Lucy Letby: The eight missed chances to stop killer nurse from murdering newborn babies

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Nine babies might have been saved or escaped harm had hospital managers and doctors not missed vital opportunities to stop Lucy Letby’s killing spree.

On up to ten occasions, suspicions were raised or events happened that linked her to the spike in deaths or collapses on the Countess of Chester Hospital’s neo-natal unit.

Crucially, doctors failed to appreciate the significance of blood test results from two baby boys – treated eight months apart – which proved that someone on the ward was poisoning children with insulin.

When consultants finally became suspicious and demanded Letby be removed from her frontline job, hospital bosses refused to believe she was to blame.

Desperate to protect the reputation of the trust, bosses moved her into an office job. But they fought to get her reinstated onto the neo-natal unit – even insisting senior medics write her a letter of apology when a formal employment grievance she pursued apparently found little evidence she had done anything wrong.

A staff chart showed that Lucy Letby was present at every chilling incident involving children on the ward

A staff chart showed that Lucy Letby was present at every chilling incident involving children on the ward

Letby, pictured here holding a baby on the ward, went on a year-long killing spree at the Countess of Chester Hospital

Letby, pictured here holding a baby on the ward, went on a year-long killing spree at the Countess of Chester Hospital

Tony Chambers (pictured) stepped down as the Chief Executive of the Countess of Chester Hospital after the police launched an inquiry into the baby deaths

Tony Chambers (pictured) stepped down as the Chief Executive of the Countess of Chester Hospital after the police launched an inquiry into the baby deaths

Medical director Ian Harvey receiving a retirement gift in 2018

Medical director Ian Harvey receiving a retirement gift in 2018

In the end, consultants were so terrified about having her anywhere near their patients that they demanded CCTV be installed on the unit. They eventually persuaded executives to go to police in May 2017 and blocked her return.

Last night Dr Stephen Brearey, the consultant paediatrician in charge of the unit, accused hospital management of a ‘cover-up’.

His colleague, TV medic Dr Ravi Jayaram, said lives could have been saved had managers acted on their concerns sooner and accused them of failing to act to protect the hospital’s reputation.

Dr John Gibbs, another consultant paediatrician at the hospital, said: ‘In the 11 months before the police got involved, after we raised concerns, senior managers were extremely reluctant to involve police, to discuss what was happening. We had to keep insisting the police be involved.’

Missed chance 1

The trial was told that the link between Letby and the unexpected collapses and deaths was first made as early as June 2015 when three babies died and another had to be resuscitated within the space of a fortnight. Dr Brearey was so worried he decided to carry out an informal review into the deaths of the infants, known as Babies A, C and D, and the unexpected collapse of Baby A’s twin sister, Baby B.

Eirian Powell, the neo-natal unit manager, also examined who was on duty during the four events. A meeting was held between Dr Brearey, Mrs Powell, and Alison Kelly, the then director of nursing, when it was noted that Letby was the only employee on duty when each baby collapsed.

But no-one took the threat seriously at that stage. Dr Brearey said he even made the remark: ‘It can’t be Lucy, not nice Lucy’.

However, he discussed the meeting with colleagues including Dr Jayaram, the consultant in charge of the children’s ward. ‘All eyes were on’ Letby from that point onwards, Dr Brearey said.

Missed chance 2

Around six weeks later, doctors failed to spot that someone had poisoned a premature twin boy, Baby F, with insulin.

Letby murdered his twin brother, Baby E, in the early hours of August 4 by injecting air into his bloodstream. However his death was put down to natural causes. The following day she poisoned bags of nutrients being fed to his brother with the drug, which lowers blood sugar.

Baffled when treatment to raise Baby F’s blood glucose failed to work, doctors sent samples of his blood to a specialist laboratory in Liverpool for analysis. The results, which showed he had off the scale levels of manufactured insulin in his blood, were telephoned through to the laboratory at the Countess several days later on August 13.

