Thirlwall Inquiry: laxed incident reporting on Letby’s ward

Neonatal staff working at the hospital where Lucy Letby harmed and killed babies did not approach incident reporting in an open and transparent way and often delayed reporting until they had conferred with one another.

“Consultants would become just a little bit louder, and the nurse voice would become a little bit lower”

Annemarie Lawrence

These observations came from Annemarie Lawrence, former risk midwife at the hospital, who gave evidence at the Thirlwall Inquiry this week.

The inquiry is examining the circumstances surrounding the murder of seven babies and attempted murder of seven others by Letby between 2015 and 2016.

Letby is currently serving multiple life sentences for her crimes following her conviction in August last year.

Ms Lawrence took up the role of risk midwife at the Countess of Chester Hospital in May 2016, working in the risk and patient safety team.

In her witness statement to the inquiry, she said that neonatal staff did not approach the Datix incident reporting system “in an open and transparent way”.

When pressed on this during her evidence-giving session, she said she found that consultants “all stuck together” and “wouldn’t go against one another”.

“So, even if they thought somebody had made a clinical omission, rather than report it they would have a conversation first, consultant to consultant,” Ms Lawrence added.

Meanwhile, she noted that band 5 and 6 nurses, as well as shift leaders, “purposely didn’t report things until they had discussed it with managers or consultants”.

The inquiry heard that, during 2016, the relationship between nurse managers and doctors was “far from equal”.

Ms Lawrence’s witness statement said nurse managers “rarely challenged the medical team even when they knew they were deviating from process or guidance”.

Nicholas de la Poer KC, counsel to the inquiry, asked Ms Lawrence to explain how she knew this to be the case.

In response, she said she had “lots of meetings” with managers and consultants where nurses were present.

“I don’t feel they had the autonomy or confidence to challenge the consultants,” she noted.

“They were very much led by the doctors.”

The inquiry has previously heard that there were tensions between doctors and nurses during the period that the inquiry is investigating.

Ms Lawrence said in some meetings discussions between doctors and nurses could be “a bit fractious” and that she could “see tensions rise”.

“I don’t quite know how to describe it really other than the consultants would become just a little bit louder, and the nurse voice would become a little bit lower and they would contribute less into that meeting,” she added.

Ms Lawrence described a “difficult relationship” she had with Dr Stephen Brearey, the senior doctor who first raised the alarm about Letby.

Just weeks into her role, she recounted a conversation she had heard between Dr Brearey and ward manager Eirian Powell, talking about a thematic review into the baby deaths on the neonatal unit.

The thematic review, published in March 2016, included a chart which showed which members of staff were on duty, including that Letby was a commonality when the deaths occurred.

Ms Lawrence had initially asked Dr Brearey for a copy but claimed he told her it “wasn’t for sharing”.

Ms Lawrence eventually got a copy of the report at the end of May 2016 after pressing him for it.

She described how, when she first read the review, Letby’s name “jumped off the page” as being present for all the deaths.

Ms Lawrence ran to tell her boss who in turn told her to take it to Ruth Millward, the head of risk and patient safety at the time.

However, when she presented the document, she said Ms Millward “didn’t want to look at it”.

Recounting the conversation, Ms Lawrence told the inquiry: [Ms Millward said] something along the lines of ‘you need to be really careful Annemarie, you can’t come in here and just start throwing accusations around about an individual nurse being present for all of these deaths. You need to have evidence… just because she’s present and on duty doesn’t mean there is a link’.”

Ms Lawrence said she left this interaction feeling “embarrassed” and did not escalate her concerns further due to being new in her role.

In July 2016, Letby was eventually moved to the hospital’s complaints team following calls by consultants to remove her from clinical duties after two further baby deaths.

The inquiry heard that the risk and patient safety team and the complaints team were on the same floor, with only a door that separated them.

In some cases, Letby would “make tea and coffee” in the risk and patient safety office which Ms Lawrence said she “didn’t think… was appropriate”.

“A lot of the deaths were avoidable and a lot of the difficulties we faced as clinicians working in that department was avoidable”

Annemarie Lawrence

Mr de la Poer asked Ms Lawrence whether Letby could have had access to patients’ notes or reports, including the thematic review, should she wish to look at them.

She replied: “I think if she wanted to look at them, she absolutely could have because she had access to the risk and patient safety team s-drive.”

Similarly, Ms Lawrence recounted one incident which she believed showed that Letby could have had access to documents relating to baby deaths.

Ms Lawrence said: “On coming to work one morning, as I came up the stairs, Lucy came out of the office, out of her office on that corridor, to greet me and she was very distressed.

“She almost jumped down my throat really [and said] ‘there’s been a collapse and a baby’s been transferred out and does that mean somebody else is going to be under investigation and I can go back to work?’

“She bombarded me with a lot of questions, and I didn’t know what she was talking about because I wasn’t aware of a collapse because, as you know, at the time there was some challenges around whether we were reporting them or not.

“But she knew this information and it hadn’t reached me.”

Ms Lawrence said there were “lots of conversations” in the department between Letby and nurse managers about how she was “being made a scapegoat for poor medical care and a lack of team working”.

Mr de la Poer asked: “Were they simply offering a listening ear or were they contributing, making comment themselves about whether it was true that she was being made a scapegoat?”

Ms Lawrence replied: “I think at the time that’s what they truly believed.”

She added that these interactions were something she had “reflected on for many, many years”.

She said: “I was working alongside somebody who initially I had thought had done some terrible, terrible crimes and… I felt ashamed for raising them.

“And then I spent some time thinking, if I had have just raised them a little bit louder, potentially I could have prevented the deaths of two of those babies and I didn’t.

“And then I had to work with her, alongside her [and] listen to conversations that perhaps she might have been innocent and it was really difficult.

“Having heard some of the things I have heard today and seen some of the evidence, a lot of that was avoidable, certainly a lot of the deaths were avoidable and a lot of the difficulties we faced as clinicians working in that department was avoidable.”

The Thirlwall Inquiry has taken a break and will resume on Monday 4 November.