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

• ITV News Granada Reports correspondent Mel Barham reports from the public inquiry.

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, 35, 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.

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