Concerns about a spike in baby deaths were not discussed at hospital board level until after the year-long attack spree of “elephant in the room” Lucy Letby had ended, a public inquiry has heard.

The nurse was removed from non-clinical duties after the deaths of two triplet boys and the suspected collapse of another boy at the Countess of Chester Hospital’s neonatal unit on three successive days in June 2016.

Consultant paediatricians had urged executives to move Letby, 34, out of the unit on the grounds of “patient safety” after a number of them had previously raised fears about her.

Less than a fortnight later an extraordinary meeting of the board of directors was held in which chief executive Tony Chambers informed them there had been an unexplained increase in neonatal mortality at the hospital trust.

The official minutes recorded Dr Ravi Jayaram, clinical lead for paediatric services, asking for one matter not to be minuted.

In a set of handwritten notes, the consultant set out Letby’s association with neonatal deaths and referred to her as “the elephant in (the) room”.

The Thirlwall Inquiry into events surrounding the crimes of Letby, convicted of murdering seven babies and attempting to murder seven others, heard various board committees failed to escalate concerns about neonatal mortality or Letby.

An entry in an “urgent care risk register” in July 2016 referred to “potential damage to reputation of the neonatal service and wider trust due to apparent increased mortality within the neonatal unit”, the inquiry heard.

Counsel to the inquiry Nicholas de la Poer KC said: “The risk was characterised in terms of reputational harm, rather than in terms of a risk to the safety of babies.”

He said it was also “noteworthy” the entry came after a thematic review in February 2016 had “clearly identified” a higher-than-expected mortality rate on the neonatal unit in 2015.

Mr de la Poer said there was no record of the consultants’ concerns of deliberate harm to babies in the urgent risk register or in the corporate directors’ group meeting minutes.

He said: “The inquiry will be seeking to understand why this is, and also why it appears that it took until July 2016, one year and one month after the first indictment baby death, and five months after the thematic review, for the concerns to be formally recorded in these forums.”

Mr de la Poer went on: “The inquiry will be seeking to understand why the concerns which were being expressed at the neonatal unit level were not escalated more quickly and clearly through the designated channels, and if they had been what should have happened.

“Why did it take until July 2016 for the increase in neonatal mortality to be discussed at a board meeting?"

Mr de la Poer also highlighted that Sir Duncan Nichol, who was chairman of the hospital board from 2012 to 2020, was the NHS chief executive when nurse Beverley Allitt committed a string of murders and attacks at Grantham Hospital in 1991.

He said: “Following the Clothier Inquiry into Allitt’s attacks, Sir Duncan was responsible for the distribution of the Clothier report across the NHS, writing to all health authorities and trusts to draw it to their attention.

“The inquiry is interested to hear from Sir Duncan about the lessons he and the wider NHS learnt from the Allitt case and why the parallel between Letby and Allitt was not drawn earlier at the hospital.”

In July 2016 the board accepted the plan of Mr Chambers and medical director Ian Harvey for an external review to be undertaken by the Royal College of Paediatrics and Child Health (RCPCH).

The review team’s first interview on September 1 was with Mr Harvey, the inquiry heard, and he was noted to have said: “Correlation of one nurse – paediatricians see as elephant in the room. Lucy Letby.

“Pattern of babies collapse doesn’t seem to follow normal pattern and respond to resuscitation in normal way.”

He added: “Had to intervene with the neonatal lead as junior doctors had been referring to her as ‘nurse death’.

“Ripples through the team and trying to function. Can’t see how to conclude without calling the police. Unless there is something to satisfy the medical staff they can call the police.”

Mr de la Poer told the inquiry that Sue Eardley, head of the review, recalled Mr Harvey stating that a non-executive director, a former senior ranking officer, had advised against contacting the police “until all other avenues had been exhausted”.

Hospital chiefs did not ask Cheshire Police to investigate the deaths until May 2017.

Mr de la Poer said it appeared “some but not all” members of the RCPCH team were aware of suspicions in relation to Letby prior to its review visit.

A consultant paediatrician on the team stated to the inquiry that if he had known of concerns about the nurse he would have questioned whether its “invited review” was appropriate and would have advised the police should be involved if any criminality was suspected.

The barrister said Robert Okunnu, RCPCH chief executive, stated to the inquiry that the review’s interview of Letby was “highly unusual” and one that should not have taken place.

He said a note of the interview recorded that Letby described being “scapegoated” and “very vulnerable”, and she contended there was no reason or evidence to redeploy her from the neonatal unit.

Ms Eardley had since accepted with hindsight that there should have been contact with the police and the review was “probably not the appropriate course of action for senior management to follow”, said Mr de la Poer.

He told Lady Justice Thirlwall the inquiry will explore the circumstances in which suspicions about Letby were raised externally.

Mr de la Poer said: “You may consider that a troubling feature revealed by the evidence is that all too often it appears that a high threshold was believed to exist for raising concerns of potential harm to babies.

“Namely, that some proof of criminality was necessary before those with the responsibility to investigate concerns could be notified.”

The neonatal unit was inspected by the Care Quality Commission (CQC) from February 16 to February 19, 2016 as part of a review of its children and young person services at the hospital, the inquiry heard.

Mr de la Poer said it was notable that Letby attempted to murder Child K in the early hours of February 17 2016, the second day of the inspection.

He said a member of the inspection team had stated she did not recall discussion of an increase in unexpected or unexplained neonatal deaths and was “certain” there was no mention of a suspicious correlation of those deaths with a member of staff.

Three other team members said they too did not remember any such concerns being flagged.

Mr de la Poer said neonatal lead Dr Stephen Brearey had told the inquiry that one of his colleagues had told an inspector “we have some serious patient safety concerns and don’t feel like we are being listened to”.

But Dr Brearey said this was “ignored” and the inspectors left before there was time to expand upon concerns.

Letby, from Hereford, is serving 15 whole-life orders after she was convicted at Manchester Crown Court of murdering seven infants and attempting to murder seven others, with two attempts on one of her victims, between June 2015 and June 2016.

The first week of the Thirlwall Inquiry will hear opening statements from the counsel to the inquiry, along with legal representatives from core participants including the families of Letby’s victims.

Lady Justice Thirlwall said it was planned that the hearings in Liverpool would finish in early 2025 and she expected her findings to be published by late autumn of that year.

A court order prohibits reporting of the identities of the surviving and dead children involved in the case.