Lucy Letby is not the first child serial killer to strike on hospital bosses watch, second day of public inquiry hears

The chairman of the hospital where Lucy Letby murdered babies was involved in distributing the findings of an inquiry into killer nurse Beverley Allitt more than 20 years earlier, the public inquiry heard today.

Sir Duncan Nichol was chief executive of the NHS when Allitt killed four children and harmed another nine at Grantham and Kesteven Hospital, in Lincolnshire, in 1991.

A career civil servant, Sir Duncan joined the NHS in 1968, before running the NHS and becoming chairman of the Countess of Chester Hospital in 2012. He held the position for eight years before he retired.

After Allitts crimes, Sir Duncan was responsible for distributing the findings of a 1994 inquiry into her attacks, which was led by Sir Clive Clothier, to all health trusts in the UK.

Nicholas de la Poer, KC, counsel to the inquiry, said Sir Duncan would be giving evidence to the inquiry.

Lucy Letby (pictured) is serving 15 whole-life orders after she was convicted of murdering seven infants and attempting to murder seven others, with two attempts on one of her victims

Beverley Allitt killed four children and harmed another nine at Grantham and Kesteven Hospital, in Lincolnshire, in 1991

Sir Duncans time as NHS Chief Executive coincided with the murders and attacks committed by Beverley Allitt at Grantham Hospital, he said. 

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Following the Clothier Inquiry into Allitts 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. 

Mr de la Poer said the inquiry would be looking into the effectiveness of several board committees at the hospital.

He said they should have acted as a funnel to escalate important matters to the full board of governors, which was made up of seven executive directors at the hospital, including chief executive Tony Chambers, and six non-executive directors.

But Mr de la Poer said it was striking that the spike in neonatal baby deaths, which fell under the remit of Quality, Safety and Patient Experience Committee, was only discussed once by that committee between June 2015 and June 2016, when Letby was killing babies in her care.

The concerns were never discussed in the Audit Committee, the Finance and Integrated Governance Committee nor the People and Organisational Development Committee, Mr de la Poer said.

In the period June 2015 to March 2017, no board committee ever escalated to the Board issues relating to neonatal mortality or Letby, he said.

Sir Duncan Nichol was chief executive of the NHS when Allitt killed four children and was responsible for distributing the findings of a 1994 inquiry into her attacks

The chairman of the hospital where Lucy Letby murdered babies was involved in distributing the findings of an inquiry into killer nurse Beverley Allitt more than 20 years earlier

Lady Justice Thirlwall arrives at Liverpool Town Hall yesterday ahead of the hearings beginning

A court artists sketch of Lucy Letby giving evidence at Manchester Crown Court on July 24

Body worn camera footage from Cheshire Constabulary of the arrest of Lucy Letby in 2018

The Quality, Safety and Patient Experience Committee was in fact the only board committee where neonatal mortality was even discussed. And…during the period of Letbys attacks, the Quality, Safety and Patient Experience Committee discussed the increase in the mortality rate on the Neonatal Unit just once. 

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The Inquiry will be asking why that was so. 

Earlier, Mr de la Poer also said that, in July 2016, following the deaths of the final two victims and Letbys removal from the ward, the concerns about the spike in deaths were added to the hospitals urgent care risk register. 

However, it was characterised as Potential Damage to Reputation of the Neonatal Service and Wider trust due to apparent increased Mortality within the Neonatal Unit. 

Mr de la Poer said: The risk was characterised in terms of reputational harm, rather than in terms of a risk to the safety of babies. Letby, 34, of Hereford, was convicted of murdering seven babies and attempting to murder seven others following two trials at Manchester Crown Court.

She is currently serving 15 whole life sentences – she attacked one of the children who survived twice – and will never be freed.