The erstwhile main enforcement of the infirmary wherever Lucy Letby murdered 7 babies said the committee "just didn't see" what was going connected erstwhile the decease complaint increased.
Tony Chambers was successful complaint astatine the Countess of Chester infirmary during 2015 and 2016, erstwhile the caregiver besides attempted to execution 7 others infants.
Mr Chambers began giving grounds to the nationalist enquiry into the circumstances astir Letby's offending by apologising to the families of her victims.
However helium said "there was a beardown level of support" for the caregiver astatine the clip doctors raised suspicions astir her, and that helium and his chap executives were "very reliant connected the processes that beryllium wrong the hospital".
After taking his spot successful Liverpool Town Hall, which is hosting the Thirlwall Inquiry acceptable up by the authorities to analyse the NHS effect to the case, helium said helium wanted to marque a connection earlier helium was questioned.
He offered "heartfelt condolences" to the families of Letby's victims and added: "I can’t ideate the interaction that this has had connected your lives, and I americium genuinely atrocious for the symptom that whitethorn person been prolonged by immoderate decisions oregon actions that I took successful bully faith."
Nicholas de la Poer KC, counsel to the inquiry, asked him what helium considered his "biggest idiosyncratic failing" successful the mode the infirmary dealt with Letby.
Mr Chambers said: "It’s really, truly hard to reply that question.
"As a main executive, arsenic a board, you are precise reliant connected the processes that beryllium wrong the hospital.
"I accidental that is the nonaccomplishment - that we conscionable didn’t spot it."
When asked if helium had personally failed, helium replied: "It's hard to accidental otherwise."
The enquiry heard that Mr Chambers held a gathering with advisor paediatricians connected 29 June 2016, which, helium said, was the archetypal clip helium had been told determination were concerns astir Letby's links to unexplained deaths and collapses of babies.
This was 5 days aft Letby murdered her last victim, known arsenic Baby P.
Letby continued moving connected the neonatal portion until 30 June - the time aft Mr Chambers held the gathering with doctors.
He told the enquiry the concerns astir Letby were "very shocking" to hear, but that "we wouldn't leap to criminality arsenic the causal factor".
Mr de la Poer suggested that what was being discussed was a "significant information concern".
Mr Chambers agreed, but added: "There was beardown rebuttal to the proposition that this 1 caregiver was deliberately causing harm.
"There was a precise beardown level of enactment for this individual."
Letby was owed to spell connected permission for a fortnight aft 30 June and afterwards was placed onto clerical duties, ne'er returning to the unit.
Mr de la Poer asked astir a gathering connected 27 March 2017, erstwhile advisor Dr Stephen Brearey told Mr Chambers the constabulary should beryllium called in.
Mr Chambers said that astatine that gathering the statement was made to interaction police, but helium did not constitute to the main constable of Cheshire Constabulary until 2 May, aft consulting with transgression barrister Simon Medland QC.
However, Mr de la Poer suggested that, successful his archetypal interaction with the police, Mr Chambers "did not contiguous the lawsuit astatine its highest" and was trying to "discourage" an investigation.
Mr Chambers responded "absolutely not", and said the infirmary "shared with constabulary precise openly and candidly what we genuinely believed to beryllium the presumption arsenic we understood it astatine the time".
The enquiry continues.