‘Tenacious’ doctors stopped Letby’s return to ward

It was discussed at a high-level meeting which concluded that “no further investigation was warranted”.

Ms Langdale said: “With hindsight, this decision may represent a significant opportunity missed.”

By February 2016, consultants on the unit, including Dr Stephen Brearey, had begun to question Letby’s presence at a number of unexpected and unexplained incidents.

Ms Langdale says a meeting took place on 8 February, 2016, involving Dr Brearey, his colleague Dr Ravi Jayaram, and other senior hospital figures to discuss and review the deaths of babies where the diagnoses had been uncertain.

The inquiry heard Dr Brearey recalled raising the fact that six of the nine babies had collapsed between 00:00 and 04:00, and that a particular member of staff – Letby – had been present.