00:00Have you got anything to say to the family except for babies?
00:29So right at the outset I just want to offer my heartfelt condolences to all
00:58the families whose babies are at the heart of this inquiry.
01:04What was your most significant personal failure do you think?
01:10One of the very enduring examples if you like is our ability to have communicated what was
01:25a very complex set of messages with information that was unclear and therefore I do believe
01:33that there was, on reflection, the communications with the families could have and should have
01:44been better.
01:45At some point on the afternoon of the 24th of June of 2016, so a full five days before
01:52you were told, the Director of Nursing, Alison Kelly, was told that the two most senior
02:02consultants in the paediatric unit were concerned that a nurse may have murdered a baby the
02:12day before.
02:13I don't believe I knew about these matters before the 29th of June because as you correctly
02:22described these are very important, very concerning matters and you can see that the
02:29actions that I took from that were very speedy and there were many, many meetings that came
02:38after the 29th of June.
02:39So my assumption is that I didn't know and should I have known?
02:43I don't know where I was, I haven't got my diary, I don't know if I was in the hospital
02:49but I think it's a fair assessment that I perhaps should have been told.
02:53Do you agree or disagree that there was a rational basis for them to be suspicious that
03:00serious crimes had been committed?
03:03Based on what was being presented there I had no reason to believe that there was no
03:08rational basis for what they were saying but what I do know from my experience across the
03:15NHS is that we wouldn't jump to criminality as a causal factor, we would want to explore
03:28a broader set of answers to those very difficult questions.
03:34Yes, and so do you agree that it appears the plan is going to be that the police are going
03:38to be spoken to on the 31st of March?
03:41Yes, that's right.
03:46Okay, now we know that the police were not spoken to on the 31st of March, do you know
03:53why they weren't?
03:58There was never any intention to not go to the police.
04:04The decision had been made at the meeting on the 27th of March.
04:09What we needed help and advice on is this was a serious escalation of matters and we
04:15needed to be clear around how we would manage that next step, what would help the police,
04:25what would help us, so we sought independent advice.
04:30Letby's family, it's fair to say, were very upset and very angry about how they felt she'd
04:41been treated unfairly by the Trust.
04:45I'm prepared to accept that we had not been as open and honest with her at the time.
04:54As you can see when you read the notes from this meeting, Letby's father was very angry,
05:02he was making threats, he was making threats that would have just made an already difficult
05:13situation even worse by threatening GMC referrals for the doctors, he's threatening guns to
05:20my head and all sorts of things.
05:32And we're just going to pick out some of the things that Letby was saying in the first instance.
05:41Do you see towards the bottom that a conversation begins about
05:46who the apology is going to be from?
05:50And if we go over the page we'll see what Letby then says, I expect four apologies.
06:00Now, did you feel in this meeting that Letby was trying to take control of what was going on?
06:12I think that was an attempt on her behalf, yes, I think she was.
06:18We can see here we will get an apology from all, do you think that is something that you
06:23said to Letby, that you would get an apology from everybody?
06:27Well I think earlier in the meeting I think that was already a position that had been agreed upon.
06:33The fourth to last entry, last sentence, Lucy don't worry, we've got your back.
06:42Yeah, clumsy language, as I've said all along the intention here was to avoid any possible
06:54escalation and eight years on with what we know and we look at this,
07:01these are the kind of things that you know you didn't get right.
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