The management team had also failed to report the deaths appropriately. It meant the wider NHS system could not spot the high fatality rates. The board of the hospital trust was also unaware of the deaths until July 2016.
This is devastating. Monitoring systems were set up after Harold Shipman, to make sure that such clear signals of something untoward would not be missed in future. Hospital management appear to have subverted those systems to protect their own reputations.
Hospital bosses failed to investigate allegations against Lucy Letby and tried to silence doctors, the lead consultant at the neonatal unit where she worked has told the BBC.
They say the head of corporate affairs and legal services, Stephen Cross, warned that calling the police would be a catastrophe for the hospital and would turn the neonatal unit into a crime scene.
Rather than go to the police, Mr Harvey invited the Royal College of Paediatrics and Child Heath (RCPCH) to review the level of service on the neonatal unit.
A few weeks later, in late January 2017, the seven consultants on the neonatal unit were summoned to a meeting with senior managers, including Mr Harvey and the hospital's CEO Tony Chambers.
When a new medical director and deputy chief executive, Dr Susan Gilby, began work the month after Letby's arrest, she was shocked at what she found.
She says her predecessor, Mr Harvey, had warned her she would need to pursue action with the General Medical Council, the doctor's regulator, against the neonatal unit's consultants - those who had raised the alarm.
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