Thirlwall Inquiry: Relaxed reporting of incidents on Letby ward

Neonatal staff who worked at the hospital where Lucy Letby injured and killed babies did not approach reporting incidents in an open and transparent way and often delayed reporting until they had spoken amongst themselves.

“The consultants would be a little louder and the nurse’s voice would be a little quieter”

Annemarie Lawrence

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

The inquest is examining the circumstances surrounding the murder of seven babies and the attempted murder of seven other people by Letby between 2015 and 2016.

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

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 at the inquest, she said the neonatal team did not approach the Datix incident reporting system “in an open and transparent way”.

When pressed on this issue during her evidence presentation session, she said she found that the consultants “were all united” and “didn’t oppose each other”.

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

However, she noted that nurses in bands 5 and 6, as well as shift leaders, “purposely did not report anything until they had discussed the matter with managers or consultants.”

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

Witness testimony from Ms. Lawrence stated that nursing managers “rarely challenged medical staff, 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 was the case.

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

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

“They were very physician-led.”

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

Lawrence said that in some meetings discussions between doctors and nurses could be “a little turbulent” and that she could “see tensions rising.”

“I’m not sure how to describe it other than the consultants would be a little louder and the nurse’s voice would be a little quieter and they would contribute less to the meeting,” she added.

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

Just a few weeks after taking on the role, she recounted a conversation she overheard between Dr Brearey and ward manager Eirian Powell, talking about a thematic review into baby deaths in the neonatal unit.

The thematic review, published in March 2016, included a chart showing which staff were on duty, including that Letby was a common fixture when the deaths occurred.

Ms Lawrence initially asked Dr Brearey for a copy but claimed he told her it was “not for sharing”.

Lawrence finally got a copy of the report in late May 2016 after pressing him.

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

Lawrence rushed to tell his boss, who in turn told him to take the case to Ruth Millward, the head of risk and patient safety at the time.

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

Recounting the conversation, Mrs Lawrence told the inquest: (Ms Millward said) something to the effect of ‘you need to be very careful, Annemarie, you can’t come in here and just start throwing accusations about an individual nurse being present for all these deaths. You need to have proof…just because she’s present and on duty doesn’t mean there’s a connection.’”

Lawrence said she left that interaction feeling “embarrassed” and did not escalate her concerns further because she was new to her role.

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

The inquiry found that the patient risk and safety team and the complaints team were on the same floor, with only one door separating them.

In some cases, Letby “prepared tea and coffee” in the risk and patient safety office, which Ms Lawrence said she “did not think…appropriate”.

“Many of the deaths were preventable and many of the difficulties we faced as doctors working in that department were avoidable”

Annemarie Lawrence

Mr de la Poer asked Ms Lawrence whether Letby could have had access to the patients’ notes or reports, including the thematic review, if she had wished to consult them.

She responded, “I think if she wanted to take a look at them, she absolutely could do so because she had access to the patient safety and risk team’s s-drive.”

Similarly, Lawrence recounted an incident that she believed showed that Letby may have had access to documents relating to infant deaths.

Lawrence said: “One morning when I got to work, when I went up the stairs, Lucy came out of the office, from her office in that hallway, to greet me and she was very distressed.

“She almost jumped down my throat (and said) ‘there was a breakdown and a baby was transferred and does that mean someone else will 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 breakdown because, as you know, at the time there were some challenges about whether we were reporting or not. no.

“But she knew this information and it didn’t reach me.”

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

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

Lawrence responded, “I think that’s what they really believed at the time.”

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

She said: “I was working alongside someone who I initially thought had committed terrible, terrible crimes and… I felt ashamed for creating them.

“And so I spent some time thinking, if I had raised them a little higher, I potentially 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 maybe she could be innocent and it was very difficult.

“Having heard some of the things I heard today and seen some of the evidence, many of them were preventable, certainly many of the deaths were preventable and many of the difficulties we faced as doctors working in that department were avoidable. ”

The Thirlwall inquiry has paused and will resume on Monday 4 November.