The hospital bosses criticised in Letby inquiry report

When the Thirlwall Inquiry published its long-awaited findings into Lucy Letby's crimes this week, the actions of NHS leaders responsible for overseeing the Countess of Chester hospital's neonatal unit - where babies had died or collapsed unexpectedly - were scrutinised.

The report painted a deeply critical picture of how concerns raised by clinicians were handled, concluding that some managers were unwilling to accept the possibility that a nurse could be deliberately harming babies.

There was some criticism of senior doctors, too, for not escalating specific worries sooner.

Thirlwall describes a "dysfunctional management and governance, a gulf between hospital leadership and clinicians, and a failure to understand the fundamentals of safeguarding".

Tony Chambers was a nurse before moving into management and had held senior NHS roles since 2004.

Lady Justice Thirlwall said he and other managers "dismissed" the idea that Letby was harming babies because they "did not believe it".

She concluded that "his intention throughout was to stall or obstruct a police investigation" once he became aware of doctors' concerns, adding that he "succeeded" in doing so for almost a year.

Thirlwall said Chambers was "determined to bring down" the consultants who had raised concerns, devising a plan to refer some to the General Medical Council (GMC) and "manage them out" if the police decided not to investigate.

His determination to bring down the consultants meant he "lost objectivity and made poor decisions", Thirlwall concluded.

She also described it as a "gross misjudgement" when he told Letby: "Lucy, we've got your back" after a grievance she had raised was upheld.

The inquiry found his "failure" to take "any responsibility for the delays and the heartache caused to the families" was "indefensible".

When Chambers resigned in September 2018, he collaborated with trust chair Sir Duncan Nichol on a resignation statement which Thirlwall described as "pure spin".

It said his departure was "not a judgement on his ability" but "a reflection of his integrity".

Thirlwall concluded he was in fact resigning to avoid a vote of no confidence.

Chambers later secured senior roles at other NHS trusts, despite what Thirlwall described as "no consideration of whether Chambers was a fit and proper person for the role he was taking on".

Ian Harvey is an orthopaedic surgeon who was Tony Chambers' deputy and the trust's medical director.

Lady Justice Thirlwall found that Harvey presented the case "as he saw it" and ensured decision-makers saw only material that supported his position, writing documents himself if necessary.

She said he "refused to acknowledge" that doctors' concerns about Lucy Letby "might be well-founded", and concluded that was why he did not refer the concerns to police in June and July 2016.

He also failed to tell Care Quality Commission inspectors about the rise in death rates in February 2016, which Thirlwall said was a "serious failure" and had demonstrated a "lack of candour".

Harvey told the inquiry that he believed the doctors' concerns about Letby were "genuine but not justified". Thirlwall concluded that "neither he nor Mr Chambers was in a position at any stage to decide the concerns were not justified".

Susan Gilby, who succeeded Chambers as chief executive, told the inquiry that she had a conversation with Harvey in summer 2018 as he was packing up his office on leaving the trust. She said he told her: "You need to refer those paediatricians to the GMC (General Medical Council)" – referring to the doctors who had raised concerns about Letby.

Later in 2018 consultant paediatricians reported Harvey to the GMC over the way he had treated their concerns. The GMC concluded that his contact with them fell below the standard expected, but there was no realistic prospect of establishing his fitness to practise was impaired to a degree that justified action on his registration.

Kelly had worked in lead nursing roles from 2003 and was also Head of Safeguarding.

Thirlwall said Kelly knew that she had to act "when there was a suspicion that a baby had been harmed and that others may be at risk" but concluded "she did not do so".

Despite Kelly's evidence that doctors had not directly told her they suspected Letby of murdering babies, Thirlwall concluded that the warnings she had received "could not have been clearer".

Thirlwall said Kelly's "misguided determination to protect her nurse" had "overridden her judgement".

When Kelly did make a safeguarding referral, long after the police investigation had begun, Thirlwall said it contained "inaccuracies" and was "misleading."

Susan Hodkinson was part of a team of three senior figures who held fortnightly meetings with Letby after she was removed from the neonatal unit.

The group "supported Letby throughout" and "made it plain to her" that the expectation was that she would return to work on the ward, Thirlwall concluded.

Hodkinson and Alison Kelly were still planning for Letby to return even after the decision had been taken to call in the police.

Thirlwall said there were "good reasons to support Letby" professionally at the time, but concluded that "every person who supported her stepped very quickly from professional support to personal friendship".

The report also found Hodkinson "did nothing" when consultant Ravi Jayaram raised concerns about three specific incidents involving Letby, including two babies she would later be convicted of attacking.

Thirlwall also concluded Jayaram should have escalated those concerns sooner.

Eirian Powell was in charge of the neonatal unit at the time and described Letby as the "crème de la crème" of nurses.

Thirlwall said Powell was "very angry" about the allegations against Letby, leading her to speak up "vociferously" for the nurse at a meeting where doctors were raising concerns.

In June 2016, Powell wrote that she had "never believed for an instant that LL was guilty of ANY wrongdoing".

Powell also told the inquiry there was an "us and them" culture between doctors and nurses, which Thirlwall said reflected a serious failure of senior management.

Following publication of the report, Hodkinson, Kelly, Harvey and Chambers issued a joint statement.

They said: "Given that there are a number of investigations under way, and that the work of the Criminal Cases Review Commission has not yet completed, it would be inappropriate for us to offer any further comment at this time.

"Our thoughts remain with the families affected by the tragic events that took place at the Countess of Chester Hospital."

Cheshire Police's Operation Duet investigation into the hospital's response to concerns about Lucy Letby is ongoing.

The force has said it was examining potential corporate manslaughter and gross negligence manslaughter offences related to the trust's response to increased mortality rates on the neonatal unit.

Alongside its criticism of individual leaders, the Thirlwall Inquiry proposed a series of reforms aimed at preventing similar failures.

They include:

• A national protocol requiring concerns that a healthcare worker may have deliberately harmed a patient to be acted upon immediately
• New requirements for board-level monitoring of the deaths of babies and children
• Mandatory safeguarding training for board members
• Stronger accountability measures for NHS managers

Lady Justice Thirlwall also called for a new barring system for NHS managers and stronger checks on managers moving between trusts.

She recommended changes to the NHS management code to reinforce the principle that patient safety should be managers' first concern.