The former chief executive of the Countess of Chester Hospital was worried about a “wrongful conviction” after the arrest of Lucy Letby, a public inquiry has heard. Tony Chambers was said to have had the concerns after Letby’s initial detention by Cheshire Constabulary in July 2018, over a string of unexplained and unexpected collapses of babies on the neonatal unit.
Dr Susan Gilby recalled what she said was a “quite bizarre” discussion with Mr Chambers, weeks after Letby’s arrest, when she joined the Countess of Chester as the new deputy chief executive and medical director. Giving evidence to the Thirlwall Inquiry into the events surrounding Letby’s crimes, Dr Gilby said she expected the hospital’s executive team would be “absolutely reeling” that a staff member had been arrested on suspicion of committing multiple murders and attempted murders “under their watch”.
She said: “What I found, and what Tony wanted to discuss with me, was his concern that actually he still believed, despite the arrest, that no deliberate harm had been caused. “He kept repeating that there was no single cause found, and I said to him ‘well it’s not for you to find the cause, you have unexpected and unexplained collapses and deaths of patients and even one of those is a cause of concern’.
“And he just was very focused on the worry that the paediatricians may have caused this nurse harm, and his worry was a wrongful conviction. “But he was still confident, even though she had been arrested, there would be no progress and there wouldn’t ultimately be a charge.”.
Letby was moved out of the unit to non-clinical duties in June 2016, shortly after consultant paediatricians told bosses that they feared she may be deliberately harming babies, after the unexpected deaths on successive days of two triplet boys. Hospital executives, including Mr Chambers and then medical director Ian Harvey, opted to commission a number of independent probes into the increased mortality, as police were not called in to investigate matters until May 2017.
Dr Gilby said she had spoken to Mr Chambers and Mr Harvey before Letby’s arrest, and sensed both believed the paediatricians were wrong about their concerns, and also that no evidence of deliberate harm had been found in their reviews. She said: “They were very dismissive of the paediatricians, and on a number of occasions it was said to me, they were just looking for somebody to blame.
“They just felt the paediatricians were unable to accept they weren’t the best and so when outcomes were poor they were looking for somebody to blame. “I was being given the impression that I had some ‘problem doctors’ that needed dealing with.”.
Dr Gilby, a former consultant in critical care, said she spoke to the neonatal unit’s clinical lead Dr Stephen Brearey, shortly after her appointment. She told the inquiry: “He started to tell me the pattern of events, not just the clinical pattern but what happened as a result of them raising concerns.
“We didn’t get very far into the conversation before it became obvious to me as a clinician, never mind as an executive, that it was most unlikely these were just clinically explainable collapses. It didn’t seem possible. “At one point, I think, I made an exclamation when he told me about a particular issue, and he said to me ‘you have been here for five minutes, you get it, we have been trying to tell them for years’.
“We spent three hours going through the timeline, both clinically and non-clinically, of everything that had happened. “I discovered clinical histories of patients who were doing well, who were expected to go home, perhaps even on the day they were due to go home, suddenly having a cardiorespiratory collapse.
“Even with adults, on an intensive care unit you have a watchlist of patients who are at risk of deterioration, or whose clinical condition is fragile, and if they deteriorate it’s not like flicking a switch, it’s a gradual worsening of their vital signs.
“What Dr Brearey was describing to me was something I had never, ever, seen or heard of in my clinical practice. “Just one of those, for me, would have been enough as a medical director or a director of nursing, to absolutely want to get to the bottom of what is happening here.”.
Dr Gilby later replaced Mr Chambers, who stepped down in September 2018. Letby, 35, from Hereford, is serving 15 whole-life orders after she was convicted across two trials at Manchester Crown Court of murdering seven infants and attempting to murder seven others, with two attempts on one of her victims, between June 2015 and June 2016.
Earlier this month an international panel of neonatologists and paediatric specialists told reporters that bad medical care and natural causes were the reasons for the collapses and deaths. Their evidence has been passed to the Criminal Cases Review Commission (CCRC), which investigates potential miscarriages of justice, and Letby’s legal team hope her case will be referred back to the Court of Appeal.
