“Basic failures” by the hospital where Lucy Letby worked had “fatal consequences”, an inquiry heard.
The former neonatal nurse was sentenced to life imprisonment last year for murdering seven babies and attempting to murder six more at the Countess of Chester Hospital between the summers of 2015 and 2016.
On the third day of the inquiry looking into how Letby, 34, was able to commit her crimes, Peter Skelton KC, representing seven of the families, detailed five “basic failures” by the hospital.
Speaking at Liverpool Town Hall, he said: “Thefirst failure was to conduct swift, careful and methodical investigations into why each of the deaths occurred and whether there were connections between the deaths.”
He added: “That was a major and catastrophic failure.”
Mr Skelton said it meant vital information was overlooked, with “fatal consequences” for other children.
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‘To lose a baby is heartbreaking experience, which nobody should go through’
‘Deaths should have been escalated’
Mr Skelton said the cluster of deaths and collapses should have been escalated to senior management within the hospital trust immediately, so they could have overseen investigations.
“It should have been in the minds of those conducting and overseeing the investigations that the cluster of unexpected and unexplained deaths might have been caused by the criminal acts of a member of hospital staff,” he said.
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The barrister said a report into Beverley Allitt, a nurse who killed children at Grantham Hospital, Lincolnshire, in 1991, sought to ensure that healthcare staff were prepared to keep their minds open to the possibility of criminal conduct.
Mr Skelton also noted how in May 2015, nurse Victorino Chua was sentenced for murdering patients at Stepping Hill Hospital.
“It is difficult to understand why events at Stepping Hill did not at the very least alert those at the Countess of Chester from the start that the cluster of unexpected deaths were the result of potential criminality and that active steps were required to rule out that possibility,” he said.
Mr Skelton said the police and coroner should have been informed at the outset, which could have had a “profound effect” on the course of events.
He told the inquiry the fifth failure was not to inform the families that the deaths were being investigated with a view to finding out why they occurred.