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Letby attacks could have been spotted earlier if dots joined up Jeremy Hunt

The attack spree of killer nurse Lucy Letby could have been spotted earlier with the “dots joined up” by an independent medical examiner, former Health Secretary Jeremy Hunt has told a public inquiry. Giving evidence at the Thirlwall Inquiry into Letby’s crimes, the Conservative MP apologised to the families of her victims as he acknowledged the “appalling crime” took place under his watch and he bore ultimate responsibility for the NHS. Letby, 35, murdered seven babies and attempted to murder seven more between June 2015 and June 2016 while she worked as a nurse on the neonatal unit at the Countess of Chester Hospital. The introduction of medical examiners across the NHS in England and Wales to provide independent scrutiny of causes of death, address any concerns from bereaved families, work with coroners and review medical records had been recommended by previous healthcare inquiries. The system was first suggested by the inquiry into the crimes of serial killer GP Harold Shipman in 2004 and then further recommended by Sir Robert Francis in his 2013 report into the neglect of hundreds of patients at Mid Staffordshire NHS Foundation Trust, the inquiry heard. Mr Hunt said it was only when the issue of funding medical examiners came across his desk again in 2023 when he was chancellor that he “pushed it through”. Since last September all deaths in any health setting in England and Wales that are not investigated by a coroner are being reviewed by NHS medical examiners. Mr Hunt said: “This terrible tragedy happened on my watch and although I don’t bear direct personal responsibility for everything that happens in every ward in the NHS, you do have ultimate responsibility for the NHS. “And insofar as lessons were not learned from previous inquiries that could have been, or the right systems were not in place that could have prevented this appalling tragedy, then I do bear ultimate responsibility and I want to put on the record my apologies to the families for anything that did not happen that potentially could have prevented such an appalling crime. “I think one of the things that could have potentially meant that what happened at the Countess of Chester was spotted earlier and the dots were joined up would have been having medical examiners.” He suggested medical examiners should be trained to see the signs or patterns of malicious harm in the work of a healthcare professional and that having “malicious actors” such as Shipman and Letby at the backs of their minds could make a “big difference”. The inquiry heard that a non-statutory rollout of medical examiners in England and Wales began in 2019. Mr Hunt said: “I think the medical examiner system when it works well is incredibly important to a healthcare system because I think it’s not just important for learning from mistakes, it’s also very important for families who have been bereaved to have someone independent that they can talk to and raise concerns. “Feedback from relatives was a very important clue for them as to where things might be going wrong.” 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. Asked what his one regret was during his spell as health secretary, Mr Hunt said: “I wish I had done more to dismantle targets because they make the NHS the most centralised system in the world and creates the wrong culture of everyone trying to please their manager and NHS England.” He said senior managers spent too much time “trying to tick boxes” to say they had met targets. Earlier at the inquiry, a former hospital chief executive denied she warned a paediatrician to distance himself from two colleagues who believed Letby may be killing babies. In March 2017, Tracy Bullock, then boss of Crewe’s Leighton Hospital, called ex-employee Dr Michael McGuigan two months into his new post at the Countess of Chester after she had a conservation with its chief executive Tony Chambers. Giving evidence last year to the Thirlwall Inquiry, Dr McGuigan said Ms Bullock told him her understanding was the consultant paediatricians were refusing to accept there were problems in the standard of care on the neonatal unit and instead they were pursuing this other line of inquiry. He said Ms Bullock added there were “two particularly ringleaders and things were likely to end very badly for those two”, and she did not want him to be affected. The ringleaders were not named but it was “obvious” it was neonatal clinical lead Dr Stephen Brearey and children’s services clinical lead Dr Ravi Jayaram, he said. Ms Bullock denied any discussion about “ringleaders” facing consequences for speaking out. She said: “I don’t recall Tony saying that to me and I don’t recall that being said to Michael. “Tony wanted to run by me the high mortality rates at the Countess of Chester Hospital. He also wanted to discuss the relationship with paediatricians and how that it had deteriorated and was worsening. “He described two consultants leading the charge – those are my words. He didn’t name either of them. He described quite tense and fractious meetings with the doctors. “Tony felt the paediatricians would not be happy unless there was a police investigation.” She said Mr Chambers told her he was “not averse” to a police inquiry but wanted other avenues to be understood and closed first. Ms Bullock added: “I was not saying to Michael ‘get out of it’. What I was saying was ‘don’t just follow sheep, be certain what the issues are’. “He said he was certain and they had discussed it at length, and he said he believed the paediatricians are right.” Letby was redeployed to non-clinical duties in July 2016 after the hospital’s seven paediatricians told executives about their suspicions she was deliberately harming infants. Hospital bosses opted to commission a series of medical reviews rather