Doctor ‘ashamed’ he failed to protect babies from Lucy Letby harm

Consultant paediatrician Dr John Gibbs apologised to parents of Letby’s 14 victims shortly after he was sworn in to give evidence on Tuesday at the Thirlwall Inquiry into the events at the Countess of Chester Hospital’s neonatal unit.

The now retired medic said: “I deeply regret and I am ashamed that I failed to protect the babies from harm by Letby, but I do understand that the parents concerned would probably prefer explanations rather than apologies.”

He said he and his fellow consultants should have contacted the police in early 2016 before Letby went on to attack other infants including the murders of two triplet boys in June that year.

The inquiry heard that following a third baby death in June 2015, he emailed his consultant colleagues to relay concerns from registrars that the infants involved “showed a strange purpuric looking rash” and that nurses on the unit were also “very worried”.

Dr Gibbs said Letby’s name came up as a “common factor” in July 2015 because she was involved in the resuscitation attempts of all three babies and another infant who was successfully revived.

But he told counsel to the inquiry Nicholas de la Poer KC that he had no suspicions that deliberate harm was being caused at that time.

He said: “It had been felt she had been unlucky to have been involved in a number of incidents.

“It can happen to any of us and it happened to me during my career, that you have a bad run. But then that stops happening if it’s just an unfortunate coincidence.”

Immediate concerns about possible deliberate harm should have been raised, though, in August 2015, he said, with a blood test result which indicated Child F had been administered synthetic insulin.

Dr Gibbs said he did not see the result and his colleagues appeared to not appreciate its significance, but he classed it as a “collective failure” by the paediatric team.

He said: “We all had the chance to look at those results.”

He acknowledged a similar “collective failure” in April 2016 when another infant, Child L, was poisoned with insulin by Letby, but medics again missed the significance of another blood test.

The consultant said he was “unsettled” by the sudden and unexpected death of Child I in October 2015 and that towards the end of that year and into 2016 he became “more concerned”.

Dr Gibbs said: “We were trying to make sense of the number of collapses and deaths that were happening, and realising Letby was around for many of them, not all of them.”

The consultant said the “full enormity of it all hit me” when he saw an external thematic review in February 2016 which looked at deaths on the unit throughout 2015.

He said: “It identified some suboptimal care issues but none of them thought to be significant enough to have caused any of the deaths.”

He said around that time he was perhaps “influenced” but “not convinced” by a “very firm pushback” from senior nurses that suspicions about Letby were “totally wrong”.

Dr Gibbs said: “There was a very strong argument put forward by the senior nurse on the unit that the suspicion was totally wrong and that we were maligning nurse Letby, and she was a very competent, safe nurse.

“I know from Dr Stephen Brearey (the neonatal clinical lead) that there was a very firm pushback from the senior nursing level that this was utterly wrong and we were being very unfair on nurse Letby.

“I was aware what happened at Stepping Hill Hospital where the wrong nurse had been accused because she happened to be on duty every time and someone else had done it and managed to conceal their activities.”

Mr de la Poer said: “If your suspicions were right, then Letby might pose a very serious danger?”

“Yes,” replied Dr Gibbs.

Mr de la Poer said: “If that was your reasoning at the time, does that risk not require immediate action? ”

Dr Gibbs said: “Yes, it should have done but perhaps it was more maybe our views were influenced by the conviction that we were wrong from the nursing side, and I regret that we, or I, didn’t go to the police at this time after the thematic review.”

He said he realised the parents of the later children harmed by Letby “will not thank us for this” but it was thought the problem would be “best managed” by the hospital’s senior executives.

Dr Gibbs added: “I did listen to nurses. The strong assertion from nurses influenced me but didn’t convince me, and no-one on the unit through that time seemed to have seen any harm to a patient. Also, post-mortems had been done that didn’t seem to reveal any harm having been caused to patients.”

He said it was his understanding that Dr Brearey told medical director Ian Harvey and director of nursing Alison Kelly on May 1, 2016 about their suspicions Letby was deliberately harming babies.

Dr Gibbs said: “He fed back to us that no decision had been made but senior managers would consider the problem and hopefully would come to a decision.

“That could have been a trigger, it should have been a trigger, that we bypass the managers and went to the police. We failed to do that.”

A meeting of the full consultant group took place on June 27, 2016 following the deaths on successive days of triplets Child O and P in which “all consultants expressed serious concerns about the number of deaths and the persistent association with Letby”, the inquiry heard.

Another consultant sent an email on June 29 which said: “we need to contact the police”, Dr Gibbs said, and a colleague replied he said the hospital “would be contacting the police soon”.

Mr de la Poer said: “Was it your understanding at that time the police would be involved imminently?”

Dr Gibbs said: “Yes, and it had taken us a long time and we delayed too long, but at least it looked like the right action was being taken.”

The inquiry was told that notes of a meeting in January 2017 between chief executive Tony Chambers and consultants recorded the latter were told subsequent external reviews of the increased mortality rate had not revealed criminality and “to draw a line” under the Letby issue.

It stated, the inquiry heard, that Mr Chambers told the medics “firmly” that the board had accepted the findings, that there was no evidence of any wrongdoing and how they had “upset” Letby and had to apologise to her.

Days later the consultants wrote to Mr Chambers asking for the board’s understanding of the increase in deaths as they had yet to read the review reports.

Dr Gibbs said: “We paediatricians couldn’t understand the increase and interestingly the board could and we wanted to know their reasons.”

When they finally saw the reviews, he said, they realised that deliberate harm had not been excluded.

On February 28 all seven consultants wrote a letter of apology to Letby, the inquiry was told.

Mr de la Poer asked: “Were you accepting that you didn’t think Letby had done anything wrong?”

Dr Gibbs replied: “We were not saying she had done no wrong. We were just apologising for the stress we had caused her and the other nurses on the unit as well.”

By that stage he said the consultants had identified eight unexplained deaths on the unit but it was “clear” that trust had broken down with senior executives.

In April 2017 consultants met a barrister instructed by the hospital who told them its purpose was to decide if there was enough reason to go to the police, said Dr Gibbs, but they had thought it was to help present their case to the police.

Dr Gibbs said: "We made it very clear that we felt he had been misled and we had been misled, and he apologised for that.”

Police were not brought in to investigate the increased mortality rate until May 2017 as Letby remained at the hospital in a non-patient role until her arrest in July 2018, the inquiry has heard.

Letby, 34, 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 inquiry is expected to sit at Liverpool Town Hall until early next year, with findings published by late autumn 2025.