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A report on the neonatal unit where Lucy Letby worked was only shown to parents at all eight years after it was written, a public inquiry has heard.
An external review was commissioned in September 2016 after consultants at the Countess of Chester Hospital raised concerns about the serial killer.
A public version of the report was posted on the hospital’s website and a confidential, unredacted version containing reference to Letby was kept private.
The mother of twins Baby E and Baby F told the Thirlwall Inquiry she had only seen the unredacted version this week.
Letby, from Hereford, is serving 15 life sentences after she was convicted in August 2023 of murdering seven children and attempting to murder seven more between June 2015 and June 2016.
Senior managers had invited a team from the Royal College of Paediatrics and Child Health to carry out an external review of the hospital’s neonatal unit in September 2016.
Those administrators have had copies of the unredacted report since October 2016.
The mother of Baby E and Baby F, who cannot be identified for legal reasons, also told the inquest that a consultant at the unit, whose name is also protected by a court order, had written to apologise. for not being open and transparent about what was happening on the unit at the time of Baby E’s death.
Baby E was murdered by Letby in the early hours of August 4, 2015, after he injected air into his circulation, the inquest heard.
He then tried to murder his brother, Baby F, by injecting him with insulin the next day.
The twins’ mother said it was a “really emotional moment” when she received the letter.
“It’s the first time anyone from the Countess of Chester Hospital has apologized to us for what happened, and I think that was really good of (the consultant) and a really kind gesture,” he said.
The same consultant also apologized to the family in court for not ordering a post-mortem examination after Baby E’s death.
The inquest heard how the boy’s mother had come in to find her son screaming, with blood on his face and Letby alone with him.
She told the inquest, at Liverpool Town Hall, she believed she had interrupted Letby in the middle of his attack and caught him off guard.
The child died a few hours later.
The next day, his twin brother, Baby F, suddenly fell ill with a heart attack, but recovered in the following days.
The boy’s mother told the inquest that the first time she knew he had been injected with insulin was when police asked her to take her son for an MRI scan as part of their investigation several years later.
The mother made several suggestions for recommendations that she would like to see the inquiry chairman Lady Justice Thirlwall make in her final report.
She suggested that there should be mandatory post-mortem examinations for all babies who die in neonatal units, and there should also be a bereavement midwife in every neonatal unit or maternity suite.
The mother told the inquest she felt “guilty” for not asking for a post-mortem examination, adding it could have saved other children.
“I carry our pain, but the sadness of other families, because it should never have passed from that point,” he said.
Lady Justice Thirlwall said she had nothing to blame and that she had done a huge public service by giving evidence.
The mother also recalled how attentive Letby was to her.
“Every time he saw me, he would hug me,” she said.
“She was as upset as I was, which, reflecting on it now, is very strange behavior, when none of the other nurses were really like that.”
The investigation continues.