Be happening, and we have to act on it and be happening, and we have to act on it and took be happening, and we have to act on it and took at be happening, and we have to act on it and look at it. It is happening, it and look at it. It is happening, it is starting it and look at it. It is happening, it is starting to happen in some maternity it is starting to happen in some Maternity Units around the uk, but we have Maternity Units around the uk, but we have heard from experts saying it is not we have heard from experts saying it is not widespread enough, and i would is not widespread enough, and i would bet is not widespread enough, and i would bet that that is something, using would bet that that is something, using that would bet that that is something, using that kind of data much more rigorously using that kind of data much more rigorously and really digging down into the rigorously and really digging down into the data, i would bet that is something that comes out of the inquiry something that comes out of the inquiry that has been announced today inquiry that has been announced toda. , inquiry that has been announced toda. � , inquiry that has been announced toda. � ,. ~ inquiry that has been announced toda. � ,. Today. Yeah, lets ust talk about that for a today. Yeah, lets just talk about that for a moment. Today. Yeah, lets just talk about that for a moment. It today. Yeah, lets just talk about that for a moment. It was today. Yeah, lets just talk about that for a moment. It was something that for a moment. It was something that was called for by the families even as the trial concluded, they were saying that they wanted to see an independent inquiry. What sort of power does not have to actually change the system . What are we likely to get from that . Change the system . What are we likely to get from that . Well, as i understand likely to get from that . Well, as i understand it, likely to get from that . Well, as i understand it, it likely to get from that . Well, as i understand it, it is likely to get from that . Well, as i understand it, it is an likely to get from that . Well, as i | understand it, it is an independent inquiry understand it, it is an independent inquiry that understand it, it is an independent inquiry that does not have statutory powers. Inquiry that does not have statutory powers. So inquiry that does not have statutory powers. So i inquiry that does not have statutory powers, so i do not think it can force powers, so i do not think it can force people to give evidence. But, honestly. Force people to give evidence. But, honestly. I force people to give evidence. But, honestly, i dont think that is going honestly, i dont think that is going to honestly, i dont think that is going to be a problem in this case. Setup going to be a problem in this case. Setup on going to be a problem in this case. Set up on that basis because these independent inquiries tend to be a bit more independent inquiries tend to be a bit more flexible, they can report more bit more flexible, they can report more quickly, and the idea, i think, is to more quickly, and the idea, i think, is to give more quickly, and the idea, i think, is to give families answers in a very is to give families answers in a very timely fashion, and also the secretary very timely fashion, and also the secretary of state, steve barclay, has said secretary of state, steve barclay, has said that he wants the families to he has said that he wants the families to be involved in the shaping of that inquiry, and he wants them very much that inquiry, and he wants them very much to that inquiry, and he wants them very much to he that inquiry, and he wants them very much to be involved. I think most people much to be involved. I think most people would agree that is absolutely the right thing to do. So we dont absolutely the right thing to do. So we dont know exactly what the remit of the we dont know exactly what the remit of the inquiry is going to be yet, because of the inquiry is going to be yet, because the process has not really started. Because the process has not really started, we do not know who will chair started, we do not know who will chair it. Started, we do not know who will chair it. Lrut started, we do not know who will chair it, but i imagine it will dig down chair it, but i imagine it will dig down into chair it, but i imagine it will dig down into the circumstances around lucy letby down into the circumstances around lucy letby and particularly focus, particularly focus on the concerns that were particularly focus on the concerns that were raised by the consultants here under that were raised by the consultants here under the that were raised by the consultants here underthe numbers that were raised by the consultants here under the numbers of staff, and why there here under the numbers of staff, and why there concerns were not listened to, and why there concerns were not listened to. And why why there concerns were not listened to, and why management here back in 201516 to, and why management here back in 2015 16 seems to be protecting lucy letby. 