The former chief executive of the hospital where Lucy Letby murdered seven babies said the board “just didn’t see” what was going on when the death rate increased.
Tony Chambers was in charge at the Countess of Chester hospital during 2015 and 2016, when the nurse also attempted to murder seven others infants.
Mr Chambers began giving evidence to the public inquiry into the circumstances around Letby’s offending by apologising to the families of her victims.
However he said “there was a strong level of support” for the nurse at the time doctors raised suspicions about her, and that he and his fellow executives were “very reliant on the processes that exist within the hospital”.
After taking his seat in Liverpool Town Hall, which is hosting the Thirlwall Inquiry set up by the government to examine the NHS response to the case, he said he wanted to make a statement before he was questioned.
He offered “heartfelt condolences” to the families of Letby’s victims and added: “I can’t imagine the impact that this has had on your lives, and I am truly sorry for the pain that may have been prolonged by any decisions or actions that I took in good faith.”
Nicholas de la Poer KC, counsel to the inquiry, asked him what he considered his “biggest personal failing” in the way the hospital dealt with Letby.
Mr Chambers said: “It’s really, really difficult to answer that question.
“As a chief executive, as a board, you are very reliant on the processes that exist within the hospital.
“I suppose that is the failure – that we just didn’t see it.”
When asked if he had personally failed, he replied: “It’s difficult to say otherwise.”
The inquiry heard that Mr Chambers held a meeting with consultant paediatricians on 29 June 2016, which, he said, was the first time he had been told there were concerns about Letby’s links to unexplained deaths and collapses of babies.
This was five days after Letby murdered her final victim, known as Baby P.
Letby continued working on the neonatal unit until 30 June – the day after Mr Chambers held the meeting with doctors.
He told the inquiry the concerns about Letby were “very shocking” to hear, but that “we wouldn’t jump to criminality as the causal factor”.
Mr de la Poer suggested that what was being discussed was a “significant safety concern”.
Mr Chambers agreed, but added: “There was strong rebuttal to the proposition that this one nurse was deliberately causing harm.
“There was a very strong level of support for this individual.”
Letby was due to go on leave for a fortnight after 30 June and afterwards was placed onto clerical duties, never returning to the unit.
Mr de la Poer asked about a meeting on 27 March 2017, when consultant Dr Stephen Brearey told Mr Chambers the police should be called in.
Mr Chambers said that at that meeting the agreement was made to contact police, but he did not write to the chief constable of Cheshire Constabulary until 2 May, after consulting with criminal barrister Simon Medland QC.
However, Mr de la Poer suggested that, in his initial contact with the police, Mr Chambers “did not present the case at its highest” and was trying to “discourage” an investigation.
Mr Chambers responded “absolutely not”, and said the hospital “shared with police very openly and candidly what we genuinely believed to be the position as we understood it at the time”.
The inquiry continues.