The chair of the inquiry investigating NHS failings to stop serial killer Lucy Letby has said it is “utterly unacceptable” that she was able to harm children 25 years after the murders of nurse Beverley Allitt.
Letby, 33, was sentenced in August to a rare whole-life order for the murders of seven babies and the attempted murders of six others at the Countess of Chester Hospital’s neonatal unit between June 2015 and June 2016, making her one of Britain’s most prolific child serial killers.
Following her conviction, which she is appealing, the government launched an inquiry led by Lady Justice Thirlwall, who on Wednesday warned that culture change within NHS neo-natal care is “long overdue”.
Beverley Allitt, nicknamed the “Angel of Death” was convicted of murdering four babies at Grantham and Kesteven Hospital in 1993. She was also convicted of attempting to murder three more and causing grievous bodily harm to another six. Allitt is serving 13 life sentences – one for each of her victims.
An inquiry into the case led by Sir Cecil Clothier QC published in 1994 identified failures of management and communications at the hospital where she worked, including a “general lack in the qualities of leadership, energy and drive”.
In a video message on Wednesday unveiling the scope of the Letby probe, Lady Justice Thirlwall said: “We all know that there have been many inquiries into events in hospitals and other healthcare settings over the last thirty years. The case of Beverley Allitt who murdered babies at Grantham Hospital in the 1990s comes to mind. Everyone was determined that it would not happen again. It has happened again. This is utterly unacceptable.
“I want to know what recommendations were made in all these inquiries, I want to know whether they were implemented. What difference did they make? Where does accountability lie for errors that are made? I intend to call experts to give evidence about this.”
Hearings for the Letby inquiry will not begin until September 2024 due to the live corporate manslaughter investigations into the Countess of Chester Hospital and a retrial Letby is facing over one count of attempted murder.
Lady Justice Thirlwall revealed that every hospital in the country has been sent a questionnaire about its neo-natal unit including questions on whether there is CCTV in their units or whether consideration has been given to installing it in light of the Letby case.
Another survey will be sent to all doctors and nurses working in baby units which includes questions on the culture within them.
Lady Justice Thirlwall also committed to investigating the issues “from the ward to the boardroom”.
She added: “No one can argue with the proposition that babies in neonatal units must be kept safe and well cared for. What is needed is the practical application of that proposition everywhere. In many units it will require profound changes in relationships and culture. This may not be easy to achieve but it is necessary and long overdue.”
The inquiry will cover three areas, including the experience of the parents and babies, the conduct of the Countess of Chester when concerns were raised and NHS management, culture and professional regulation.
Lady Justice Thirlwall said: “The parents of the babies who were murdered or suffered injuries, some life-long, live with the consequences every day. On top of their grievous loss, they endured years of uncertainty about what had caused death or injury. For some, uncertainty remains.
“All have made it plain to me that they want to do all they can to make sure no one else suffers as they do. I, too, with the help of the inquiry team and many others, will do all I can to make sure that no one else suffers as they have. It is unconscionable that this situation would ever occur again.”
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