At Liverpool town hall on Tuesday, a public inquiry will begin into the tragic deaths and collapses of babies eight years ago at the Countess of Chester (CoC) hospital for which the former neonatal nurse Lucy Letby has been found guilty of murder and attempted murder.
One of the inquiry’s principal aims is to give the babies’ bereaved families a sense that lessons will be learned. Led by the senior court of appeal judge Lady Justice Thirlwall, it will consider the experiences of the parents of Letby’s victims, examine whether management at the hospital was too slow to identify a serial killer, and whether Letby should have been suspended earlier and the police called in sooner.
Letby has been convicted across two trials of murdering seven babies and trying to kill seven others. Her attempts to appeal have been rejected. Yet in recent months mounting concerns have been raised by senior professionals about the evidence used to convict her.
Letby has now instructed a new legal team, with the barrister Mark McDonald being asked to apply to the Criminal Cases Review Commission to have her murder convictions returned to the court of appeal for a fresh hearing. “The fact is juries can get it wrong, and we know from previous cases that the court of appeal can too,” McDonald said.
Others, including many of those expected to give evidence at the inquiry, have faith that justice has been served in the Letby case.
The inquiry will begin its hearings in this highly unusual context: its very premise – that a murderer was at work – being the subject of dispute.
Last month the Guardian revealed that 24 senior experts had written to the government urging it to either pause the inquiry or expand its remit. The letter said the narrow terms of reference could lead to “a failure in understanding and examining alternative, potentially complex causes for the deaths”.
At the heart of the inquiry are the families whose children died or have been left with disabilities. Solicitors acting for some of the parents have said that the questioning of Letby’s convictions was distressing for them and that the inquiry was “vitally important”.
Aside from any debate over the safety of Letby’s convictions, the inquiry is likely to unearth a series of reports outlining many failings in the unit that could have plausibly caused the deaths of babies.
The Guardian has seen the findings of these reports, which paint a troubling picture of the state of neonatal services at the hospital when the babies died. It is an assessment backed up by sources familiar with the hospital, and other leaked documents and emails.
Our investigation reveals a hospital unit operating beyond its skills and capacity – one that was understaffed and suffering from low morale, lacking the expertise to deal with babies with serious needs, and operating from a tired building struggling with a superbug and with sewage backing up into its rooms.
Concerns raised after deaths
The CoC is a local district hospital on the outskirts of Chester, in north-west England. In 2015, when the hospital started to experience a rise in the number of deaths of premature babies, its neonatal facility was classed as a level-two local unit. This meant it could care for newborns with medical needs from 27 weeks. Bigger hospitals in the area dealt with babies more premature than this, or ones with complex problems.
In the previous year the unit had experienced four deaths, but between June 2015 and July 2016 there was an unusually high number of mortalities – at least 13 babies died.
The paediatric team of doctors and consultants grew increasingly worried. Suspicions about Letby were raised with management after her presence when many of the babies died or collapsed was noticed. She was suspended from nursing duties following two further deaths at the end of June 2016. Two years later, after a lengthy police investigation, she was arrested and eventually charged in November 2020.
But during the period of the cluster of deaths, there were staff at the hospital, including managers and members of the nursing team, who rejected the suggestion that Letby was responsible, and raised possible alternative causes for the increase in deaths, including medical explanations.
Top managers took action and various reviews – both internal and external – were conducted, including a report by the Royal College of Paediatrics and Child Health (RCPCH).
The Guardian has seen the conclusions of two other reports – the first produced by a nursing manager, the second a review by an independent neonatologist into 17 deaths and collapses. Neither found foul play, but they did highlight serious concerns about the state of care at the hospital.
‘Understaffed and underskilled’: staff record difficulties
In March 2015, a few months before the cluster of deaths, the nurse manager of the neonatal unit, Eirian Powell, recorded one of several entries on the hospital’s internal register of risks to patient safety on her ward, saying: “We are currently understaffed and underskilled..
This register is a dynamic, regularly updated tool to alert managers to serious problems needing their attention.
A further entry in late October 2015 recorded a specific troubling evening, four nights after another baby had died. There had been no senior doctor present overnight, Powell wrote, only a middle-grade doctor and a junior doctor still in training. Between them they were trying to cover five separate areas where babies and children might get into difficulty: the paediatric ward, the neonatal unit, the labour ward, casualty, and the ante and postnatal ward. The middle-grade doctor had become waylaid in casualty with a very seriously ill child, leaving the junior to cope with the rest.
