later expected to track to california and nevada. it'll weaken to a tropical storm but still bringing the risk of devastating flash flooding and strong winds. the british government has ordered an independent inquiry into how a nurse came to murder seven newborn babies in her care and tried to kill another six. lucy letby was found guilty after a trial in manchester which lasted ten months. while lucy letby has been convicted of seven murders, the bbc has learned there were actually 13 deaths on the neonatal unit where she worked in a one year period. that's five times the usual rate, and lucy letby was on duty for all of them. an investigation by bbc news and bbc panorama has also revealed that doctors on the unit were raising

concerns for months about letby but that senior managers ignored them and protected lucy letby. our social affairs correspondent michael buchanan has this exclusive report. this is the story of an nhs trust that didn't 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 didn't 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 i'm 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 brearey 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.

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 didn't 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 today's verdict. michael buchanan,

bbc news, cheshire. i spoke to michael buchanan — and a short time ago he told me more about what sir duncan nichol said. for a year, the countess of chester hospital in the summer of 2015 and the summer of 2016 when 13 babies died in unexplained circumstances. and we now know that the pediatricians at the unit, the neonatal unit, were raising concerns about what was happening. the board were not made aware of this problem despite the number of deaths being significantly higher than they usually were. but in the summer of 2016, they did become aware of it. and one of the things they decided to do at that point was to launch a series of external independent investigations to try and understand why these babies were dying. and none of these investigations would ever properly commissioned are properly completed.

and they never got to the bottom of what was happening. but what what sir duncan nichol, the former chairman of said in a statement this morning, is that he feels that the board was misled by the by the managers of the trust and particularly refers to a document they were giving in december of 2016, in which he says that they were told explicitly there was no criminal activity pointing to any one individual when in truth, he goes on to say, the investigating neonatologist had stated that she had not had the time to complete the reviews fully know now, this is a reference to a london based neonatologist who was asked by the trust at one point to see if she could help them understand why the babies were dying. she told them explicitly that she didn't have the time to do it and it would need further investigations. but according to the statement from sir duncan nichol says this morning the board were actually told that that those reviews by her had found there was no criminal activity at all.

so what reaction has there been to all of this, then? well, we have been in touch with two of the former senior leaders of the trust at the time, the former chief executive and the former medical director. the former chief executive said that what was shared with the board was open and honest and represented the trust's best view of what was happening at the time. the former medical director say that all the comments he made to the board were true to the best of his knowledge, both of them and indeed sir duncan nichol say they will cooperate fully with the inquiry. but there is also a second inquiry, a public inquiry. there is also a second review that was ordered three years ago by sir duncan nichol and the former chief executive at the time, looking into how the trust handled the allegations against lucy letby. as i said, it was commissioned three years ago. we still don't know when it's going to be published. dr stephen brearey led the team of seven consultants on the neonatal unit at the countess of chester hospital who shared concerns about the deaths.

he spoke 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 can't be lucy, nice lucy. tell me about when you remember first meeting lucy letby. i don't recall the first time that i met lucy letby. she started work in 2012.

she didn't strike me as too different to most nurses on the unit. you didn't have any worries about her doing thejob? i don't 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 didn't 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. you'd asked for an urgent meeting. that's correct, yes. as a group, our concerns were rising. there's 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 restful weekend.

and she turned to me and said, "no, i am back on shift tomorrow." which struck me as being incredible, really. the other staff were very traumatised by all of this, they were crumbling before your eyes almost. and she was quite happy and confident to come into work on the saturday. and it was, shortly after that, that lucy letby was taken off duty. yes. would you say that was the tipping point? certainly, the tipping point for the consultant body, who wanted to work in a safe environment. we had a number of meetings with senior management, it was quite clear that they were not going to budge and they didn't think it appropriate to go to the police at that stage. do you think it's the case that if you hadn't persisted,

there would never have been a police investigation? i'm sure, yeah. that was the intention of the executives, was to somehow close this case. was this a cover—up? i don't know how you'd define a cover—up, but to us, the evidence in front of us was quite clear. it felt like they were trying to engineer some sort of narrative, a way out of this that didn't involve going to the police. if you want to call that a cover—up, then that's a cover—up. can expectant mothers coming into the unit have confidence? i think those parents can expect, em... ..as high a level of care on our unit as any unit in the country. it's upsetting, this. we've got though a particularly hard time, and i think

we owe it to the families, for them to know that the staff care. detective chief inspector, nicola evans, was the deputy chief investigating officer, on the case. she told our correspondent, judith moritz, how the team at cheshire police first responded to the allegations. the general feeling at that time was almost of disbelief that this could have occurred from a policing perspective. we often start off with a crime and then we investigate from that point. in this case, we started off way before that, and so actually what we started with was the birth of babies and we investigated from that point. and so during that period of time, it's really hard to believe that anybody would be harming tiny babies.

