The mother of twin boys targeted by Lucy Letby said she “carries the sadness of other families” that the serial killer was not stopped earlier, a public inquiry has heard.
In August 2015, Letby, 34, assaulted Child E, which caused bleeding, and also injected air into his bloodstream, and nearly 24 hours later she poisoned Child F with insulin.
She went on to murder three babies and attempted to murder five more, until she was removed from the Countess of Chester Hospital’s neonatal unit in July 2016.
A doctor told the parents a post-mortem examination was not necessary for Child E, as it was thought he had died from a bowel condition which was common in premature babies, when in fact no sign of the condition was detected on a X-ray.
And they were informed that Child F’s deterioration was because of a catheter infection, and were unaware he had suffered an episode of hypoglycaemia and that blood tests had shown an abnormally high level of insulin.
Giving evidence on Wednesday at the Thirlwall Inquiry, the mother of Child E and Child F said she learnt the full details of both incidents at Letby’s criminal trial.
She said: “It took us through our children’s lives essentially hour by hour, and to find out that Child E had that significant bleed to the point of it being very, very unusual, and for no post-mortem to be warranted from that, made me question why.
“Why was the post-mortem not mandatory? Why was it left to me to make that decision?
“I feel guilty for not requesting that, because if that had come back and something would have been on it, there is a lot of babies that could not have been involved in this case and it could have stopped there.
“That weighs very, very heavily on me and that decision was ultimately ours.
“That’s painful to think about so I carry our grief, but the sadness of the other families, because it should never have gone past that point.”
She went on: “And it’s the same when I realised that the insulin reading was there, and it was seen, and nothing was done.
“That could have been an end to this whole horrendously sad turn of events but it wasn’t.
“And I think although the doctors and consultants worked really hard to save Child E, there should have been some curiosity as to why he was bleeding.
“Why Child F’s insulin was not just a little bit over, it was in the 4000s? Why was it not investigated?
“We put our trust in these people. I put my trust in them to do the right thing and the best thing for my children.”
Inquiry chairwoman Lady Justice Thirlwall told her: “You have absolutely nothing to feel guilty about, nothing. You have nothing to blame yourself for, nothing at all.”
The doctor who advised Child E’s mother that a post-mortem examination would show no new information later apologised to her in the courtroom, as she gave evidence at the criminal trial.
Child E’s mother told the inquiry: “It was a really emotional moment because it was the first time that anyone from the Countess of Chester has apologised for their part in what happened, and I think it was extremely brave to do so.”
She said she first became aware of any investigation in February 2017, when the hospital’s medical director, Ian Harvey, wrote to inform them about an external review of a greater number of deaths than expected on the neonatal unit in 2015 and 2016.
She said: “I received that letter via a black taxi knocking on my door, about 30 minutes before that report was due to go live online on the hospital website.
“I was absolutely mortified.”
Her only previous contact from the hospital, she said, was when they rang twice to ask for the return of a breast pump, which she used at her son’s funeral, when she had in fact already returned it.
The inquiry has heard that families affected were provided with a redacted version of the Royal College of Paediatrics and Child Health report which omitted details about concerns from consultants about “Nurse L”.
Child E and Child F’s mother told counsel to the inquiry, Rachel Langdale KC, she would have liked to have seen the full report at the time.
She said: “I think the Countess of Chester being transparent and open with what they were investigating would have given me peace of mind, not thinking I had missed something.
“I blamed myself for a lot of things that happened in that time. I don’t think it should have been held back. To do that, I think it’s quite hideous to be honest.”
She subsequently made numerous attempts by phone to set up an appointment with Mr Harvey, but he “hid behind his secretary”.
Asked what suspicions she had about Letby at the time, or since, she said Letby’s behaviour after the death of Child E was “very different” from other nurses.
She said: “She was very attentive of me. Whenever she used to see me she would hug me.
“She was just as upset as me which, reflecting back on it now, is very odd behaviour, when none of the other nurses were really like that.
“They were very professional and cared for Child F in the correct way, while she was really emotional. I thought she was being kind.
“She looked like every time she spoke to me she was on the verge of tears, very upset.”
She recalled that she and her husband took a hamper to the neonatal unit in October 2015, because “we were so grateful to have a child that was still with us.”
Child E and F’s mother told the inquiry: “I think I mistook people’s kindness. They seemed caring, they had our best interests at heart, and it turns out one person didn’t, and they betrayed everything and did the most unimaginable thing possible.
“For me, my children are not left with anybody. They don’t get left in any medical setting with anyone.
“The worst thing happened to us, it happened to us twice, it was not going to happen a third time. We protect those children with everything.
“I ask questions and I don’t take people at face value, and I think that was part of my naivety at the Countess of Chester.
“I took people at face value. I took what consultants said and I took what Lucy Leby said at face value and for what it was, but a lot of it was lies.”
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, between June 2015 and June 2016.
The inquiry is expected to sit until early 2025, with findings published by late autumn of that year.
