Lucy Letby: Thirlwall Report identifies manager failing

The report, published at Liverpool Town Hall on Tuesday, set out ‘dysfunctional management and governance’ at the Countess of Chester Hospital through the period of Letby’s offending more than 10 years ago.

Letby is serving 15 life sentences for the murder and attempted murder of multiple babies at the hospital’s neo-natal ward.

The Thirlwall Inquiry published its findings with Lady Justice Thirlwall highlighting that Eirian Powell failed to treat the now 36-year-old Letby on her level of qualification.

The report said that Ms Powell viewed Letby as a ‘star’ because of her ‘willingness to learn and offer herself for extra shifts’.

But the inquiry referred to an earlier incident in her career in 2013 when she pumped 10 times too much morphine into a baby.

This led to her being ordered to carry out this procedure in front of a senior nurse by a then acting manager but Ms Powell reversed that decision in favour of Letby who sent a message to a friend stating ‘she thought it had been escalated more than it needed it be’.

However, the report said: “I accept that drug errors are made in hospitals, but it is not easy to see how a requirement that a nurse should be asked to practise the required competencies – having been involved in the administration of a potentially fatal dose of morphine – could be described as out of proportion to the error.

“The (nurse) did not think it had been escalated more than it needed to be.

“Letby was a very junior nurse and yet she achieved the downgrading of the response to her error."

Another example of a lack of management of Letby was Ms Powell telling another nurse ‘to keep her out of intensive care’ when she was not scheduled to be on it.

But, the report said, she never followed this up with Letby.

The report said: “There are two possible explanations for that: either she did not think this conduct was serious, or she did not want to confront Letby.

“The first is out of the question, since the instructions to put Letby on an outside nursery had come from her.

“The second is possible, since Letby was prepared to take on extra shifts, so it may have been that Ms Powell did not want to upset her.

“Whatever her reasons, Ms Powell was allowing Letby to break the rules.

“Letby was not a senior nurse – she had only been qualified for three years.

“Ms Powell had a duty to manage her effectively. She failed to do so over the morphine incident (see Chapter 2).

“She failed to do so when she interfered with the care of Baby C (see Chapter 3). She failed to do so here.

“As a result, Letby knew she could ignore instructions from a shift leader, she could shout and she could move between nurseries to find excitement.

“There were no adverse consequences for her arising from any of those behaviours. This was a management failure by Ms Powell.”