Hospital boss altered baby deaths review to make two Lucy Letby victims appear to have died naturally, inquiry finds

Hospital boss altered baby deaths review to make two Lucy Letby victims appear to have died naturally, inquiry finds Ian Harvey, 68, altered the document without the "shocked" author’s knowledge before using it to mislead the board at Countess of Chester Hospital, the review found A hospital boss altered a review into baby deaths to make it appear that two infants murdered by Lucy Letby had died of natural causes, a public inquiry has found. Ian Harvey, 68, changed the document without the knowledge of its “shocked” author before using it to mislead the board at Countess of Chester Hospital into allowing the former neonatal nurse back onto the ward. Letby, 36, ultimately never returned to work after doctors pressured senior executives to call police.s In her 822-page report, published on Tuesday, Lady Justice Thirlwall was scathing about the conduct of medical director Harvey and other “dysfunctional” hospital leaders, who she said had “completely failed” to protect babies from harm. The judge, who oversaw the £18.5million inquiry, found that at least three babies could have been saved had managers acted sooner to suspend Letby and involve police. Instead, managers commissioned reviews by the Royal College of Paediatrics and Child Health and neonatologist Dr Jane Hawdon, neither of which established why babies were dying. Dr Hawdon, then a consultant neonatologist at Barts Health NHS Trust in London, was commissioned by Harvey, a retired orthopaedic surgeon paid £175,000 a year, to review the medical records of 17 babies who collapsed at the hospital between June 2015 and June 2016. The group included 13 deaths and four “near misses”. But Lady Justice Thirlwall found that Harvey had failed to tell Dr Hawdon about concerns that a member of staff may have deliberately harmed babies, or that the deaths were unexpected and unexplained. Dr Hawdon initially concluded that the deaths of five babies – known as Babies A, D, I, O and P – were unexpected and unexplained and required “a broader forensic review”. But after Harvey sent her Baby D’s post-mortem report, she emailed him saying she agreed with the pathologist that the baby had died from pneumonia. Harvey subsequently amended her report to state that Baby D had died from natural causes – without consulting her. The inquiry report said Dr Hawdon was unaware of Harvey’s amendments until she was told about them by the inquiry. She later learned from evidence given by the pathologist that Baby D had died “with” pneumonia, rather than “of” the infection. Dr Hawdon then concluded that pneumonia was “no longer a plausible contribution to [her] death”. Letby was convicted of murdering Baby D, a full-term girl, by injecting her with air during a night shift in June 2015. Dr Hawdon also accepted during questioning that Baby E, a twin boy, should have been included on her list of unexplained deaths. She had been told he died from a gastric bleed but accepted that the cause of the bleeding was unknown. Letby was convicted of murdering Baby E by ramming a medical instrument into his throat and injecting him with air in August 2015. During the inquiry, Dr Hawdon was shown a copy of her report with the words “necrotising enterocolitis”, or NEC, added beside Baby E’s name. She told the judge she had not made the addition and said NEC, a potentially fatal bowel condition affecting premature babies, “did not fit well with the pattern of health issues” before Baby E’s collapse. Harvey accepted in evidence that he had made amendments to Dr Hawdon’s report. Dr Hawdon also said she had assumed Harvey would share the findings with the babies’ parents under the NHS duty of candour, which she described as a “given”. The judge found that he did not. Some parents eventually received excerpts from the review, but only six months after it had been completed. Written in medical language, the excerpts were described by one mother as “not meaningful at all”. Dr Hawdon said she was “shocked” when shown what had been sent to parents. The mother of Baby C, a premature boy murdered by Letby in June 2015, told the inquiry the material gave no introduction, author, date or context and appeared to be neither signed nor dated. She said the family had been told in-depth investigations had found no cause for concern, yet what they received appeared “woefully inadequate” and left her “upset, distressed, extremely annoyed” and “perplexed”. She said she was left with the impression that “something significant” was being hidden from the family. Other parents were unaware that investigations had been carried out into their babies’ deaths or that their children’s medical records had been shared. Letby is serving 15 whole-life sentences for murdering seven babies and attempting to murder seven others, including one infant she attacked twice.