But by then Baby F’s blood sugar had stabilised and he had been transferred to a different hospital closer to his parents’ home.

One of the consultants, who was not named in court for legal reasons, realised the results were abnormal. She even looked to see if any other babies on the unit were being given insulin at the same time – which they weren’t. But she did not suspect foul play. She failed to flag the results to Dr Brearey or any other colleagues and they were effectively ignored.

Alison Kelly was the director of nursing and quality and had been on a salary of £130,000 at the time Letby went on her killing spree

Alison Kelly was the director of nursing and quality and had been on a salary of £130,000 at the time Letby went on her killing spree

A chilling green post-in note was found by police. On it Letby had written 'I AM EVIL, I DID THIS' in capital letters

A chilling green post-in note was found by police. On it Letby had written ‘I AM EVIL, I DID THIS’ in capital letters

Missed chance 3

Almost three more months passed, during which time Letby attacked another baby girl before she murdered her fifth patient. The infant, another premature baby girl, known as Baby I, died on October 23. Later that day consultants on the neo-natal unit decided to flag their concerns again in an email to Mrs Kelly.

However Dr Jayaram said they were ‘fobbed off’ and Letby was allowed to continue working.

Missed chance 4

All the signs missed by hospital bosses that a killer was murdering newborn babies  

Hospital chiefs at the Countess of Chester ignored crucial warnings killer nurse Lucy Letby was targeting newborn babies.

  1. Two doctors carried out reviews following the deaths of three babies died in the space of two weeks in June 2015.  Despite Letby being on duty when the babies died, nobody took the threat she posed seriously.
  2. The second missed chance to stop Letby was around six weeks later when doctors failed to spot someone had poisoned a premature twin boy, Baby F, with insulin.
  3. Hospital chiefs ‘fobbed off’ an email from consultants over concerns following the death of Baby I. 
  4. An independent review by neonatologist Dr Nim Subedar raises concern about Letby on February 8, 2016, but the nurse continued to work at the hospital. 
  5. In February 2016 Letby was interrupted tampering with the breathing tubes of a premature baby girl. Letby was doing nothing to help the baby, even though the newborn’s oxygen levels were plummeting. Despite this, the doctor on duty failed to confront Letby or make a note of her inaction.
  6. Hospital bosses ignored a request for an urgent meeting about Letby from a consultant for three months. By then five babies had been murdered and six harmed by Letby in nine months. 
  7. Letby was moved onto day shifts but two days after the move, in April 2016, she poisoned a second twin boy, Baby L, with insulin. Again, for a second time, doctors failed to pick up on his abnormal blood test results when they were returned. Baby L’s notes by a junior doctor who didn’t flag them to the consultants or realise their importance. 
  8. Two babies were murdered by Letby in the space of 24 hours. Calls were made for Letby to be removed from the ward immediately. But again, managers failed to act. 

Soon afterwards, Dr Brearey commissioned an independent neonatologist to carry out a ‘thematic review’ of deaths on the unit. Dr Nim Subhedar, who was based at the Liverpool Women’s Hospital, reported his findings on February 8, 2016.

Although Dr Subhedar found no explanation for the increase in deaths, Dr Subhedar also flagged that Letby was the only nurse on duty during each event. He had been unaware of the association that had been made previously, Dr Brearey said.

Missed chance 5

In the same month Dr Jayaram’s suspicions heightened when he believed he interrupted Letby tampering with the breathing tube of a very premature baby girl, known as Baby K.

He claimed he found Letby stood next to the baby’s incubator ‘doing nothing’ even though her oxygen levels were dropping and she had begun to collapse. Baby K was transferred to Arrowe Park, where she died three days later. Letby was charged with attempted murder of Baby K but the jury failed to reach a verdict in her case.

Dr Jayaram admitted he failed to confront Letby, make a note of his suspicions in Baby K’s medical notes, or put in a formal report or complaint. He explained medics ‘were thinking the unthinkable’ and insisted hospital management were aware of his and his colleagues’ concerns. But another chance was lost.