The shortage of doctors was a problem raised by others. One of the consultant doctors wrote to the chief executive, Tony Chambers, in December 2015 complaining that staff on the unit were “chronically overworked” and “stretched thinner and thinner”.
The pressure of the shortage appears to have been taking a serious toll on morale. The consultant said: “Over the past few weeks I have seen several medical and nursing colleagues in tears … they get upset as they know that the care they are providing falls below their high standards … When things snap, the casualties will either be children’s lives or the mental and physical health of our staff.”
Nearly a year later, and after Letby had been removed from the ward, the RCPCH report said circumstances were not very different from those on many units but highlighted the shortage of senior doctors, given the acute medical needs of the babies admitted. At the time there were seven consultant paediatricians, one with a special interest in newborns , but no consultant neonatologist. They had to double up on the paediatric and neonatal wards. They were overstretched, awaiting the appointment of two further consultants, and “there should have been a greater level of consultant presence on the ward”, especially at peak times, the report said.
A unit ‘out of its depth’?
A leading, practising UK neonatologist, who has looked post-trial at each of the deaths in the Letby case, reviewing medical details given by the prosecution in court, told the Guardian: “The overall impression is that of a neonatal unit that was out of its depth, slow to recognise problems and inexperienced in dealing with them. This is not a criticism: they were a level-two unit that found itself having to provide level-three care [for the most critically ill and very premature babies].”
She stressed that she had not had access to full medical notes of the babies in the trials and asked to remain anonymous, feeling that alternative viewpoints about Letby’s conviction were better expressed in private. But she said she believed there were plausible alternative causes of death and deterioration in the case of each death. “There were delays in realising babies were in difficulty, poor recognition and management of [serious medical episodes known to affect premature babies], delays in instituting treatment, repeated occurrence of failed intubations [the difficult and delicate insertion of breathing tubes into tiny babies],” she said. “These factors cause further deterioration of already compromised infants and increase the likelihood of death.”
Dr Jane Hawdon, a consultant neonatologist at the Royal Free hospital in London, was asked by the CoC to review 17 cases in which babies had collapsed or died in more detail and individually. The conclusions of her report, seen by the Guardian, were that the deaths or collapses of 13 babies could be explained, and “may have been prevented with different care”. Four cases she was unsure about were reviewed in forensic detail by a further neonatologist who is understood not to have found foul play.
Hawdon recommended changing the criteria for consultants’ out-of-hours attendance, and making sure junior doctors and nurses felt empowered to call on them. She advised better training for doctors in giving antibiotics promptly, and help from Alder Hey hospital in Liverpool, with special packs for doctors to cope with getting breathing tubes in when it proved difficult.
Problems with the level of care in the unit came up in Letby’s retrial and conviction of the attempted murder of baby K. An experienced consultant neonatologist at Arrowe Park tertiary hospital said that by the time the baby involved had been transferred to their more specialist care, her death had become “unavoidable” – in part because of suboptimal care by doctors at the Countess of Chester.
Staff ‘calmer and more confident’ after unit downgrade
In July 2016, about the time the RCPCH was asked to conduct its review, management at the CoC downgraded its neonatal unit to a level-one special care unit. This limited the premature babies that it took into its care to those born at 32 weeks’ gestation or over, an age where the medical complications and risks were much lower.
The RCPCH team found the unit more suited to that level, stating that “staff reported feeling calmer and more confident and morale/sickness has improved … The consultants also reported that in the two months since the change, infants have been sick but recovered as expected.”
Letby had been removed from the unit, coinciding with the downgrading to a lower level. The number of deaths fell thereafter.
Less-experienced nurses replace senior staff
Another major concern at the time, both at the CoC and nationally, was the shortage of nurses. The neonatal unit was operating with the number of nurses a fifth lower than required by national standards. It should have had one nurse to each baby in its intensive care room, a ratio that was frequently breached.
The Care Quality Commission specifically highlighted in its June 2016 report into the hospital that the level of neonatal nurse staffing was a concern, while the RCPCH recommended the hospital recruit two top grade neonatal nurses, apparently unaware that the unit had previously had these.
