Families 'will never know for sure' how many babies could have been saved if Lucy Letby had been stopped sooner

Families 'will never know for sure' how many babies could have been saved if Lucy Letby had been stopped sooner Publishing her Thirlwall Inquiry today at Liverpool town hall, Lady Justice Thirlwall said there was a "complete failure" to protect babies at the Countess of Chester Hospital where Lucy Letby worked Grieving families affected by killer nurse Lucy Letby "will never know for sure" how many babies could have been saved if the hospital acted sooner, an inquiry has found today. The Thirlwell Inquiry into the murders said: “It is clear that some babies would have been saved and some attacks would have been prevented if action was taken earlier.” Delivering her report at Liverpool town hall, Lady Justice Thirlwall found there was a "complete failure" to protect babies on the neonatal unit at the Countess of Chester hospital. In a series of devastating findings, the inquiry suggested it was possible three babies may have lived if action against Letby had been taken sooner. 'No apology or action can undo what happened' Newborn twins may not have died and five others harmed if she had been removed from the unit in October 2015 after the death of a baby, when corridor conversations about Letby began. A third baby who died, a two-month-old girl, and two others who suffered unexplained collapses may also have been protected if a doctor had detected an earlier insulin poisoning in August that year, the report said. During the inquiry, Dr ZA said she “deeply regretted not recognising or flagging signs of deliberate harm saying it felt “so fantastical and unlikely”. The Trust said today: “No apology or action can undo what happened at our hospital.” Jane Tomkinson, chief executive of the Countess Trust, said: “We are however truly sorry for the events that occurred in 2015 and 2016. “We acknowledge the findings of the Thirlwall Report and will approach its recommendations with openness and a firm commitment to build on the progress we have already made in improving our hospital's governance, safety and culture since that time.” She said they were a “different organisation” today but acknowledged there is “more to be done” adding: “What took place at the Countess of Chester Hospital NHS Foundation Trust in 2015 and 2016 and the impact it had on so many people will not be forgotten. We will always remember.” Letby, 36, is serving 15 whole-life prison terms after being convicted of the murder of seven babies and attempted murder of seven other newborns at the hospital in 2015-2016. Yvette Cooper says government must act Health Secretary Yvette Cooper described the report was thorough and devastating and said it was now the government’s responsibility to act. She said: “At the heart of this inquiry have been 13 families who lost their newborn babies, or who saw them experience serious collapse or injury at the hospital 10 and 11 years ago. She could not fathom the grief and pain of the parents and families and pointed to shocking failures at the hospital. Cooper added: “Worst of all, the trust repeatedly failed the parent. It failed to keep their beloved babies safe. For parents to be kept in the dark for years about what was happening is, as Lady Justice Thirlwall has said, reprehensible” Addressing the families directly, she added: “On behalf of the government and the health service, I am profoundly sorry for the failures set out so clearly in this report, for the harm, distress and unthinkable loss for their families and for the failures to keep their babies safe.” She said she had asked officials to urgently develop plans for cot cams, one of the key recommendations of the inquiry. 'This cannot be allowed to happen again' Lawyers for the families called for what they called “meaningful and lasting change”. Carla Duprey, from Bond Turner, said: “What matters now is that the findings are properly understood, that the recommendations receive the attention they deserve and that they lead to meaningful and lasting change. “For the families involved, the consequences have been life-changing and continue to this day.” Richard Scorer, from Slater and Gordon, who acts for three families said: “The families I represent were looking for a clear analysis of what went wrong and strong recommendations to prevent this happening again. The report delivers both. Lady Thirlwall is clear that the police should have been informed in August 2015, not 18 months later, and that hospital managers misled the families and the trust failed in its duty of candour.” He said the families welcomed the 17 recommendations made by the report, adding: “The challenge now is to ensure that recommendations are implemented without delay. Far too often public inquiry recommendations are left to gather dust. This cannot be allowed to happen again." 'This cannot be the end of the matter' Tamlin Bolton, from Irwin Mitchell, representing the families of seven children, said: “Today will be an emotional day for many families, many of whom continue to live with the consequences of what happened. “Lady Thirlwall’s report paints a damning picture of what happens when concerns over patient safety are not listened to and acted on. In her own words a dispiriting and at times shocking account of multiple and repeated failings by organisations and individuals. “Failing to escalate concerns, failing to appreciate the seriousness of the risk, failures in safeguarding, failures in governance and oversight, failures in the HR and whistleblowing process, failures in the interactions with external bodies.” She added: “At the Countess of Chester, patient safety should have come first. It did not. The families recognise that no system can guarantee that deliberate criminal acts will never occur. But when concerns are raised about patient safety, they must be listened to, investigated properly and acted on without delay. “The report today and the criticisms and failings highlighted in it cannot be the end of the matter. The families deserve more than expressions of regret and promises of change.” Management at the hospital was described as “dysfunctional” with behaviour that was “high-handed… and foolhardy” the report said. Director of nursing, Alison Kelly, medical director, Ian Harvey and chief executive Tony Chambers, who were all named in the report, released a joint statement saying: “We are carefully reviewing the Thirlwall report and its recommendations. 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.” The Care Quality Commission admitted it failed to be “sufficiently investigative and inquiring” when it came to the Countess. Dr Toli Onon, the chief inspector of hospitals, said the regulator was "truly sorry" and will play its part in implementing the recommendations. She said: “Our 2016 inspection of Countess of Chester Hospital did not identify an increase in neonatal mortality. Crucial information was not shared by the hospital - however, what is also very clear is that we as the regulator did not take an approach which was sufficiently investigative and inquiring.” Cheshire Police said they would review the contents in light of their ongoing investigations. The force has launched an investigation into the Countess of Chester Hospital focusing on the senior leadership and decision-making to determine whether any criminality has taken place concerning the response to the increased levels of fatalities. Three members of the senior leadership team arrested on suspicion of gross negligence manslaughter were bailed pending further enquiries.An individual was arrested and bailed on suspicion of perverting the course of justice A force spokesman said: “Our thoughts remain with the families of the babies – who have always been at the heart of this case.” Letby’s case is currently being reviewed by the Criminal Cases Review Commission. Her barrister Mark McDonald said: “The reality of the Thirlwall Inquiry is that it has been conducted on the premise that an innocent woman is guilty of crimes she has not committed. "Millions of pounds of taxpayers’ money have been spent on the inquiry, which would have been far better spent on addressing the UK’s broken neonatal system and providing equipment and support to wards across the country. "Reports from over 30 world-leading experts now sit with the CCRC, and it is paramount that Ms. Letby’s case is referred to the Court of Appeal as a matter of extreme urgency.” While the inquiry report was being published a small group gathered outside the town hall to protest in support of Letby.