and that was the general feeling at that point. and it wasn't until we got further on in the investigation, where we'd established that a crime had occurred, that really the size of this investigation and what we were about to embark on really hit home for people. when you first started investigating, how evidentially complex did it appear to be? the size and scale of this investigation is huge. ultimately, we've got a trial where we're presenting 17 murder and attempted murder cases all at once. and so right back at the beginning of the investigation, it was really clear that this was going to be a really complex investigation. to put that into some context, one set of medical records in relation to one of the children in this case was over 8,000 pages long. and so we then had to instruct

a number of experts and people to help us understand what those records were telling us. and then clearly, from that point on, we were reconstructing what was happening between 2015 and 2016, and the amount of material that goes with that is huge. and so from the very beginning, it was clear that this was going to be a very wide—reaching investigation and also that it would take some time. and it was really important to recognise that then, so that we could explain to the families of these children, of these babies, exactly how long this was going to take and why it was taking so long. this investigation is centred around tiny babies on a neonatal unit who should have been in a really safe place. lucy letby acted under a cover of trust. and she abused that trust.

she abused the parents who put their utterfaith in her to look after their tiny, tiny babies. she abused her colleagues and herfriends in order to commit these crimes. it is huge, this investigation. the emotional attachment that lots of people have to it is unsurprising. but that comes with a level of responsibility that we have from a police perspective, and from my perspective, that we have to get this right because it is too important. and it's so far—reaching for us not to, which is why it's taken time, because getting something right sometimes isn't doing it in the quickest fashion. how important was the discovery of the first insulin case, and do you remember when you first learned about that? the first insulin case was discovered after we asked the experts to review sibling cases,

and we were shocked really to the core to find that a baby had been injected with insulin. and i think on any level, anybody would understand that level of shock at the time. and it did take some time to process. and clearly we were right to send those extra cases off. and they are important pieces of evidence within this case. it's another layer of another layer. it's another layer of another layer of kind of surprise, i suppose, as to the depth that lucy letby went to. what did you find when you searched lucy levy's house, her phone, her belongings? we found a lot of written material during the arrest of lucy letby and the searches. a lot of that material has been shown in court. and what we would say, confessional notes that

were in lucy letby�*s immediate possessions and then other items such as handover sheets that were kept around lucy letby�*s property, and at her parent's property, isn't something we expected to find. if i'm honest, we didn't expect to find that level of material. and then it took us some time to go through that in detail, to cross—reference that and actually try to understand where that fit with the rest of our evidence and investigation. the post—it notes, particularly the one, the green note — "i am evil. i did this." what does it tell us about her, her state of mind, who she is? those notes were clearly dealt with within the trial, and we see them as confessional notes as to what she has done. they were kept quite close to her in her personal belongings. so i think that probably tells us something about what they meant

to her. and what story does that tell you? items like the handover notes, i mean, are they trophies? have you looked at reasoning behind it? we haven't received an explanation, a plausible explanation from lucy letby, as to why she kept that material. and it's difficult for me to answer as to why she kept those things. i think there have been a lot of reasons put around that as to whether they're trophies, whether she collects them. i personally feel as though they would be strange things to have at your home address and actually the number, particularly of handover sheets, that we found were in excess of 250. and not to know that they were there, i think, is an unreasonable explanation. how would you describe lucy letby�*s character? because matching the person we've all been looking at in court with the scale of these crimes has been very difficult. lucy letby for me is beige

in that she is normal... ..woman in her 20s with a normal life, a social life, a circle of friends and her family. and she was embarking on her career within the neonatal unit. she used that normality to form trust, and then she abused that trust. and that kind of cover of trust allowed her to commit the crimes that she committed. it's hard, though, isn't it, to marry the scale of those crimes with that normality to make sense of it? yes, it's difficult even to imagine that anybody would commit these crimes and therefore you expect the person to have committed them to be somebody almost totally outrageous and different. the fact that she isn't either of those things make it

