The erstwhile aesculapian manager of the infirmary wherever Lucy Letby attacked and killed babies conceded determination had been a "potential missed opportunity" to halt her.
Ian Harvey, present retired, was the astir elder clinician astatine the Countess of Chester Hospital erstwhile Letby murdered 7 babies and tried to termination 7 others betwixt June 2015 and June 2016.
A nationalist enquiry into the circumstances astir Letby's crimes heard a tally of 3 unexplained deaths of babies connected the neonatal portion successful June 2015 were not reported arsenic a superior incidental by the hospital.
Mr Harvey said that portion determination was thing to "link them together" this nonaccomplishment was a "potential missed opportunity".
The Thirlwall Inquiry astatine Liverpool Town Hall heard that connected 13 August 2015 Mr Harvey was invited to a Serious Incident Review gathering relating to the 4th babe to die, referred to arsenic Baby E.
Mr Harvey said nary nexus was drawn betwixt Baby E's decease and the 3 deaths successful June that year.
Rachel Langdale KC, counsel to the inquiry, asked Mr Harvey if, successful August 2016 erstwhile the infirmary was helping the coroner hole for an inquest into the decease of Baby A successful June the erstwhile year, immoderate notation was made of Letby.
"By then, you had each been talking successful assorted meetings astir whether Letby is sidesplitting babies," she said.
"Do you deliberation the coroner was adequately informed astir the suspicions and concerns you had astir Lucy Letby sidesplitting babies, and whether oregon not Lucy Letby was looking aft this baby?"
Mr Harvey said helium did not know.
Ms Langdale besides asked wherefore Mr Harvey failed to be a gathering to sermon the deaths of 2 triplets, Baby O and Baby P, connected consecutive days successful June 2016.
"It’s hard to ideate thing much superior successful the hospital," she said.
Mr Harvey said helium "couldn't say" wherefore helium missed the meeting.
The enquiry was past shown an email concatenation involving respective consultants which Mr Harvey was copied successful to.
In an email connected 29 June 2016, Dr Murthy Saladi said: "At the infinitesimal we are each nether suspicion and the lone bureau who tin analyse each of america I judge is the police."
Another consultant, Dr Ravi Jayaram, replied to accidental that helium and Dr Stephen Brearey were "trying to conscionable with the execs ASAP to sermon precisely this" but "they bash not look to spot the aforesaid grade of urgency arsenic we do".
Mr Harvey past replied to each the doctors connected the email concatenation to accidental "this is perfectly being treated with the aforesaid grade of urgency… each emails cease forthwith".
Asked wherefore helium asked each emails to stop, helium said helium was trying to "dampen down" an "extreme situation".
"I afloat judge that I got that wholly wrong," helium said.
"That email doesn’t work arsenic it should person done.”
Earlier, arsenic helium began giving evidence, Mr Harvey asked to code the enquiry and said helium was "sorry for the hurt" that had been caused to the families of Letby's victims.
"It was lone ever my tendency to person a harmless infirmary and to beryllium capable to archer the parents what had happened connected the neonatal unit, and if I failed successful those aims, I americium genuinely sorry," helium added.
Letby is serving 15 full beingness presumption successful situation aft being convicted of 7 counts of execution and 8 of attempted murder, including 2 attempts connected the aforesaid victim.
The enquiry is owed to beryllium until aboriginal 2025.