- See more Daily Mail on Google - save us as a Preferred Source
In the end, Lady Justice Thirlwall's report into what happened at the Countess of Chester Hospital between June 2015 and June 2016 painted a grim and chaotic picture.
asserted
what → see → picture
The hospital management was 'dysfunctional', and an 'us-versus-them' mentality pervaded among staff.
asserted
mentality → pervade → staff
Some of those who had suspicions about the uncharacteristically high number of deaths in the neonatal unit kept quiet.
asserted
who → have → unit
Others who raised the alarm were dismissed.
asserted
who → raise → alarm
Reviews were carried out as opposed to calling in the police.
asserted
Reviews → carry → police
It meant Lucy Letby was able to carry on murdering babies, and seriously harming others.
asserted
Letby → mean → others
'Errors were made by nurses, doctors and managers at the time of these events,' Lady Justice Thirlwall said in her report yesterday.
asserted
Thirlwall → make → report
While the inquiry was not charged with investigating Letby's criminal convictions or her guilt, it did at least offer a telling insight into the nurse at the centre of the probe.
asserted
it → charge → probe
It emerged that feedback on Letby's performance was mixed while she was training.
asserted
she → emerge → performance
She was said to be lacking in enthusiasm for the job and, chillingly, her communication skills with families and drug calculations were below par.
Lucy Letby was initially found guilty of murdering seven infants and attempting to murder seven more following a ten-month trial at Manchester Crown Court
Significant concerns were raised during her final placement in 2011.
asserted
concerns → say → 2011
Her mentor noted that Letby was 'quiet, withdrawn and struggled to build relationships with children, families and colleagues'.
asserted
Letby → note → children
The inquiry heard that, despite Letby's efforts to address these issues, she failed a mid-year assessment.
asserted
she → hear → assessment
Yet she was particularly chummy with top bosses, something which may have clouded their judgment.
MISSED OPPORTUNITIES
The judge pulled no punches in pointing the finger of blame at senior managers including Alison Kelly, Ian Harvey and Tony Chambers, who 'dismissed the idea that Letby was deliberately harming babies', as late as June 2016.
uncertain
Letby → cloud → June
She said it mattered little whether or not they believed allegations against Letby – they should have acted.
asserted
they → say → Letby
Ultimately, there were delays in contacting police which could have prevented babies being killed or harmed.
uncertain
babies → be → police
The judge said: 'It is striking that on 29 June 2016, Ms Kelly and Mr Harvey both believed that the doctors' concerns meant that the police should be called, but by the end of that day they had accepted Mr Chambers' view that other steps should be taken first, even though they both knew more about the detail of the concerns than he did.'
asserted
he → say → concerns
Mr Harvey, the medical director, told the inquiry he regretted that they did not go to the police in June 2016.
asserted
they → tell → June
Lady Justice Thirlwall said neither he nor chief executive Mr Chambers was in a position to decide whether the doctors' concerns had any credibility.
asserted
concerns → say → credibility
Lady Justice Thirlwall arriving at Liverpool Town Hall where she delivered her public inquiry report on Tuesday
She said safeguarding action should have been taken by moving Letby off the ward following the death of Baby I in October 2015.
asserted
action → arrive → October
There were even opportunities to stop her two months earlier after a consultant 'disregarded' evidence which suggested Letby poisoned a baby with insulin.
uncertain
Letby → be → insulin
Another doctor did not flag in February 2016 that he saw Letby's failure to act to help a baby girl, whose breathing tube she was later convicted of dislodging.
asserted
she → flag → girl
TREATMENT OF PARENTS
Some of the judge's most emotive language was reserved to describe the 'reprehensible' treatment of the babies' parents.
asserted
Some → reserve → parents
She accused hospital bosses of using the potential risk of upsetting parents about the allegations against Letby as a 'convenient argument' to justify delaying contacting the police.
asserted
She → accuse → police
Families were not even told about the investigations into the deaths of their children.
asserted
Families → tell → children
The mothers of four children were 'all misled', either in face-to-face meetings or in written communications, she said.
asserted
she → mislead → communications
Lady Justice Thirlwall added: 'Risks to reputation and disruption are not of the same order.'
asserted
Risks → add → order
The inquiry heard several parents were given leaflets about bereavement, but no support.
asserted
parents → hear → bereavement
The judge said: 'This was not good enough.'
asserted
This → say → ?
The report highlighted the 'serious failure' of a seemingly ingrained 'us-versus-them' attitude between doctors raising concerns about Letby and her nursing colleagues determined to protect her.
asserted
report → highlight → her
It meant senior nurses and managers leapt to Letby's defence.
asserted
nurses → mean → defence
Senior nurses demonstrated 'unquestioning loyalty to Letby' allied with the 'certainty that there was nothing in the consultants' concerns'.
asserted
nurses → demonstrate → concerns
This, said the inquiry chairman, 'seems to have prevented them from considering the doctors' concerns with an open mind or thinking about safeguarding'.
asserted
chairman → say → safeguarding
The inquiry heard nursing director Ms Kelly and medical director Ian Harvey did not attend a meeting arranged with senior paediatricians in June 2016 to discuss neonatal mortality.
asserted
Kelly → hear → mortality
The inquiry report, more than 800 pages in length, was released on Tuesday
But head of nursing Karen Rees was of the view that there was a 'them-and-us' approach between the doctors and nurses.
asserted
Rees → release → doctors
The report added: 'It should never have been about nurses against doctors.
asserted
It → add → doctors
It was about keeping babies safe.
asserted
It → keep → babies
'Had that governed the approach of the managers, they would and should have sought to work with the doctors, not against them.
asserted
they → govern → them
'Characterising this as nurses versus doctors distracted from the real issue: that steps needed to be taken to protect the babies.
asserted
steps → characterise → babies
The report found head of safeguarding Ms Kelly 'knew she had to act when there was a suspicion that a baby had been harmed, and that others might be at risk'.
uncertain
others → find → risk
But, the judge said, Ms Kelly did not do so.
asserted
Kelly → say → ?
…and 8 more, not listed.
The Aporia