Missed chance 6

Around this time, Dr Brearey demanded an urgent meeting with the hospital’s executive team.

However, his request was ignored for another three months and Dr Jayaram said medics ‘faced pressure… not to make a fuss.’ Dr Jayaram said: ‘I wish we had bypassed [the managers] and gone straight to the police. We by no means were playing judge and jury at any point but the association [with Letby] was becoming clearer and clearer.’

Missed chance 7

Also in February 2016 the hospital was inspected by the independent heath watchdog, the Care Quality Commission.

Sources told the Health Service Journal that concerns were raised about the high mortality rate on the unit, and of the difficulties faced by consultants in getting managers to take their concerns seriously.

Although the CQC report raised issues around staffing levels and the skill-mix on the neo-natal unit, both children’s and maternity services overall were rated ‘good.’

The regulator also praised the Trust’s overall culture, saying it was ‘very positive’ and that ‘staff were able to raise concerns.’

The CQC said it informed Mr Harvey at the time about the consultants’ claims around raising concerns, but insisted it had no record of any problems being flagged about high death rates.

Missed chance 8

By February five babies had been murdered by Letby in nine months. Doctors had noted a lot of the collapses and deaths had taken place on night shifts, when parents were less likely to be around and fewer staff were on duty.

Mrs Powell was asked to move Letby onto days but, on a day shift just two days later, she poisoned a second twin boy, Baby L, with insulin and tried to kill his twin brother, Baby M, by injecting him with air.

Again, doctors failed to pick up on his abnormal blood test results when they were returned. Dr Gibbs said the test results were entered into Baby L’s notes by a junior doctor who didn’t flag them to consultants or realise their importance.

Missed chance 9

In May, Dr Brearey finally got the meeting with management he had been requesting since February. He told the BBC the executives present, who included medical director Ian Harvey and Mrs Kelly, appeared in denial. Again, they refused to act and Letby was allowed to continue working.

Chief executive Tony Chambers told the Mail there was ‘no evidence,’ other than coincidence and a ‘gut feeling’ that Letby was behind the attacks.

Missed chance 10

In early June, Letby attacked another premature boy, Baby N, who had been born with the blood clotting disorder haemophilia.

However, the tipping point came a few weeks later when she returned from holiday and murdered two of three triplets in the space of 24 hours.

The boys were considered in a good condition for triplets when two of them, Babies O and P, suddenly collapsed and died.

Karen Moore was one of Letby's direct line managers. She was the former head of nursing for urgent care in 2015. She is pictured at her retirement party in 2018

Karen Moore was one of Letby’s direct line managers. She was the former head of nursing for urgent care in 2015. She is pictured at her retirement party in 2018

Ruth Millward (pictured) was in charge of risk and patient safety whilst the babies were being harmed

Ruth Millward (pictured) was in charge of risk and patient safety whilst the babies were being harmed

Court artist sketch of Letby sobbing. She denied murdering seven babies and attempting to murder six others in the neonatal unit of the Countess of Chester Hospital between June 2015 and June 2016

Court artist sketch of Letby sobbing. She denied murdering seven babies and attempting to murder six others in the neonatal unit of the Countess of Chester Hospital between June 2015 and June 2016

How Letby’s close friend broke down in tears as she recalled feeling the final heartbeat of her first victim 

By Nigel Bunyan 

One of Lucy Letby’s closest friends broke down during the trial as she recalled feeling the final heartbeat of the killer’s first victim.

The nurse, who had mentored Letby from her days as a student, was giving chest compressions to Baby A as a team of medics fought desperately to save his life in June, 2015.

But unknown to her, the colleague she had worked alongside for more than three years had furtively injected the infant with air.

Nurse A was shift leader on the unit when Baby A suddenly collapsed. As medics crowded around, she was given the role of reaching into the incubator to deliver gentle chest compressions.

At the same time a paediatrician was administering tiny doses of adrenaline one by one. After each dose, all of those involved in the resuscitation listened for signs of a response.

