then medical experts really started to look at the very complex medical evidence that was presented to jurors and started to find weaknesses in that as well.

9:08One of the most difficult things about all this was that at the trial, there were no defense medical experts. Speaking on behalf of Lucy Letby, she didn't call a single medical expert to challenge any of the really complex medical evidence. So the jury were essentially left with all of these prosecution witnesses, which backed up the prosecution's case that she was guilty, but then didn't have anyone casting doubt on these. At the time? At the time, until much later. And then as medical experts started to raise concerns publicly, And remember, this is a really difficult thing for medical experts to do as well, to put their professional reputations on the line, to challenge the convictions in a case that is so sensitive, polarizing and emotional as well.

10:04At this point, as far as I'm aware, Lucy Letby has exhausted her appeals, but the UK's miscarriage of justice watchdog, the Criminal Cases Review Commission, is looking into the case and they say that they'll be looking at this report with interest to assess whether it has any bearing on their review of the case. Josh, what is the significance of that and could it lead to another appeal? So the Criminal Cases Review Commission has been looking at a dossier of evidence compiled by Letby's defence team since February last year. They're expected to decide within months whether to refer the case back to the Court of Appeal.

10:42They've been monitoring the Thirlwall inquiry, as you would expect them to do, because they want to be across every single detail of the case. and this 822-page report is really meticulous in how it records what happened at the hospital at that time. I don't think that this will have a huge bearing on the outcome of the CCRC investigation because it doesn't touch on medical evidence. It's not about whether these babies were murdered or not. This inquiry worked on the assumption that they were murdered and they were deliberately harmed. So that's taken for granted. It's based on the findings of the two criminal trials and the two Court of Appeal rulings.

11:28And so what happens now? Are there any other criminal investigations ongoing? So there's two criminal investigations ongoing by Cheshire Police. They're into corporate manslaughter by the Council of Chester Hospital Trust and they're into a separate criminal investigation into three hospital executives on suspicion of gross negligence manslaughter. Those three executives were arrested last year. That investigation is ongoing and in parallel there's this CCRC investigation into whether the convictions are safe or not. But all sides will be looking at this inquiry to sort of understand its significance.

12:17And it will take many weeks, potentially months to do that, I think. Josh, it's difficult to imagine the trauma that some of these families have gone through. And I wonder, I mean, we've heard from some of the lawyers representing them today. What have we been hearing? What have they said? Many of the families were inside Liverpool Town Hall reading this report at the same time as we were. I know that they were bracing for it. They were expecting it to be a harrowing read. You've got to remember this is 10 or 11 years since their children either died or were seriously harmed. Some of those children are still living with lifelong effects of what happened to them in hospital.

12:58So it would have been a very, very difficult experience for them, I'm sure. And just over the road from the town hall where I am, there are protesters who are claiming that Lucy Lettby is innocent, carrying placards and chanting, which can be heard inside the town hall. Wow, that's painful. So it's a really difficult experience for them. And since they've had time to digest it, they've said that this can't be the end of the investigations. I know they're particularly keen that Cheshire Police continues its work into potential criminal wrongdoing among those who are at senior positions in the hospital and that's what they will look for next.

13:40There's still so many loose threads. Josh, thank you so much for joining us. Thank you. That's it for today. Thanks again to our North of England editor, Josh Halliday. Today in Focus will be back tomorrow morning and the latest will be back tomorrow evening. This episode was produced by Angus Neal, the senior producer was Ryan Ramgobin, the executive producer was Zoe Hitch and it was presented by me, Nashi Nick Bahl.

14:06Around the time that I was finishing my PhD, I was feeling really awful. You message your mum saying, I'm struggling. Her reply is suspiciously polished. I called my mum and I just railed on her. I was like, mum, did you just use chat GPT? Blackbox, The Chatbots, a new series from The Guardian Investigates about the strange things happening between AI and us. The whole series is out right now. Search for Black Box wherever you get your podcasts. This is The Guardian.

15:02Everything your operation needs, all in one place. Right now, qualified shippers get a real, dedicated person to get you set up and switched over for free. So when peak season hits, you're ready to go. Switch today at ShipStation.com, code audio.