Killer nurse Lucy Letby might have been stopped sooner if there had been an impartial health worker at her hospital, ex Health Secretary Jeremy Hunt tells inquiry
Killer nurse Lucy Letby could have been stopped sooner if there had been an independent medical examiner at the hospital where she murdered babies, former health secretary Jeremy Hunt admitted today.
Delays in appointing specialist doctors to look into deaths not investigated by a coroner in NHS hospitals meant the ‘dots’ were not joined up, the senior Tory MP told the public inquiry into her crimes.
Mr Hunt admitted the idea of medical examiners was first recommended after the inquiry into serial killer GP Harold Shipman, back in 2004.
But he accepted it took more than 20 years for the Government to make them a legal requirement in every NHS hospital.
Crucially, there was no medical examiner in post at the Countess of Chester Hospital between June 2015 and June 2016, when Letby murdered seven babies and tried to kill another seven more on the neo-natal unit.
Only one of the babies’ deaths was ever examined by the Cheshire coroner at an inquest, the Thirlwall Inquiry has heard.
Mr Hunt told the hearing, in Liverpool, that a medical examiner might have ‘made a difference.’
‘It could have potentially meant that what happened at the Countess of Chester Hospital was spotted earlier and the dots were joined up,’ he said.
Former health secretary Jeremy Hunt arrives at Liverpool Town Hall, to give evidence at the hearings into the murders and attempted murders of babies by nurse Lucy Letby
Lucy Letby, from Hereford, is serving 15 whole-life orders after she was convicted at Manchester Crown Court
Crucially, there was no medical examiner in post at the Countess of Chester Hospital between June 2015 and June 2016, when Letby murdered seven babies and tried to kill another seven more on the neo-natal unit
‘It’s something that I look at as being one of those things that we took too long to implement.’
One of the responsibilities of a medical examiner is to talk to bereaved families and the inquiry has heard that, in at least one case, the mother of a twin baby boy, known as Baby E, would likely have raised concerns about Letby’s behaviour.
This could have raised a red flag as early as August 2015 – two months into her 13-month killing spree.
Mr Hunt, the MP for Godalming and Ash, apologised to the families of Letby’s victims, saying as Health Secretary in 2015 and 2016, he had ultimate responsibility for what happened and for Letby being allowed to operate ‘on his watch.’
‘The Health Secretary has ultimately responsibility and accountability for the NHS and what happens in the NHS,’ he said.
‘It’s appropriate that I open my comments by saying to the families associated with this terrible tragedy that it happened on my watch as Health Secretary and, although you 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 apology to the families for anything that did not happen that potentially could have prevented such an appalling crime.’
Mr Hunt blamed the estimated £40million cost and a shortage of doctors nationally for delays in installing medical examiners sooner.
The Thirwall Inquiry is being held at Liverpool Town Hall (pictured) and commenced on September 10, 2024
Chair of the inquiry is Lady Justice Thirlwall pictured listening to evidence at Liverpool Town Hall
Mr Hunt admitted the idea of medical examiners was first recommended after the inquiry into serial killer GP Harold Shipman (pictured), back in 2004
Although a pilot scheme meant some medical examiners were installed in a small number of NHS hospitals between 2016 and 2018, he said it was only when the issue of funding medical examiners came across his desk again, in 2023, after he had been promoted to Chancellor of Exchequer, that he ‘pushed it through.’
The requirement for every hospital death not referred to a coroner to be examined by a medical examiner became law in September.
Mr Hunt also said that because ‘half of us die in hospitals,’ deaths were perceived as normal in the NHS, so ‘we do not make the effort we should to understand’ them, as happens in other industries.
He said installing medical examiners in all NHS hospitals who are trained in spotting patterns of harm and who would have ‘malicious actors,’ such as Shipman and Letby at the backs of their minds, could make a ‘big difference.’
Mr Hunt said his one regret as Health Secretary was that he didn’t scrap the huge number of targets hospital bosses are expected to meet every year, which he said was detrimental to patient safety.
One of the responsibilities of a medical examiner is to talk to bereaved families and the inquiry has heard that, in at least one case, the mother of a twin baby boy, known as Baby E, would likely have raised concerns about Letby’s behaviour (Pictured: Lucy Letby being arrested)
Mr Hunt, the MP for Godalming and Ash, apologised to the families of Letby’s victims, saying as Health Secretary in 2015 and 2016, he had ultimate responsibility for what happened and for Letby being allowed to operate ‘on his watch’
The requirement for every hospital death not referred to a coroner to be examined by a medical examiner became law in September (file image)
‘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 spend too much of their time ‘trying to tick boxes’ to say they are hitting them, Mr Hunt added.
‘Frankly, it means they are rushed off their feet and worried about the numbers they are giving NHS England,’ he said.
‘That crowds out the opportunity for long term strategic changes. They are being kept on such on a short leash by managers in NHS England and I do think that is culturally bad for the NHS.’