Finally, they realised they could do no more to help him. ‘There was nothing,’ the nurse said in tears. ‘Just one more heartbeat’.

Nurse A had chosen to give her evidence from behind a screen rather than catch sight of the woman in the glass-panelled dock a few yards away.

She told the jury she had never seen a neonate look the way Baby A did that day.

‘He looked very ill. He had a discolouration pattern I’ve never seen before. He was white with sort of purply blotches. He looked cyanotic. It was these purple blotches with white that I’d not seen before, all over his body’.

Asked where in particular on his body, she replied: ‘Everywhere. Maybe more torso…no, I can’t remember clearly. I just knew it was very unusual.

‘It had come on very suddenly. It was just so unusual and very unexpected’.

Nearly three months later same nurse appears to have almost stumbled on an explanation for the first three murders.

She told Letby in a WhatsApp about the death of Baby D: ‘There’s something odd about that night and the other 3 that went so suddenly’.

Letby responded: ‘What do you mean?’

Nurse A: ‘Odd that we lost 3 and in different circumstances…’

But then she pulled back. ‘Ignore me,’ she wrote a few moments later. ‘I’m speculating’.

Their brother survived after his parents demanded he be transferred to a specialist unit. Following the death of Baby P, on June 24, Dr Brearey was so concerned he telephoned Karen Rees, a senior nurse in urgent care, and demanded Letby be removed from the ward immediately.

But Mrs Rees refused Dr Brearey’s request, saying there was ‘no evidence’ Letby was responsible. Letby was allowed to work the following day and, during this shift allegedly tried to murder her final victim, Baby Q, leaving him with brain damage. The jury failed to reach a verdict in his case.

Letby worked three more day shifts that week until she was finally stopped from nursing patients on the unit on June 30. Managers redeployed her into a clerical role, telling her the move was temporary while an external review was carried out.

Five days after Baby P died, consultants again emailed Mr Harvey urging him to call in police.

But, according to the BBC, he replied: ‘Action is being taken’ and ‘All e-mails cease forthwith.’

Instead, Mr Harvey invited the Royal College of Paediatrics and Child Heath (RCPCH) to review the unit. He also asked Dr Jane Hawdon, a premature baby specialist in London, to review the medical notes of babies who had died on the neonatal unit.

In the meantime, Letby had been re-deployed in the Risk and Patient Safety Office, which gave her access to sensitive documents relating to the neonatal unit and some of the senior managers whose job it was to investigate her. But she ‘hated’ the job, so in September she launched a formal grievance against the hospital in a bid to get back to frontline nursing.

The RCPCH completed its report in November 2016, recommending ‘a thorough external independent review’ of each death. Dr Hawdon’s report also recommended four of the baby deaths be forensically investigated.

However the four deaths were never examined and, when Mr Harvey presented the reports to the board of directors, in January, it is alleged there was no mention of a need for further investigations.

The internal grievance procedure also found no evidence Letby had done anything wrong and, at a meeting in January 2017, Mr Chambers told them: ‘I’m drawing a line under this, you will draw a line under this, and if you cross that line, there will be consequences.’

Managers ordered the consultants to apologise to Letby for the ‘victimisation’ she had suffered or face a referral to medical watchdog, the General Medical Council.

Dr Gibbs told the Mail: ‘The managers decided Lucy Letby had done nothing wrong, that our concerns were unfounded and that she would be coming back to work and we had to apologise to her. We felt very uncomfortable that the problems were not being addressed.’

The doctors wrote the apology but, fearful Letby could soon be back treating babies, refused to back down, eventually attending a meeting with Mr Chambers and a panel which included a senior police officer.

‘As soon as the police officer heard that a member of staff might be involved he said this has to go to the police,’ Dr Gibbs added.

Dr Jayaram, who was also at the meeting, added: ‘I could have punched the air.’

The next day, Cheshire Police launched a criminal investigation into the suspicious baby deaths.

