Health Inspectors Unaware of Unexplained Deaths at Letby Hospital, Inquiry Hears

A public inquiry has been informed that health inspectors were not made aware of concerns regarding unexplained fatalities at the neonatal unit of a hospital where Lucy Letby was employed. The Care Quality Commission (CQC) watchdog conducted a standard inspection of the Countess of Chester Hospital for four days in February 2016. On 17 February, during this inspection period, serial killer nurse Letby tried to murder a baby girl, identified as Child K, by removing her breathing tube. The Thirlwall Inquiry is currently investigating the events and conditions related to Letby’s criminal acts. Letby, aged 34 and originating from Hereford, received 15 whole life imprisonment sentences for the murders of seven infants and the attempted murders of seven others between June 2015 and June 2016. The inquiry, held at Liverpool Town Hall, was informed that an external “thematic” review conducted in early February 2016, which examined 10 deaths on the unit in 2015 and January 2016, observed that “some of the babies suddenly and unexpectedly deteriorated and there was no clear cause for the deterioration/death identified”. This review also identified that six infants experienced cardiac arrests between midnight and 04:00 GMT, though it determined that no consistent pattern was evident across all cases investigated. Helen Cain, a CQC inspector, testified to the inquiry that she was not aware of this review during her inspection and would have inquired about it had she possessed that knowledge. Craig Carr, counsel to the inquiry, questioned, “There was no discussion of incidents of unexplained and unexpected deaths at all?” Ms Cain responded, “No.” Mr. Carr then asked, “What is your explanation for the failure [of the CQC] to detect some of those concerns?” Ms. Cain stated, “I think some of it is the data. “There is always a lag with data and sources of data so I think that is a consideration. “And I think very much with the on-site inspection you can ask a lot of open questions, a lot of general questions, but you are very much reliant on people’s responses.” She further explained that none of the individuals interviewed, including consultants and nursing managers, had brought up any concerns regarding a rise in neonatal mortality or unexplained and unexpected deaths. The inquiry, convening at Liverpool Town Hall, is anticipated to continue its sessions until early 2025, with its conclusions slated for publication by late autumn of the same year.