2015 16 seems to be protecting lucy letby, ratherthan 2015 16 seems to be protecting lucy letby, rather than really vigorously investigating what was going on in the unit investigating what was going on in the unit. A , investigating what was going on in the unit. ,. , the unit. Many of those questions that they families the unit. Many of those questions that they families want the unit. Many of those questions that they families want answers l the unit. Many of those questions i that they families want answers to. We have been bringing you a lot of the reaction and statements from people involved in this. We were talking there about the hospital and about the fact that a lot of the administration has changed since the time of lucy letby� s offending. Ian harvey is the former Medical Director, he was in place when lucy letby was carrying out those crimes. I want to bring you his full statement. He says, at this time, my thoughts are with the babies whose treatment has been the focus of the trial and with their parents and relatives who have been through something unimaginable, and i am sorry for all their suffering. As Medical Director, i was determined to keep the baby unit safe and support our staff. I wanted the reviews and investigations carried out so that we could tell the parents what had happened to their children. I believe there should be an inquiry that looks at all events leading up to this trial and i will help it in whatever way i can. That is a statement from ian harvey, the former Medical Director at the countess of Chester Hospital, who was imposed at the time of lucy letby� s offending, the time that this trial has focused on, this trial which has found her guilty of murdering seven babies in her care and attempting to murder six more. Now, questions, as dominic hughes, was saying, have been asked about the reporting procedures in this case and the robustness of the response from the hospital. An investigation by bbc news and bbc panorama has uncovered the fact that, in fact, panorama has uncovered the fact that, infact, Child Mortality panorama has uncovered the fact that, in fact, Child Mortality on the unit was far higher than would have been expected, and in fact when concerns were raised, they were dismissed by senior members of staff. Our social Affairs CorrespondentMichael Buchanan has this exclusive report. This is the story of an nhs trust that didnt properly investigate why 13 babies died in a one year period. Instead, it turned against the very people who wanted the police to examine the deaths. There is only one Serial Killer of babies that has worked in that organisation, and the Executive Team were not the people who were responsible for the deaths of those babies. But they had some opportunities to get to the bottom of what was happening. Susan gilbeyjoined The Countess Of Chester Nhs Trust A Month after lucy letby was arrested. Within two months, she was made Chief Executive, a post she held until last december. Through documents and speaking to staff, she learned what the trust knew about the Serial Killer. The first three babies died injune 2015. The Executive Team held a meeting at which it was agreed that an external investigation into the deaths would be held. It never happened. By october, with seven babies now dead, a Staff Analysis of the incidents made a link between all the deaths and lucy letby being on shift, but it was still seen as coincidental. In february 2016, with ten babies now dead, the director of nursing, alison kelly, and ian harvey, the Medical Director, were asked for an urgent meeting to discuss the deaths and lucy letby� s links to all of them. They didnt respond for three months. The paediatricians were discussing the terrible nights on call that they were having. One of them said, every time this is happening to me, that im being called in for these catastrophic events which were unexpected and unexplained, lucy letby is there, and then Somebody Else said, i found that. And then someone else had the same response. And they all realised that the common factor for each of them was letby� s presence on the unit. Injune 2016, two babies died on consecutive days. 13 children had now died. Lucy letby was on shift for all of them. The day after the second death, the nurse was due back on the unit. Paediatrician Steve Brearley rang the duty manager asking for her to be replaced. The manager refused. I challenged her. I said, are you saying that you are making this decision against the wishes of seven Consultant Paediatricians . And she said yes. And i said, well, if you are making this decision, are you taking responsibility of anything that might happen tomorrow to any of our babies . And she said yes. Lucy letby went to work, and a baby unexpectedly collapsed. We were urging them to investigate our concerns appropriately, and most of us felt the most appropriate way to do that would be to go to the police. The response from the Medical Director was unsupportive. In an e mail to the paediatricians obtained by panorama, ian harvey wrote, action is being taken. All e mails ceased forthwith. The police were not called. Instead, in september 2016, the Royal College of paediatrics and child health was asked to carry out a review of the Neonatal Unit. It urged the trust to investigate each death individually. This didnt happen. Around this time, lucy letby launched a Grievance Procedure against the paediatricians. The internal process agreed that she had been discriminated against and victimised by the doctors on the unit. With the paediatricians wanting a Police Investigation injanuary 2017, an extraordinary Board Meeting was held. The Medical Director, ian harvey, gave a verbal report. He said external reviews had not highlighted any individual as being linked to the deaths and that the trust was ready to draw a line under the issues. The Chief Executive, tony chambers, said he had met lucy letby and her parents to apologise for what had happened. A statement Written By Letby was read out, detailing how hard the past few months had been for her. The meeting decided lucy letby would return to the Neonatal Unit after the paediatricians had written a Letter Apologising to her. This is the letter sent to her, signed by all seven of the paediatricians. Against their wishes, they apologised for any inappropriate comments that had been made, going on to say, we are very sorry for