Hospital bosses were warned on several occasions about the worrying spike in infant deaths on the neonatal ward - and the link with Letby. But a court heard these warnings were 'fobbed off'. Pictured is the  Countess of Chester Hospital's neonatal unit

Hospital bosses were warned on several occasions about the worrying spike in infant deaths on the neonatal ward – and the link with Letby. But a court heard these warnings were ‘fobbed off’. Pictured is the  Countess of Chester Hospital’s neonatal unit

Terrified doctor so worried serial killer nurse Letby would slaughter an only surviving triplet begged medics at another hospital for help 

BY NIGEL BUNYAN 

A distraught doctor was so terrified that Lucy Letby might murder the only surviving baby from a set of identical triplets that she pleaded with a medical team from another hospital to take him away.

The female paediatrician had already witnessed the inexplicable, bewildering deaths of Baby O and Baby P twenty-four hours apart, and saw the killer nurse as a ‘mortal threat’ to their brother.

Colleagues from the higher level Arrowe Park Hospital had been called in to collect Baby P, but when he died the Chester doctor joined his parents in asking their lead consultant, Oliver Rackham, to take the surviving baby instead.

The medic, who cannot be named for legal reasons, had no way of knowing at the time that Letby had murdered both infants in cold blood – just after returning from a holiday to Ibiza with two friends.

But neither she nor her colleagues could fathom why they’d been unable to save either of them, and sensed that Letby was somehow responsible.

The 33-year-old (pictured with a baby), started her killing spree while working the nightshift at the Countess of Chester Hospital's neonatal ward

The 33-year-old (pictured with a baby), started her killing spree while working the nightshift at the Countess of Chester Hospital’s neonatal ward 

In evidence, the doctor’s voice dropped to a whisper as she re-lived the moment she joined the parents at the cotside of their surviving baby.

‘The baby’s dad was stood next to him, sobbing and literally begging Dr Rackham to please take him.

‘And even though I didn’t beg, and in a professional way of saying it, in my heart I just wanted him to leave too because that’s the only way he was going to live. I wanted him to be in a safe place’.

In cross-examination by Letby’s barrister, Ben Myers KC, she agreed she felt the child was in ‘mortal danger’ from the nurse.

‘What had happened to those two babies was not normal from a medical point of view. I had my doubts and wanted to speak to my colleagues.

‘I just honestly said what I have felt. I’ve not dramatized anything. It’s tragic enough as it is’.

A short time earlier Letby had made her already infamous remark about Baby P. The same woman doctor had been speaking optimistically about his recovery and told the killer and some of her nursing colleagues the transport team would be arriving soon.

Letby looked across at her and said: ‘He’s not leaving here alive, is he?’

‘I found it absolutely shocking at the time. I turned round and said ‘Don’t say that!’ In my mind he was very much alive. I said that and left the room’.

She went on: ‘We have babies who are very, very sick and very, very unwell. Some of them become increasingly unwell, but you still keep hoping, you still keep trying.

‘I’d never let myself think they wouldn’t live. It’s that hope that keeps you going. When I heard her say that I don’t even know if I was upset. I was just shocked’.

The doctor experienced yet more of Letby’s callousness when she went to break the news that there would have to be a post mortem on (Baby) P.

‘Staff Nurse Letby was against the door and she was very animated, saying to the parents ‘Do you want me to make a memory box, like I did for (Baby) O?’

‘She said it like it was a bounty pack. I remember thinking ‘This is not a new baby, this is a dead baby. Why are you excited about this?’

What the medic didn’t know was that by this stage Letby was controlling things and enjoying the pain she was causing – both to the babies and the colleagues around her.

Even as she had been optimistically awaiting the arrival of the transport team, Letby knew that ‘the end game’ for Baby P was the little boy’s death.

Nick Johnson KC, prosecuting, summed it up in his closing speech. He told the jury: ‘She was enjoying what was going on, and she was happily predicting something she knew was going to happen. She was, in effect, playing God’.

Post source: The List

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