Thirlwall inquiry: Latby Hospital chairman admits ‘huge personal failure’

The former chairman of the hospital where children were murdered by serial killer Lucy Letby has said his decision not to invite doctors to an important meeting was a “huge personal failure”.

Sir Duncan Nicol chaired the board of directors at the Countess of Chester Hospital when Letby killed seven infants and attempted to kill seven others between June 2015 and June 2016.

He also described an “emotional meeting” with one of the doctors after the police investigation began where he apologized for not intervening sooner.

Sir Duncan has spoken publicly for the first time at a public inquiry into the case about Letby’s humiliation and the circumstances surrounding the NHS response.

Latby was removed from the neonatal unit in July 2016 and placed on clerical duty after senior consultants criticized his non-compliance. Concerns were raised about the apparent mortality and the association with child falls.

However, at an extraordinary board meeting on 10 January 2017, the hospital’s medical director, Ian Harvey, recommended “supporting” her return to the unit.

Senior consultants were invited to an earlier extraordinary board meeting on 14 July 2016 in which one, Dr Ravi Jayaram, said his suspicions about Letby were the “elephant in the room”.

However, he was not invited to the second meeting.

Sir Duncan told the Thirlwall inquiry, sitting at Liverpool Town Hall, that he accepted it was ultimately up to him to decide who attended the meeting.

“I personally consider it a big failure on my part that the consultants were present at the first extraordinary meeting of the board and they were not present at that meeting and they should have been,” he said.

He also offered an emotional apology to the families of the Latbi victims.

“I’ve never been faced with a situation that caused so much anger and stress,” Sir Duncan said.

“I wanted to say that the Countess of Chester Hospital failed to keep the children in her care safe and that is something that has caused me great stress over time, and more importantly It has caused unimaginable grief to the families whose children died and I am very sorry that it happened the way it did.”

Sir Duncan, who was chief executive of the NHS Management Executive between 1989 and 1994, was also asked about another meeting on 30 June 2016 which was attended by senior directors and some doctors.

Counsel for the inquiry Rachel Langdale QC said records of the meeting showed consultant Dr Jim McCormick said: “This is Beverley Elliott.[Harold] Ship’s Condition.”

Allitt was a nurse who was Imprisoned for murdering four children In Lincolnshire in 1991, while Shipman was a GP. who killed 215 patients over a 30-year period.

Ms Langdale asked: “Did you sit down when you heard that?”

Sir Duncan said he could not recall the comment.

Sir Duncan also said comments made by Mr Harvey to the hospital’s quality, safety and patient experience committee on 19 September 2016 were not correct.

At this meeting, a report by the Royal College of Paediatrics and Child Health (RCPCH), which was commissioned to review the neonatal unit, was discussed.

Mr Harvey told the meeting that the RCPCH “showed no immediate concern” after being asked to review the neonatal unit – when it had actually called for an investigation from Letby.

The inquest heard that no attempt was made to contact the police until May 2017, when the board sought advice from criminal barrister Simon Medland QC.

Sir Duncan said: “Mr Medland reported back to us that he had found no evidence of crime but he used an expression which is fixed in my memory, along the lines of ‘If the events are still unknown, Call the police.”

He added: “I wish we had received this advice in July 2016.”

Ms Langdale asked Sir Duncan about the email he had sent to Dr Jayram on 25 May 2017.

The email said: “I want you and your consultant colleagues to know how sorry I am for the personal trouble you are and all of you are suffering and for not intervening sooner. from”.

On the same day Sir Duncan personally went to find Dr Jairam, the inquest heard.

He told the inquest that the two men had an emotional conversation, adding: “I remember we put our arms around each other.”

Sir Duncan told the inquiry he now appreciated that Latby was given “a lot of sympathetic support” by senior managers who “didn’t see enough” of the board.

The inquiry heard Letby’s parents, John and Susan Letby, sent a letter to Sir Duncan in July 2017 describing their daughter as “single for punishment”.

The letter called for a meeting “as soon as possible” as “the distress caused by this situation has become unbearable”.

Sir Duncan said he did not respond to the email, which came after a police investigation into Letby began.

The inquest has previously heard evidence from the families of Letby’s victims that they were “kept in the dark” by the hospital.

Asked where the Linwoods, who represent some of the families, fit into the “big picture”, Sir Duncan said: “The families were not in the big picture.

“We didn’t do the proper duty of candor to the families and that was a failure.

“A serious failure.”

The inquiry, now in its 12th week, is expected to sit in the New Year.

Letby was convicted of seven counts of child murder and eight counts of murder, including two attempts on the same victim.

She is serving 15 life sentences.