the stress and upset you have experienced in the last year. Though the paediatricians feared being reported to the regulator, they kept going, urging the trust to report the cases to the police, something the trust did eventually in 2017. Protecting the reputation of the organisation was a big factor in how people responded to the concerns raised. They were dragged kicking and screaming, the Executive Team, to calling the police. That would certainly be the conclusion that i would reach. At the time letby was arrested in july 2018, she was still working at the trust. No disciplinary action had been taken against her. The strong opinion was that nothing would be found. There was a Brief Overlap of three or four days between myself and the outgoing Medical Director, and his parting words to me, to my surprise, were you need to refer the paediatricians to the gmc. They were not referred to the general medical council. Instead, all the executives who doubted the doctors and supported lucy letby left the countess of chester trust. They all refused to comment ahead of todays verdict. Michael buchanan, bbc news, cheshire. For viewers in the uk, a bbc panorama documentary . Lucy letby the nurse who killed . Will be available to watch on iplayer later today. We have been bringing a reaction through out the last few hours on bbc news, reaction from various people involved in this trial, and we brought you the response from the countess of Chester Hospital, this was the hospital in which lucy letby was the hospital in which lucy letby was working, in its Neonatal Unit, when she carried out these murders and attempted murders over this 12 month period, and we had a statement from doctor nigel scawn, the current Medical Director at the countess of Chester Hospital. I speak for the whole trust when i say how deeply saddened and appalled we are at lucy letby� s crimes. We are extremely sorry that these crimes were committed at our hospital. And our thoughts continue to be with all the families and loved ones of the babies who came to harm or who died. We cannot begin to understand what they have been through. This case has had a profound impact on our patients and our local community, and also our staff. They come to work every day determined to provide safe and high quality care for all of our patients. Our staff are devastated by what has happened, and we are committed to ensuring that lessons continue to be learned. We are grateful for the cooperation of our staff, especially those that have maintained the utmost professionalism was giving evidence in this trial, sometimes on multiple occasions. We will continue to support them and our other staff to ensure they receive the care and support that they need. We would like to extend our thanks to Cheshire Police for their extensive investigation and the work they did to bring this case to trial. Wed also like to thank them for the comprehensive support that they have provided to all the families involved. Since lucy letby worked at our hospital, we have made significant changes to our services. And i want to provide reassurance to every patient that may access our services that they can have confidence in the care that they will receive. Finally, and most importantly, our thoughts are with all the families and loved ones at this very difficult time. Thank you. That was dr nigel scawn, the current Medical Director at the countess of Chester Hospital. Lets also hear from dr Stephen Brearey, who used to work in the Neonatal Unit, he led the team of seven consultants in that unit, one of the people who raised concerns that he said were not acted upon, and he has been speaking tojudith moritz. If we go back to the summer of 2015, when did you first become concerned . A review of the care of all three babies was done, and there was nothing in common that we could pin these three deaths on. But the Staff Analysis did identify that lucy letby was on shift for those three episodes. And did that worry you . Well, i think i can remember saying, oh no, it cant be lucy, nice lucy. Tell me about when you remember first meeting lucy letby. I dont recall the first time that i met lucy letby. She started work in 2012. She didnt strike me as too different to most nurses on the unit. You didnt have any worries about her doing thejob . I dont think anybody did. It is something that nobody really wants to consider, you know, that a member of staff might be harming the babies under your care. Can you give us a sense of what was happening in the unit over the summer and autumn of 2015 in terms of there being more unexplained collapses and deaths . It was the first time i started to have some concerns about the unusual nature of the collapses and the deaths. I e mailed the unit manager after this death in october, and i asked to discuss lucy letby and her association with the deaths. Some of the babies did not respond to resuscitation quite how we would have expected them to. Most babies get a heart rate back, their breathing would get better, but that didnt happen in these cases like you would expect, which was unusual. As the year turned into early 2016, particularly february 2016, things took another turn. Youd asked for an urgent meeting. Thats correct, yes. As a group, our concerns were rising. Theres no communication from senior managers in the trust. And how long did it take for that meeting to come about . The meeting did not happen until may. Tell me about the fact that after two of the triplets died injune, you had a debrief, talk me through what happened. Lucy letby was there, she was sitting next to me. I spoke to her towards the end of the meeting, and i said how tired and upset she must be after two days of this, and i hoped that she was going to have a res