really difficult to accept what has happened. but i think that's because it's so hard to understand why anybody would commit crimes of this nature against babies on a neonatal unit because it's so unimaginable. because it's so unimaginable. also because a lot of this is circumstantial evidence. no—one saw her doing anything. there are those who just don't believe she's guilty. the links in this case are so powerful and that circumstantial evidence is really powerful evidence of what was happening during that period and also the links around lucy letby herself and what she was doing. and our evidential case has taken so long because it's been so important to make those links and cross—reference that evidence, which is ultimately evidence from witnesses, from digital

material, from medical records. and once you put all of that together, that's a really compelling case. you've been involved in the process of telling families who thought their children had died naturally, that's not what happened. what was that like? it wasn't lost on anybody within the investigation team that these people, for those who have lost babies, have grieved for those babies. and we then have approached them to tell them that actually something suspicious has happened. i can't imagine. i can't even begin to imagine how that feels. and i hope that we have gone some way to answering some of their questions. i don't think we've answered all of them, but i hope that we've answered some of them and that in time that gives them some peace of mind as to what's happened. what's the unanswered question? i don't think we know why lucy letby has done this. and we may never know why.

and that's really difficult to take. i can't imagine how a parent must feel accepting that, because i find that really hard to take and really hard to swallow, to think that we might never know why these things, these crimes have happened. and that's why i say we've answered some of those questions, but not all of them. lucy letby has been given the opportunity to explain. and she did cooperate with us during those interviews, and she has given evidence during the trial. i don't think she's gone any way as to explain what's happened, and ifeel like a lot of her explanations were actually quite unreasonable. this, for me, is not now about lucy letby. this is about the babies, their parents, their siblings and their wider families having the answers, getting some peace of mind as to what's happened and being able in some way to move on with the rest of their lives.

they have been incredibly resilient and strong throughout this investigation, and their composure and the dignity that they have shown during the trial has been really overwhelming. they've also shown true compassion to each other in supporting each other through the trial and listening to ultimately some of the most private things in their lives. and that has really been overwhelming. and what about the staff at the hospital, the doctors who were trying to raise the alarm, who've had their own journey? i think this case has been so far reaching for so many reasons. clearly, the families and the parents are right at the heart of that. but also, we've spoken to thousands of people and witnesses, hundreds of them have become witnesses in the case and the trial

and numerous witnesses have come back to trial on more than one occasion to give evidence. they are still professional people. they are still nurses and doctors. they're still working on the neonatal unit. and the impact on them is huge as well. and that they're still caring for tiny babies whilst trying to deal with and accept that this has happened in plain sight, in their plain sight. and then to come and give evidence at trial. i think the impact of this case isjust so far—reaching and on many human levels. you'll have heard, everyone's heard of harold shipman, beverley allitt. can you believe that this has happened on your patch? it's really difficult to believe, to accept. i think there'll be some time of reflection for everybody that's been involved as to what we've been

involved in and what this means in the future. but it has been a really shocking investigation to be part of. and i really hope that i'm not part of anything like this again. you are watching bbc news, plenty more coming up, don't go away.

live from london. this is bbc news. the uk government orders an independent inquiry, after a hospitalfailed to investigate allegations against lucy letby — the nurse found guilty of murdering seven newborn babies in her care. uk police investigating the murder of 10—year—old sara sharif, found dead in a house in the southeastern town of woking, have identified three people they want to talk to in connection with the inquiry. sara's father, urfan sharif, his partner, beinash batool, and urfan's brother, faisal malik. hurricane hilary heads towards north—west mexico before heading to california as it weakens

to a tropical storm, the most powerful weather system in the us state in more than 80 years. hello, i'm lukwesa burak. the british government has ordered an independent inquiry into how a nurse came to murder seven neonatal babies in her care and attempted to kill another six. lucy letby was found guilty after a trial in manchester in the northwest of england, which lasted 10 months. the inquiry will consider why concerns raised for months by doctors, who worked with her, were not taken seriously by managers at the hospital in chester. nick garnett reports. hello, lucy is it? yes.

hello. my name's muted i from cheshire police.