Michele Worden, who had been an advanced neonatal nurse practitioner (ANNP) at the CoC before being made redundant in 2007, had publicly warned in letters sent at the time to newspapers that in her view the removal of nurses at her level was creating risk.
The most senior nurses were gradually replaced over the following years with less-experienced ones and cheaper nursery nurses who did not have a registered nursing qualification. “When you had ANNPs and senior nursing sisters with decades of clinical experience, the fact the consultants weren’t there enough didn’t matter so much. We recognised problems, we’d seen them before. But it became an accident waiting to happen,” Worden told the Guardian.
Lack of beds and resources to relocate babies
This litany of challenges was compounded by the temporary closure of an intensive neonatal care unit in a hospital in north Wales, which created more demand on the CoC unit in 2015 and 2016. The hospital was also dealing with several multiple births.
Many of the babies it found itself caring for should not have been at the Chester hospital. The NHS reorganised the care of newborns in the early 2000s. The theory was that very premature, low-weight babies did better in specialist hospitals that would be regional centres of excellence, so resources should be concentrated on those. Alder Hey was one such regional tertiary centre.
But at the time intensive care cots in Liverpool were often not available, nor were the highly specialised regional transport teams – often a consultant doctor and a senior nurse needed in an ambulance for hours – to move ill babies across Merseyside.
Powell, the nurse manager, had recorded a lack of available transport as a high risk to babies on the hospital register in March 2016, highlighted in red under the register’s traffic light system.
A couple of months later Powell sent a “neonatal unit review assurance” document to other managers. The document, seen by the Guardian, seemed to be a response to the suspicions raised by some of the doctors about Letby.
“The Cheshire and Mersey transport service have been involved in a few of these mortalities and they may have survived if the service was running adequately,” the document said. It added that the shortage of intensive care cots at Alder Hey had contributed to the mortalities. In at least one case, it said: “If there had been a bed sooner, the infant may not have died.”
Contaminated taps and sewage at ageing hospital
On a more basic level the hospital was old and struggling to maintain hygiene standards.
Powell highlighted other red-alert risks to patient safety on the neonatal unit. For months, the unit had struggled to eradicate the contamination of its taps with a potentially lethal, antibiotic-resistant bug, Pseudomonas aeruginosa. The problem went back to at least May 2015 and was still unresolved in early summer 2016. The superbug did not show up in blood tests on the babies, but its presence was another risk the already under-resourced hospital was struggling to deal with.
It also served as a signal of how far standards had deteriorated. Sewage had backed up repeatedly into the unit from the drains – a problem that had been continuing for years. Worden recalled a unit “falling to pieces, ceiling tiles dropping off. We regularly had sewage coming up in sinks. Any source of infection on a neonatal unit should be the highest priority because it can kill.”
The RCPCH report provided a dispiriting description of the unit’s physical environment: a tired, cramped, inadequately lit, underfunded facility, that had been built in 1971.
Hopes for the Thirwall inquiry
Contacted by the Guardian for a response, the hospital said it could not comment while the inquiry, and police investigations, were continuing, as did the RCPCH and Alder Hey. Powell did not respond to questions.
Many of the hospital managers familiar with the challenges facing the neonatal unit will in the coming weeks be called to give evidence, as will the Royal College. Expected to last many months and cost millions, the inquiry has already racked up costs of about £3m, mainly in legal fees, on preliminary work.
A growing number of voices believe it is vital for the inquiry to openly consider whether there could be causes other than murder for the deaths of babies in the care of the hospital.
Jane Hutton, a professor of medical statistics at Warwick University, and one of the signatories of the letter sent to the government about the inquiry, said: “You have to look at all the deaths and collapses. How premature were the babies, what birth weight were they? If there are more twins or triplets who shared a placenta, you can’t be surprised they became ill at the same time. They are much higher risk. Consultants were absent, junior doctors were reluctant to ask for help, there was sewage. All the potential alternative explanations need to be considered.”
Last month, the Conservative MP David Davis added his voice to such concerns, writing separately to Thirlwall urging her to broaden the terms. The inquiry, he wrote, should “be broad enough to consider alternative explanations and evidence, and address the concerns now being raised”.
