Letby inquiry finds hospital bosses silenced the doctors who raised the alarm
The Thirlwall Inquiry into events at the Countess of Chester Hospital has published its full findings, and the picture it paints of hospital leadership is damning.
Rather than acting on the concerns raised by consultant paediatricians Dr Stephen Brearey and Dr Ravi Jayaram, senior executives spent almost a year trying to discredit the doctors instead.
The report finds that Chief Executive Tony Chambers, Medical Director Ian Harvey and Director of Nursing Alison Kelly treated the consultants, not Lucy Letby, as the problem.
Executives considered referring the doctors to the General Medical Council and even discussed managing them out of the hospital, rather than properly investigating the unexplained deaths and collapses on the neonatal unit.
The Inquiry concludes that Chambers' intention throughout was to stall or obstruct a police investigation and that he succeeded in doing so for almost a year. Police were eventually contacted in May 2017, 11 months after the doctors first raised their concerns.
Parents were not told about the suspicions surrounding Letby until she was arrested in July 2018, something the Inquiry describes as unforgivable. Regulatory failings compounded the problem. The Care Quality Commission's 2016 inspection did not identify the rise in neonatal mortality and a safeguarding referral was not made until March 2018, despite concerns having been raised more than two years earlier.
Chair Lady Justice Thirlwall's recommendations focus heavily on protecting clinicians who speak up. They include a Suspicion of Deliberate Harm Protocol, clearer employment policies that put patient safety above institutional reputation and a proposal for a panel of independent experts who can be called on quickly when concerns are raised about a member of staff.
Fiona Morrison, Director and Co-founder of TLA Medicolegal, said: “This report shows exactly why properly qualified, independent medical experts matter so much in cases like this.
“When hospital management chooses to shut down concerns rather than investigate them, it takes people outside that system, with the right clinical expertise and no institutional loyalty to protect, to get to the truth. Doctors like Dr Brearey and Dr Jayaram should never have had to fight this hard to be heard.”
The findings land against a backdrop of continuing scrutiny over the expert evidence in the case itself. Two members of the international panel reviewing Letby's convictions, chemical engineering expert Helen Shannon and bioengineering professor Geoff Chase, have withdrawn their support from her defence team, citing concerns over the scientific credibility of some of the arguments being advanced.
Separately, barrister Mark McDonald has been reported to the Bar Standards Board for alleged professional misconduct.
Fiona added: “Whatever view anyone takes of the wider case this only reinforces the point. Every expert involved, on any side, must be able to stand fully behind the evidence they give.”
The full Thirlwall report is available at thirlwall.public-inquiry.uk/the-report.